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 delves into the topic of nocebos and their impact on individuals with osteoporosis, particularly concerning the fear of fractures. He addresses a question from listener Lisa Moore about the common advice given to patients with osteoporosis, which often includes avoiding bending, twisting, and lifting. Dr. Jones explores whether this advice is helpful or potentially harmful, emphasizing the need for evidence-based practices in managing osteoporosis. He highlights the fear surrounding flexion-based exercises due to outdated research linking them to increased fracture risk, and encourages a more balanced perspective on movement for those living with osteoporosis. Tune in for valuable insights on how to support clients in overcoming fear and maintaining an active lifestyle.
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.
Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Dry Needling division lead Paul Killoren shares research on the efficacy of ultrasound-guided dry needling compared to landmark-based dry needling for safety & clinical efficiency.
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.
Dr. Rachel Moore // #ICEPelvic // www.ptonice.com
In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore unpacks a new way to conceptualize coning or doming in our pregnant and postpartum clients, and if we actually even care that it happens at all
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!
Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall covers the subjective & objective factors to assess a patient for a shoulder labrum injury as well as the manual therapy & exercise treatment to crush their plan of care
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.
Dr. Brian Melrose // #LeadershipThursday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses removing barriers for patient compliance.
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.
Dr. Christina Prevett // #GeriOnICE // www.ptonice.com
In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses the efficacy of rehab in hernia prevention, management, and post-surgical care.
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.
Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses how your body's regulation can be influenced by various factors such as stress, sleep, and activities of daily life.
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.
Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com
In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Alexis Morgan discusses passing on the positives of the pregnancy, labor, and delivery process with patients.
Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.
If you're looking to learn more about 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!
Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses ways to identify and treat medial tibial stress syndrome (MTSS), commonly known as shin splints, in the cross-country running athlete population.
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.
Alan Fredendall // #LeadershipThursday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses SHOWING patient progress, SHOWING justification to be paid more, and SHOWING patients how you are different than the competition
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.
Alan Fredendall // #TechniqueThursday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the difference between myofascial decompression & cupping, if myofascial decompression works or not, and how to elevate the use of myofascial decompression in practice
Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.
If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.
EPISODE TRANSCRIPTION
ALAN FREDENDALL
Myofascial decompression. What is it? How does it work? Does it work? And how can you elevate what you're currently doing practice if you're already implementing this style of soft tissue treatment?
WHAT IS MYOFASCIAL DECOMPRESSION?
So let's take it from the top and let's talk about what is myofascial decompression, sometimes abbreviated MFD. and how is it different from cupping? So you may consider these in your mind to be synonymous and that is very very wrong. Why? Calling myofascial decompression cupping is really a misnomer because if we dig deep people have been cupping each other for many many many thousands of years. It comes from eastern medicine and you may have seen it in practice, maybe you do it in practice, maybe you've seen it on social media or the internet, and you see people laying in a static position, sometimes with their whole body covered in plastic or glass cups, right? And so that is cupping, that is sitting in a static position, that is using things like meridian or chi points, the idea that maybe we're removing toxins from the body, and you may even heard of something called wet cupping, where we pull blood to the surface with a cup, and then maybe we puncture it with a needle or a knife and we draw blood out of people. So all of that is kind of in the sphere of the term cupping. And what's very, very, very different about myofascial decompression is that we are using some sort of pump, manual or automatic, to get a decompressive effect through the tissue. And in the context of myofascial decompression, we are always, always, always, always, including movement. We are never having people lay statically with just cups on their body. We are not educating them that we're removing toxins from their body or altering their chi or anything like that. And certainly, hopefully, you are not cutting people open and using the decompressive pressure of the cups to suck blood out of their body, right? And so that is the difference between cupping and myofascial decompression. Both use plastic or glass cups, but they come from very, very different paradigms in why we're using it, what we're doing, and the effect that we're hoping to have. So with myofascial decompression, we know now with MRI studies that when we put these cups on, if we have enough pressure, we know that we can put hundreds of millimeters of mercury of pressure through this cup, and that we can sometimes reach the level of the bone. And so we are decompressing not only just the skin and the fascia beneath the skin, but down to the level of the muscle, fascia between levels of muscle, and even deeper levels of muscle all the way down to the bone. And so thinking about the various levels, when you look at your forearm, for example, what is between you and the outside layer of your skin and the bone? Several layers of tissue. We have our epidermis, we have our dermis, we have super fascial tissue and fascia, we have deep fascia, and then we get into the fascia in and around the muscle. We have the epimysium, we have the paramycium, and we have the endomysium. And that we know with a large enough cup and enough pressure from one of our pressure guns that again we can reach the level of the bone. So we're using higher pressures combined with movement to create this decompressive and sometimes sheer force effect on the tissue, combining the decompression with the movement, that is myofascial decompression. And that is how much different it is from traditional maybe Eastern medicine, quote unquote, just cupping. So the second question that we often get and the second point I want to make is often, does it work? There is a lot of myths on social media and the internet that this is not doing anything, that this could never cause a change in tissue. and that is team Patently Untrue. Certainly, if you do this wrong, you can be very ineffective with this style of treatment, but if you do it right, it can be very, very effective. So I wanna give a shout out to Dr. Chris DiPrato. He's a physical therapist out in the Bay Area of California. You may have heard of him. He owns the company Cup Therapy. He teaches myofascial decompression courses. We had the pleasure of taking one of his courses a couple weeks ago when he was here in Michigan, and we had a great time. In particular, I love to learn all the research he had to share. And some of that research around does this actually work is pretty mind opening. And my point with today's podcast is that when we elevate our techniques, we elevate the efficacy and the efficiency of our techniques as well. And again, certainly, if you do this wrong or sloppy, you will have a minimum effect on the tissue. But if you do it right, you can have a profound effect on the soft tissue of the body.
DOES IT ACTUALLY WORK?
And Chris shares that in his course when he seeks to answer the question, does it actually work? Chris has used cups with myofascial decompression on embalmed cadavers. He has used them on fresh or what may be called wet cadavers. And he has used them on live living people in an MRI tube and looked at what is happening to the tissue when we have a large cup with a lot of pressure in it. What do we see? And what he has seen over the years doing these studies himself of having people in MRI tubes is that with a large enough cup and enough pressure, again, we can begin to decompress multiple layers of tissue, fascia, muscle all the way down to the level of the bone, which is pretty significant. And that in general, the more hydrated the tissue, the more decompressive effect we have seen. So when he has tested this on embalmed cadavers where all of the body water, liquid blood, everything is removed and the tissue is essentially dried out, we see a minimal effect when we use this technique. But when we use it on a fresh or wet cadaver or a living person that still has blood, all the sorts of fluid that we have inside of our body, that we get a much more profound effect. And more importantly, looking at these MRI studies, we see that not only do we see that effect in the moment, but that we see that effect for at least three to five days after we have done the myofascial decompression. So what is it? It is a technique using high pressure with movement to create a decompressive effect and some sheer force on the body. And does it work? Yes, if you do it right. So that's what I want to spend the rest of this podcast episode discussing.
INTERLUDE
Before I do that, I just want to introduce myself. My name is Alan. I have the pleasure of surfing as our chief operating officer here at ICE and a faculty member in our fitness athlete and practice management divisions. This is Technique Thursday. On Thursdays, we either cover leadership topics or we cover technique topics. Today is a technique topic today. And it is Technique Thursday, which also means it is Gut Check Thursday. This week's Gut Check Thursday comes from our own fitness athlete faculty member, Joe Hinesco, who sent me a nice little number for you all to do this week. It is every two minutes, hop on a fan bike, an echo or a salt bike, hammer out 20 calories for the guys or 15 for the ladies. And then any remaining time in that two minute window, you're going to do max repetitions of a barbell thruster. with the prescribed weight of 95 for guys and 65 for ladies. The goal there getting hopefully at least 10 thrusters every round and your workout is finished when you hit 75 thrusters. So the moment you hit that 75th thruster you are done with the workout. So it rewards an aggressive start, it rewards somebody who can be aggressive on the bike but still hop off and pick up that barbell and do big sets of thrusters. So If you try that and you hated it, send all that shade towards Joe. He's the one that came up with this workout, so send that his way. And then I just want to plug again, Chris DePrato cuptherapy.com. He has live and online courses, a level one course, a level two course, both live and online. And if you finish today's episode and you want to learn more about this, maybe you're like me and you kind of just started doing this without any formal training. I promise you, if you take his courses, you will come away with a lot of very actionable stuff that's going to do nothing but elevate these techniques in your own clinical practice. So let's talk about this.
PRACTICAL APPLICATION
Let's talk about practical application. First things first, if you have done cuffing before, You have probably seen clear cups. What's the difference? We also have cups. These are rock pods. We have these in the clinic as well. What is the main difference? The main difference is that I cannot control the pressure with something like a rock pod. All I can do is essentially stick it on my skin and get whatever pressure comes out of it, right? That might be not enough pressure to do anything and I may have to reset it. And then I basically am just getting lucky maybe with enough pressure for the patient to maybe feel something. But this is not ideal. It does not have a way for us to control the pressure. It does not have a way for us to objectively measure how much pressure we're using. And most importantly, we can't see through this, right? We can't see the tissue. We can't see what's happening underneath the tissue. There is some important stuff that can happen inside of a clear cup that you'll want to see. and I won't steal Chris's thunder, I'll have you take his course to learn that, but it's really important that we have a clear cup, and that we have some sort of control over the pressure, that we have some sort of pump gun, automatic or manual, to pump up the pressure, and really be sure we're just not getting a random application every time we put on a cup like a rock pot. So what does that look like? We have a manual gun, right? It has a trigger here, you connect it to the cup, and you pull pressure out, right? You decompress. And then with this style of cup, you just squeeze to let the air out. Now, what's great about Chris and Cup Therapy that has really made me feel good about this technique is they have solved the problem of how much pressure exactly am I using so that I can be sure if I repeat this treatment in the future, or maybe somebody else has to repeat this treatment for me, they're using the same pressure as me. Lo and behold, the automatic pressure gun, right? So you can see right here, if you're listening on the podcast, you can't see anything. So go over to our YouTube channel, or our Instagram page and watch me on the video. But what you'll see here is we have a pressure gauge, right? And it's measured in millimeters of mercury. It goes from zero up to 760 millimeters of mercury. And as you apply the cup, you will see the pressure gauge change. And that can dial you in more on how much pressure you're putting through the cup. And again, let you hopefully repeat that treatment in the future. And also be sure you're reaching the levels of tissue depth that you want to be working at. So this is a very, very great tool. This is brand new as of this year, I believe. So if you've taken his course before, you'll want to jump on cuptherapy.com and buy one of these. But this is very, very, very, very nice. And so I'm going to put this on myself. I'm going to put some, just some free up, and then I'm going to show you all how great it is with this auto pressure gun. So just putting some lotion over the area where I'm going to apply the cup. I'm going to apply the hose to the cup like so, and then I'm going to squeeze the pressure gun. Doing this one handed is super tough, but I think we can get it. There we go. And so you can hear the gun working a bit. And now as I take the hose off, you can see some pretty darn good pressure, right? A lot of tissue deformation right there, a couple of inches of skin fascia and muscle pulled into the cup. And I can tell you, this is a very different feeling than just having something like a rock pod or otherwise just a squeeze application silicone cup. This is right on the border between discomfort and pain. However, it is enough pressure that I could move those muscles. I could do a bicep curl. I could do pull-ups. I could move my forearm through whatever range of motion I wanted to, and you can see that cup is not going anywhere, and that comes down to making sure that we have enough pressure through the cup that we're reaching not only enough pressure that we can move with the cup on, but again, that we're reaching the levels of tissue depth that we want to achieve. And that is very, very easy to do with the automatic pressure gun. Let's talk about those pressures. What are they? If we really want to reach deep muscle or reach even the levels of intermuscular tissue and fascia, we need to have a lot of pressure through these cups. We need to have 300 to 600 millimeters of mercury. What is the problem with a cup like this? Or what is the problem with the manual gun? I have no idea what pressure I'm at, right? Hence the importance of the pressure gauge on the new automatic gun. Going down in pressures, if I just want to reach the level of the deep fascia, the pressure comes down a bit, 200 to 400 millimeters of mercury. And then if I want to stay superficial, even maybe if I just want to promote some lymph flow, maybe a patient has some swelling or some lymphedema, I can keep the pressure really light, 40 to maybe 150 millimeters of mercury. Again, how can I be sure I'm keeping pressure light enough to only promote lymph flow? Well, with something like a silicone cup or even the manual gun, I have no idea how heavy or how light my pressure is. And so again, it reinforces the need for that automatic pressure gun. And now I would say the key here, and again, the difference between myofascial decompression and cupping is that when we have these cups on, we're doing some sort of movement, right? Chris will take you through a whole protocol in his course of how to get the cups on and how to slowly introduce movement to an area, especially maybe if it's very restricted or very painful, but also different applications using lighter or deeper pressures to inhibit or facilitate different muscles. For example, he's a big fan of putting cups with heavy pressure on the traps for somebody who does a really contrived trap shrug when they lift overhead. And if you want to maybe isolate the deltoids or the upper back, and sort of think about turning the traps off a bit, we can stick some cups on the trap and really put a lot of pressure through those cups. It's going to be really hard to engage and move those traps, and it's going to promote movement through the muscles that we want to target. Again, maybe the deltoids or the upper back. And he has a number of different examples and circuits scenarios for you in his class but the key is the pressure matters and we can't know what pressure we're at if we don't have an objective way to measure it and then track it over time and for me that was a big game-changer what I learned is I was simply not using enough pressure using something like a silicone cup or or using something like a clear cup, but with just the manual gun. Simply not putting enough pressure into the cup to get the treatment effects that I was looking for. And certainly, probably not being light enough on the other end, if I wanted to do something like promote lymph flow, or I just wanted to have some cups on some muscles to facilitate muscle activation, I was probably going too light for deeper structures and too hard for more superficial structures. or movement facilitation. And again, the automatic gun with the pressure gauge changed all of that.
SUMMARY
So what is myofascial decompression? It is not cupping. It is using pressure, specifically various ranges of pressure depending on the level of tissue that we want to target. always combined with movement to promote movement through that muscle, movement through that tissue. That is very different from cupping where people typically lay in a static position, have a number of different cups applied to them, usually with no idea how much pressure is being put through that cup. Does it work? Yes, if you do it right, it works. As with most things in life, if you do it wrong, it won't work very well. And so understanding that if we have enough pressure through a large enough cup, we can move through several layers of tissue, including all the way down to the level of the bone, which is probably much more of a pronounced effect than maybe we ever thought possible. How can we get better at this? I would recommend if you haven't yet that you take Chris's course. You learn where to put these cups to target different muscles, to target different movement patterns, and that more importantly than anything else, you get yourself that automatic gun either from Chris's website or that you get with the level two course where you have that objective pressure grade knowing that different levels of pressure will target different structures and have different treatment effects. So it's really important we know what those are and what we're trying to achieve with that patient in front of us. us. So I hope this was helpful. Big shout out again to Chris. I reached out to him before doing this episode and just ran this by him and we really appreciate all of his collaboration. You'll notice that ICE does not have a myofascial decompression course. We think Chris is doing it better than anybody else and if it's not broke, don't fix it. So just go see Chris if you want to learn more about this. He runs a fantastic course, very evidence-based, Very movement focused, which you know, anything from us here at ICE, that's what we're all about. So just go see Chris if you want to learn more about this. I hope you all have a wonderful Thursday. Have fun with Gut Check. I don't think you will. Again, if you hate it, just send Joe those nasty messages. Just pass me right on by and go right to Joe. And I hope you have a wonderful weekend and a fantastic Thursday. Bye everybody.
OUTRO
Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.
Dr. Julie Brauer // #GeriOnICE // www.ptonice.com
In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses important tools for acute care PTs: a good attitude, a backpack, a white board, resistance bands, sticky notes, and gait belts.
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
JULIE BRAUER
Good morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division. and I am coming to you live from my garage. So this morning what we are going to dive into are fitness forward tools that you can use in acute care and I'm going to do my best to demonstrate some of these tools that you can use to start loading these really sick folks up early. All right so We are going to dive in first by talking about the most important tools that you need to have with you as you go through the hospital and you go visit your patients in their rooms.
TOOL #1 - THE RIGHT ATTITUDE
So number one, the most important tool that you need is the right attitude. You have to have the right attitude about this. So let me unpack that. Bringing fitness forward care to sick older adults in the hospital. It is not about getting them to do a sexy deadlift with a dumbbell. It's not the sexy thing. It is not, holy crap, I just got this patient, they're in a hospital gown, they're super sick, and they're doing a deadlift with a dumbbell in the hospital. It's not about that. It's not about being able to get the video of that or the picture of that and being able to share that. That is sexy and that is cool and it is badass. However, the meaning is deeper. What the attitude you need to have is, is that you have this beautiful, amazing opportunity to plant a fitness forward seed in this patient who is sick, who has a ton of medical complexity, and you only get to see them potentially one time. You've got one shot to plant that seed and potentially be the catalyst that sets this person up on a better trajectory of health. That's an amazing opportunity. And I would encourage you all to be obsessed with that opportunity. Okay. Every single time I would go into a room, I thought, wow, I have this opportunity. I've got one shot. I could be the catalyst that changes their lives. And the thing about you all who work in acute care, man, you are doing some dirty work, right? You are seeing folks, whether they're young or old, they have multiple types of diagnoses and medical complexities. You are seeing them at their worst and you are seeing them in a very, very vulnerable situation. The fact that you are able to plant that seed yet you don't get to see the sexy outcome and yet you give them your whole heart and whole soul is so important. And it's hard to be in acute care and know that you're not going to get to see a sexy discharge where a patient is lifting a super heavy barbell or they are going all out on an assault bike. You're not going to see that. And that's tough, but you have to reframe it to be, I'm going to be obsessed with having the attitude that I could go into every single one of these rooms, plant the seed, and the patient is able to walk into an outpatient clinic. They want to do fitness-forward care because I planted that seed. And I think that's an incredibly, incredibly important story to tell yourselves so that you can continue to have the motivation to go in and see these folks who are sick day after day. And many times you may not actually get to get them to do the cool fitness board stuff. Okay. So that's the most important thing is having that right attitude. Okay.
TOOL #2 - A BACKPACK
So the second tool that you're gonna need to bring along with you to every single room is a backpack, all right? You absolutely need a backpack. So this is not the backpack I used in acute care. I used the backpack that they gave us as like a Christmas gift one year. This is a Nomadic. This is my travel backpack. This is a very sturdy, but very expensive and nice backpack. I do not recommend getting something like this to go into hospital rooms, okay? But I do recommend that you get something that's sturdy because you're going to be carrying around a lot of stuff in it. So get yourself the backpack. So what are we putting in the backpack? You're going to put weights in the backpack. No, most acute care therapy offices do not have weights. But you can bring your own. So I would bring a 15 pound dumbbell. and an eight-pound dumbbell, and I would put that in my backpack. Now, some of you are not able to bring a backpack potentially into the patient's room. Cool, then you bring it around and you leave it at the nurse's desk, okay? But the idea here is that you're bringing everything with you so that there is no excuse that you don't have the equipment because you're in the hospital. So you have your weights. Now, I've had people say, well, Julie, isn't that tough to carry around? And I say, yes, it is tough, it's heavy, but who else would want to be able to go rucking through the hospital with weights more than fitness-forward clinicians who are here listening this morning? I thought it was awesome. I felt like I was getting a lot of fitness in by carrying this stuff around throughout the hospital all day.
TOOL #3 - THE WHITEBOARD
Okay, so after weights, you're gonna have a whiteboard, okay? I'm using a whiteboard right now for my talking notes for this podcast. you all are going to want to use a whiteboard to create workouts with your patient. So have your dry erase markers and as you are digging into their meaningful goals and you're coming up with functional movements that match those meaningful goals, you are writing this stuff down, you are coming up with reps and sets, you are doing this with your patient. Now, I will say, you're not going to buy these and leave these in patient's rooms, right? This stays with you, okay? You can take a picture of this and give it to your patient, or the really cool thing about acute care is that they typically have whiteboards in the patient's rooms, and they're usually filled with some random information many times they are covered up with Call don't fall signs Those become great whiteboards. Okay, so I usually they're not helpful We all can can agree that call don't fall signs are not something that prevents somebody from falling. So I they're great whiteboards so I would take those down turn them around and with my dry erase markers cut right down the whiteboard on those signs then I would leave that in the patient's room maybe I would go find a couple extras and I would put some motivational phrases on there like uh i remember one very specifically i'm trying to kick covid's ass so i can get home in shopwood something like that or something that lets the providers know a little bit more about this patient their name is something that i always put on these signs their name and something about them a goal an interesting fact i want to try and have every provider who walks into the room treat this person a little bit more like a human than a number or a diagnosis and that's a way to do that so whiteboard, slash use the hospital whiteboards, use those signs that are all around the room, turn them over, use those as your whiteboard.
TOOL #4 - RESISTANCE BANDS
Okay, next, resistance band and TheraBands. Okay, so both. So resistance band is something like this, okay? These offer a lot more resistance than a TheraBand. However, I usually would bring a bag of theravans because i want to be able to leave some with patience right you can do endless things with the TheraBands. I would tie them to the bed rails many times. So even folks who are typically they're just lying supine majority of the day because they're so deconditioned, you can tie those around on the bed rails. They can pull from above, they can pull from the side, there's a lot of stuff you can do with them just tying them to the bed rails. with the resistance bands, this is where I would many times get people up into standing and I would do something like a paloff press. So if they're standing here and this is attached to the bed rail, I can have them do a paloff press to work some core. I can have them do some rotations, you can do rows, you can do a whole bunch of stuff with those resistance bands, but those come with me. I'm not leaving those in the room.
TOOL #5 - STICKY NOTES
Okay, next are sticky notes. Okay, sticky notes are amazing because they're versatile. So I have sticky notes and then even better than sticky notes, I have a really bright, uh, note card. And then I've also used paint swatches that you can get for free at Lowe's or Home Depot. Okay. So what I do with sticky notes or these things, they become targets, right? So if I'm gonna have folks be reaching for things or stepping to things and maybe I'm calling out colors or I will write on a sticky note a number and then they're not only doing a motor task, they're also doing a cognitive dual task perhaps, These are great tools. They're light, they're easy, they're cheap. The other thing I like with the sticky notes is I'd like to put little notes on them for people. So if I'm using targets with a sticky note, perhaps to show them exactly where I want them to do their deadlift, pick the weight up from and put it down on, I will put a note here that just says like, you're a badass or never give up or something like that. And then that's something that the patient can keep. So they're wonderful for targets. They are wonderful to do some dual tasking. So you can have people reach for yellow or reach for a number that is written on one of the colors. So you can yell out the color or the number. Very versatile tools, very easy to carry around with you.
TOOL #6 - GAIT BELTS
All right, and then also obviously a gait belt. You need to have a gait belt. obvious reasons for safety but also i have used a gait belt before and i have put it around the bed rail and okay i have never ripped a bed rail off of anything by putting the gait belt around it and tugging on it okay so i'll just say that are they the most sturdy things in the world no i've never ripped one off so that's my preface there. But I have looped this around the bed rail and then perhaps someone is sitting in a wheelchair and they have a really hard time just sitting up tall in their wheelchair, their core is very weak, I will do almost a modified rope climb where the gait belt is around the bed rail and they are pulling themselves up to sit tall, and then going back to the back of their seat, the back of their wheelchair, and then pulling themselves up to sit tall. I've done this in home health, where I looped this to the end of the bed, the bed frame, what am I calling it, footboard. But typically, in acute care, there really isn't a big enough space in those footboards, maybe some of them, but definitely a really cool tool to use to do unmodified rope climb really get that core activated for someone who is so weak that they barely can even sit tall in their wheelchair.
TOOL #7 - SNACKS
Okay and then lastly You need snacks, okay? Don't forget your snacks. I became so much more efficient and so much more productive when I started bringing food up on the floor with me and putting that in my backpack. So, get you some nuts, get you a bar, a little bit of healthy sugars, maybe some, I always had like clementines or mandarins, those were one of my favorite snacks. Make sure that you have some fuel so you are not having to really put a big stop in the middle of your day. You're not going down to the cafeteria, getting crappy cafeteria food, and it just kind of keeps you focused. When you take that break and go down to get a snack or a coffee, I think it just puts you in that mindset of like, I'm going to just chill and not work as hard. When you just keep hammering throughout your day and you're able to do that because you have fuel, it's really important. Okay, so that is what I put in my backpack. All right, so let's talk about some specific acute care hacks to load up your patients when you don't use the weights. Okay, so let's throw the weights out. My favorite hack, one of them, is to use towels. All right, now this is a towel that I have soaked in water. All right, because a soaked up towel is really heavy compared to a towel that's not soaked in water. So I will roll a towel up and I will put it in the toiletry buckets that are in every single patient's room. So usually these buckets come with soaps and little doodads, things like that. I just get rid of that and I soak up towels and I put them in the basin. Now, you can do a whole bunch of stuff with this. So for someone even in sitting, even having to hold on to this basin, can be very challenging. We can increase the difficulty by going overhead. We can increase the difficulty by doing some marching in sitting. We can do a deadlift from sitting. We can then get up into standing and we can do a deadlift as well. So the great thing about this is it's a great way to introduce the hinge to a patient who is post-op lumbar fusion. Yes, I am loading up someone who is post-op lumbar fusion day one. Why? Because they're going to be discharged. They were probably never taught how to do a hinge in the first place, which contributed to them ending up having surgery. and I want to be the person to break that cycle, right? They're gonna go home, they gotta empty the dishwasher, lift up Fluffy's kitty litter box, whatever it is, why not teach them here and now? So I will put the towel in the basin, and then I will teach them how to properly hinge with an elevated surface in the basin. So I'm teaching them a hinge pattern, loading it up a little bit so that they know how to properly hinge when they go home, okay? And less amounts of things you can do with that basin. The next piece of equipment that I love are your bedside commode buckets. Yes, the things that poop usually goes in. But this is not what we're using them for. We are using clean bedside commode buckets, okay? So the cool thing, buckets, they usually have a handle, okay? So it makes it a lot easier to hold on to than potentially the basin. So what I will do is I will put a bunch of crap in the bucket. So I will put my weights in there or I will go and get a bunch of ankle weights because typically therapy departments and acute care have ankle weights, put them in the bucket and now we got some load. So you can do the same thing. You can deadlift with the bucket, okay? you could do my favorite, which are carries. Okay, so loaded carries. So as you're walking with your patient, they could carry on to the bucket. And the cool thing is that it adds a little bit of a perturbation. Okay, so they're getting an internal perturbation just by holding on to an object. There's a truck coming by, I'm sorry. I am out in my garage. and there is destruction going on in my neighborhood. And it's disruptive. So I'm gonna wait until they go by. Okay, they're hanging out. I'm just gonna talk louder. Okay, so with the bucket, Come on, my friends, keep it moving, keep it moving. Don't say no on a live podcast. Okay, with the bucket, what you can do is if someone is non-ambulatory, they can hold on to the bed rail and they can go like this, back and forth with that bedside commode bucket full of equipment and full of weights, okay? They could hold on to it, hold on to the bed rail and march, just like this. They can swing that bucket forward and backwards. There's a lot of things you can do with the bedside commode buckets to add in a little bit of a perturbation. Okay, lastly, we'll talk a little bit about how to put all this stuff together. So when you are with your whiteboard, right? And you're talking and you're sitting with your patient and you're figuring what movements that you're going to do. This is where you can start introducing what an EMOM is every minute on the minute. You could start introducing what a rounds for time is. So very, very early on, typically patients don't hear about this stuff or feel what intensity is like or load until they're way into their journey and they go into outpatient potentially, right? So the amazing thing is that you get to start introducing them to what a workout is like this early on. Imagine that seed that you've planted, then your patient will understand what it's like to lift heavy and to work hard. They go to home health or they go to inpatient rehab and then they go to outpatient and they're able to advocate for themselves and understand, okay, This is too easy. I don't need that yellow TheraBand or I'm not working hard enough. This isn't challenging enough for me. You are able to give them that opportunity, which is absolutely amazing. And remember, you can be the one that has an impact on them. Farther down the road, you are not going to see that sexy discharge, but you were able to be the catalyst to spark some change. Okay. All right, my friends, that is all. The next time I come on here, I will actually show you an example of like an EMOM or a rounds for time, some examples of what I would actually do with patients in acute care. I will also, on the ice stories, I will post some of my reels I made back when I was in acute care, going back into the archives. I will post on our story my reels that show some of this stuff in action. Lastly, talking about our courses that are coming up. MMOA Live will be in Alabama, we will be in Minnesota, Wyoming, and Oregon for the rest, not the rest of September, we're not in September yet, but in September, so many opportunities to catch us live on the road. Alright everyone, have a wonderful rest of your Wednesday.
OUTRO
Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.
Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Justin Dunaway takes a deep dive into a series of three studies tracking the same cohort of patients over 10 years and what they say about the importance of short term changes!
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 Persistent Pain 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
JUSTIN DUNAWAY
All right, team, good morning. I am Justin Dunaway, lead faculty with the Institute of Clinical Excellence, coming at you live from Portland, Oregon. Welcome to another Clinical Tuesday. I am lead faculty for Total Spine Thrust and also our Persistent Pain Comprehensive Management course. 32nd cohort just began yesterday. So if you're thinking about jumping in that will the registration will remain open for another day or so So if you're thinking about it, go ahead and take a look But enough about that. Let's get into today's topic today we're gonna talk about full thickness a traumatic rotator cuff tears and looking at physical therapy or Surgery and what what kind of predicts that stuff? and it's really cool because it's a series of three studies over a decade that looked at the same same kind of cohort of humans and And while I'm going to talk a bunch about these three studies, realize that this really is more than a story about rehab for rotator cuff tears. This is really a story about the importance of our ability to demonstrate within session and between session change, early, often, and frequently. And at Ice, we often hear that we are obsessed with incessant change. We are obsessed with our ability to show short-term changes. And I couldn't agree with that sentence more. Like, totally. I am absolutely obsessed with that. The second half of that, though, which I don't agree with, is that short-term change, within-session change, those things don't matter. What we're really talking about is regression of mean or natural history. And short-term change doesn't predict long-term change. And I couldn't disagree with those sentences more on lots of different levels. But I think that the story I'm about to tell, the three studies that we're about to walk through, give some of the best evidence and support for the need for short-term and within-session change, for at least one of the many reasons why this stuff is so important. So let's dive in. First study, study number one, the effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears, multi-center prospective cohort study by Kuhn and Dunn, 2013. Mouthful. But basically what they did is they took a whole bunch of humans, 452 of them, that had full-thickness chronic degenerative rotator cuff tears, and all of them got six weeks of physical therapy. And then at the end of the six weeks, they were asked, you know, how are you doing? And they got one of three options. They could stay cured, in which case they were done, and we'll just check in at 12 weeks, and then at a couple time points over the next two years, or they're improved, in which case they would get another six weeks of physical therapy, or no better, and then they could opt for surgery. And then at the 12-week mark, the people that were left, that weren't cured in the first six, asked them the same question. If they were cured, awesome. If they were anything but cured, they were offered surgery, and then tracked over the next two years. The physical therapy protocol, I couldn't get my hands on the full version of Appendix A that went into detail about what they actually did, but in the study, in the methodology they just talked about doing the physical therapy was range of motion, was postural control, was scapular training, was mobilizations, was general strength training stuff. And I've got some thoughts on that and we'll dive into here in just a second. But the outcome here is what they found is that less than 25%, okay, full thickness chronic degenerative rotator cuff tears, less than 25% of the 452 people in the trial at the end of the 12 weeks needed surgery. At the six week mark, only 6% of people opted for surgery. At the 12 week mark, that number was up to 15. And then over the next two years, a few more trickled in and that went up to like 24%. So at gut shot, 75% of people with full thickness rotator cuff tears went on to have excellent results in pain, disability, range of motion, strength, functional stuff, and went totally back to life. That's awesome. That's huge, right? The second piece The thing I want to think about here, though, is I think that number could be a bit better, right? I'm going to make an assumption that once we dive into the exercise protocols there, were they really doing strength stuff? Were they really looking at multi-joint movements, overhead presses, rows, pushes, horizontal presses, things like that, and dosing them appropriately for strength? you know, thinking about low or high sets, low reps, two to three minute rest at roughly 80% of their calculated one rep max, or are they doing like three sets of 15 with a band? And call it strength. I have no idea. My assumption is that we probably could be a bit more aggressive with exercise, and I bet that number could get a bit better. But 75% is awesome. So let's run with that. And the conclusion of this first study, which is super important, That if I'm just gonna read the quote if a patient avoids surgery in the first 12 weeks He or she is unlikely to undergo surgery at a later time point up to 12 up to two years So this is the first point here if the patient doesn't opt for surgery in the first 12 weeks They're probably not going to get surgery so our ability to to show them functional improvements in the first six, in the first 12 weeks, is absolutely huge. Because if they don't feel like they need surgery at the end of the 12 weeks, they're not going to get it probably ever. And when we think about conservative management versus surgery, both these things can be effective. But there is massive risk to surgery, right? There's massive financial risk. It's super expensive. And then thinking about the risks of anesthesia, of something going wrong during the surgery, of infection, of interactions, adverse events with the medications, opioid addiction. All of these things are risks of surgery that don't exist in conservative management. Okay, so that's the first study. If you don't opt for surgery in the first 12 weeks, it's unlikely that you're going to. 75% of humans got totally back to life without needing surgery. Study number two, predictors of failure of non-operative treatment of chronic symptomatic full thickness rotator cuff tears. Same research team. This was published in 2016. Again, looking at the same cohort of 452 individuals, This time what they wanted to see is, okay, 25% of you failed conservative management, failed physical therapy. Why? Is there anything in there? Is there anything about you that predicts whether you will or won't do well with physical therapy? And this was really cool. So they looked at all the patient demographics. They looked at age, they looked at sex, they looked at pain, severity of the tear, disability, chronicity, activity levels. They looked at work status and education and handedness and really everything under the sun. And what they found, the first thing they found is that structural factors were not predictive at all. Tear didn't matter, pain didn't matter, disability didn't matter, what your MRI didn't look like. None of that stuff predicted whether you needed surgery or not. The number one most powerful and really only significant predictor of whether you went on to need surgery or not for your full thickness rotator cuff tear was belief that physical therapy wouldn't help you. That was it. If you believe physical therapy would help you, you succeeded, you didn't need surgery. If you didn't believe that, then you opted out and went for surgery. And then smoking status moved the needle just a little bit, which makes sense. If you're smoking, your body is widely inflamed. Things heal slower. Your pain systems are far more sensitive. And then the other thing that was a very small predictor was activity levels. If you had higher activity levels, you were slightly more likely to opt for surgery early. And that makes sense too, right? My shoulder hurts. I can't do all the things I want to do. I'm still trying to do them. Things aren't getting better quick enough. Give me the magic bullet. The important thing here, again, one, structure was not predictive. Two, the only real strong predictor was your belief in physical therapy. Now, this is where it gets interesting, right? If that is the thing that determines whether you get surgery in the first six to 12 weeks, or that's the thing that determines whether you get surgery, and most humans are gonna make that decision within the first six to 12 weeks, you cannot make the argument that within session change and short term changes don't matter and probably aren't the most important thing there is, right? Because I cannot, if the thing that determines whether you need surgery or not, whether you get into that MRI tube, whether you get in the OR suite, whether you're getting those injections, pills, things like that, is your belief that physical therapy can help you, I cannot think of a more powerful way to foster that relief than having some tools in my toolbox that when you walk in the door, very quickly, I can modulate your pain, I can change your pain, your pain pressure threshold, turn on painfully inhibited muscles, gain some access to proprioception, and then get out into the gym and do some things that actually build capacity in humans, and demonstrate that thing within session, and then session after session after session. Short-term change and within-session change are the things that get patients to believe in physical therapy. And belief in physical therapy is the thing that keeps the patient out of the OR. Simple as that. That is the most important tool we have to foster those beliefs. Okay, study number three. This one just came out like last month. The predictors of surgery for symptomatic, atraumatic, full thickness rotator cuff tears change over time. Same research team, again, looking at these same humans that were in this study. Now this is tracking them down 10 years later. The first thing that pops out is that at the 10 year mark, only 27% of these people went on to get surgery. So you think about that, at the two-year mark, it was around 24%. So just a few more people kicked into the surgery over the next two, between two years, year two and year 10. Most of them, over half, opted for surgery before the six-month mark, and then the rest of them slowly trickled in over the next 10 years, with it kind of being less and less each year down the road. At the six-month mark, And everything prior to that, the most predictive thing, again, whether you need surgery or not, was belief in physical therapy and nothing else, right? So those beliefs are gonna be powerful all the way up to the six month mark. Everything we can do in that window to convince patients. that this is the path they need is gonna be the thing that keeps them off the other path. Beyond six months, it doesn't switch to structure, it doesn't switch to pain and disability and any of that stuff. The only two predictors beyond six months were if you were on worker's comp, and again, if you reported high levels of activity. Now this is super important too, right? Because okay, we're six months, we're a year, we're two years, we're five years out. We've done physical therapy, it didn't work, we've kind of forgot about it, that's off the table. And now, the stuff that's really bugging us is the fact that, okay, we're still having trouble at work, we're on workers' comp, we're kind of in that system, we still have all these activities that we want to do that we can't do the way we want to do them, now it's time to do something else. It's important to realize that overall, at the 10-year mark, 70-ish percent of humans, again, didn't need the surgery. And this is an interesting bullet point, too, because one of the things that you'll frequently hear is that, great, people do well with conservative management for rotator cuff tears. But if you don't repair it anyway, you set the patient up for degenerative changes, arthritis, problems down the road. What this study showed us is that the 10-year mark, the 70% of humans that did well with conservative management 10 years ago in that six to 12-week PT window, All of them were successful. And the success that they gained 10 years ago didn't decline over time. They didn't have more disability. They didn't have increased pain or arthritis or things like that. Their gains stuck. And this is one of a few studies that look at conservative management for rotator cuff tears, track them out over long periods of time, and show that there is no negative mechanical effects from not repairing that thing. So, the important stuff here, the key clinical factors here, is that team, at the end of the day, beliefs and expectations are the foundation. They're everything. They're the thing that drive the decisions that patients make, right? And if we don't have the ability to demonstrate change to our patient, if we don't have the ability to show them, not just tell them, But show them time and time again, ruthlessly, within session and between sessions, slowly building up functional outcomes, session after session after session, they're not going to buy this. And if they don't believe in what they're doing, if they don't believe in physical therapy, if they don't think that this is the thing, that's the stuff that determines, OK, am I going to get shots? Am I going to be taking pain medications? Am I going to end up in the OR suite? We need, what this research tells me is that we really need to drill down on our ability to have tools in the toolbox that create quick, transient changes in pain, range of motion, muscle activation. And I get that that's transient, but what we're doing is we're open a window. And then once that window is open, we absolutely have to jump through it, get right into the gym and start doing the large functional movements that build capacity in humans. And then be ruthless about your comparable measures, your functional stuff between sessions and your objective stuff within sessions. and make sure that multiple times every session, you're showing patients change. In every session, when they walk in the door, you can show them change over time. This is where you started. This is where we were after the first week. This is where we were after the second week. The better we get at that, the better we get at demonstrating change in the moment and showing them incremental change over time in the short term, the better our odds of keeping these patients out of the surgical suite. If the only thing that separates these two groups, physical therapy or going under the knife, is their belief in the power of what we're doing in the clinic, then we have to invest everything we have in our ability to demonstrate those changes. All right, team, hope you're half as excited about these three studies as I am. I think it's a really cool thing to look at and then track these patients over the last 10 years. If you got any questions, throw them in the chat. Have an awesome day in the clinic, and I look forward to seeing you out there.
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.
Dr. April Dominick // #ICEPelvic // www.ptonice.com
In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick discusses 4 topics to cover early in rehab for an individual who had a prostatectomy surgery in order to promote optimal physical and mental recovery!
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
APRIL DOMINICK
Post-op prostatectomy, unique considerations for the PT. Let's talk about them. Today on the podcast, we'll talk about four topics that are unique to post-op appointments when it comes to treating someone with a, or after a prostatectomy. Overall, we address the person who comes in for prostatectomy care with similar basic foundations that we would any other post-op person, like rotator cuff repair, post-op knee replacement. We do this in regards to respecting general tissue healing guidelines and timelines, restoring mobility and function, as well as using those progressive overload principles in order to achieve those goals. Don't let the prostate piece scare you. It's basically the same, except for a few considerations that we'll talk about today. You are the musculoskeletal expert, and you can use what you already know for these general post-op sessions. The post-op PT eval will be, like I said, similar to the pre-prostatectomy eval that I talked about in my previous episode, number 1765. In that episode, I outlined some basic education on prostatectomy, options for surgery. I go into detail about what a rehab session would look like from the subjective to the objective to the treatment and, uh, week over the most common complaints, which are urinary leakage and erectile dysfunction. So the biggest takeaway from that episodes besides how to outline your eval and session is that pelvic floor muscle training prior to a prostatectomy is key for having incredible impacts on improving health-related quality of life post-op. So again, the outline of a prehab evaluation for someone prior to their prostatectomy will be very similar to the post-op. So I just wanted to take out some key pieces or topics to focus on today that are unique to someone who had a prostatectomy. So we'll talk about how to educate, intervene, and I'll give you some tools for four different branches of our post-prostatectomy tree. The first branch we'll talk about is surgery specifics and general pelvic floor knowledge. The second thing we'll talk about is bladder function. Then we'll go into sexual function. And our fourth branch is the psychosocial piece. So let's dive in.
SURGICAL CONSIDERATONS
Branch number one, surgical considerations to ask the patient. So the patient comes in, they've had their prostatectomy. What do we need to know about their surgery? Well, first off, we need to know which type of surgery did they have. And we're today talking about a full prostatectomy, so removal of the prostate and some seminal vesicles. So which type of surgery was used? Was it open, meaning they had much larger incisions in the abdomen in order to get to the prostate? which is gonna have a huge effect on rehab. Number two, is it a laparoscopy? And that's gonna be a lot smaller incisions on the abdomen, or was it robotic assisted? Generally speaking, those are smaller incisions. They have less trauma and much shorter hospital stays. Another important question to ask is how long was their catheter in? And on average, it's about one to two weeks. If it's longer, there is a big potential to impact short-term bladder function, like urgency, frequency, leakage, and there is a greater risk for UTIs. And then if they know about this, a lot of times they don't really know about this, but if they know about it, any information about how much nerve sparing was achieved during the surgery. We know now the greater the nerve sparing, the likely that there is better function from a bladder side of things, as well as sexual function. So that's just some general surgery considerations. Now we'll dive into pelvic specific education that we can give. In terms of the pelvic floor, most people don't know what the pelvic floor is and don't know how it's related to the surgery they just did. So ensuring that the individual has some visual models or pictures of the pelvic floor itself and how these muscles relate to bladder, bowel, sexual function, supports, and things like that. Then making sure that they know, hey, this is the surgery that you had. Here's what happened, if they're okay with you talking about it. That way they understand why they're experiencing certain side effects. And then asking them, very much understanding what is it that they need in terms of lifting? Do they have a toddler at home? Do they have a grandchild that they're lifting or a caregiver? What are their job duties? Does their work require that they lift? And making sure that we have those in mind so that we can prioritize those with their rehab goals. Still under our pelvic branch, we can also get some objective measurements from them, outcome measures that are really helpful for this population. From a bladder side of things, the International Prostate Symptom Score is helpful. They also ask about nocturia or nighttime leakage. And then the NIH chronic prostatitis symptom index, it talks about impacts of symptoms and their quality of life. From a sexual function standpoint, the erectile hardness scale and then the international index of erectile function, those basically have them rate their erections and the quality of those. And then psychosocially, there is a prostate cancer specific index cancer patients and it measures health-related quality of life, physical function, as well as emotional well-being. So those are some outcome measures that you can track changes of with your patients. And then still on the objective side of things for the pelvic floor, we want to get a general orthopedic assessment and pelvic floor specific assessment. And during that pelvic floor assessment, we are looking at hyper or hypotenicity. We are understanding what their awareness is of their pelvic floor, their connection, coordination, strength, so many different things that we can look at. And you can do an external visual palpation of the pelvic floor. And you can do an internal a digital rectal exam. However, that's only going to be once they are cleared by the physician around six to eight weeks. So that was all the surgery considerations that we want to ask, then the pelvic floor, just kind of like things that we want to go over, objective measures.
BLADDER FUNCTION
Now we're going to move into the bladder function and talk about education, exercise, and some general tools and resources for that branch. So education wise, we want to be educating these individuals that urinary incontinence is extremely common in this population. It can be significant and very much improve. We usually see most improvements within the year. Clinically, I've seen a lot of improvements in that first three to six months, especially if they're able to come in for PT. And then we want to be telling them about, hey, here's some education on pads, how you can use the weight of the pad to be a specific measurement for whether or not they're improving in their urinary leakage. So weighing the pads is a lot more objective of a measurement than asking, How many paths do you go through? And then teaching them, hey, there's different levels of absorbency of the pads. That could be another measure. If you need one that has a much lighter absorbency, then that can be another sign that you're improving. And then from a daughter's side of things, educating them on taking note of your daytime leakage and nighttime leakage. Reminding them that, hey, if you After the surgery, once you become more and more active, you may notice at first some more urinary leakage and we expect that. for some people. And as they do therapy, we also expect that to get better. So also being mindful for these tracking changes and suggestions. Some individuals may have a lot of anxiety with tracking these changes. So being careful with who it is that you actually recommend being very diligent about tracking. And then from an exercise standpoint to help with bladder leakage, we're always going to start with pelvic floor muscle training. And that can be isolated at the very, very beginning. And then, and we can start that as soon as the catheter is removed. There aren't any solid research-based protocols on how many reps exactly and how often and whatnot, but we generally want to be starting with isolated pelvic floor muscle contractions and then pairing that with functional movements pretty much right off the get-go. I'm gonna say sit-to-stands are one of the biggest and most common ADLs that someone post-op will have leakage with and because think about how many times we stand up to during our day as well. So really harping on mechanics and breathing and bracing strategies to help limit the urinary leakage with that. And then of course lifting, walking, returning to specific sports or job duties is going to be how we also want to pair our functional activities. our pelvic floor muscle training. Then we want to be teaching about breath mechanics and bracing strategies. So really leaning into, hey, there is a spectrum of breath mechanics like using an open glottis versus using a closed glottis. That's going to be a lot more intraabdominal pressure. And really teaching them how to gauge that pressure at the beginning to reduce the strain that they have with activities like standing up. Also ensuring that, hey, when they are lifting, they are not straining. They are not, as we like to say in the pelvic division, going down to the basement. And because that is going to increase unnecessary pressure on the area that is healing. And then progressively building up to increasing intra-abdominal pressures as well as external loads as they return to lifting or impact or return to their sport. From a bladder side of things, the tools that we can use, a penile clamp would be a tool that lightly puts pressure around the mid-shaft and then in doing so it kinks the urethra and that's going to over time increase bladder capacity and help them if they are struggling quite a bit with urinary leakage. All right, so that was the bladder branch.
SEXUAL FUNCTION
Now we're onto the sexual function branch. The sexual function piece, often the most distressing post-op change. Education-wise, we want to make sure that they understand, hey, there is no longer going to be wet ejaculate post-op due to the removal of the seminal vesicles. You may have a loss of penis length, Expect that. And then also reminding them that, hey, there may be some changes in your erection and orgasm, such as delayed onset or reduced intensity, maybe some increased pain or reduced sensation, but that is why you're working with me. We'll work together on some of those pieces. and then from an exercise or modality perspective for sexual function. Obviously, pelvic floor muscle training is going to be really helpful, making sure that they have an understanding and awareness of which muscles or where they need to be working if there are restrictions to the pelvic floor. So we can teach them some self-mobilization techniques, not only at the pelvic floor, but also globally at the hips and abdominals as well. And this is going to help promote local blood flow, which is what we need for sexual function and for interaction. And then modalities like dry needling plus stim are helpful for local and global blood flow. And then of course, regular aerobic exercise, 150 minutes a week, that is going to 100% improve their blood flow and just overall physical health in general. Other non-musculoskeletal tools that they can use to help with sexual function, penile pumps that can help with erectile function by increasing the local blood flow and maintaining penile length. There are various protocols for using these. And then a lot of folks are also recommended to use medication like phosphodiesterase to help with post-prostatectomy and sexual function.
PSYCHOSOCIAL CONSIDERATIONS
And then our third branch, the psychosocial branch. While this surgery removes something physically, we cannot forget the ricochet effects it has on the person's mental and emotional well-being. exercise levels pre and post-op, let's use this as an opportunity to create lifestyle change, to increase their aerobic and resistance exercise frequency so that they're not leading that sedentary lifestyle post-op that maybe they did pre-op. This is going to obviously improve mental health and the physical effects post-prostatectomy. While the surgery does affect the client, it also affects their social life. Say leaking or wearing a diaper, going out to happy hour, not a great look. And then also it includes the romantic partners or maybe even caregivers. So ensuring that we are addressing not only the individual who was affected from the surgery, but others in their life. And then tools wise, the Prostate Cancer Foundation, it's a great resource for finding providers, treatment centers, support groups, and there's a space for caregivers. So I really liked that website. Then there's the Mojo app, and that focuses on the psychological side of sexual function for erectile dysfunction. So it's created by a psychotherapist and pelvic floor physical therapist. There's lots of different exercises, little modules that they can go through. A support group is also included. It is not prostatectomy specific, but I think it's a great resource from the psychosocial side of things. And then of course, mental health providers are huge, especially those that are versed in pelvic conditions or even someone who's a sex therapist.
SUMMARY
Okay, in summary, we know that prehab is vital for these prostatectomy patients in order to improve their outcomes post-op. Post-op prostatectomy, the general guidelines of tissue healing are very similar in how we would use progressive overload principles, very similar as any other kind of operation or post-op. There's just those unique considerations that we talked about. We talked about that tree with some different branches, so making sure that surgically we asked them about specific questions like what was the type of surgery, how long did they have their catheter in from a bladder function branch. We talked about education of the pelvic floor itself and anatomy so that they understand why leakage is happening. We talked about breathing and bracing strategies and using those to up or down ramp the pressure to affect urinary leakage. And then we talked about pairing the isolated pelvic floor muscle contractions and coordination work with whole body strengthening and functional activities. Definitely focusing on sit to stands as they have the greatest urinary leakage. And then we talked about sexual function, ensuring that they know there are changes in their penis, like the erection, orgasm. They can do self-limbalizations to help with restricted areas. They can use the Mojo app, the penile pump, to assist in erectile function. And then from the psychosocial piece or branch, we talked about resources like the Prostate Cancer Foundation, mental health providers for both the client and the caregiver. So our next online cohorts, if you all are interested in pelvic classes through ICE, Our next online level one cohort starts September 9th. Level two starts October 21st, and that's where we really deep dive into post-op considerations. And we also talk more in depth about prostatectomies. Our next live courses are in Hendersonville, September 7th and 8th, Milwaukee, September 14th and 15th, and Galesbury, Connecticut, September 21st and 22nd. Thank y'all so much for listening, and I will catch you next time.
OUTRO
Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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.
Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko discusses the concept of maximizing health & fitness. What is the most optimal route for most people?
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
JOE HANISKO
This is Fitness Athlete Friday. I want to welcome you to the PT on Ice Daily Show with the Institute of Clinical Excellence. My name is Joe Hanisco. I am one of the Lean faculty alongside Mitch Babcock and Zach Long in the Fitness Athlete Division. In terms of what we have going on in the Fitness Athlete Division, we'll quickly chat on that before we get rolling on the topic of over-optimization today. We are kind of wrapping up our year in 2024. We can see the end of the fall coming in and we have a few more live courses, three or four courses in the state of Colorado coming up here shortly in April. We have Texas coming as well and I know Mitch is going to be ending out the year down in Florida trying to get some sunshine down there. So if you're looking to get on one of our live courses, we have three or four left in those areas kind of spread out nicely across the U.S. I know that we are also about to kick off our Level 2 online course here in September shortly. So beginning of September, if you're looking to get on to Level 2 Clinical Management of Fitness Athlete online, hop onto that. If you're trying to complete your certification or get through that process, We only offer that course twice a year, so it's going to be a few more months before we get back on top of that. But yeah, I'm looking forward to meeting you guys and hopefully catching you on the road here. Over-optimization. I'll have to be clear when I dive into this because I think a lot of us, especially at ICE and our following and all you guys out there in the Army, we love health. We love wellness. We love to optimize and perform. at our best and I think that's great that we're putting our minds into what makes us better humans, better athletes, makes our clients healthier and happier people as well. But lately I've been fielding a lot of questions from my clients on optimization and how to maximize their health. And what I'm starting to see is a trend here in which there's a few things happening and that people are putting so much energy into being perfect that it's kind of coming back to haunt them. and or they're forgetting the basics and I wanted to chat about that. You know you think about optimization from a health metric standpoint you have to think about time investment and sometimes financially investing into this as well but from a time perspective you think I have 24 hours in a day to make the best decisions for myself in terms of my health and well-being And right off the get-go, 30-ish percent of that should be consumed with just proper sleep. If we're getting six, eight, 10 hours of sleep, you're getting a good 30 to 40% of your 24-hour day wrapped up in sleep, which is fantastic, but what I'm getting at there is already a big chunk of time is removed from one thing that should be optimizing your health, which is sleep, and we should be prioritizing that, but that's a chunk of time that you're already devoting to your health and wellness. that leaves you with, you know, 14, 16 hours or so. And most of us are working professionals, and we probably spend six to 10 hours a day working. So you add your eight to hours of sleep to maybe six to 10 hours of work and you quickly are eating up 75% of your time and that leaves maybe 20, 15, 20, 30% of your day left over to make decisions that are kind of not being made for you at this point. And this is where the extra optimization stuff would fall into. But again, what I want to get at here is that in that small chunk of time, you guys are all real humans just like me where we have, uh, after our work day, we have kids that we have to take care of. We might have games that we have to go to. We have grocery shopping, we have meal prepping, we have yard work to do, you name it. We have responsibilities and that 20% that we have left over our day starts to get whittled down to very little time to, uh, to be strategizing what is the best effort to help maximizing my health, my fitness journey outside of the things. that I'm already doing and outside of the time that I'm devoting to work and to sleep, a big chunk of what our 24 hour day gets eaten up into. So what I'm getting at here is when I have clients come in, they're talking about, Hey Joe, do I invest time or money into a cold blanch or maybe a sauna? Which one do I go with? Like which one's going to give me the best benefit? And then they roll into, well, I heard about red light tables and laying in one of those might be helpful for cellular repair and reproduction, which is I think possible, but also, Getting out there a little bit Or do I go and invest time into this laser? Therapy that I've heard is helpful or half possibly, you know during my workouts I'm trying to do some CrossFit stuff stuff and some strength workouts But how many days a week and how much time do I have to invest into? zone two training and then yesterday Joe I listened to a podcast about vo2 max and how Although zone two may help with your VO2 max, high intensity, more interval style training is going to be even more beneficial for my VO2 max. I should certainly do that because that's correlated with mortality. But I can't forget that just building muscle is also correlated with mortality. And then after I do all that, I would like to make sure I have time to breathe and do some meditation and work on some cyclic sighing or some box breathing technique for 15 or 20 minutes a day. But which one should I choose? Should I do nasal breathing stuff? Should I focus on the cyclic sign? And it should leave me some time to then hopefully organize all my supplements because I know that I have inflammation in my body and ashwagandha is gonna be helpful for that. And I'm already trying to take creatine and I heard that magnesium might help me with my sleep so I should probably think about buying some magnesium and figuring out when to put that into my life. And then before I make any decisions, I should certainly go talk to a healthcare professional about getting advanced blood panels and screens done so that I know where all my metrics are so that I can make the best decisions for those supplements and I'll slap on a CGM at the end to make sure that my blood glucose isn't out of control. I hope that was confusing as I ran through that because it is confusing. We have so many freaking things out there now in the last probably, I feel like the popularity has really spurted up here in the last three years maybe now, but certainly every year it seems to be putting more and more energy in. How do I be perfect? How do I make my human body as perfect as can be? Hear me loud and clear. I support people in making good decisions. I try to make good decisions myself. I have been interested in some of these optimization techniques and I have also pursued some of these optimization techniques and theories. What I'm getting at now is that I'm sensing and there's this palpable level of stress that is coming alongside with people trying to be optimized in their health journeys. They are putting so much time and energy into Researching listening and figuring out what is best that they might actually missing the opportunity to do one thing really really good for themselves and therefore not see the benefit or if they are putting energy into optimizing This palpable stress that I'm feeling now, I feel like is actually creating the problem. And the problem is perfection. The stress that comes with being perfect, I feel like could drastically, especially in the everyday human like us, drastically outweigh the benefits of what those optimization tactics are trying to lead to. This is just sort of a paradox now that we're stuck in between how much time and what techniques am I and should I be willing to invest in to see the best outcomes on my overall health and wellness and where do I put them into my daily routine? I think this is the big paradox that we are running into. So my purpose of this talk today was not to necessarily dive into the weeds on cold plunging and red light and supplements I think there's enough research out there, and really the research, like most research, tends to be somewhere in the middle on a lot of these things, that yes, there could be a benefit. Sometimes I believe the benefit is in that upper 1%, meaning that it might make a small change, and so therefore, statistically, there is a benefit. we might be missing a greater opportunity for change focusing on other things. Or it's 50-50 just because some things work for some people and some things don't work for other people or how you execute that in terms of a protocol may not be optimal. So for an example, I know that a lot of people who have invested into red light I'm sorry, to sauna and heat exposure are doing so without really diving into the literature and showing that much of the research, especially the Finnish research that has all the proposed benefits of cardiovascular health with heat exposure. The duration and the heat intensity of these things is insane like most of us don't have a sauna if we're using like a red light Infrared sauna for example that will ever get to the 150 60 70 or higher range like some of these studies are having people who are able to spend 15 to 30 minutes a day or more in a true sauna and that is reaching 180 plus degrees. And then they're reporting results of these cardiovascular benefits. And then people over here in the US are just jumping into the 120, 130 degree infrared sauna and spending 15 minutes there a couple of times a week, uh, and rather than every single day. And then assuming that they're getting that benefit, which I don't know if that is true. I don't know if that will help. I, I can't say that there's been research to show that if you do it halfway that you'll get the same results. Uh, but also it's possible that people are wasting their time with that was what I'm getting at. And so, So this is where it gets like a really slippery slope. So the purpose of this chat today was not to get into the weeds, not to get into the science behind it, but to get into a very clear reminder that the palpable stress that I am feeling as a clinician in terms of conversations is real. I know that it is out there. And I think that what we need to be doing is reminding ourselves and our clients that what they have to be focusing on first is taking their meds. This is an abbreviation that we've used at ICE over the last couple of years now that If we can invest in taking our meds, meaning the M of meds is the mental health side of things. If we can focus on doing something that we enjoy doing for our mental health, putting time and effort into relationships, whether it's with our spouse, our kids, our friends, or all of the above, maximizing our relationships are going to be huge. That is the mental health portion that we certainly cannot deny has a massive contribution to our wellness, our longevity, and our overall well-being. The E is exercise. I think we're all on board that exercise seems to be the most consistent in terms of improving people's health, physical and mental health. And there are a lot of ways to exercise. Find the thing that you love the most and stick to it. If that means that you aren't getting in strength every single day, VO2 max training every single day, Zone 2 training every single day, mobility work every single day, or some combination of that, that is okay. Find something you enjoy doing, help your clients understand that the idea should be that consistent daily movement is the goal and that it doesn't have to be perfect. You don't have to hit every protocol and everybody's understanding what it takes to be maximal, but you need to invest in exercise. That is big. Move daily, find what you love to do and repeat that over and over again. So the M, mental health meditation. the E, exercise, the D, the diet side of things. There are a thousand diets. We know that research on nutrition and dietary information is scattered because humans respond differently to different approaches, but also because there are many different ways to do this well. But we want to remember for most people it's going to come down to maximizing the types of food that they put into their body, the quality of food that they're putting into their body. Choose whole foods. Choose foods that come directly from the earth. Whether you're vegan and you eat nothing but fruits and vegetables and grains or you're a carnivore and you're eating, you know, ribeye steaks every single day. I don't care what that is. If it comes from the earth, you're probably making a better decision than if it comes from a box. Dial that in, maximize your protein intake because we know that the research is very consistent, that the more protein we get in across our lifespan for all different reasons will help with longevity, will help with health, help with performance, and then focus on reducing but also balancing the negatives. Reducing your alcohol intake, reducing your overall sugar intake, possibly the seed oil conversation comes into this as well. But balance that out because when we go zero to 100 on that, a lot of times people are going to slip. They're going to make mistakes and I think that can sometimes lead to frustrations or thinking that they're not getting the best benefit from doing so. And we do know that balance is okay with nutrition. If 80 to 90% of your choices are the right choice, that five, 10, 15% slip here or there that going out with your family and enjoying pizza and maybe a beer with some friends. you're going to be okay. So with the diet, we focus on real foods. We focus on protein intake and we focus on balance, balancing the negatives, reducing them as much as possible, but balancing and enjoying our life because that will tie back into our relationships and the mental health. And last but not least, and we've already touched on this a little bit, is the S, the sleep side of things. Like as much as you can get is clean and clear and the quality as best as you can get. That is what we need to focus on. I think the biggest piece of advice from most literature, that I've read in the time that I've spent looking into sleep is that if you can make your sleep life consistent, if you can go to bed within 30 minutes of a certain time, if you pick 10 p.m. as your goal time and you're in bed by 930 to 1030 or around 10 o'clock every day and you're getting up at the exact same time, give or take 30 minutes or so on either end, you're going to be in a good spot there to help balance out rhythms, circadian rhythms and hormones in the body and you can put as much time into that quality sleep as you can get and you're going to be in a great spot there. So I think we need to not completely disown these optimization tactics. I am not saying that you couldn't and you won't possibly see benefits from cold plunging and sauna. You very well could be or from red light or nasal breathing and just certain meditation tactics or certain supplements. Yes, there's value in those. What I am saying is that if you're trying to maximize everything, you are going to see that. I think that the stress, the palpable stress of being over optimal will outweigh the benefits of the optimization itself. So our resolution, we focus on taking our meds. We would take them every single day, mental health, exercise, diet, and nutrition, and sleep. Take our meds. I hate to break it to you all, but I don't think yet that we're at a spot where you're going to live forever. What I think we need to be focusing on is that we can maximize the time that we do have on earth here. And that comes down to not only doing the right things, the right choices, but balancing them in a way that we can enjoy our life and not feel constantly stressed by the decisions that we're making. You're given your, your panel of genetics when you're born. There's not much that we can do about your genetics, so don't stress too much about your genetics. Your epigenetics, what you can do with your environment and how your genetics might play out is more important. If you have slightly higher cholesterol because it seems to be a genetic component of your body, Don't lose control over that. Maximize your meds. Not literally pharmaceutical meds, but the meds that we talked about and put as much energy into that healthy lifestyle, exercise, diet, everything there. And I think you're going to be better than the average. You're going to turn out okay. Take advantage of your time. Enjoy your time here on earth, guys. Take your meds, do the right things. If you feel like you want to dabble in one or two optimization techniques, that is perfectly okay. But don't let the stress of optimization outweigh the benefits of just living a healthy lifestyle. Hopefully this is a good reminder. Hopefully you can take these conversations to your clients or to yourself. Sometimes for me, even it was a gut check at times. So happy to kick off your Friday here, Fitness Athlete Friday, but this is probably more of a general topic on health and wellness. I'll look to see you guys in the row over the next couple of months. I'll be in Colorado, April 13th, 14th, I think, Long Mountain, Colorado, just north of Denver with my last CMFA course for the year. at least live and hopefully we'll see you on the level two guys. Have a great Friday. We'll talk to you later.
OUTRO
Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning 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.
Alan Fredendall // #LeadershipThursday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses using the reMarkable writing tablet to reduce daily documentation burden to 5 minutes per day
Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.
If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.
EPISODE TRANSCRIPTION
ALAN FREDENDALL
How can we make our documentation more remarkable? Often a very boring topic, but a necessary topic as we are required by law to do a treatment note for every single patient that we see. So today we're going to talk about what is that law that requires us to do those notes. And then we're going to talk about new technology and a new way to think about documentation that's probably going to streamline everyone's documentation in a very significant manner. How can we potentially reduce our documentation burden to maybe five minutes per day?
DO WE HAVE TO DO DOCUMENTATION?
So first things first, what is that law that says we have to do a note for every patient that we treat? That law is actually the HIPAA law. Way back in 1996, the Health Information and Portability Accountability Act, or what we know as HIPAA. And so that has a lot of things in it about not sharing protected health information, about in 1996 the emergence of the internet and what we can and can't do with submitting patient data electronically. But the main thing it establishes is that we do need to do documentation on every single patient that we see, and that that documentation be available to be transmitted electronically via fax or email upon patient request. Prior to this law, we just basically handed over copies of paper documentation, and it could be a lengthy amount of time before patients could get access to their records. In this day and age, patients need our notes sometimes for things like reimbursement. If we're a cash-based practitioner and they're trying to get out-of-network reimbursement, they may need it to submit because they got the day off work or something like that. And so there's a lot of reasons why folks may need their documentation and why they may need access to it very, very quickly. So the HIPAA law of 1996 established that documentation must be available to be transmitted electronically immediately to patients or other providers with patient approval upon request. Some of you may have interacted with a patient who needed documentation because they were involved in an automobile accident or something like that and they need that documentation to then send on forward. HIPAA also mandates that we keep documentation for up to six years and that essentially means the best way to do that is to store it electronically instead of maybe in an old filing cabinet. Now the thing about HIPAA is it says that documentation must be available to be transmitted electronically via email or via fax, but what it does not say is that our documentation must be inherently electronic. Documentation can still be written as long as it is transferred or changed into an electronic format, stored for those six years, and then available upon demand to be sent when requested. And so we're going to talk about how that opens up freedom for us today to do documentation maybe in a very different way that we have not considered before. Before we get into that, what are the penalties for not following this? What if I don't do notes? What if I just never do notes? What if I'm a cash-based practitioner? I don't interact with other healthcare providers on a regular basis. My patients pay me cash. Most of them aren't asking for auto network reimbursement, so they're not trying to see those notes or see super bills or see claim forms or anything like that. You should know the penalties here are quite severe because we are dealing with a federal law and we are dealing with the federal government. So with HIPAA, they have a four-tier system for violations, Tier 1 through Tier 4. Tier 1 is the lightest punishment. Tier 4 is the highest punishment. Tier 1 is considered that you were not aware of what you were supposed to do, and that you could have not avoided what happened. Now, this is kind of in regards to maybe accidentally revealing protected health information, but also if you don't have documentation stored electronically, and you literally can't submit it to someone, and also that you didn't know that you had to do that. That little caveat that you're not aware that you committed a violation is going to be, the burden is going to be on to you to prove that. If you can prove that though, that you literally had no idea what you were supposed to do and you have no way to fix it, the penalty for that is only $100. Very, very light. But realistically, no one lives here, right? Everyone is aware of what they're supposed to do and probably has a way to reasonably fix it. And so we kind of immediately move up to Tier 2. Tier 2 is you're aware of what you were supposed to do, but there's no way that you could have avoided that violation. This is a very common area for us to live in, right? Let's say you finish with patients for the week on Friday afternoon, and then hey, you're catching a plane, you're going on vacation with your family for a couple weeks, but oops, in that couple weeks while you're gone, a patient requests a note from you. You are aware that you needed to comply with that, but you're just not able to do that, right? Your maybe physical note is sitting on your desk next to your computer at the clinic still. There is no way for you to convert that to an electronic format and then transmit it to the patient. that comes with a little bit steeper fine, that's a $1,000 fine each time that happens. And then we kind of move things very, very quickly when we get to tier three. Tier three is the tier where we start to use the term willful neglect, that you are aware you need to do this, you did not do it, but you are willing to catch up on all of the neglect that you have committed in the past. Now when this happens, the fine jumps up to $10,000, right, a tenfold increase. And then tier four is willful neglect, but you're not willing to correct it, right? You know you're supposed to do notes, you know you're supposed to store them electronically, but essentially you show a habit, you show a pattern of just not doing that, even maybe if you've gotten in trouble in the past. And so tier four is the most punishing tier. Tier four comes with a fine of $50,000 every time that happens, so a very severe penalty. And so when we talk about that in the context of our brick by brick class, when we're teaching people to open their practice, the easy rule is just do it, right? Don't try to butt heads and win an argument with the federal government. The fines are very severe. The penalties are very severe. Just do it as annoying as it is. And my second and third part of today's podcast is showing you that we can make it we can't get rid of it completely, but that we can make it quite simple. So let's talk about that right now.
USING THE REMARKABLE
Let's talk about making your documentation remarkable with the remarkable. So if you're listening on the podcast right now and you're only hearing my voice, go over to our YouTube channel, the Institute of Clinical Excellence YouTube channel, and find the video of this so you can see what I'm doing. So this is a Remarkable. I'll close it up for you. It's got just a little folio and then it opens up and it's essentially just a tablet, right? This does allow finger input, but more importantly, it comes with a very nice stylus that lets you write the same as if you were writing on paper. So what we have been trialing here at our clinic in Michigan is using the Remarkable to replace our electronic documentation. So you can see what I have on here is I have a bunch of body chart templates. And so we have a folder for every day of the week stored on this tablet. And then we have body charts for every patient that has come into the clinic for treatment that day. So let me open up a brand new template for you all to look at. And now you can see here is our body chart template, just like we used to do on physical paper. Now it is on this tablet. We can write all over this thing. We can write eggs and eases. We can shade body charts so we can do our subjective and objective when patients come back into the clinic. And then the nice thing is with remarkable, we can add blank pages so we can itemize our manual therapy. And we can write all over this thing. And whatever we want to itemize, should we choose so can also be included in this template. And so what's nice is as soon as I finish this, it's automatically saved as a PDF, both on this tablet. But more importantly, it is saved back to a laptop or desktop computer. And I'm going to tell you in a second how we can put the tablet together with your EMR and basically have your documentation burden fall off a cliff in a really nice way.
INTERLUDE
So before we do that, I just want to take a break, introduce myself. My name is Alan. I am the Chief Operating Officer here at ICE. This is Leadership Thursday. We talk all things small business management, practice management ownership, tips and tricks. I am the lead faculty in our fitness athlete division, so you'll see me on Fridays for Fitness Athlete Fridays, and also the lead faculty in our practice management division, where we talk about all things related to practice management in our brick by brick course. It is leadership Thursday, that means it's gut check Thursday. This one, very simple, 30-20-10, toes to bar, paired with single arm devil's press. Rx weight for gentlemen, a 35 pound dumbbell. Ladies, a 20 pound dumbbell. And then just to make it hurt a little bit worse, you're gonna do a 400 meter run after each round. I tested that workout last weekend. I think I came in somewhere around 11 minutes. So not as fast and intense as last week. And then our Brick by Brick course starts up again on October 2nd. That class always sells out. Our current cohort is finishing up week six, talking about Medicare, talking about documentation, doing a deep dive into the stuff that we're gonna talk about.
SYNCING NOTES TO YOUR EMR
So how do we put our knowledge that we need to do documentation, it needs to be electronically available, with something like the Remarkable tablet. And the nice thing about Remarkable, like we talked about, is that when you finish a document on the tablet, and you close it out, it automatically syncs via the cloud to an app on your laptop or desktop computer, and that document is available immediately. So our previous documentation system, we would still do paper body charts, we would come back to our EMR, and we would hand type our notes. And that was okay. That maybe took three to five minutes for daily note, maybe 10 minutes for initial evaluation. That is all gone now, right? Because we have our body chart on the, on the remarkable and now we're doing electronically and it is updating to our computer in real time. What does that mean? That means we no longer need to come back to the computer and hand type our notes. It also means for maybe some of you that we're doing that and maybe taking a picture of your body chart or scanning it into your printer, that is okay. But again, that is a lot of burden, right? That's a couple more minutes per patient. What's great about Remarkable is that document, that body chart is available immediately as a PDF on your desktop that you can simply upload into the patient's chart on your EMR. And so now our documentation, all of the boxes of our soap note just says see PDF from this date, right? We are no longer typing. That carries over from daily visit to daily visit, see PDF this date, see PDF this date. And in that patient's chart of that date is August 1st, 2024, August 7th, 2024. And it is a PDF copy of the body chart and it is HIPAA compliant, right? It's electronically available and it has all the stuff that documentation needs to be sound and legally compliant, right? It has a subjective, it has objective, it has assessment, it has plan, it has some itemized treatment to justify if we're gonna bill insurance, for example, why we're billing insurance and for how much. And so for us, switching to this system has reduced our total documentation load to about five minutes per day, which is really, really, really incredible when you think about it. We already had given two hours in the workday for admin time, following up with patients, documentation, that sort of thing, and now that administrative burden has reduced down to about five minutes a day. And so that's just extra time that our therapists have that's not spent typing stuff that they have already written down on a paper body chart anyways. What's nice about this, this remarkable system is that you can take it into the treatment room and it looks no different than if you have a body chart on a clipboard or something like that. It's not as intrusive as a laptop. Obviously it's not as annoying as typing, right? just chipping away and typing as somebody's trying to talk to you. It's very, very low maintenance and it's really awesome. Now, what are the cons of this? There are some cons. They are expensive. They're about $500. I have asked for a coupon. I have asked if they do volume discounts. They do not do any of that. They know what they're doing. So there is a con of the price. And then the other con is that this thing is really kind of worthless outside of this specific niche, right? Unless you happen to want to journal on it, unless you happen to hand write a lot of other stuff in your life that you also wish could be available immediately electronically, the remarkable doesn't have a lot of value for you. That being said, We love how nice it writes. It writes the same as paper. We love that because it really can't do anything else, it has a super long battery life as well. So we have transitioned our documentation system to that and we're very, very happy with it. So with documentation, HIPAA law requires that we do documentation for every single patient, that there is a penalty if we don't do that, and that we should probably follow that unless we wanna get in trouble. But there are different ways to think about doing documentation other than just typing forever into those boxes on your EMR. That this might seem like a step backwards, because we're writing now, but because of the technology that powers the Remarkable, because it is available instantly as an electronic PDF, and can significantly speed up your documentation time. So give it a shot. The company's name is literally remarkable. Look it up. There are a lot of other competitors emerging as well. And I'm sure in the next couple of years, we'll see more of these become prevalent. Writing on these has on electronic devices has been around for a while. Many of you may remember the Palm Pilot. However, you know, it had a two inch screen and you couldn't read what you wrote. So this is a significant step forward. The writing is beautiful. We're very happy with it. And if you try it out, let me know how it goes. So make your documentation remarkable. Hope you have an awesome Thursday, a great weekend. Have fun with Gut Check Thursday. See you later, 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.
Dr. Dustin Jones // #GeriOnICE // www.ptonice.com
In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses the 3 steps to consider when helping folks with a fragility fracture
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
DUSTIN JONES
Hi, good morning folks. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. We're live on Instagram, we're live on YouTube. Thank you podcast listeners for tuning in. Today, we are going to talk about the three main steps you want to focus on to manage fragility fractures. all about fragility fracture management. This comes from an ICE student question that I really appreciate. I want to take the opportunity to address kind of our whole crew because we're all dealing with individuals that have had that fragility fracture. What in the world do we do after that insult has happened? So I'm going to read this question verbatim and then we're going to get into the goods. So Melissa McNulty, PT out in Oregon. It says, ICE provides some great guidance regarding what to look for, how to screen for vertebral fracture in those with osteoporosis. Can you please tell me, will you still work on strengthening with those with known fragility fractures in the spine? If so, how will you modify? Also, what about the history of a fragility fracture and how far out slash what evidence slash degree of healing do you need to see before you feel comfortable loading that area? I love this question, Melissa. These are all questions I think All of us have asked ourselves, right, when we have gotten that referral, we've evaled that individual with a nice, fresh fracture, maybe it's been a fragility fracture of the vertebra, maybe it's been, you know, femur, maybe it's been, you know, radius or ulna, for example. We all have these things, these doubts. I don't wanna do more harm, but I know this person needs to move. How can I do this in a safe manner? So I wanna start off with defining what a fragility fracture is, right? Because I feel like this gets thrown around a lot, but the definition of a fragility fracture is when you have a fracture that's a result from a fall at a standing height or less. So if someone has a fracture related to a fall, if they were standing high or less, that's considered a fragility fracture. This could be in multiple areas, right? So we often hear fragility fractures associated with fractures of the spine or vertebra, but it could be of the femur as well. So we need to be clear on what that means. So this person has had a fall. more than likely some type of balance deficit, right? They got in some type of dicey scenario, they weren't able to maintain their balance, they weren't able to land in a manner that distributed force and lowered the impact forces, and so they've had a fracture. I think there's three main steps that we want to focus on. What's unfortunate about this is this is a very difficult thing to study. in terms of what are some of the best interventions, what are safe interventions for individuals after they've had a fracture. So, the evidence is very limited compared to before they've had a fracture, right? We've got tons of evidence to support exercise and balance training, functional training and, you know, a lot of kind of that falls prevention. side of things. We have a lot of evidence there, but post fall there's not as much evidence of how to support these people well, which that is growing. There's a lot of people in the kind of osteoporosis fall space that are doing a lot of really good work, but the evidence is relatively limited. One thing we can be confident to say is that we need to get these people moving. I think that is our first step.
STEP 1: DEFINE THE ENEMY
What I like to think about is in that first step is what we really want to do is we want to define the enemy. As a clinician, it's easy to get someone and to see their chart and see they've, you know, maybe you've may seen some scans, some images you may, you know, have kind of this picture of like, man, they've got this very unstable, unstable situation, unstable fracture, for example, and you focus so much on that particular area. And I think that is where we can go wrong. What is the biggest harm to this person? is not the actual injury, it's the effects of the injury. And especially when we're talking about older adults, when we're talking about working with these individuals, the biggest threat to their independence and their quality of life is their decreased physical activity and their increased sedentary behavior. Their lives completely change after they have a fragility fracture. So we need to be aware of that. And when we have increased sedentary behavior, we're not doing a lot of things maybe out in the community that we once were doing. They give us a lot of purpose. There's a lot of deconditioning that can happen. There's a lot of mental health issues that can happen as well. So we want to combat that. That is the enemy. And so our goal is to try and get that person moving as much as possible so they can continue to do the things that are meaningful to them. It is a very, very delicate scenario. I experienced this, and I don't think I introduced myself. Sorry, my name is Dustin Jones. I'm one of the lead faculty within the older adult division, but I've spent a lot of time in home health, and I would see this in home health where these folks live these vibrant, kind of community-based lives, going out, doing this, yada, yada, yada, and then they had that fracture, and they may have still had some ability to participate in some of those things, but they didn't. And their sedentary behavior went up through the roof, physical activity went down, and over a stretch of weeks, deconditioning really set in that has massive implications for this person in terms of their quality of life and health outcomes. So I want to define the enemy. I don't think it's that particular injury. I think it's the effects of the injury, and we need to be very aware of that and combat that as much as we can. This is where, when we're working with Betty, for example, that we're saying, Betty, I need to get you as fit as possible. Yes, I know you've had that vertebral fracture and it's painful, but we're going to be able to work around that. So you're not going to experience as much pain. We're going to get you as strong and fit as possible in all the areas out around that area, which is ultimately going to help that area heal as well. Betty, how fit will you let me get you? All right. So one, we need to define the enemy. Beth Lee, she's tuned in on Instagram, she asked the question, does it include any environment like a fall on ice? That's a great question. In the literature that I've read that is defining a fragility fracture, it doesn't necessarily say anything about environmental factors. It just says fall, which is an invert and landing in a lower surface. or the ground, right, from a certain height, standing height or less. So, Beth, I'm going to assume that you can go ahead and throw in an environmental factor like ice. It basically indicating that this person likely has, you know, some bone marrow density issues. There's, you know, some type of balance deficit or scenario that led to them losing their balance. So, I think it's safe to say you can throw that in there. Good question, Beth. So one, we define the enemy, it's not the injury, it's the effects of the injury.
STEP 2: PLAY OFFENSE
Number two, then we play offense. In this scenario, we do want to protect the fracture, right? I don't want you all to walk away and think that we're just doing, you know, 80% 1RM deadlifts, you know, three days out from a vertebral fracture. I don't think that's a good idea. That's probably harmful for that individual. We want to protect that area and give that bone the space to do its job and heal and don't want to continue to pick the hypothetical scab, if you will. But we attack the deficits that are present. So we're often going to find strength deficits in other areas that we know can contribute to someone's risk of falling. We know we're going to more than likely going to find different balance deficits. Maybe they have difficulty with their reactive postural control and their different stepping strategies in different scenarios. We want to be able to attack that. Maybe they have an endurance-based deficit that when they do go on that long walk, relatively long walk to go get their mail, for example, that they start to have a decrease in their balance performance. Or, man, their balance and their stability really crashes when we add maybe a motor dual task component or a cognitive dual task component. We still want to assess them for those deficits and attack them. And so we can have a well-rounded program where we're building up their physical capacity, their balance capacity, their endurance capacity, while we're allowing that particular area to heal. And obviously this is going to look different for different injuries and kind of the level of injury, but we need to think about protecting the area but attacking the deficits that are present. If we can attack the deficits without, you know, causing more harm to the area, man, you're gonna do that person a huge service. And so for me, like in the context of home health, it was a lot of that. Like vertebral fractures, we would avoid kind of the end range, you know, flexion, twisting. We would kind of avoid those scenarios, but man, we would hit it hard on their endurance. I would try and get them as strong as possible in these other areas while respecting, you know, that particular fracture. What's really important I think particularly about this phase when we're kind of trying to attack deficits is that we're able to get accurate feedback on are we doing damage to that area and this is where pain management is really important for a lot of folks that typically they will have some type of pain medication prescribed on board which you know, for many of us, right, that gives us the ability to do a lot of activities because it's lowered their pain levels. But medication timing can be important here because I do want to be able to get some type of feedback that, oh man, that really hurts in that particular area. So I don't want them to take, you know, their meds, you know, an hour before so they're, the meds are in full swing and really masking a lot of that pain signal that can be helpful. I may have them take it 20 minutes before, for example, or if it's a relatively low pain level, let's take it at the end of the session. To get that feedback can be really helpful for your exercise selection and your dosage as well, all right? So step one, we define the enemy. It is not the injury, it's the effects of the injury. Number two, we play offense. Meaning, we're still going to protect the fracture, but we're going to attack deficits.
STEP 3: PREPARE FOR THE NEXT FALL
And number three, we want to prepare them for the next fall. We often talk about falls prevention, right? And in reality, falls prevention is usually in practice trying to prevent the next fall. I really want you to shift your thought to preparing them for the next fall. A lot of people fall. you've probably fallen within the past year. I don't want to say falling is a normal part of aging per se, but if we can prepare people for the next fall, that may actually prevent a fall or prevent an injurious fall. Now, when we typically talk about falls preparedness on this podcast in our courses, we're talking about fall landing techniques, we're talking about floor transfers, getting up from the ground, so on and so forth. And I think that's very appropriate for fragility fractures once they are healed and stable. So for some, this may be 12, 14, 16 weeks out. For some individuals, it may be a whole year, right? Like it definitely varies, but we can scale and modify fall landing techniques to a very safe and short range of motion to allow them to practice some of these principles to lower the impact forces that they experience if and when they do have a fall. So I think that's important. I'd be very conservative there. Make sure the fracture is very stable, it is healed. That's probably at the end of a plan of care. But along with false preparedness is preparing the bones for the future onset, right? And that is going to be getting those bones as strong as possible. And so, once those bones are healed, then this is anecdotally, right? There is not a lot of evidence really to show the effectiveness of a post-fragility fracture progressive loading, which that's growing. But for now, a very slow progressive loading of those particular areas I think is warranted once that fracture is healed. What can be really helpful for individuals is just showing them how to use their body in a manner, particularly with the vertebral fracture, related to Melissa's question, is like, for example, teaching them a hip hinge versus a rounding of the spine to pick something up. Like, that's something we probably want to be teaching that relatively early on in the rehab process, but I think we can really start to load that later on once that fracture has healed. And so we wanna think about preparing for the next fall. That's fall landing techniques, that's floor transfers, but it's also progressive loading too, that's fine. It's impact training. It's doing some of these things that we'll go over in detail in our MOA live course and then our level two course as well. The dosage is very tricky and the progression is very tricky, right? Because we're dealing with a somewhat delicate situation, so we need to be very respectful, but it can be done. And that's what I think we need to do for these folks that have had this fragility fracture. They've had a fall, a lot of fear on board. It changes their lives in so many ways. I think first we need to define the enemy. It's not the injury, it's the effects of the injury. We're trying to get this person as fit as possible, get them moving as much as they can so they can continue to do the things that they love. As they do that, we want to play offense. We want to protect the fracture but attack some of these other deficits as we're allowing that area to heal. So, it may be a lot of balance training, you know, strength training of other areas, but there's typically a lot that we can work on. And then, as things become more stable, as that fracture is healed, which it may be 12 weeks out, it may be 52 weeks out, right, depending on that individual and their rate of healing. We're starting to, you know, think more about preparing for the next fall. We're preparing the bones by progressive loading. We are showing them how to fall so they can distribute their load, lower their impact force to prevent that injury, showing them how to get up from the ground, so on and so forth. I think if we follow those three things, we can improve someone's confidence and hopefully get them back to where they were before the fracture and maybe even better, right? So, let me know your take on this. Evidence is relatively limited in this post-fracture category. I know Laura Gray and Gorio is doing some really awesome work, really pushing forward on developing some research studies and speaking to building the evidence post-fracture. And so, I'd love your all's take. What's your experience? What have you found? Just go throw comments on the Instagram video for those that are watching YouTube or listening on the podcast.
SUMMARY
Before I go, I do want to mention some of our Modern Management of the Older Adult courses that are coming up. All three of our courses, we have two online courses and a live course, those three culminate in the ICE Certified Specialist in the Older Adult. So that's a certification for those badass clinicians that are able to handle basically whatever kind of walks in through the doors or whatever they walk into in the home. Our level one online course, the next cohort is starting today, so Wednesday, August 14th at 8 p.m. So we have a few seats left, so hop in there if you've been wanting to do that. The next one won't be until later this year. Our level two is going to be in October, and then our live course, we've got several coming up. This upcoming weekend, if you're in Alaska and want to have a good time, Jeff Musgrave on set up, you're going to be in Anchorage, Alaska, August 17th to 18th. Then September 7th through 8th, we got a doubleheader, one in Mobile, Alabama, and then Minneapolis, Minnesota. And the following weekend, September 14th and 15th, we have another doubleheader in Bend, Oregon, and then Casper, Wyoming. We'd love to see you all. Love to practice some of these techniques, these fall landing techniques, progressive overloading, so we can help serve these folks that have had these fragility fractures. All right, you all have a lovely rest of your Wednesday. I'll talk to you soon.
OUTRO
Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning 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.
Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich discusses how to know when to challenge or change movement patterns vs. when to be ok with more freedom of movement
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 PT on ICE Daily Show. My name is Cody Gingerich. I'm one of the lead faculty with the extremity division and I'm jumping on here today to talk about when to be picky about movement. So, The last several years in PT, there has been kind of this shift in differing opinions on how specific do we need to correct every tiny little movement fault that we see in people, all the way to like, hey, however they move, this is just kind of how this person moves and we can just get strong in whatever positions that they feel comfortable with. And so I want to talk about a little bit of the like, finding that middle ground and there's a time when yes, we need to just let somebody potentially move how their body is going to naturally move versus also, hey, that moving pattern doesn't look good, isn't efficient, could be leading to the injury that they're dealing with and how should we and when should we correct that? So the old adage kind of, uh, that I like to use in that like thought process is it doesn't matter until it does, which is basically saying nothing other than, um, there are gonna be points in time where you have to understand that person moving in front of you and understand where their pain is coming from and then is that movement pattern the problem for their pain, okay? And so the number one thing is that there is no way without any context behind the person in front of you. Like if you just see a video of somebody that you have never met and you watch them move and you say, oh yeah, we need to correct that, that would be not a time where you can fully say that. Okay. And so I would encourage you to, to kind of get rid of that out of your brain of like, if you don't have any context behind that person moving and you just think, well, that movement pattern is incorrect and we would definitely need to fix that. I would argue that that wouldn't be the correct mindset going into that. However, if you have that same person and you see their movement pattern and you understand the sport or the activity that they're doing, and potentially if they are dealing with pain, then all of a sudden we can have that conversation of, is that movement pattern creating some of the issues? Are we putting undue stress on different tissues because of the way that they're moving? Okay, and so a couple examples of this, a lot of times this is going to be if we talk about patient population. If we're dealing with someone who is an older adult and they have a very low movement standard already, like they have not really done much moving and they are generally deconditioned and just need to create any type of strength adaptation as possible. Of course we want to teach them how to hip hinge and teach them how to squat and do some of that, but does it need to be the cleanest, prettiest squat or hinge that you've ever seen? Arguably no. Okay, right now we need to just get all of their muscles moving together in whatever capacity they can in order to just start that strength training process, change their their homeostasis change their overall body structure so that they can move one thing to another. Okay. And so with that population, I would say, go more on the air of how they're moving is not quite as important as what they're doing and what they're moving. Okay. Of course, changing from a squat to a hinge or whatever pattern you're wanting to look at a lunge, a step up those type of things. But if their knee shifts a little bit one way or the other, or they have a bit of like a hip shift when they're squatting, or it's not the prettiest hand you've ever seen, like their chest isn't quite upright, like all of those things, you want to try and work towards them, but you don't want to limit their ability to do that movement because it doesn't look perfect. Additionally, if you're dealing then, if we flip the coin and we talk about more high level athletes, If we talk about high level athletes and you are just watching them move and don't have any context yet, and you see them and they say like, potentially this is like top of the top, right? They have potentially created adaptations and movement standards and movement positions that create the proper adaptation for whatever sport they are doing. So if you think more unilateral sports, I've been watching the Olympics the last couple weeks, right? There are some incredible, incredible athletes. Those people are not going to be symmetrical. So if you think about a shot put thrower, like those people are incredible. Both men and women like throwing those weights incredible distances. They are not doing that on both sides. So they're going to naturally have one of their their push off leg and they're throwing arm is going to be stronger. And so when they do then bilateral movements, there is a chance that that might not look exactly the same every time. But if they are not dealing with any pain or discomfort, then maybe that's not really a big deal at all. And that's actually helpful for them. When we want to start looking at actually diving into some of those, like, hey, we need to really adjust how you're moving and pay really close attention is going to be when A, either that same athlete that I just talked about is dealing with pain and it's more of a unilateral thing, or B, if potentially the way they're moving is inefficient for the sport that they're doing, right? So sometimes when we think about, especially our fitness athletes, When the clock is going, their body just says, hey, I need to get from point A to point B as fast as possible. And a lot of times, as fast as possible does not necessarily mean as efficient as possible, and they end up overloading one joint, one muscle, something, because that is the way their body has just started to adapt, because there is a weakness lying somewhere. Okay, so then in those moments when there is actually pain involved, that's when without that context, you're not going to have any idea. But with context, we can start teasing out, are there weak points? Are there mobility deficits? Are there different reasons why they're moving in these poor movement patterns? Okay. And so a lot of times that's where just a poor movement pattern, but if you end up looking at it and say, well, everything is moving or everything is strength wise, pretty equal. Their mobility is pretty equal. Now we're dealing with something a little bit differently, but if there is a weakness leading to a movement restriction or a mobility leading to a odd movement pattern that ends up overloading those tissues, Now we need to start looking at, well, we need to potentially strengthen that area of weakness or improve that area of mobility. And then that freedom of movement can increase. And now we have a little bit less stress taken off of the tissue that's irritated and the other potential tissues can take up some slack as we build them up. So as opposed, this is kind of going backwards again. So in our heads, when we're watching movement patterns, think more so, is this something where we are creating an overload of a tissue that is unnecessary and creating pain? And what is weak that is trying to make that happen? And sometimes the weakness area can be the thing that's irritated or sometimes you could actually have that stronger side or stronger tissue area be the thing that is just constantly being used repetitively, repetitively, repetitively. So with the example of our fitness athletes, think one of those athletes that does, if they're doing burpees and they do like to do step back or step up burpees and they like one side over the other, okay? A lot of times that is not a problem at all. And they just continue to build some strength there and they might have side to side issues. But then all of a sudden, if that starts to show up in their squat and they have a big shift when they're trying to get out of the hole, that is now their body trying to utilize that stronger side to do a lot of that work. And it's going to start showing up in other areas over time. And then if they develop pain along that whole route, these is the context that you want with movement patterns. Now, all of a sudden, we need to build up that strength at the other side, maybe clue them into, hey, when you're doing burpees, I need you to alternate legs every single time so you're not just repeatedly lunging on one side or the other. Okay. And so at that moment, now we are adjusting movement patterns and then working on their squat patterns. So it might, we might need to say, okay, we need a pause and we need to make sure that when we drive out of that hole, we aren't getting any type of shifting this side to side, and we're not overloading that one hip or that one quad that you feel dominant in. Okay? So that's where, with this, when does it matter versus when does it not? Okay? When we're talking about our lower level athletes, people who have not necessarily moved in a long time, those first six months potentially, of course we're building into, like, we want to still coach good movement patterns, but don't limit their ability to move weight and get stronger just because it isn't exactly perfectly correct. Still allow them, still you're always fighting for good movement patterns, but keep letting them build some strength just as they're naturally growing. And then as that starts to build up, now we can hone in on some of those nuances. As an elite athlete, if they potentially need those differences in movement patterns, but in the absence of any type of pain, or anything like that, don't just automatically assume they need to really change how they're moving or that asymmetry in their squat or their deadlift or something like that is a problem. It might be an adaptation that they literally need. When we need to start changing and looking a little bit more closely and honing in on very specific movement patterns, think more so if pain comes on board, with any of those movement patterns or you notice a big mobility deficit or a big strength deficit that causes that shift or that change in movement pattern and if you can then either coach that out or change their strength or mobility, that's then when we can start teasing out some of these nuances in movement. In the extremity course, we talk a lot about extrinsic versus intrinsic cueing. Our extrinsic meaning not saying, hey, squeeze your lats, squeeze your glutes. Those are more intrinsic things that people think about. But instead, it's like, hey, I want you to drive your head through the ceiling. Okay, so doing something like that, I want you to punch that bar through the ceiling, or I want you to drive, like break a board under your feet when you're standing up out of the squat, something like that, where you're going extrinsic cueing. And that's gonna be more so, can you cue some of these movement patterns out? If we notice more of that weakness or a mobility type of deficit, that's when we need to really hone in on, are we really thinking about moving in the right patterns and using the correct tissues and muscles that we want? And can we get a little bit more specific? If you're noticing, hey, that lateral hip is a little bit weak or their quad is a little bit weak, Now, all of a sudden, if you're doing more specific movement patterns, you can start thinking, hey, I really need your brain at your quad and you can like tap the quad, you can have some kind of stimulus at the quad, I really need your brain focusing in on this quad. And that's where at the out of the bottom of that squat, I need you squeezing that really, really hard. or I really need you thinking like that muscle that we just got burning from a leg lifter or doing the side steps like that's that area in your hip that I really need you honed in on. And that's going to create some of those movement pattern shifts as well. So utilize both our extrinsic coaching and or intrinsic cueing in order to change some of those movement patterns. If you have determined like you have that context with your patient, you understand like there needs to be some nuance to this movement pattern that's going to be more efficient for that person. And they have been working around something for a very long time and their muscles have adapted to that. And now it's getting to a point where it needs to be addressed. Okay, that's what I've got for you today. Hope y'all have a wonderful weekend. We have an extremity course coming to you next weekend. I believe Lindsey's going to be up in Bozeman, Montana. So as far as if you're trying to find a late last minute jump into a course, we'd love to see you out there. Otherwise, hope everybody has a great day.
OUTRO
Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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.
Dr. Jess Gingerich // #ICEPelvic // www.ptonice.com
In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jess Gingerich defines hypertonicity as it relates to the pelvic floor and the role of the pelvic floor in the body as contractile tissue.
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
JESSICA GINGERICH
Good morning PT on ICE podcast. My name is Dr. Jessica Gingerich, and I am on faculty with the Pelvic Division here at ICE, and I am coming to you today to talk about the hypertonic pelvic floor. We got a great question in our online course about hypertonicity in the pelvic floor around pregnancy. And so before I dive into this, when we talk about hypertonicity in the pelvic floor, we really don't care necessarily if it's prenatal, pregnant, postnatal, really anywhere in the lifespan. We're gonna treat it relatively the same. there may be some factors that we think about at each stage of life but relatively we're treating it the same.
DEFINING A HYPERTONIC PELVIC FLOOR
So first and foremost the definition of a hypertonic pelvic floor and the reason I put that in air quotes is because we will hear so many different things overactive pelvic floor tight pelvic floor is when the pelvic floor muscles are in a contracted state um or a spasm And so, the symptoms of this can be leakage, heaviness, pressure, a dragging sensation in the vagina, painful insertion, whether that is during intercourse, a tampon insertion, vaginal exam, or anything else. urinary urgency, frequency, constipation, incomplete emptying that could be of the bladder or of the bowels, coccyx pain, pelvic pain, low back pain, and hip pain. So when you have your client that comes in and they say, oh my pelvic floor is so weak because I pee all the time I just can't control it. recognize that that could be their pelvic floor sitting in a contracted state with the inability or I want to say inability or awareness to relax. And so when we think of that contracted state with the inability to drop, recognizing that with that could come weakness as well. So there's a lot of different bubbles that we want to make sure that we are not missing when it comes to a tight pelvic floor.
THE ROLE OF THE PELVIC FLOOR
The role of the pelvic floor is to contract. So if you can kind of conceptualize my shoulders as the pelvic floor, we want to close the holes and lift and we want to also be able to open the holes and drop. We want to be able to do this during a lot of different tasks and that can be toileting, intercourse, achieving an orgasm, lifting weights during daily tasks, so that's your laundry basket, the kiddos, or even your body weight, lifting your body weight up off the floor or out of a chair. And then as well as just the gym, being able to do things in the gym and having the ability to essentially tension your pelvic floor to the tasks in front of you. When we think of a tight pelvic floor, we kind of have, as a pelvic floor profession as a whole, have kind of gotten into this, the Kegel, you know, not doing the Kegel, it's kind of like lost its meaning in our space, right? If you have a tight pelvic floor, stop doing Kegel, stop, stop, stop, stop, stop. Really, that's not what we want to do. We often hear to not do the Kegel because you're in that contracted state. So if I'm already here and I do a Kegel, I'm not getting much range of motion. I'm not going anywhere. However, we need to know how to do a Kegel for a couple of reasons. A, when you cough or sneeze, the reflexive nature of your pelvic floor should be to squeeze. We want that reflex, we want that ability to be able to do that. We want to train that. But the other thing that we can do is we can utilize the Kegel to improve our proprioceptive awareness, right? So if I am in this contracted state and then I go and do a maximal Kegel, I might be able to then now, okay, here, that's where I'm in that down or relaxed position. It can help improve your proprioceptive awareness. So key goals should absolutely be a part of the plan of care. Teaching the person what a pelvic floor contraction feels like, so what does it feel like when they are closed and up, as well as what does it feel like when they're open and down. So we call that the attic and the basement. We've said this before, it's really nice to use those terms. So if you're out in the gym or out in public, you can ask your client, are you in the attic? Are you in the basement? Rather than asking them whatever cue you gave them during their pelvic floor exam, you're not out there asking if they're squeezing their buttholes. That's really kind. Teaching them how to do this can be done with internal cues or external cues, recognizing that someone may respond better to one or the other. And so you're gonna need to be able to do both. If you are a therapist who does not do internal exams, that's fine. You can refer or you can take our live course and learn how to do the internal exam. and teach this person how to do a Kegel with right there feedback, there's your tactile cue, squeeze my finger. That can be so so helpful and remembering that this is going to create awareness and just teaching them where they are in space. Now, we talked about the kegel. Other passive interventions are gonna be that diaphragmatic breathing. We talk about this all the time. Using that big belly breath as the diaphragm descends, it's gonna take the pelvic floor with it. It is a passive range of motion of the pelvic floor. They can do this in different positions. They can do this in child's pose. They can do this in a happy baby. They can do this in a supported squat. And then also lastly is the functional dry needling. We can use dry needling to help calm down the pelvic floor. Now, the last bits around what we wanna do in the plan of care for a hypertonic pelvic floor is not discharge once this person says, oh my gosh, I know I'm in the basement, I can feel it, I just know I'm there. Or I'm in the attic, my holes are closed, I know that. We want to load them. We want to make sure that when this person comes in symptomatic, that we are teaching them where they are in space, we are changing their symptoms, but now we are loading them. We are getting them back to where they were, ideally beyond where they were. We want them to not have symptoms, but we want them to not need us, really. So getting them stronger, so getting them into a gym, whether you are teaching them about, or I guess really learning what their love language is around exercise, and then leaning into that. And showing them the type of programming that they may want, encouraging them to certain gyms. I know here in Greenville, we have a ton of gyms. I've got a lot of options with a lot of wonderful coaches that I can essentially push these people towards. once they are symptom free and feeling a little more confident in the gym. So that is what I've got for you today. Join us online or on the road. So head over to PTOnIce.com to look at where we are next and we look forward to having you.
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.
Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses what creatine is, how we get it, and the concept that not everyone may need to supplement creatine
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
ALAN FREDENDALL
Do we really need creatine? If not, who does? Let's start today by talking about what is creatine? How do we get it? Where does it come from? What does it do from a performance perspective? And then let's finish about talking about potentially who may and who may not need to take creatine.
WHAT IS CREATINE?
So starting from the top, what is creatine? You've probably heard about it. You've probably taken it at this point and how do we get it? We're going to reference a lot the International Society of Sports Nutrition position papers which come from the International Society of Sports Nutrition. They publish their own journal and more importantly they publish these position papers on a frequent basis that cover a wide variety of of supplement diet and nutrition topics. They are incredibly comprehensive. They cover the thousands and thousands and thousands of supplements that are up there as well as all of the articles, the other thousands and thousands of articles that have research about those supplements that come out on an annual basis. And so these position papers are great because they do such a great job of summarizing all of the research in this area. And so asking the question, what is creatine? Where does it come from? 95% of the chemical known as creatine is found in our skeletal muscles, so our working muscle. And then about 5% is in our brain. We do have a little bit in our liver, but primarily, creatine is stored in our muscle. We have to get it somehow externally. We do not make it on our own. We usually get it between one to five grams a day. is what we're looking for. And that primarily comes from eating red meat such as beef or coming from fish, approximately 16 ounces about a pound per day. And so if you think that you are not eating that much red meat or fish or eating that at all, and you know that for sure, maybe you follow a vegan or vegetarian based diet, then the recommendation for many, many years has been supplementation, typically as five grams of creatine monohydrate per day. If you've ever taken this or you've known somebody who's taken this, it kind of just comes in a big tub like protein powder. It is a tasteless, odorless white powder that you can certainly do what we would call a dry scoop with some water. You can mix it with water or juice. It does not have a taste at all and so it does not really need to be mixed. It can be taken at any time of the day. And over the years, there have been different research papers on the concept of preloading creatine, taking a large dose to kind of bump up levels in our system and then tapering off to the maintenance dose. And what really decades of research at this time point have shown is that just taking five grams a day has the same effect as any sort of preloading, deloading effect. Just taking that five grams every day gets you to the levels where it's found to be optimal.
WHAT DOES CREATINE DO?
So that's what it is and how we get it. What does it do in our body? Why is it so talked about? Creatine has a number of great effects that have been shown in the research and have been shown and reinforced and validated over again many, many, many years of research. In general, typical results of having enough creatine in your system whether that comes from eating more of the food sources that creatine is found in, or by supplementing, that we can increase our lean muscle mass by approximately five pounds, we can increase our muscular strength, we can reduce our blood glucose levels, we can improve our anaerobic power output, and we can also see improvements in brain function, which is an interesting new area of research for creatine that we'll talk about in a few minutes. Creatine allows for more creation and storage of the chemical known as ATP. We learned about that back in high school. That is the chemical that powers cellular work inside of our body. It also improves muscular hydration and it improves the rate of protein synthesis. So all good things that we would like to have as much of going on as possible, right? With creatine, there's a lot of myths about what it does. What does it not do? It does not increase water retention or bloating, even in some papers having people take four times the dose, taking 20 grams a day. Creatine is not an anabolic steroid. You cannot get in trouble for taking it. It is completely legal to take it. Anabolic steroids, by nature, are some sort of form of testosterone or some chemical, some sort of what we might call a precursor chemical, that results in increased levels of testosterone in the body. Creatine does not do that. It is not an anabolic steroid. Creatine does not cause kidney damage. Again, in studies following folks taking really high volume doses, 20 grams plus a day, no effect on the kidney, and certainly all of the research on five grams a day, no effect on the kidney. Creatine is safe for adolescents and kids. Remember, we primarily get this from our food, and so you can't, if you're somebody that eats red meat, if you're somebody that eats fish, you can't not eat creatine, right? You're getting it every time you have a serving of red meat or a serving of fish. And so no matter what, even if they don't supplement, kids are getting it every day. Kids tend to eat a lot of food, especially teenagers. And so arguably they're probably getting the same amount that an adult might supplement with anyways. And so just know that it's unavoidable and because they're already getting it and they have no adverse reactions. Also, it's naturally found in our muscles that it is completely safe for adolescents and kids to take. When we talk about what types of creatine are out there, what is the most effective? There is zero peer reviewed evidence that creatine sources found in energy drinks, meal replacement bars, you've probably seen them if you've had an energy drink in recent years. It's all over the top. I've got I've got an energy drink can right here. It's four in the morning, what's right across the top. Pure creatine is advertised right on the energy drink can. Meal replacement bars, pre-workout powders, all that sort of thing. Is that as effective or maybe more effective than taking that creatine monohydrate, that five gram scoop from that big jug? Overwhelming evidence would say no. That over time, all of these studies, regardless of dosage, regardless of other creatine type that is not creatine monohydrate, creatine monohydrate consistently outperforms all of the other chemical derivatives that are out there. So, if you are somebody that needs to supplement, just know that just because your energy drink can or your protein bar says it has creatine, it's probably not a biologically available source that's actually going to result in you getting the effective creatine that you want. When in doubt, go with that scoop of creatine monohydrate. Okay, our most important point, who needs it? Looking at research and that sort of thing, who needs it? If it's not everyone, who is it?
INTERLUDE
And before we get to that point, I just want to take a break and introduce myself. My name is Alan. I'm the chief operating officer here at ice. This is the PT on ice daily show, a daily physical therapy podcast talking about all things related to rehab and fitness across the spectrum. Today is Fitness Athlete Friday. We talk about all things helping the functional fitness athlete, the CrossFitter, the Orange Spheres, the bootcamp. We also talk about supporting our endurance athletes, runners, bikers, swimmers, that sort of thing. So if you are working with that population, you want to get better at working with that population, Fridays on the podcast are for you. I teach a course called Clinical Management Fitness Athlete. We have a three course series here at ICE, two online courses, level one and level two, and a live course. Our level one course just started this past Monday, and our level two course will begin on September 1st in just a couple weeks. You need to have taken the level one online course to take the level two course. And then our live course, where we get you moving barbells, We have you learn how to max out, practice maxing out, a lot of different concepts found in the fitness space that are going to be important for you if you want to work with this population. You can catch us out on the road. Our friend Zach Long will be in Austin, Texas, September 7th and 8th. Joe Hanesko, another one of our instructors, will be in Longmont, Colorado, September 14th to 15th. and Mitch Babcock will be in Houston, Texas, September 28th to 29th. Just want to pause and say congratulations to Mitch. Mitch is my business partner here in Michigan at our clinic. We coach CrossFit together, we teach these courses together. Mitch is a great friend and him and his wife just had a beautiful baby boy on Wednesday night and so they're at the hospital this morning loving on that baby. So if you follow Mitch, go give him a like, go give him a positive comment. I know he'd appreciate that.
DO YOU REALLY NEED CREATINE?
So do we need creatine supplementation? A really cool article came out towards the end of last year from Moriarty and colleagues in the journal Brain Science, a journal looking at the emerging area of research of creatine supplementation on cognitive performance, specifically in older adults. But what I like about this study is they did a really good job of breaking the population of study subjects into different subgroups, right? And essentially we had four subgroups. Not unlike anything else we are tending to find about the human race as a whole, humans tend to categorize into subpopulations whether involuntarily from things like genetics or voluntarily, right? And so this study did a good job of breaking out younger individuals from older individuals and also those consuming a meat-based diet or a vegetarian or vegan-based diet. And so they essentially found that there are four subgroups here. These subgroups all had the same experimental effect, which was they're taking creatine and they're having some different stuff measured. And what is great about this study is while the aim was to look at cognitive effects, it really kind of let us know, based on what people eat in their age, who might be the person that will benefit the most, and maybe who is a person that, especially if they're hyper fixated on getting their creatine dose in, maybe they don't need to worry as much. And so finding younger individuals aged 11 to 31 that consumed a meat-based diet saw minimal to no improvement in this study with creatine supplementation. Younger individuals, again, aged 11-31, consuming a vegetarian or vegan-based diet saw more improvement, right? And that makes sense given that we talked about you primarily get this from food sources being red meat and fish. And so that if you don't eat those, you have sort of a deficit that you need to shore up. A third subpopulation, now older adults, the other side of the age spectrum, older adults, age 66 to 76, consuming a meat-based diet with no diagnosed cognitive impairment, saw minimal to no improvement. So, young or old, eating meat, no cognitive impairment, minimal effect from creatine supplementation. The final subgroup, older adults age 66 to 76 consuming a vegetarian or vegan-based diet with diagnosed cognitive impairments, saw the largest improvement in the study group. Why? Again, we've talked about it. Folks eating meat on a regular basis are getting that one to five grams of creatine that we need to eat per day. And so for those folks, even regardless of age, it seems like additional supplementation is unnecessary. And so who needs it at the end of the day? Or we should say who needs it the most? It seems to be that older folks who maybe are beginning to show signs of mild cognitive impairment, or definitely who have a diagnosed cognitive impairment, and especially who consume no red meat or no fish or very small amounts, less than 16 ounces per day combined, have the most to benefit from creatine supplementation, especially in regard to improving cognitive performance. But also that in general, the second group right underneath that was even in a younger population, 11 to 31, those folks, again, based on their dietary choices, no red meat or fish or a smaller amount, those folks also saw an improvement from creatine supplementation. So it seems to come down to lifestyle, right? If you are eating red meat, if you're eating fish on a regular basis, especially if you're getting close to 16 ounces, right? Eight ounces of ground beef and rice for lunch, eight ounces of fish and veggies or whatever for dinner, you are checking the box on getting that creatine from your diet. And so that is not to say you should not take creatine and see what happens, but just that if you take it and you're diligent about taking it, and you're consistent with taking it, and you don't see those improvements that we talked about earlier, those improvements in lean body muscle mass, muscular strength, anaerobic power, that is to be totally expected if you don't see those improvements. At the end of the day, should you use it? I would always say with a supplement like creatine, try it. It has almost no risks as we talked about. It is incredibly cheap, literally a couple cents per serving. A giant tub of creatine is like 20 bucks and you get like 500 servings out of it. And so at the end of the day, if you've never supplemented with it, even if you think you're getting enough from your diet, just try a cycle, right? Try taking it for a couple of months, be diligent about it, take it every day like you're supposed to take that five gram dose. But also don't be upset at yourself. If you don't see these massive improvements, likely from your diet, when you begin exercising regularly, possibly many, many years ago, you saw those gains that you would have seen with creatine supplementation. because you were already getting enough creatine from your diet. So you already got the benefit, don't be upset that you're missing out.
SUMMARY
So creatine, what is it? Where's it come from? Should you take it? creatine is a chemical we have to eat, we use it to power muscular energy functions and other functions throughout our body, and especially our brain. And that new lines of research, especially investigating the effects on the cognitive system, have shown that there seems to be groups of people who benefit the most, and the groups of people who benefit the least. Primarily, those eating a small amount or no red meat or fish who do have a mild cognitive impairment, a diagnosed cognitive impairment, will benefit the most. And even in younger folks with no concerns about cognitive impairment, if they are following that diet with a small or no amount of red meat or fish, they will also benefit. On the opposite side of that, young or old, without any diagnosed cognitive impairment, eating a meat based diet, Those folks seem to have the least to gain from creatine, but again, like we said, all that being equal, try it out if you haven't and see if you like the results or not. So, that's creatine. We hope you have a fantastic Friday. Have an awesome weekend. We'll see you next week. Bye, everybody.
OUTRO
Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.
Dr. Lindsey Hughey // #TechniqueThursday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey explains the rationale behind myofascial decompression or "cupping" for patellar tendinopathy and provides a technique demonstration.
Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.
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EPISODE TRANSCRIPTION
LINDSEY HUGHEY
PT on ICE Daily Show, waiting for YouTube and Instagram to catch up. So we are live on both. How's it going? I am joining you again this week on the PT on ICE Daily Show. Welcome. I'm Dr. Lindsey Hughey. I currently serve as one of the division leads at extremity management. And today I want to share with you a myofascial decompression technique for patellar tendinopathy. So today is either Technique Tuesday or Leadership Thursday. So we're bringing Technique Thursday to you all live. My model today is Daniel, my son. So what I want to unpack is a little bit about how do we know someone has patellar tendinopathy and who this might be appropriate for. with patellar tendinopathy, show you the technique, literally just demo it for you live, what you do, and then we'll chat also like how do you know the treatment worked. So we'll talk a little bit about our test retest options for patellar tendinopathy. And then we'll call it a morning technique Thursday, not Tuesday. Great to be with you all again. So first things first, someone with patellar tendinopathy is going to complain of a recent spike in load. Usually it's energy storage and release activities like jumping, sprinting. The other complaint, vice versa, they might have is that a dramatic de-load where they haven't, maybe it's their off season and then they stopped loading completely. this might flare up that patellar tendon. They will complain of pain with energy storage movements, and they'll specifically complain of pain right at the patellar tendon, where that inferior border of the patella sits to the tibial tubercle. When you palpate that as the clinician, that will be tender to palpation. Often when they extend their knees, so you're doing manual muscle testing of quadriceps, that will also cause their symptoms to blip. Having them do a one-legged squat on a slant board is another load test that will often bring on symptoms. The person with moderate to high irritability, patellar tendinopathy, often has coinciding hypertonicity throughout their quadriceps. So when you palpate, it's not just that patellar tendon that is bothering them. Like their quad also is kind of guarded around that knee joint. So myofascial decompression can be a great adjunct to treatment. If you've heard any podcasts that I've done on tendinopathy, you know, that load is our love language, or if you've been at our course, you know that. So ultimately, the teller tendinopathy is going to be healed by high tensile loading that involves loading the local tendon, the local muscle, quadriceps, the chain, and then off eventually gets into energy surge and release. So know this treatment technique that I'm about to show you is just an adjunct to care that creates a modulating window of opportunity to load that person better. So consider it's moderate to high irritability human. And so that's someone that like not just is their activity or sport starting to get interrupted. It's usually our basketball or volleyball players, but also like daily life is starting to get aggravated. They're not sleeping as well. Their performance has dropped. These folks need that treatment that kind of takes that edge off. So without further ado, you kind of understand who the person with teller tendinopathy is, who would be good to execute this treatment on. I want to show it to you. So I'm going to kind of move the camera around just a tiny bit. so that you can really see the quadriceps. So we're going to do one of two things. We'll make sure we've exposed the area. I want to not only get myofascial decompression to the quadriceps and hit each part, but I also want to decompress that patella and the patellar tendon. So to first decompress the patellar tendon and the patella, I'm going to use a silicone cup. So these silicone cups are awesome. The way we'll apply these is we're going to create negative pressure. So you really want to squish this in and then apply firm pressure down with your body, being mindful that this could be an irritating area. The way I would explain it to the patient is we're using this cup to just kind of offload that bone, that patella, and then offload the patellar tendon a bit. So I'm going to create that negative suction and compression. If you have very hairy patients, you're going to want to put some lubricant like a Biotone around that. Just a little bit will go a long way, but again, more hair endowed folks might need a little bit more. So we're going to go here. I'm going to create that negative pressure, I'm going to press down, and then if I've done a good job creating that suction, there'll actually be a little dip or dimple in the silicone cup. The cups I'm using today are from Chris DiPrato and his team. They are amazing cup therapy if you follow them on social media. I love their products. This comes in their kit, this silicone cup, and then their curved cups. These are actually their newest ones are what I'm going to use to hit the vastus lateralis, to hit vastus medialis, and then I really want to get after rectus femoris. I want to make sure I hit all three parts. You can't really get that intermedius without a needle. So we're going to hit those main more superficial areas. So we're going to hit that vastus lateralis first. And then I'm going to place that curved cup and then create suction with our gun. And there's various guns. This is a manual pump that you can use. There's ones with gauges and then electronic gauges. We want about 300 to 600 millimeters of mercury if you do have that pressure gauge that actually gives you a reading. So we'll hit vastus lateralis in two different spots. So one here and then one a little higher. I'll step away so you can see. Then we're going to want to go vastus medialis. So now I'm just on that inner part of the quadriceps. And then we want to hit that rectus femoris and I can hit here and then I can even do one more a little bit higher. I want to show you just there's, these are the newest curve cups. These are awesome as well. So I wanted to show you that. We'll go a little higher and we're really trying to hit that muscle belly here, not tendon. So then this is attached to patient. And I'm not just going to leave him sit here. So I promised him I wouldn't actually make him move. So I'm just going to talk through this. But I'd actually have him do some knee extension with those on. So mod to hired ability, we want to create an analgesic response. So we'll have them do some isometrics, shooting for that 45 second hold, trying to do five reps. So we'd start with just probably doing like a quad set where he'd like push his knee down and then maybe lift a little bit or combine it with a straight leg raise. That would be like level one. As soon as we can get him up and weight-bearing, I want to do like a wall sit or a Spanish squat with these on. So he's in this decompressed, he, they, she, whoever your patient is, decompressed state, and they're still loading. So it's not a static laying there thing or treatment. So once cups are applied, right, I do some kind of active treatment. I've named a few. Lowest level would be that knee extension with a lift and or just doing a nice quad set, then getting to a wall sit or a Spanish squat in a reduced range. We usually start about 60 degrees. And then we take the cups off, right? Reassess the soft tissue. Daniel's probably like, please take these cups off, mom. What we'll do is reassess the soft tissue, but not just the soft tissue. I want to see, is there less hypertonicity? I want to see, is the tendon, after I've palpated it, become a little less tender to palpation? In addition, I want to probably test a load test, like that slant board, if we had just tested that. And you may even see a change in motor response. So if you took your dynamometer, took a quadriceps reading, and then also got an NPRS, did this treatment, Then retested using your dynamometer, you often will see not only a change in pain, but you can even see motor uptick. So an increase in that strength measurement just because pain has now dampened. So this treatment doesn't take a long time, but can be super effective for our patients with that mod to high irritability where life is starting to get interrupted by their patellar pain.
SUMMARY
Thank you for joining me this morning to learn one of my favorite techniques that I'll use for my folks with patellar tendinopathy. I hope you all have beautiful clinical Thursdays, whatever you do in the clinic, and will consider using this with your patient. If you want to learn more about research concerning patellar tendinopathy and how to load your folks well, join us on a weekend soon in extremity management. So we will be in not only North Dakota, but also in South Carolina, August 24th, 25th. So you have two opportunities coming up, and that'll be our last opportunity of the summer. So really jump in if you haven't yet. And if you want to learn a little bit about some myofascial decompression techniques, our colleague Chris DiPrato, we're a big fan of his courses. We also integrate that in our courses as well. So thanks again for joining me. Cheers. Happy Thursday, everyone.
OUTRO
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