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

In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses the role & function of tendons in the body, traditional rehabilitation approaches to treating tendinopathy, as well as a new procedure called TENEX for tendinopathy management.

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

LINDSEY HUGHEY
Morning PT on ICE Daily Show. How's it going? Welcome to Clinical Tuesday. I am Dr. Lindsey Hugey and I will be your host today and we're going to chat all things TENEX and TENEX care specifically for our tendons. So I'll chat with you a little bit about what it is, what the procedure proposes to do and kind of what we're seeing in regards to its effects So the title officially today is, does TENEX get a 10 for tendinopathy care? So let's dive right in. And I do want to say, spoiler alert, it does not get a 10 for tendinopathy treatment. So first, before we dive into what is TENEX, Let's just chat about in general what tendons need to heal as a little reminder to kind of set the stage. And if you've been to our extremity management course, this will just really be a review.

TENDON FUNCTION
But our tendons in their most basic function, they connect muscle to bone. They are to act like a spring and they are to be mechanoresponsive, right? To take on load, transmit force up and down and across. they are responsible for speed and acceleration, they need to take on compression and friction. As soon as we spike loads quickly or dramatically deload activity, we will see changes in capacity of not only that tendon, for better or for worse, but also in the structures they're attached to. So consider the muscle, local muscle, and then that bone. So not just the tendon will either gain and be challenged by spikes in load and or will reduce, right, if you dramatically deload. So come to our course if you want to, extremity management, want to learn even more about that, but that's kind of tendon basics. For those that have treated tendinopathy and are in the outpatient space, folks that do a lot of repetitive action or athletes often get tendinopathy at some point in their life. And this results in pain. It can result in sickening and swelling at that tendon, but really it's decreased performance, whether it's in their job that they need to do and or their sport participation. And a lot of folks think this is just going to go away on its own. And they'll try conservative measures, whether it's they've looked it up on Dr. Google or they've consulted their doc. And I want to set the stage of what's really being told for conservative management of our attendants. It's rest, it is NSAIDs, injections, surgery, PRP, stem cell, shockwave therapy, and then physical therapy is on there as well, but we know there's a lot of treatment variation in our profession in regards to building the capacity of that tendon.

WHAT IS TENEX?
Now on this list for conservative management is TENEX. So I kind of want to set the stage. We now know what kind of tendon function, what will challenge a tendon, and now we know what is really recommended for tendinopathy care. We tend to see, because of this treatment variation as well, right, from rests to anti-inflammatories to surgery and physical therapy, somewhere in between, we see people, and then some folks just not getting care at all, going on to chronicity. telling their docs that, you know, this is hanging on for more than three to six months. I'm not getting better. My performance is lessening. I'm having difficulty at work. And so TENEX was developed. And so we're gonna dive into the treatment. Is this helpful for tendinopathy? So TENEX , T-E-N-E-X, for those listening, is prescribed for those recalcitrant cases that aren't responding from that list we just reviewed. What it was developed in Lake Forest, California by TENEX Health System in collaboration with Mayo Clinic. And what it is, is it's ultrasound guided percutaneous needle tenotomy. It's a mouthful. And what they do is they use a needle, a small incision is made with this specialized device called TENEX, the device is inserted, it delivers ultrasonic energy to the damaged tendon tissue, and it emulsifies that damaged tissue into a soft liquid form, and then that's removed through the same incision. Basically, using oscillations in high frequency to debride and aspirate the diseased tendon, all guided under ultrasound image. The rationale for TENEX, is that it is minimally invasive for those that have been struggling for three to six months to even a year. It's minimally invasive as stated, but they're not going to have a ton of a recovery period. They'll get back to their activities. There is like a very wide variation here, but they'll say anywhere from three weeks to 12 weeks. The goal and kind of the underlying theory of why does TENEX work is that it is stimulating the body's natural healing process. And ultimately that helps restore tendon function. That's what the kind of the proposition is. And then they keep selling that it's minimally invasive and it's shorter recovery than like your typical surgeries that they'll do for tendinopathies. with the cell, they usually will sell the shorter time of two to three weeks back to your sport, back to work without any issue.

DOES TENEX WORK?
And so what are patients saying about this? So patients, when we look at systematic review level studies, and there's more than a handful of these, we are seeing these patients reporting reduced pain, reporting improved function, returning to their sport, And what's interesting is they're seeing even at a year-end, three-year mark, these patients still reporting improvement in combination with these TENEX procedures. And so we kind of have to take a pause about our biases because here at ICE, you know, and if you've been to our course, we really believe load is our love language for tendon care. And that's really the only way to remodel that tendon is high tensile loads. And so what should we be thinking and advising our patients on, knowing that this procedure exists, it's existed since 2010, knowing that even in the last five years, we've gained some systematic review studies in various areas of rotator cuff, Achilles tendinopathy, gluteal tendinopathy, our lateral elbow tendinopathies, all of these areas are showing evidence of improved pain and function. But there's a lot of unknowns, right? So like, what do we tell our patients? Because they're going to ask, especially if they're kind of looking for that quick fix, and maybe they just started out of care with you as well. Well, I think we have to be honest that we don't actually know a lot of long term data. in combination with physical therapy. So you'll see that often after this procedure, they are recommended physical therapy. So what we don't know is the differentiator yet. Is it physical therapy that is actually helping or is it that TENEX? In addition, that bias that I told you about that I want to share is that you still have to restore capacity to surrounding tissue. So even if you clear out this like dead tissue right this tissue that is specific or excuse me that's been linked to possibly being painful for this patient you still have to lay down new fibers in that tendon, you still have to challenge the local muscle, you still have to help that bone health and so all that doesn't go away. My bias here is going to be that physical therapy when done very well should prevent this TENEX from ever having to happen because we should be able to right away respect that irritability of the patient dampen their pain symptoms right whether they have some degenerative tendon on board or not we might not know but if you respect irritability and then gradually load that person load that local tendon load that local muscle challenge the chain and then as that goes well then start to add in some energy storage where the patient has to take on compression and friction and spring-like movements, we don't have to get to these invasive procedures. But it's that variation in our practice and the things that are just readily recommended on the internet and from docs, which is RESS and NSAIDs and getting stem cells or PRP, these like quick fixes, quick fixes that never really address the underlying problem. So while TENEX, I think there are some promising results and we really have to acknowledge that. I'm going to give it a 5 out of 10 because we do see in those people that are getting TENEX that they have improved pain and function consistently. Only giving it a 5 because We have an opportunity here that TENEX is not the answer, right? We see folks on the other side of that TENEX. It's not TENEX giving the 10 out of 10 pain free, right? Or 10 out of 10 function. It is really in that conjunction of getting the tendon capacity back up. So thank you for kind of going on this little journey with me about TENEX. It's been a question that's been popping up on weekends, you know, what do we think about TENEX and what do we tell our patients? What I'm going to say overall in concluding this is that those suffering from chronic tendinopathy, they may have their mind set that this is what they want to do. Know that you can partner with them. before that and after. Like you are going to be a part of their care no matter what to build up that capacity. You can educate in that way and let them know and I can attach them if you're interested that there are systematic reviews showing promise with this. know that as Dr. Justin Dunaway says, beliefs and expectations are the foundations on which outcomes are built. So if the patient believes TENEX is going to help, it is going to help with pain and function. If they believe physical therapy is going to help, it's going to help. And if in conjunction together, they believe it's going to help, it's going to help. So we really have to have a biopsychosocial approach to this too, not just the facts about the procedure and what TENEX is resulting in on a systematic review level. What really matters is what does the patient believe that's going to help and what's going to get their tendon ultimately more healthy.

SUMMARY
I appreciate you joining me to chat a little bit about something that's a little outside of the scope of our normal weekend. And if you want to learn more about the tendon continuum, the complex pathophysiology that's happening, we take a deep dive over an hour long lecture on day two of our course that dives into all the latest literature on tendinopathy. our upcoming opportunities to do that and join us. We have two, August 24th and 25th. I'll be in Bismarck, North Dakota, and Cody will be in Greenville, South Carolina. We would love you to join one of us, right opposite ends of the spectrum. And then the next opportunity will be September 14th, 15th in Denver, Colorado. So join us on the road if you can. Thanks for chatting with me a little bit about 10X today. Have a happy Tuesday, everyone.

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

In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Heather Salzer discusses a case study involving helping a patient increase her calorie & protein intake during postpartum to improve her recovery & performance.

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

HEATHER SALZER
Good morning, PT on ICE Daily Show. Happy Monday. I'm Dr. Heather Salzer and I'm here with the Pelvic Division at ICE. And this morning we are going to talk about hacks to hit protein and calorie needs to help us stay out of low energy states and avoid RETs. So at the ICE Pelvic Division here, We talk a lot about REDS, also known as relative energy deficiency in sport. It's something that can have widespread effects. It can affect our immunity, sleep, energy across the day, muscle building function, and then a lot of pelvic kind of class specific things like fertility, increase our risk of urinary incontinence. If you want to deep dive into REDS, please join us in one of our pelvic we go into it in great detail, but when we talk about it, we always get the question of, okay, well, if I need to be eating that much, or if my clients need to be eating that much, that feels like a lot. How can we actually get there? So for the podcast today, we're gonna go through a case example, and as we talk about that, discuss overall calorie needs from Red's perspective, and protein needs, because that's something that a lot of people struggle with as well. And as we go through that example, we'll go through hacks of little changes that someone could make in their diet to make these things a little easier. So meet Kristen. She is our client today, and she is 32 years old and around 160 pounds. She's got a three-year-old at home and a 10-month-old that she is breastfeeding. Kristen runs two to three days a week at a pretty moderate, sometimes higher intensity, and she also crossfits around three days a week. She's also pretty busy chasing around her three-year-old and while carrying her 10-month-old with her as well. So how much does Kristen need to be eating a day when you ask her and are getting some feedback from her? So someone with her general demographics would need relatively about 1,500 calories just at absolute baseline doing nothing else. When we add in her activity across the day, we're looking at closer to 2,500 calories. Then we add in breastfeeding on top of that and she's sitting at close to 3,000 calories a day in terms of her caloric need. if we're thinking about how much protein we want her to be getting, likely we're trying to be somewhere in that close to one gram of protein per pound of body weight, just because of her high activity and breastfeeding. So we're looking at like 150, 160 grams of protein. That can be a lot. When we ask this question to our clients, a lot of times, her it's like, whoa, I am not getting anywhere close to 3,000 calories and you want me to eat how much protein? Don't you know that I have kids that I'm chasing after? When am I supposed to meal prep enough to make all of that happen? So let's go through her day, talk about what she might be eating to start with, and then little tweaks we can make to change it along the way. So we ask her, Kristen, what do you eat for breakfast? And she says, well, some days I have got, I do like two eggs, some toast and some fruit. And other days I do some oatmeal with berries and milk. Okay, if we think about that, we're maybe getting 15 grams of protein and probably like 300 calories on top of that. That's not a super strong start to the day. So we ask her, hey Kristen, Do you think you can add another egg or maybe some egg whites to those eggs and a breakfast sausage on top of it? She's like, yeah, that seems reasonable. Or on oatmeal days, can we do overnight oats instead of hot oats and put a scoop of protein powder and maybe a couple tablespoons of chia seeds in there? And then all of a sudden with either of those options, we've upped protein closer to 30 to 40 grams and now we're sitting at like 700 calories. So starting off strong with a good breakfast is a nice way to already help us get those totals earlier in the day. Side note on the oatmeal, I don't know about you but I have tried putting a protein powder in hot oatmeal and it gets chunky. Overnight oats are fantastic and that protein powder scoop is a good way to up the protein on that. So moving on to Kristen's day, we are about mid-morning and she's like, yeah, usually I don't really have time to eat again till breakfast or till lunch. I get going with my day. I'm pretty hungry when I'm breastfeeding, but then I keep going and I really just don't have time to eat again until lunch. So we say, What can we do to make it easier for you to get a snack? Can we have a protein shake that you make with breakfast that's sitting in the fridge ready to go? Can we have some yogurt that can be easily grabbed? Where are you doing your breastfeeding right now? Do you have a station set up? Can we put some protein bars there? Can you grab your yogurt on your way there? Can we stash some protein bars in your car? So finding a way to get her a snack in the morning that can pack an extra 20 grams of protein and maybe another 200 cals on top of that. Breastfeeding, for this specific example, can be a great time to get it. Baby's getting their nutrients in. I promise they won't mind with some crumbs on their head. Fuel yourself while you're fueling baby. That can work great. So, we've already increased by adding in some snacks, packing her breakfast a little bit fuller, now we get to lunch. And we ask her, okay, Kirsten, what are you eating for lunch? And she's like, well, I've been trying really hard to be good about my nutrition and getting in healthy things, so I've been meal prepping turkey and cauliflower bowls. I say, okay, awesome, I'm so excited that you're taking the time to meal prep, that can take a lot of time. And how much are you eating? And she's like, well, I've got this little Tupperware. And you go through it together and you calculate it. And really, she's getting like maybe 400 calories and maybe 20 grams of protein in her little Tupperware. And you ask her, are you full by the time you're done eating lunch? She's like, eh, maybe. You're like, do you think you could eat a little bit more? And she's like, yeah, probably. So you say, girl, you gotta get rid of your tiny Tupperware. The big mixing bowls with a lid, that is where it's at. And we see if we can increase her serving size just a little bit. Can we add especially a little bit more protein into that, up that turkey percentage? Or also she's using cauliflower rice, which great to get some veggies. but maybe we're not getting enough calories overall, so can we add some brown rice and white rice into that mix in addition? Now, we've taken her lunch from 20 grams of protein to maybe closer to 40, and 400 calories closer to 800, just by slight small ups in that serving size. We hit mid-afternoon, we're back to breastfeeding, happens again, And we have some other snacks set up by her station. Maybe she's grabbing a handful of trail mix with some unsweetened dried fruit and some nuts. And so we're getting another 10-ish grams of protein, maybe 400 calories. And we made it back to dinner. We ask her the same thing. Do you feel really full after dinner? And she's like, Eh, not necessarily. And then, so it's like, okay, her family's making tacos for dinner tonight. And she's like, yeah, normally I eat like two-ish tacos. And then I get distracted trying to feed my three-year-old who's thrown their taco meat to the dog on the floor. And then before I know it, all the food's gone and we're on to the next thing. We say, let's prioritize getting you an extra taco. So yet again, without doing more work from a meal prep or food prep standpoint, we're able to increase protein a bit and increase over calories. So say that bumps us up to maybe again, like another 40 grams of protein and 800 calories. So if we look back at our day, Kristen maybe started off with maybe hitting 75 grams of protein and 1500 calories. which will definitely not be enough. That's like baseline function if she were to do nothing else across the day. With a few of our little swaps, we've gotten her really hitting that 2,900 calorie mark that we talked about would be ideal for her and closer to 150 grams of protein. So again, we boosted up her breakfast, adding in a little bit more, made snacks convenient that she could grab, and upped what she was eating just a little bit for lunch and dinner and made a big difference. Now, obviously, you wouldn't want to jump somebody who had been eating very low to a ton all at once. They may feel way more full, so that might be more of a gradual transition. But if you can even start with just, hey, let's really prioritize adding in one more protein-heavy snack. How can we make that easier? Is it making some protein balls over the weekend that you have in the fridge that you can grab? Like I mentioned, is it stashing that protein bar in the car by the breastfeeding station? How can you make that easy to hit those numbers? Now, in an ideal world, when somebody is dealing with, when we're noticing as we ask them questions about their diet, that we're not getting enough calories if we think they need to have a little more protein, it would be wonderful to refer them to a registered dietitian. It is great to have resources in your community of places that you can refer people out to. But the reality is, a lot of the time, they're not going to make time for another appointment. So you are their nutrition resource. The APTA says that it is within our scope of practice to talk about nutrition. So start asking. You will be surprised about the answers you get Especially, our example today was within that postpartum population, but this could be transferred over to any of your clients. Another great group that we really need to be asking about this is our teenage athletes, especially our female teenage athletes. And it is sometimes wild how low of a calorie count those people are getting in a day. Now, if we're wanting realistic Like if we're really wanting to know exact numbers, it is helpful to track for a day or two and see where they're at. Tracking, you can use like MyFitnessPal as a free app that allows you to track across the day. And that's a good idea to be able to see where the calories at versus where we want them to be and where's the protein at versus where we want it to be. I know tracking can be definitely triggering for some people, especially when we're talking about this population I like to recommend, can we do it for a couple days to get a baseline of what you're eating? And then a couple more days on top of that so that you can see, oh, wow, this is where I actually need to be with that. And maybe it doesn't have to be a long-term thing, because it also takes a lot of time in addition. If that's off the table, again, just go back to what are some of those little changes that you can ask them to make and maybe start with just one change at a time. So again, can we add that snack in or can we increase serving size at one meal?

SUMMARY
If this feels like a topic that you're like, man, I really wish I was a little bit more comfortable talking about nutrition, ICE does have a self-paced nutrition course. If you go to free resources on the app, you can access that. And if you're interested in learning more about REDS and its impact on all things pelvic, such as fertility, urinary incontinence, you should jump into one of our pelvic courses, either live or online. We've got some coming up. Our next online level one cohort is going to start on September 9th. and level two starts on August 19th, and then there's lots of opportunities to join us on the road as well. We'll be in Hendersonville, Tennessee on September 7th, Wisconsin on the 14th of September, and then Connecticut on September 21st. I hope this helps give you some ideas about little changes that we can make to make sure that our clients and you are getting the calories you need to do all of the awesome stuff that you want. Happy Monday, everyone, and go crush some breakfast.

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses the importance of the need for simultaneously strong & flexible lats to optimize performance & reduce injury risk in CrossFit and other functional fitness athletes.

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

ZACH LONG
It is August 2nd, 2024. I am your host today, Dr. Zach Long, lead faculty inside of our fitness athlete division, teaching our live course and our level two course that we just, uh, just changed the name of that. So excited to talk to you today about the lats specifically in the CrossFit athlete, why this is such an important muscle group for us to appreciate and why I call it the glutes of the upper body because it's just that important of a muscle. We focus so much in the lower body on glute development for athletes, for health, for performance. The lats are the key when it comes to the CrossFit athlete. Why is it key? Two big reasons. Number one, lat inflexibility will drastically impact many skills the CrossFit athlete is trying to develop. But what I want to focus on a little bit more today is lat strength. So let's get rid of the flexibility issue first. So if your lats are tight, what we're going to so commonly see is all overhead lifts affected. But we're really going to see athletes struggle with things like the overhead squat, whereas they're going down into that squat and their hips being flexed, that lat inflexibility is going to really wreck havoc on somebody's overhead squat. And then when we look at so many gymnastic skills as well, If you can't fully open that shoulder up into in-range flexion, you'll struggle with your kipping mechanics. Things like handstand walking will also be drastically impacted if you don't have great lat flexibility. But again, our focus today is going to be a little bit more on the strength of the lats and why that's so important. So obviously we all know that the lats create shoulder extension. So they're going to take our arm from being overhead down towards our side and behind our body. That is a movement pattern that shows up so much in CrossFit, probably more than any other recreational fitness activity. So if the lats aren't strong, movements like your kipping pull-ups, your muscle-ups, your toes-to-bars, are going to be impacted. Even your deadlifts, your cleans, your snatches, the lats are so important in those movements to keep that barbell close to your body and become more mechanically efficient in those movement patterns. So we've got to have really strong lats. I think one great example that I love to do when we're teaching a live course to help people really feel and understand how important the lats are in just barbell-based movements is to have somebody do a hip hinge holding an empty barbell. You slide that barbell down your thigh as you hinge over, and then you stop with that barbell sitting right at the patella. And then you take a second and you let that barbell drift three or four inches out in front of your knees, and then you pull it back to where it's touching your knees. You can do that a few times. And what you'll notice really quickly when you do that is as soon as that bar starts to drift away from your body, you'll feel your back tension really increase as your lumbar paraspinals have to work a lot harder when that barbell gets away from the body. I often explain this to my patients as carrying your groceries into the house. You don't carry your groceries into your house with your arms at 90 degrees of flexion in front of your body. That would not be an efficient position to carry that load. That's what the lats do in your deadlifts, cleans and snatches. So, how do we determine if someone's lats might be weak? That's tough to do. So I have a couple different things that I look at that kind of hones me in on thinking that this might be the case. Number one, does somebody just not have strict pull-up capacity? If somebody can't do that first strict pull-up, then I know that we need to build overall lat strength, then just overall vertical pulling strength. But once somebody has that, then there are a couple other things that I like to look at as well. Number one being, in their strict pull-up, where do I see those elbows at? So where I ideally want to see is when they're pulling themselves up, I want to see that humerus is pretty much staying kind of in the plane of the scapula, about 30-ish degrees forward from being in pure abduction. What I'll really commonly see is individuals that as they do their pull-up, those elbows come really far out in front of their body, almost in like straight flexion or 90 degrees of adduction. And what that usually indicates to me is somebody that's relatively stronger in their arms compared to their lats. So if you jumped on a pull-up bar today and you did a wider elbow angle pull-up and a really narrow angle pull-up, what you'll notice immediately is that as soon as you go more narrow, you will feel your arms working drastically more. So those individuals that go forward elbow position in their strict pull-ups are often weak in their lats. And then there's another great test that I like that's really specific to the CrossFit athlete. We show this in the live course, so this might be a little bit difficult to visualize on the podcast, but I get a very light box or bucket on the floor directly in front of a pull-up bar, three or four inches in front of a pull-up bar on the ground, athletes hanging from the pull-up bar, and I have them go into a hollow body position as if they were doing a kip, but we're doing it really slow. And what I'll usually see is that athletes with strong lats and great kipping form, great hollow body positioning, as they go into that hollow body position, you'll see their toes slide nice and smoothly up and down the box. For individuals that are weaker in their lats and they leverage and utilize their hips too much in their kip, they'll flex their hip, they'll go into a piped position, and you'll see that box actually get pushed forward as they do that motion. So there's three different things that I kinda look at that cue me in to somebody needing lat strength. Now, obviously, that is important for both, for performance, strong lats are gonna make you better at the movements that we see in CrossFit, but I also think that this is really important for us to appreciate as rehab providers, because when somebody has weak lats, we often see their rotator cuff and elbows get beat up as a result of that. So imagine somebody's putting in a high volume of kipping movements, toes to bars, pull-ups, et cetera, on a pull-up rig, but their lats aren't super strong. They're relying a lot on that momentum generated by the kip to get themselves over the bar, but they don't have the lat strength to control that eccentric motion. So they're going to come down a little faster. They're going to be a little less controlled. And when they hit that in range flexion down at the bottom, you're just going to see a little bit more force get thrown at the shoulder than if they had more lat control in those movements. And so very frequently, what you're going to see is those individuals with a little bit of lat weakness are the ones that are showing up to the clinic with rotator cuff tinnitopathy of the shoulder. And they're going to show up with shoulder instability issues. because that shoulder's just getting taxed more because of those weak lats. So, so frequently when I'm treating somebody with gymnastics-based rotator cuff tendinopathy or shoulder instability in the cross-fit population, I'm giving them rotator cuff strength work in an EMOM combined with some lat strength work. And we'll talk about a few drills for that in just a minute. One other thing that you'll very often see, especially in those forward elbow pullers, is that you'll find that they very commonly are those individuals that show up to the clinic with medial elbow pain. They're going to show up with golfer's elbow, medial epicondylogel. that medial elbow is getting overloaded because so much of what we do in CrossFit is already grip intensive. They're dead lifting, they're cleaning, they're snatching, now they're jumping up on the rig. But their rig work is also done in a way that puts a little bit more stress and emphasis on the elbow. And a lot of times that elbow just can't keep up with the load that's being placed on it. So obviously, again, you're loading up the elbow and trying to make those tendons a little bit more robust. but a huge component in those individuals also has to be strengthening those lats so that the elbow's just not getting constantly beat up in those CrossFit workouts. So it is super common for you to see my rotator cuff and elbow rehab programs in the CrossFit population having lat accessory work in it as well. So now I want to talk through my four favorite lat accessory works, excuse me, five. 1. Pull Up Variations Pull up variations are number one. Number two, I really love banded front levers. So especially for athletes trying to learn some higher level gymnastic skills, the toes to bars, the bar muscle up, etc. A banded front lever is a killer exercise to isolate the lats. That one does take a decent amount of strength to do. Number three, racked shins. Man, if you haven't played with racked shins in your own personal fitness journey, I really wanna encourage you to play with this one because it is a killer lat exercise. I mean, the first time you do it, you're gonna spend the next four days unable to raise your hands over your head. So what you do here is you set a barbell up on J-cups to where it's at about chest height, and then in front of you, you either get a tall box or maybe an incline bench, and you place your feet up on the box or incline bench. So your hips are flexed. while your shoulders fully overhead. So it just puts a massive stretch on the lats and then you do essentially a pull up with those feet a little bit elevated. Look up a video of this if it doesn't make sense, but that big lat stretch down the bottom really crushes the lats. And again, you're gonna be sore for days if you do that one. Number four, straight arm pulldowns. So I prefer this with a cable column, but a lot of CrossFit gyms aren't going to have a cable column, so then we just do bands. We get a band attached to the top of the pull-up bar, hold it with both arms, arms straight, and then we keep our arms straight as we go from shoulder flexion down into extension. So what that's going to do is it's going to completely take the arms out of the equation here, and really focus on isolating the lats to extend the shoulder. So this is another one that I really like for that individual that has that really forward elbow pull. I'm just gonna completely take their arms out of it. I might have them a couple days a week doing straight arm pull downs, a couple days a week doing toe assisted pull downs to build up their lat strength. And then number five, the RNT row. So I get a band position tied to like a upright of a squat rack at about knee to hip height. I'm holding the band at the same time that I'm holding a dumbbell or kettlebell. Now I'm doing a rowing motion where the band is resisting shoulder extension and my emphasis here isn't on pulling the weight to my chest. My emphasis is on trying to pull my elbow back towards my hip. When you focus on pulling the elbow back to the hip with that band resisting shoulder extension, you're going to find that the lats just get really, really isolated. For individuals that when they're doing pull ups or we're doing some of the other exercises that we've already talked about, tell me that they just don't feel their lats working as they do that. That's my favorite exercise to just build a little bit of awareness of the lats. It's great for strength. The negative is that we're only training from about 90 degrees of flexion down to zero, so it's a little less specific. But when I need to create that mind-muscle connection to get them to feel and engage their lats, I absolutely love that drill. So there's five different exercises and a couple different ways to test out the lats.

SUMMARY
So I really hope that you come away from this really appreciating how important that muscle group is for the CrossFit athlete. If you want to dive deeper in this stuff, we focus on lat strength a ton in our Fitness Athlete Live course, again, just because it's so stinking important. And so we've got a number of different live courses coming up that you can check out all across the country. In September, we've got three courses. We're going to be in Austin, Texas, Longmont, Colorado, and Spring, Texas. And then through the rest of the year and early into 2025, we're going to be in New Orleans, Orlando, Florida, St. Petersburg, Florida, Atlanta, Georgia, and Salt Lake City. So you've got a lot of different options across the country to catch fitness athlete live. And I also want to mention that Our Level 2 course, if you've already taken Level 1 online, Level 2 starts up in September as well. And that course always sells out. We have a few more seats available. We're about a month out from the start of that course, but it will sell out in the next two weeks. So if you've taken Level 1, and you wanna move on to Level 2, and you wanna move on to getting your ICE Fitness Athlete Certification, then you need to go sign up for that Level 2 course as soon as possible, because it's gonna sell out really soon. Hope today's episode gave you a few clinical tips and look forward to seeing you next time and at live courses. Have a great one, everybody.

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett as she discusses the difficulties of working with older adults in practice including medical complexity, being unsure of where a plan of care is headed, and other interactions that patient may have had or is currently having inside of the healthcare system.

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

CHRISTINA PREVETT
Hello, everybody, and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of our lead faculty within our Modern Management of the Older Adult Division, and we are riding on a high right now. If you've been following us on Instagram, we just had our MMOA Summit where 10 of our geriatric faculty descended on Littleton, Colorado, and we just had an incredible time connecting And when you have these cup-filling weekends where you are just eye-to-eye with other clinicians and you are connecting with your team, I always feel like there is a lot of reflection that happens in those weekends, and I was down to meet him. And I was really thinking about where we have gone in the last seven years since modern management of the older adult has been a thing and where the profession has gone. And I thought today we would talk a little bit about the good, the bad and the ugly that we see right now as truly just realities of being in geriatric practice. And I think about, you know, Christina of 2016 and Christina of 2024 and what Christina of 2024 would tell Christina of 2016 as, you know, you get more experience under your belt. You get more clients that you've dealt with. You get how you've worked through really complex scenarios and how you've dealt maybe with some of the heartbreak that can come with really sad stories in geriatric practice. And so I have four things that I wanted to speak to of realities of working in geriatric rehab as a clinician and kind of our thoughts and feelings on them.

IT'S NEVER JUST ONE THING
The first one is what I tell a lot of my students or individuals who are just getting into geriatric rehab or just counseling or mentoring on getting into the geriatric space is an acknowledgement that sometimes it can be really intimidating because it is never just one thing in geriatric rehab, right? I work in traditionally outpatient and if I am working with younger folks, it's usually that they're coming in for one specific injury, right? Like they have had something happen and their shoulder hurts or they sprain their ankle and you are working on the ankle. Of course, you're gonna zoom out and you're gonna work on the entire person and we're gonna look upstream and downstream if necessary, depending on what joint it is. But we're kind of working on that one orthopedic thing. That's never the case in geriatric practice. And as we get into higher levels of institutionalization, it becomes even less likely that there is only one thing going on. And that is where clinicians can get in the weeds, right? They can get into these interactions where, yes, they have knee pain or yes, they have hip pain, but they've had surgeries that have gone wrong, or they are a lower or a higher surgical risk, lower likelihood of getting surgery because they have unchecked diabetes, or they're having troubles with sensation now because of diabetes, or they've had heart attacks, or they're on 15 different medications, and they all pop up in the BEARS criteria, and they're all having interactions, and you're unsure if their pain is because of the drugs that they are on, or the things that they are experiencing, or mental health concerns, and there is just a lot. And that can almost give us analysis paralysis. And it can also tend to lead us to really conservative management because you're thinking, oh my gosh, there's so much medical complexity here. I don't know what to do. And my advice in those situations is twofold. Number one is the benefits of doing exercise, especially appropriately dosed exercise, far outweigh in almost all scenarios, outside of the absolute contraindications outlined by the American College of Sports Medicine, the negatives of sedentary behavior. I'm gonna repeat that, that benefits, even in medical complexity, of doing appropriately dosed exercise when possible far outweigh many of the harms or any of the harms, especially when monitored, of doing nothing. And that is always a helpful reframe.

EMBRACE THE JOURNEY, NOT THE DESTINATION
And the second thing is that you don't have to know everything or exactly where you're going you just need to know the next step. And, you know, a lot of times we beat ourselves up in rehab that we don't know the prognosis or the expected end game or what individuals are going to be able to do after our care. As you get to know individuals and as you see how they respond to rehab, as you see their willingness to do things at home and the support that they have, and you get to know a little bit more about them, that picture will become more clear. But when there is a lot going on, know that exercise trumps no exercise, and just know the next step. Because it can. It can be really intimidating when there's a lot of multi-morbidity going on, but that's why they're coming to you with doctoral level education, right? Like, they need that medical monitoring. If they didn't need that medical monitoring, or if they didn't have real barriers like pain, to being able to engage in a physical activity program, they would be going to a gym. And hopefully the goal is that we can transition them there to exercise program or group therapy or whatever it might be. But they need your help at this moment and they just need you to give them the next step. So that's number one. When it's intimidating, we want to think exercise over no exercise and let's go with the next step.

BE AWARE OF THE PATIENT'S PAST INTERACTIONS WITH THE MEDICAL SYSTEM
The third thing that is sometimes or oftentimes an unfortunate reality of working with older adults is that they've had a lot of time to interact with the medical system. And we know that when individuals start interacting with the medical system, they oftentimes become afraid, number one. And number two is that they've had lots of chances to have communication with providers and that communication can be the good, the bad, the ugly. You know, I had a client just the other day, she was in her mid-60s, and she had had history of compression fracture with osteoporosis, and she was told by her previous PT that, it's all right, just make sure you don't fall, because if you fall, you're gonna be a paraplegic. And that was just one conversation that probably was like, you know, 15 seconds of that PT's day, but she was talking to me five years later, so that had happened to her when she was in her early 60s. She was now in her late 60s. And she remembered that sentence and it stuck with her. And she was seeing me for hip, low back pain, secondary to a lot of deconditioning. And I freaking wonder why that deconditioning happened. And that was one interaction. And so she's had other interactions with other providers as well. that have been able to tip the scale in the I want to do more category or I'm afraid because of what I have or what is a condition that I am experiencing or that is in my body that is making me afraid to move my body. And When we have those types of thoughts or when they've had some of those negative interactions, we talk about it at MMOA as when helping hurts, as when I have to hope, I have a really hard time with the PT one, but I have to hope that people are trying to be helpful. But when we think about the way that our medical providers and our allied health providers are taught, ourselves included, in PT and OT, We are taught to look for dysfunction. We are taught to look for what is wrong and fix what is wrong. But what that means is that is the frame of reference that we go into our conversations. Here, let me outline all of the things that are wrong with you in our next action steps. And I'm not saying this is something that's bad. I'm just acknowledging that when you have a person in their eighties who have now had 30, 40 years, if not more of interactions where every time they see a medical provider, they're being told all the bad stuff. And it's, we're trying to be concise with our, our appointments. We're really trying to get into the weeds of what's wrong and we're trying to get enough time to, to fix it. And people are coming to see us because something is wrong. I'm not saying that these are, these aren't bad things, but Those can chip away at a person's sense of self, a person's independence, or their confidence in what they can do, and can leave individuals, especially when framed through a really ageist lens of now that you're X years old, I don't expect you to ever be able to do this again. It can make individuals either one, very weary, of your interactions. I'm sure many of you listening to this, and I know I've had it, where you have somebody who's very angsty about the medical profession, and you are that representation of the medical profession, and you sit down and you say, hey, tell me what's going on with your foot. I remember I had a client who was in his mid-70s. I was like, tell me what's going on with your foot. He was coming in for ankle pain, and it was like fire was breathing out of his mouth. He was like, rawr, about everything. it was because he had been tossed around from provider to provider because they weren't going to fix his ankle, but then he had too much arthritis to fix with the procedure they wanted before, and they waited too long, and now they couldn't do the first surgery. And so he had been really tossed around from colleague to colleague, and he was really upset, and I was at representation. And so when you have individuals who've had a lot of experiences with the medical field, the first thing is that we have to tread lightly sometimes because we may be going against or counter message to people that individuals are already seeing. This is probably my biggest issue right now or the hardest thing that I am navigating in my practice is when I'm working with an older adult who has other providers who are telling them different things about the same condition. I have a client right now who is working with an osteopath and a naturopath and her family doctor and me and they're all giving her messages about what's going on with her low back. Many that I personally do not agree with. I'm sure they may not agree with me. And I feel horrible because I feel like she's getting so much mixed signaling and many of it is fear-focused messaging. And then it's really difficult for her to navigate when nobody's on the same page. And so just an example of where, you know, things can go awry really quickly in these really complex situations because they are interacting with more than one person and we oftentimes work in silos. And that is just the reality of working with older adults. And so my next step and something that I don't always get this right is that I try to acknowledge where that provider is coming from and then give my two cents that hopefully is adding to or not in completely the opposite direction of the messaging of the other provider. And that is an art. And it can be very difficult when you get really frustrated. Like I've had situations with some of my clients where I'm very frustrated at the other providers because it's creating difficulties for me to be able to get individuals to load appropriately. And right now our medical system is set up in this hierarchy where my doctoral level education is not the same as the medical provider's doctoral level education, but trying to acknowledge those past experiences. leading with kindness, recognizing that maybe kindness has not been given or time has not been given in other interactions, and taking it one step at a time when we are working with individuals who have had the majority of their interactions with medicine being very negative. And that's just the reality of something that we are going to be dealing with more commonly in geriatric practice. So number one is we are working with complex patients. So it can be intimidating when you aren't working on just one thing. There's a lot going on. Number two is that they have had a lot of experiences with medicine and that can bias them or make them jaded or make them upset. And I don't mean that to cast blame on them. I'm pointing that finger at us around why that has happened. The number three, the reality of working with older adults, and this might be able to be extrapolated out to everybody kind of in rehab, is that we have a lot of burnt out people in our healthcare system. And this particularly impacts our older adults because they are the ones who tend to see more multidisciplinary teams, right? When they're in hospital, they're interacting with social work and nursing and medicine and then us, and then they're coming to home health and they have a caseworker and they have, you know, they have more chances to have individuals who are burnt out in care. And we are, in geriatric practice, most commonly working in multidisciplinary teams, especially when we're in higher levels of institutionalization. In outpatient, PTs and OTs, we tend to be in silos where we work with just each other. Maybe we're in a multidisciplinary team where you're sharing with a chiro, or you're sharing with a massage therapist, or whatever that might be, but it's less, and it's less direct interactions with those individuals. And when people are burnt out in care, especially if it's things outside of the patient care, like a lot of clinicians will say to me, well, Christina, it's not my patients that are burning me out. It's everything else around my patients. It's the percentage of productivity. It's the documentation standard. It's fighting with the insurance companies. It's fighting with other not fighting, but having discussions with other parts of our team who are trying to advocate for care for my person because they have so much going on and it would be so much easier if X profession would be able to help with this or, you know, like, and then they're talking with X professional and they're burnt out too. And this is one where this is probably the ugly where We are not in a position right now where we have too many people who are helping. We are in dire need of mental health providers. The demand on our, not mental health, our medical providers, the demand on those medical providers all across the system, like allied health, nursing, medicine, is becoming higher and higher. We have an aging demographic coming, which means that there is even more demand And it is also a business working in healthcare, whether you're in socialized medicine, like I am in Canada, or if you're in privatized medicine, like in the United States, there is a business model and it is a reimbursement game. And that means that we are unfortunately usually understaffed and the mental health of providers is leading to burnout. And so this means, right, when you have a burnt out clinician, it can be difficult to provide the appropriate dose of care because it requires more effort. It requires more effort in our communication with our providers. It requires more effort on our side. And I think my solution, there is no solution because this is a very complex topic, is more just acknowledging where you're at, right? And acknowledging where you're at is the first step of figuring out how that's reflecting in your caseload. And I do not mean this to have any shame and blame. I mean this as burnt out providers. It influences everything. It doesn't just influence their care. It influences their family life. It influences how they interact. It influences the joy and the pride that they experience in their job. And we are in a time, and I think, you know, it started in COVID. It's still experiencing this backlash of it. where we have individuals who are not happy in their setting because of being burnt out, because of the way that healthcare is set up right now. And the first step is the acknowledgement of that. And the second step is trying to figure out, is there a way for you to get yourself out of it? And that might be going to therapy, that might be having conversations about your workload, that might be talking around the culture in your workplace, if that is somewhere that you are staying. And taking that step to work on you as a provider, because when you do that, then you're more likely to dose your care appropriately. Because if you're exhausted, it is a lot easier for you to do C to Therax than it is to do higher level, more supervision required care. And it is okay to acknowledge that some of that under dosage has come from the fact that mentally you are not in the healthiest space right now. And unfortunately that is a reality right now of being in geriatric practice in a lot of settings. And I guess the last extension of that is that coming in to those interactions, acknowledging that that might be where your colleagues are may give us the opportunity to have really fruitful conversations and maybe come in to those interactions with a bit more patience and understanding and trying to come from a place of kindness to hopefully work to repair fences and amend cultures that just need a dose of patience and kindness in combination with all the logistical and administrative stuff. But some of those things are outside of our control. And so these are things in our interactions that are within our control. So I have talked about the good, the bad, the ugly. And I want to finish with the good. So we talked about how, number one, it can be intimidating being in geriatric practice. There's a lot of complexity there. I always say that my caseload is chronic, complicated, and cranky, like cranky joints, not cranky people. Though I guess sometimes I get cranky people. That two, we have had individuals, the older they are, the more likely they are to have interactions with healthcare or decades of interactions that may have not been the greatest. We have a culture right now that is burnt out. And we need to acknowledge where that burnout is and take the steps in our interactions with our people to try and understand that. And number four is I want to leave you with so much hope, so much hope because the tides are changing, right? We have a team at MMA that is in every setting, right? We have PTs, we got OTs, we got people in acute care, in long-term care, in home health, in mobile Part B, in outpatient that are doing the things that we teach in our course around appropriately dosed care. We have been able to show proof of concept across a variety of different settings. And when we first started MMA and it was just a little bitty idea that Dustin and I had, we had people tell us that we have no idea what we're talking about. that I'm wasting their time, their caseload could never do this. And that has changed. And we are seeing that you are not often the only provider who is putting a weight in somebody's hand and doing a deadlift. You are not the only person who is getting Laverne, like Trisha posted about, who is doing 157 pound sled push in long-term care while her tech or her aide is helping carry her oxygen tank beside her. We are seeing that the spread of the ripples in geriatric practice to give our older adults the best possible care is happening. Gosh, it is slow. We have been at this for eight years, eight years. I started my PhD in geriatric practice in 2016, where we were trying to change the dosing schema for working with our older adults. It is starting to change and it's going to take time. It's going to take a concerted effort. It is going to take all hands on deck. But gosh, I left this weekend with MMA Summit and thought it's changing and we are seeing that change. And I feel so blessed and thankful that we have a team now that is working on that change and that They are kind of going forth and talking to clinicians. And I'm so thankful to the clinicians who spent time listening to our messages. And I'm so thankful to the older adults who have been in my care, who have trusted me with their care and seen some of the changes in my practice over the last 10 years as a practicing clinician. I am just filled with so much hope and so much joy that we are going to leave this profession better than how we got it. And you all are such an integral parts of that experience. So if you want to see us on the road, that's all I got for us today. Alan's going to say that I'm just doing 20 minute episodes now. But if you are looking for our last minute content course this weekend, Julie is in Newark, California, and Dustin is in Salt Lake City, Utah. I'm. Then our next course is August 17th, 18th. Jeff is up in Anchorage, Alaska. If you are looking for the kids to be in school and then go to Con Ed, September 7th and 8th, I'm in Mobile, Alabama. That's the first time we're ever teaching in Alabama, which is kind of neat. So super excited to get out there. If you have any thoughts, questions, concerns about any of the stuff that we were talking about today, or if you want to kind of add your two cents, I would love to hear it. Post it in the comments below. I'm excited to continue this conversation, and I hope you all have a wonderful. week.

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

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 three breathwork strategies: box breathing, physiological sighs, and 4-7-8 breathing and their implications to PT practice.

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

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

EPISODE TRANSCRIPTION

ZAC MORGAN
Thanks for watching! Good morning, PT on ICE Daily Show. I'm Dr. Zac Morgan, Lead Faculty here with Cervical and Lumbar Spine Management, bringing you this morning our top three strategies for breathwork. So breathwork is one of those things that clinically I've used a lot more the last couple of years than I did the first few years of my career. And part of that is, or a lot of that is, I think my ability to describe it to people. But another big part of it is personal experience with breath work. So I think early on I had a healthy amount of skepticism myself about things like doing nothing or sitting around focusing on nothing but your breath. And it wasn't something that I practiced regularly. So it was something that was harder for me to implement clinically when I would, when I would suggest it to clients. didn't have good uptake rates. They often did not do the breath work or did not do mindfulness meditation. And there often were just barriers in the way. And really personally for me, this journey started a little bit around a year ago, a little bit over a year ago. My dad had open heart surgery and it just was a stressful time of life, a lot of busy things going on. And then on top of that, a big surgery like that with a family member, And I remember during that time having some realizations about stress internally that clinically have helped me a ton. I mean, for instance, my shoulders, I grew up as a swimmer, so my shoulders have always been fairly mobile. And that was never really an issue for me. But I can't tell you how many clients stand in my office and kind of complain about in the front side of their shoulders and it was something I always had a hard time relating to when I would hear people describe it and I always thought of it as muscle tightness and a lot of just issues surrounding the shoulder and then during that week that my dad was in the hospital the same thing happened to me. So like I said I've always had plenty of mobility and then all of a sudden that just went away. I had that same exact feeling of tightness there in the front side of my shoulder. It's very familiar from a lot of subjective exams And that's where I started implementing some breath work. And starting to implement that breath work, I noticed an immediate impact on my shoulder mobility, which was not what I was expecting. I was expecting to just be able to sleep better or unwind a little bit better. But from a musculoskeletal perspective, my shoulder range of motion improved, shoulders felt better. I was able to kind of return to all the activities that I was looking to return to. So it really made me buy in, which has helped me a lot clinically from a being able to leverage that personal experience with the client in front of me. So I would encourage you to start using this some, but within using Breathwork, I think some really actionable strategies surrounding it are what make for more success. So rather than just saying, hey, try some breath work with your clients, which is probably maybe a little simplified version of what I was doing prior to starting it myself. Now what I do is I give it more like a prescription. So rather than just encouraging trying some breath work, I give a very specific prescription of different types of breathwork for people, all to stimulate parasympathetic outflow. So let's go through the top three that I've had success with. And again, I feel like the more prescriptive you are with these things, the more your client will believe that it's important to you as a provider. And then also something about receiving a prescription makes people a little more compliant. So there's three big ones that I want to talk about this morning. The first one's box breathing. The second one's physiological sigh. And then the last one is 4-7-8 breathing. I do feel like I get the best uptake with box breathing, so let's start there. And let's just describe what box breathing is and how to prescribe this with clients. I've had a lot more success by having them on the front end, prior to starting the box breathing, testing their CO2 discard time. So the reason this kind of came into my purview was the Huberman article that came out a couple years ago. I'll put that link in the comments of this video. But essentially they just kind of described how they use some of these protocols with the clients in that study. They were looking at breathwork, mindfulness meditation, and kind of seeing what helped. And it turned out all of it helped. But they gave a little protocol to determine someone's CO2 discard time. And essentially what you do is have the person seated comfortably. They take four normal breaths, breathing in and out of their nose. And then they take a very large breath in their nose. then they exhale as slowly as possible. That exhale can come from nose or mouth or both. The point though is to exhale as slowly as possible. Now you as the therapist are going to time your client doing that prolonged exhale. And if their time lands between zero and 20 seconds, their box breathing time, so how long they breathe, hold, breathe, hold. So inhale, hold, exhale, hold. The time that they do that protocol, if it's 0 to 20 seconds, their prolonged exhale is going to be 3 to 4 seconds. If they can do a prolonged exhale between 25 and 45 seconds, I'm going to have them do their box breathing with 5 to 6 seconds of each chunk of the box. And then lastly, if they're able to do a really long exhale beyond 50 seconds, then I would have them do their box breathing with 8 to 10 seconds. So that specificity of having them test prior to doing the box breathing protocol, for whatever reason, has really increased the compliance rate for a lot of my clients. I think knowing that it's designed for you versus just, hey, here's some breath work, just for whatever reason, builds some compliance. So definitely box breathing is the one that I get the most success with. Again, to quickly describe box breathing, you're going to inhale for a period of time, hold for a period of time, exhale for a period of time, hold for a period of time. That period of time is determined by that CO2 discard test. Secondly is physiological sigh. So probably a little bit of an easier setup here because you don't need to test anything. But the point of a physiological sigh is going to be two inhales through the nose and then a really prolonged exhale that kind of sounds like a sigh, kind of a sigh. type sigh, that can come through the mouth. But those two prolonged inhales, they're going to come through the nose. And the first one is going to be about 80% of your lungs capacity, and then the second one is going to be the top 20%. So you take a really big inhale through the nose, kind of cap things off with a second inhale through the nose, and then as long of an exhale as you can do, making that kind of sigh sound as you do so. So it kind of looks like this. The longer you can make that exhale, the better. So that's physiological sigh. So there's just another option outside of box breathing. And then the last one is 4-7-8. So for 4-7-8, you're going to breathe in for four seconds through the nose. Hold for seven seconds and then exhale however you want to for eight seconds. So that prolonged exhale in both the physiological sigh and in 4-7-8 breathing seems to really stimulate parasympathetic outflow. So with all three of these strategies, the person has to be really compliant to see success. And honestly, it's a more the merrier type of situation. Now, obviously, if you were only sitting around doing breathwork all day, that would be an issue. But for most people, they're not going to do that. So what I usually try to start with is a minimum of once a day. So the person needs to set a three to five minute timer and just perform whatever breathwork strategy we just dictated with that person. and perform it for three to five minutes. Now, I would really prefer that person to do this three to five times a day, especially if they kind of run higher stress, if they're a little higher anxiety, if their blood pressure is up. If they're basically anyone that we interact with in the clinic, most of those people would benefit from doing this a little bit more frequently throughout their day. And so I kind of describe it to them as an acute way of dropping your blood pressure, an acute way of dropping your stress. And if you can kind of titrate that throughout your day, you'll be able to stay a little bit more regulated. And so within that, I would really suggest spending a little bit of time mapping that person's day out with them, like helping them strategize. Here's where this could work, like perhaps before the baby wakes up, but perhaps before the kids wake up, perhaps at lunch, just finding a quick spot that they could do the quick three to five minutes of breathing. The beautiful thing is we're really only asking for five to 15 minutes of this person's day. which is a really small ask, but they won't be successful without your help figuring out where to put that in their day. So I think that's the biggest tip is really regardless of which of these strategies you choose, I think they all work well. Make sure you help that client figure out where they're going to put it throughout their day. and how to fit this into their habits. Once they start doing it, usually compliance is pretty decent because they feel so much better. So it's really just breaking down that first wall of compliance and I think being specific with your prescription and then helping them fit it into their day are the main ways that I've had success with that. So I think this is a really important thing that should be in a lot of our plan of cares, because you think about when people are so stressed, whether that's because they're in pain or just the other demands of being a human on planet Earth, most of our clientele tends to run a little bit higher stress. And so due to that, it's really nice to help them find that release valve in ways other than exercise or sleep. not that I don't want them focusing on that as well. Just another kind of focal strategy for managing these things. Again, personal experience and being prescriptive has been really helpful for me with. So just some actionable things to try in the clinic. So my big suggestion is breach this subject with people. Be willing to talk about it. Be willing to practice some of these yourself so that that way you have some personal experience with them and then help them fit it in their day. If you do those things If you're able to do those things, you'll have a lot more success getting compliance with breathwork with your clientele.

SUMMARY
That's all I've got for you all this morning, so just some really quick actionable strategies. Try some of these today in the clinic, whether that's on yourself or with a client. If you have anybody that seems really wound up, I would really encourage trying these things. If you're looking for some upcoming courses, I want to kind of just point you in the direction of the next few cervical and lumbar that we have coming up with ice. So if you're looking for cervical, August 24th and 25th will be over in Bend, Oregon, so on the west coast. If you're looking more in the middle of the country, September 7th and 8th, we've got Midwest City, Oklahoma, and then more on the east side of the U.S., October 5th and 6th in Candler, North Carolina, so right outside of Asheville. If you're looking for lumbar this weekend, we'll be right outside of Pittsburgh in Aspen Wall, Pennsylvania. August 10th and 11th, Longmont, Colorado. So right outside of Denver. And then August 17th and 18th, Grass Valley, California. So beautiful northern California there, not too far from Sacramento. So if you're looking for any courses, we'll be kind of all over the place these next few weeks. That's all I have for you all this morning, team. I'll drop that article that I mentioned in the comments of this video and let me know if you have any successes or issues with breathwork as you're implementing this this week. Thanks, team. That's all I got for you. Have a good rest of your Tuesday.

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

In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore highlights the ways the 2024 Paris Olympics are changing the narrative around motherhood for athletes and providing resources and support along the way

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

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

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

EPISODE TRANSCRIPTION

RACHEL MOORE
Guys, good morning. My name is Dr. Rachel Moore. I am here this morning representing the pelvic crew and I am so excited to talk to you guys about the Olympics and some pretty big stuff that's going on in the Olympics this year. The Olympics is huge in my area. Simone Biles actually lives like five minutes away from me, which is like my claim to fame humble brag. My daughter went to her gymnastics gym. And so if you've seen the Simone Biles documentary that's on Netflix, We were like fangirling and fanboying. We were watching it because we're like, oh, that's where Libby does gymnastics. So Olympics are a pretty big thing in our area, in our neck of the woods. And I think the Olympics this year are really interesting. And I wanted to get on this morning to highlight some of the things, especially when it comes to women in sport. that are really kind of setting apart this Olympics from ones in the past. If you didn't catch it, the opening ceremony was on Friday. It was a really interesting one because they were just kind of doing this parade of river boats down the river. And they incorporated all of these architectural pieces of France architecture into the opening ceremony. So it was pretty interesting to watch. And it just kind of set the tone for how different this year's Olympics are from a lot of the other Olympics in the past. So one of the key things that I think is really interesting, and I didn't even realize this until somebody else on faculty had shared a story about this, is that this is the first Olympics that has been almost equal representation as far as genders go. So the IOC set out to have a goal to have 50-50 participation between male athletes and female athletes. for this year's Olympics. And they actually just barely fell short of that goal. So the way it shook out with the amount of athletes that showed up and qualified and came to the Olympics was 51% male, 49% female. But that's pretty wild to see almost equal representation at this competition on a global level. A lot of us in the ice world are involved in CrossFit. We're kind of used to seeing that 50-50 representation. And that's one thing that really makes CrossFit unique compared to a lot of other sporting organizations. And so it's cool to see this transition or start seeing this change in this shift towards women in sport take this like worldwide platform where it's not a male-dominated thing and we're seeing more females represented and within that we're seeing more women that have children represented so motherhood is really starting to take a front row seat to the Olympics. So Allison Felix, who is the most decorated female track and field athlete, she's a US athlete. She actually made headlines a while ago because she lost her sponsorship with Nike when she told them that she was pregnant. And so that was this huge shakeup as far as women athletes and females in sport of, we are not a liability when we're pregnant. We're not less than because we choose to have children. And a lot of women, we see this a lot where People are delaying having children because of this athletic window and this fertility window kind of overlapping And so when athletes decide to start their families and then there's this response where they get dropped in their sponsorships, that sends us a certain message about what a female's role is and what her worth is in sport when she becomes a mother. And so Alice and Felix really spoke out against this and started this really amazing conversation about this overlap and about maternity leave and about just female in sport and how motherhood fits into that role. She took this to the Olympics this year. Um, so she's at athlete representative for the IOC and she actually started an initiative and it did great. And it's a thing now to open a nursery for mothers with young children at the Olympics. So historically the way it's always shook out in the past is that children are not allowed in the athlete village where athletes and coaches stay for the duration of the competition. So if somebody was breastfeeding a baby and also competing at the Olympics, they either had to choose to be separated from their baby for the duration of that competition, or they would have to kind of foot the cost of lodging for themselves. The problem with that is that Olympics is expensive and not everybody has the funds to even go compete at the Olympics. But then if we're thinking that somebody qualifies for the Olympics and now they have to pay for a caregiver maybe for their child and also they have to pay for lodging for their child or they're not going to be able to To be there that could make somebody not go to the Olympics that had qualified and had earned their spot So it's pretty cool to see this shift start happening. The nursery is actually sponsored by Procter & Gamble So Pampers is like branded all over it it's kind of funny if you look at pictures because they literally put Pampers and like every square inch that they possibly could and But it's a really exciting thing. So it's for children that are diaper age and below and their parents and their caregivers can go and kind of get away from the chaos of everything that's happening at the Olympics and have a quiet space to be together to spend time together. to bond. And then really a big thing is to nurse. The Tokyo Olympics, the last summer Olympics that we had, was right in the kind of height of the pandemic, or I guess kind of the downhill trickling of the pandemic, if you guys remember. And there was a lot of restrictions on the athletes. And so the athletes weren't allowed to bring support people, families, people had to stay behind. They were traveling with this like skeleton crew. And IOC The mothers to spend time with their children and to be able to nurse was Honestly pretty laughable. It was pretty wild if you if you just google like tokyo nursing room olympics Um, there's a picture of one of the athletes like two-year-olds laying on the floor And there's like a folding table with two folding chairs next to it And that's where the athletes would go To spend time with their children in between their events when they weren't training or they weren't preparing for the games again, if we're thinking about the message this sends that really tells people like you're here to be an athlete and everything else doesn't matter like we don't care that you also might be a mom oh it's it's okay you need a space well here's this like folding chair in the corner that message is so different this year the message the ioc is sending this year is that we recognize that the maternal timeline and the athletic timeline might overlap and your worth is not only as an athlete and we recognize that your worth also exists in motherhood. Allison Felix had this really cool quote. She said, I think it really tells women that you can choose motherhood and also be at the top of your game and not have to miss a beat. That's amazing. We preach that all the time in our division. We talk a lot, again, about how the fertility window and the athletic window overlap. And what we're starting to see is this trend of women pushing back and saying, yes, we can still be athletic. Yes, we can still be in the top of our sport. and also show up for our families, and also feed our babies, and us be their primary source of nutrition while we're training for the Olympics. So it's really cool to see this take, again, a worldwide platform to acknowledge that these things can exist at the same time. There's a couple other countries and groups that are showing up for their athletes as well. So the French Olympic Committee is actually paying for hotel rooms for their breastfeeding mothers. to stay in so again before athletes would stay in the athlete village with their coaches partners and babies would stay elsewhere they couldn't go spend the night with them they had to be in the athlete village so the french olympic committee this year has started an initiative where they're paying for hotel rooms for nursing mothers where they can go spend the night with their baby their partner can be there as well so kind of minimizing this interruption between this mother-baby bond and what's really cool is that they made a statement that this isn't just because quote-unquote the Olympics are here in our home ground This is something that we want to see carry over into future Olympics. So they're really again just kind of setting this example that motherhood matters and that we can do both. So really exciting to see when we look at the numbers. The US has 338 women on their team, which is the highest amount of women. on an olympic team france has 293 so these top two countries as far as women and female representation are really just showing up for all uh seasons of females lives um from what i could find i was trying to google like exactly how many moms are on the olympic team and um i even asked chat gpt i was like what percentage of olympic athletes are moms And it was like, we don't have that data. But I did see several articles that said that this year the USA team has 16 moms that are representing the US and five of them are on the basketball team. So kind of astounding that out of 338 athletes, if that number truly is 16, that's pretty wild. But again, it's really cool to see that representation and that acknowledgement as a whole. it's really exciting that we're seeing this culture shift that we have believed in and we have seen again in the crossfit world with annie thora's daughter and now tia and all of these top athletes really embracing their motherhood and talking about how motherhood has affected them as an athlete and watching this happen not just in the crossfit world where we all kind of live and spend time but in athletic world as a whole is so exciting and I just can't get over the fact that the Olympics, which is this massive platform that so many people are tuning into, are really highlighting and bringing attention and awareness to the fact that these athletes are also mothers. These athletes are doing these things simultaneously and it can be done. It's a really exciting message We are all about it here at ICE. We are here for it. We're excited to see it continue. And here's hoping that at future Olympics, we only see these accommodations grow between other Olympic committees, other country delegations, and that this nursery just continues to take off and that the athletes really enjoy it.

SUMMARY
If you guys want to hop in to our pelvic courses, we have a lot of chances to catch us in September. So we've got Hendersonville, September 7th and 8th, Wisconsin, September 14th and 15th, and Connecticut, September 21st and 22nd. So a lot of ways that you can come hang with us on the road in September. Our next L1 cohort starts September 9th, and our next L2 cohort starts August 19th. So if you're interested in an ice course, especially in that pelvic division, Head on over to PT on Ice and sign up for your course. Otherwise, keep an eye on the Olympics. If you guys have a favorite sport, comment it below. Let me know what it is that you're going to be watching. Obviously, I'm going to be all in on gymnastics because Simone Biles is essentially my neighbor, even though she's really not. But trying to get my daughter into horseback riding, so I keep hyping up all these equestrian things. so that she falls in love with horses. It's not working yet. We'll see. You guys have a great week. I hope you guys crush it. Thanks for tuning in. Bye.

OUTRO
Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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 how effective the strict press & front squat are in developing maximal performance in the clean & jerk and snatch.​

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
Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. We hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as a lead faculty in our fitness athlete division. It is Fitness Athlete Friday. It is the best darn day of the week. We talk all things CrossFit, Olympic weightlifting, powerlifting, bodybuilding, running, rowing, biking, swimming, If you are working with an individual who is active recreationally, trying to be competitive, whatever it is, Fitness Athlete Friday is full of tips and tricks for you. Today we're going to be talking about Olympic weightlifting. Olympics start today. Opening ceremony is just a couple hours away, 12 Eastern. And we'll be watching America's Olympic weightlifters take the stage in a couple of weeks on August 7th. And so talking about if we only could do two exercises to have a significant improvement on our Olympic weightlifting, what those exercises might be. We certainly see a lot of interesting suggestions on social media about ways to improve our performance, improve our technique, improve our clean and jerk and snatch.

WHAT DOES THE RESEARCH SAY?
But if we look to the research, what is actually the most effective? So today, we're going to be referencing a paper from Arthur Zetshin and colleagues back from 2023. In the Journal of strength and conditioning research, the title is associations between foundational strength and weightlifting exercises in highly trained weightlifters support for general strength components. And so we're going to talk about what this paper is, what this paper looked at, what this paper found, analyzing the outcomes of this paper, and then how to take those and apply them in the clinic, in the gym with our patients and athletes. So, with this paper, what was the research question? The research question, is there an argument for doing some specific general strength movements that would translate to higher skill, higher technique barbell movements, specifically in Olympic weightlifting, the clean and jerk and the snatch. And if those movements exist, what are they and how much do they contribute to the performance of the clean and jerk and the snatch? And so this paper, looking at it really quickly, took 19 highly trained Olympic weightlifters. They all had been performing Olympic weightlifting training for at least five years. and had them perform a one rep max of a couple different movements across the two week period in randomized order. So they asked them to max out their clean and jerk, max out their snatch, max out their deadlift, max out their strict press, and max out their front squat, and across 14 days, every couple of days, perform one of those max attempts, and then analyzing the data and trying to observe any sort of relationship in the variance between performance on what we consider the power lifts or the strength movements, which would be the deadlift, the strict press, and the front squat, and then compare that to how does that translate to what that person's max clean and jerk and what that person's max snatch is. And some really interesting data here, finding that 59% of the variance of the contribution to the clean and jerk is associated with maximal strict press and front squat strength. And that 62% of the variance in contribution to performance on a snatch is also associated with maximal performance on a one rep max strict press and front squat. And so finding in this paper that there is really no association at all between how strong someone's deadlift is in their performance on the clean and jerk and snatch. And you might think that's interesting because I might assume somebody who has a heavier deadlift should be able to have a heavier clean and jerk or snatch. But as we've taught in Fitness Athlete in our Level 1 course, our Level 2 course, our live course, for many, many years, when we really dig deep into the research on what's happening with the deadlift, we know it's not a pull off the floor and neither is the clean and neither is the snatch. That when we take somebody, whether they are going to just deadlift to the hip or whether they're going to bring that barbell, to the front rack position with a clean or all the way overhead with a snatch, that first pull off the floor is really kind of a misnomer to call that a pull. That is a press off the floor and we have several studies that look at EMG activation in the body of what is happening with a deadlift, what is happening with the first pull of a clean or snatch. And we know that the quadriceps are the most active muscle during that first pull. And that tells us it's not a pull, right? It is a press off the floor. That's how we instruct athletes in the gym, patients in the clinic, that this is a press off the floor. Imagine you're sitting on a leg press machine. If we took you in your deadlift setup position and rotated you 90 degrees, got rid of the barbell, put the weight on a plate underneath your feet, you would look like you were sitting on a leg press machine. And so it is a press off the floor. And so it makes sense that because it is a partial range of motion press off the floor, that it just does not contribute as much as we might think to our clean and jerk and our snatch performance. But finding that we had moderate to high correlations between strict press and front squat strength with both clean and jerk and snatch performance. So why is that? Why these lifts? How can we interpret that analysis? When we really think about what a clean is and what a snatch is, Try to keep it simple, especially in the CrossFit realm where people may have never been exposed to these movements before. Often our cueing is very simple. Hey, a clean, we're going to jump off the ground and land in a front squat. A snatch, we're going to jump off the ground and we're going to land in an overhead squat. And so Olympic weightlifters already do a lot of front squats, they need a lot of thoracic and shoulder strength, they need to keep their clean as close to the front squat as possible, because that is half of their score in Olympic weightlifting, right? Just two movements clean and jerk and snatch, you got to be got to be good at both of them. Likewise, a snatch is a jump into an overhead squat. And while the study didn't look at performance of overhead squat compared to snatch, It makes sense that a front squat would pair really well with a snatch. When you think about the receiving position of a snatch, a very vertical torso, very strong, stable shoulder position, it requires strength and mobility out of every joint in the body. You need to have excellent shoulder mobility and strength. You need to have excellent thoracic mobility and strength, excellent hip mobility and strength, excellent knee and ankle mobility and strength. a really, really vertical torso position in the bottom of that snatch. And so that front squat really sets us up a strong, tall, vertical torso position. We are training our legs in a squat pattern. We're working on our thoracic and shoulder strength and mobility at the same time. And so it checks a lot of boxes that we see and makes sense that it translates well to the snatch position. What we see, though, in a lot of other research is that we always look at the back squat, and we look at relationships between back squat strength and Olympic weightlifting, and we often find almost no relationship. And that also makes sense. Back squats tend to have more of a forward torso, more of a hinge-dominant position, especially if somebody is a powerlifter, in a way that just does not translate as well to movements like the clean and the snatch. And so understanding that it makes sense that these relatively simple, boring movements, the strict press and the front squat are showing to be really good developers for our clean and our snatch.

APPLYING THE RESEARCH
So what can we do with this data? What does that help us do in the clinic, in the gym with our patients and athletes? Well first things first, you're probably not going to blow any Olympic weightlifters mind if you tell them they need to get a stronger strict press and they need to get a stronger front squat if they want to be a better Olympic weightlifter, right? Most of them are probably gonna say, yeah, I knew that before I came to this appointment. Do you have anything else for me? When we look at folks who are training specifically Olympic weightlifting, they are already doing a lot of overhead lifting, they're already doing a lot of squatting, often several sessions per week, right? It's not uncommon to find competitive Olympic weightlifters performing some combination of back squats, front squats, overhead squats every other day throughout their week as they're training. Likewise, they're doing a lot of strict press, they're doing a lot of push press, they're doing a lot of jerks, they're doing a lot of accessory work that's going to reinforce overhead lifting. and squat patterns as well. So you're probably not gonna really rock the boat with a true, dedicated, even recreationally competitive Olympic weightlifter and definitely not somebody that is trying to be a professional or is already a professional Olympic weightlifter. They are hopefully already doing all of this stuff in a way that you don't have a lot to intervene on. But outside of that, somebody who maybe wants to get more into Olympic weightlifting, and especially with our functional fitness athletes, our CrossFit athletes who are doing clean and jerk and doing snatch as part of their CrossFit training, they always want to have a heavier clean and jerk and a heavier snatch, right? If they're coming to you and saying, is there anything I could do? I have an extra 30 minutes a week. I have an extra hour a week. I really want to get a stronger clean and jerk and a stronger snatch. For that population, it's tough to recommend to them just do more clean and jerk and snatch. because they're likely already doing it as part of their CrossFit training and they may even be doing it throughout the week in different variations, right? To be doing a high repetition, low load, power snatch and then metabolic conditioning workout and then maybe to maybe later in the week doing a strength piece that looks like higher load, lower volume snatching focused on developing the snatch. So it'd be tough for that person to recommend that they somehow find time in that same week to do more snatching. Instead, what is going to be a really effective and safe recommendation as far as not introducing too much volume to that equation is to recommend to that person, hey, find some time to do more strict press and more front squat. We talked a lot back in episode 1745 back during deltoid week of the importance of the strict press for developing the deltoid, that the deltoid is the powerhouse of the shoulder, but strict press is often neglected or completely ignored in programming. People skip strict press day when it's at the CrossFit gym. They may skip it when it shows up in accessory programming because it's not fun, right? They may do a push press or push jerk or split jerk instead. which doesn't really help improve our clean and jerk as much as it could and our snatch as much as it could because we're not training the shoulder as much as we're now training the legs when we transition to a push press or a jerk motion. Way back, episode 1567 with Midge Babcock, the title of that episode, Don't Be a Jerk with Your Jerks, he covered a lot of research that shows as we transition to that push press, as we transition to that jerk, we're now using 60 to 80% from our legs to get that weight overhead. And so we're not really developing true shoulder strength as much as if we do the strict press. And so just recognizing with that CrossFit that functional fitness population, they're probably skipping or not doing really foundational strength movements like the strict press, And like the front squat, because they are seen as boring, right? They are seen as maybe repetitious. But that is kind of the point that by doing those things more consistently, more frequently, we're going to bump up our front squat strength, our strict press strength, and we'll see a nice translation to improvements in our clean and jerk and snatch. alongside also continuing to do the clean and jerk and the snatch. And so my recommendation for a lot of folks who come to see me for help with maybe performance of what can I do, I have some extra time, is to give them some sort of undulating program that allows them hopefully in the span of the same week to touch a clean, touch a jerk, touch a snatch, a front squat and a strict press maybe even within that same week. And so, teaching those patients, those athletes, of how to optimize their sessions. Of hey, if you're gonna go into the gym, and you wanna introduce more of this stuff, what does it look like? It looks like we should do the Olympic lift first, we should do the power movement first, because those muscle fibers are gonna be the easiest to fatigue, and the longest to recover. So if we're going to clean or snatch that day, we should do that first. We can follow that up with what we might call a power lift, a strength movement. we don't need to be as explosive with those movements, those fibers are not as fatigued. And so we can do something like a clean, and then do a front squat, we could do something like a snatch, and then do a front squat, we could do a clean, and then we could do a strict press. And then at the end of the hour, towards the end of our session, whatever our timeframe might be, we have time for maybe a conditioning piece, if we're a crossfitter, and we want to keep working on our metabolic conditioning, or maybe just some extra accessory work to further develop leg strength, overhead strength, core strength, all the stuff that we need to be a really solid Olympic weightlifter. And so that might look like moving back and forth between power variations of the snatch and clean and adding in extra front squatting, making sure that we're not squatting too much, we're not lifting overhead too much, and just trying to find them a nice blend where they can add in some extra volume without increasing their risk for injury in a way that they're gonna find that time well spent and see those clean and jerk see those snatch numbers go up. And I always love when somebody just wants to do weightlifting, they don't want to do any conditioning that day or anything else. I love my favorite piece for developing overhead strength. Every two minutes for 15 sets, you're going to do five sets of three reps of a strict press somewhere between 70 80% of your max. You're going to transition to five sets of three push press, again, somewhere 70 to 80% of your max push press, and then finish out same rep scheme, same idea with the jerk. And so as our shoulders get fatigued, we bring in more and more of the legs in a way that overloads the shoulders really nice and gets us a nice 30 minute weightlifting session. And so that can always be beneficial for patients as well.

SUMMARY
What can you do? What can you advise someone when they want to improve their clean and jerk and snatch and they're not already a professional elite Olympic weightlifter, share with them that the most bang for their buck is going to be working in more strict press and more front squat into their training. Ideally, if we can do that every week, increase that consistency, increase that frequency, we know that's going to be a way that's going to productively overload the system. We know the research supports that those two movements have the highest contribution to performance on the clean and jerk and snatch, and that's really where we can help athletes work that into their programming and see them develop the clean and jerk and snatch the way they want so that they can hit new PRs. Team, if you like to learn about this stuff, if you like to hear about this stuff, our next class of clinical management fitness athlete level one online begins this next Monday. We have about eight seats left. Those will definitely be gone by the end of the weekend before the class starts. That literally happens every cohort and has happened for every cohort for many, many, many years. So don't be that person that emails on Tuesday morning. We're going to have to tell you the class is full. And then if you've already taken Fitness Athlete Level 1, Fitness Athlete Level 2, start September 2nd after Labor Day, and that class is already over half full, that'll probably be the last class of Fitness Athlete Level 2 for the year, so don't miss that one if you're on your way to working towards your Clinical Management Fitness Athlete certification. That's all I've got for you this Friday morning. I hope you have an awesome weekend. Enjoy the opening ceremony, the start to the Olympics, and keep an eye out for Team USA lifting on August 7th. Have a great Friday. Have a great weekend. Bye, everybody.

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

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the current state of healthcare & rehab as an industry, who the big players are, what (if anything) is being done to change things, and how individual therapists can begin to affect meaningful change

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

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

EPISODE TRANSCRIPTION

ALAN FREDENDALL
Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. We hope your day is off to a great start. My name is Alan, the pleasure of being our Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete and Practice Management Divisions. It is Leadership Thursday. We talk all things practice, ownership, business management. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday comes directly from ICE's CEO, Jeff Moore. sent this to me last week said hey I was just goofing off in the gym trying to get some lifting and cardio in together and so he sent me a workout of 100 bench press with the weights on the barbell 135 for guys 95 for ladies and a hundred calories on a fan bike for guys 80 for ladies with the caveat that you can break up that work however you like you can Do 100 bench press straight through, 100 calories on the bike straight through. You can break it up into 10 rounds of 10 and 10, 20 rounds of 5, 5, 5. Whatever rep scheme suits your fancy, you are allowed to do that as long as you get all of those bench press and all of those calories done. that bench press weight should be light to moderate for you enough that you could potentially do five to ten reps unbroken. If it's so heavy that you could only do maybe singles or doubles or triples it's going to take you a long time to work through a hundred so keep that in mind. Other than that just pace yourself on the bike. There is no use racing that bike to finish a couple seconds maybe faster than normal only to lay on that bench for 30 seconds before you feel like getting some reps in. So just treat it a moderate approach on that bike and hammer out that bench press as able. So that is Gut Check Thursday. Today we're talking about changing the status quo. What does that mean? We're talking about the status quo as it is across healthcare in general, but of course specifically to rehab today on PT on ICE. So we're gonna talk about what is business as usual in rehab, who are the major players, We're going to talk about what is currently being done to address some of the issues across the rehab professions and again in particular physical therapy. And then are there more effective ways to try to change things.

WHAT IS BUSINESS AS USUAL IN REHAB?
So let's get started first by talking about what is business as usual. And in the rehab industry, the healthcare industry in general, we have what is really going on across pretty much every industry in the country of a slow merger acquisition consolidation of small to moderate companies being bought out by larger companies and slowly paring down the amount of organizations who really offer the same or similar service. A good representation of this is the airline industry. We only have four major airlines left. Southwest, Delta, American, and United. 20 or 30 years ago, there were over a dozen. And in the wake of some of the IT issues we had last week, we may even see that Delta and American could be going away soon if they don't fix their IT infrastructure and get their feet back on board. And so we see that there are just a handful of major players in the industry. And we would label those too big to fail kind of organizations. We have the same phenomenon going on in physical therapy and again in healthcare in general. When we look at healthcare, when we look in particular at rehab, we really have four major players. We have health insurance companies that control the care that patients are able to receive. and the amount of time providers have to spend paperwork wise on providing that care and also the amount of money that providers get. We know that almost every American has health insurance and so that health insurance for the foreseeable future is going to be part of the equation and therefore these health insurance companies are a big player in this industry. We have just a handful of health insurance companies, about 10, that generate $1.3 trillion collectively and employ over half a million people, with an average profit increase every year of about 9% year over year. And these 10 companies insure about three-fourths of Americans. So again, a very consolidated, condensed industry. where if any of those companies were to go out of business or something, it would have a lot of ramifications for the economy, for patients, and for providers. And so health insurance companies stand as one of those too big to fail type of organizations in this equation. Right after health insurance companies are health care companies. Large, national, across state lines, corporate, health care clinics, whether they are primary care clinics, dental clinics, urgent cares, physical therapy clinics, whatever, we see the same issue across all health care professions is that over time we are slowly paring down that the vast majority of clinics are owned by a large corporation and that usually as we get near the top of these organizations, Nobody involved in the leadership or management of the company is actually a healthcare provider. And so these are large, for-profit clinics that provide some sort of healthcare treatment. In the rehab industry and physical therapy in specific, just eight companies are closing in on owning 75% of all outpatient physical therapy clinics. And so that's very similar to health insurance, right? A small amount of companies own the vast majority the organizations and clinics within the industry. We have universities as our third player in the equation. They are responsible for educating entry-level students and getting them prepared to become new clinicians. They certainly have a stake in the equation here. And then finally we have the government itself. That can be kind of vague when we say the United States government. We're kind of really referring to enforcement organizations, Medicare, IRS, who are trying their darndest to try to regulate the other three organizations, big players in the industry. And what we find when we look at the intersection of all these giant, large, too-big-to-fail organizations is that we find that Over time, they have become intertwined. They have developed a symbiotic relationship with each other such that it would be really hard to affect significant change on one piece of the puzzle without it affecting everything else downstream. We see that universities have grown their cohort sizes so much that they are now graduating hundreds. Hybrid programs with multiple cohorts starting per year are getting close to graduating thousands of physical therapists per year. And all of those students need clinical placements. Those large corporate health care clinics are happy to take those students and put them to work for some free labor. I think we've probably all experienced that. at one point or another in our student career. And when those universities grow these cohort sizes, they begin to need those large clinics to have places to send their students to. And those clinics rely on those students, again, as part of their labor force alongside their staff therapists as well. We see that health insurance companies need, at some level, some providers to take their insurance so that they can offer to their customers, our patients, that there are some providers who take your insurance. If we get to a level where no one is taking insurance, health insurance companies are gonna be in a lot of trouble, and so we see that they are trying to hang on and kind of fight back against a shift across healthcare towards cash-based physical therapy and trying to go around the insurance system. And then finally we see that the United States government hasn't necessarily quit trying to enforce curb all the fraud waste and abuse in Rehab in health care in general what we see is they've kind of changed their policy over the years instead of throwing people in jail or busting up companies or that sort of thing that they have shifted their strategy to just collect fines right if they can't and stop it, then they will collect a piece of the revenue that all these different organizations are making. And so you see that fines are becoming much more popular than actual legal action when the government tries to get involved in significant issues with fraud, waste, and abuse in healthcare. So that's business as usual currently. Universities pumping out students, big corporate clinics taking students, offering students a job, health insurance companies playing both sides against the middle and then the government just trying to come in and take a little bit off the top at the end of the day. And really what we see happening is at the end of the day, there's really no impetus to change business as usual, the status quo among those four groups. It is working well enough that there is no significant push to really change things.

WHAT IS BEING DONE TO CHANGE THINGS?
What is being done to change things? You may have noticed what we did not mention in one of those big players was an organization like the American Physical Therapy Association. Not much is being done here because not much can be done. If we take a second, and please don't hear that this episode is just an episode designed to dump on the American Physical Therapy Association, but structurally it is not designed to hang on and try to enforce or weigh in or make any sort of decisions or affect really a lot of long-term change on any of the issues we see among the big players in our industry. That when we look at what is the APTA, really it is a non-profit member organization. It's not a charity. It's not a church. It's a member organization, it's a non-profit, it doesn't pay taxes, and so at the national level it really can't affect change. Nothing about our profession is regulated on the national level, it is all regulated on the state level. Your scope of practice, whether you can manipulate the spine, dry needle, whether who can prescribe exercise, who can do cupping, who can do blood flow restriction, all those different scope of practice issues are all handled by individual state legislations. And because of that, the APTA cannot really weigh in. They can also not weigh in because they can't legally weigh in. When we look at how the APTA is structured, it's structured as a non-profit corporation. It is forbidden by law, as is every non-profit company, every church, every anything, from engaging in political activities. So what the APTA has is a secondary organization called the PT PAC, the Political Action Committee. That is an entirely different organization. It's an entirely different pool of money. And that is the group that can try to lobby for things like mitigating Medicare reimbursement cuts. But that in general, on the national level, by design, it can't be effective. And just being an APTA member without donating any extra money to the PT PAC itself doesn't really allow us as individual clinicians to help the APTA effect change either.

HOW DO THINGS ACTUALLY GET DONE?
So, how do things actually get done then? Things really get done in our profession at the state level. State legislation, changing scope of practice, doing things like expanding direct access, opening up the ability to dry needle. We saw Washington just get access to dry needling a couple months ago. That was a state-led initiative from the clinicians in that state, from the state physical therapy chapter, and from the state legislature in Washington. That is how things actually begin to move around in our profession. And the unfortunate thing is you cannot join, just join your state chapter. You have to join the APTA and then also join your state chapter at the same time. So you can't be a part of just your state without being a part of the national organization, which I personally believe is a little bit unfortunate because I'd rather see my time and money go towards the organization that's going to affect the most change, which is going to be my state chapter. A really good example right now, we're close to completely removing direct access restrictions here in Michigan, and that is led on the state level. A guy over on the west side of the state, Dustin Karlich, he is pushing that initiative with the Michigan State Physical Therapy Association through the Michigan State Legislature, and we're hoping that that gets heard in the fall meeting of the state legislature. and that we have direct access restrictions completely removed here in Michigan. And again, that is all done at the state level, not at the national level. So what can we do? What can be done? If that is the status quo, if that is what is currently being done, and most of it is being done at the state level, What can we do to try to change the status quo? We hear a lot here at ICE, you know, what is being done about this issue? What is being done about that issue? And the truth is, not a lot, right? We're not expecting to see reimbursement probably go up ever again. We've talked about why that is. The math just doesn't math with that. And so if we can't meaningfully affect the change that we want to see, especially at the level that we want to see it, what can we do as individuals and what can be done to try to change things in our profession? The first is to recognize, like, hey, we're in a Cold War event, kind of, right? These big organizations that don't really want to change things are pitting themselves against each other, and again, they don't really have an impetus to change. We see a lot of proxy fighting going on, arguing back and forth about who and who cannot dry needle or use cupping or blood flow restriction or whatever. We kind of have these proxy fights across the country. We go back and forth constantly. And the truth is, we need to recognize, hey, how did we actually win the real Cold War? We've significantly changed our strategy, right? How did we do that? We stopped expecting that doing the same thing over and over again would create meaningful change, right? We stopped going into small countries and propping up a government to fight against the Soviet Union. We recognized after 50 years of that, that that wouldn't work. What we did instead was we shifted to focus on our economy, we shifted to focus on being self-sufficient with natural resources, and we went an economy-driven strategy instead of a military-driven strategy, and that's what actually ended the Cold War. We see a very similar recommendation here inside the PT profession. What is the strategy? Literally anything except what we're trying to do, which has not worked in decades. This is one of my favorite books of all time. This is a hefty book. None of you are probably going to read this. That's okay. This is Army FM 7-8, Field Manual 7-8. It is infantry tactics. What I love about this book is probably a thousand pages of how to fight a war. What I love is that almost every section starts with, if what you're currently doing is not working, stop trying to expect a lot of change by doing the same exact thing over and over again. Change your strategy, right? Do the unexpected. There is a whole page in here on how to react to an ambush and the first sentence is, if ambushed, attack back immediately. Why? It is the unexpected thing to do. We have to do the same thing in physical therapy. Do the unexpected strategy because the expected strategy, the thing we've been trying, for the past 50 years or so has not really changed anything and we should not expect that doing the same thing over and over again will affect any sort of meaningful change. If we just stick our head in the sand and say, certainly someone is going to fix all of these issues soon, we should not expect that those issues will be fixed anytime soon. So, what are our recommendations? Support your local state PT association. You can't join it directly, but you can support your state PT PAC, your political action committee, which means that you can give money to your state physical therapy association that they can use to pass meaningful legislation in your state. So if you're in a state and you want access to dry needling, you want access to spinal manipulation, cupping, blood flow restriction, you want better direct access, you want whatever, it's going to change most likely at the state level and so support your state level association. As an industry, as a profession, we need to recognize that slowly over time, we're moving towards a state where it is not going to be possible to accept every single insurance and run a sustainable and profitable practice that lets us pay our therapists what they need to make to make a decent living while working at a reasonable volume, right? We have moved over the years from 40 patients a week to 60 patients a week to 80 to the average now is climbing towards a hundred patients a week that is Unsustainable and the again the idea that we can just do the same thing over and over again and expect change is not going to happen we're not going to to really make any meaningful change by trying to see a hundred patients a week or 120 patients a week and to try to generate more money to be able to pay more people. There are limits to how much you can get, how much you can work, and we need to recognize that over time, if things don't change with insurance, we need to let that ship sail. That is a tough transition, that is a hard transition, but it is a transition that is going to have to happen to some degree at some point in time for almost every physical therapy clinic in the country. unless things meaningfully change. How can those things change? There are systems in place for us to report our outcomes and increase our reimbursement from insurance. Almost nobody does that because it takes time, but it is possible. We're going to see our reimbursement here at our clinic here in Michigan go up 20% in 2025 because we are reporting our outcomes and And we are getting rewarded with more reimbursement. So there are systems in place, but if you don't want to use those systems or do those tasks, you need to recognize that you need to let that insurance ship sail. And it means that you're not going to be on it. And then over time, we'll need to probably pare down our insurances and potentially be cash only across the majority of the profession. And then as individuals, what can we do? Yes, we can support our state physical therapy association and state PT pack, but we can also stick up for ourselves. Every time you go to work for somebody that overworks you and underpays you, you confirm to the leadership of that organization that there is another sucker out there who is willing to accept that, right? And we just perpetuate the cycle that we have been trapped in for many decades. And again, what is the best strategy? Anything different than what we're already doing. So when you are given that quote unquote opportunity from that organization, and it looks terrible, don't take it. There are 34,000 physical therapy clinics across the country. Find a different one. There is a clinic for you that is going to pay you well and respect your time and autonomy. I guarantee it. It just might not be three minutes from your house, right? We sometimes need to choose a little bit of discomfort to make a meaningful bump in our own individual practice and our own individual work inside of the bigger profession.

SUMMARY
So changing the status quo, recognizing we're kind of stuck in a cold war with several organizations that are too big to fail, that don't really have an impetus to change what they're doing because it's working well enough for all of them. What is being done currently? Not a lot on the national level because it can't. We have to stop expecting that black helicopters with agents in suits from the American Physical Therapy Association are going to drop out of helicopters and just fix things. There are only 160 people that work at the APTA. Almost all of them are administrative roles. There are very few people there that are doing a lot of of groundwork because the groundwork of our profession happens at the state level. So what can we do to support that? Support your state physical therapy association. If you're like me and you don't want to join the American Physical Therapy Association just to support your state association, you can still support your state's physical therapy political action committee PAC PAC by donating money. If you go to that website I think you'll be surprised by how few people donate and in reality how much gets done at the state level with a relatively small amount of manpower and money and that if we all just gave a hundred bucks to those organizations I think we'd be really surprised at how much more change we see affected if only in our individual states, but how effective and how large that change could be across our profession. So, when in doubt, if your courage strategy is not working, literally do anything else, right? Write from the Army Field Manual. If you are being ambushed, attack back because that is the strategy that is least expected. Do something different. Go around insurance companies, support your state political action committee, and stop working for employers who don't respect your autonomy and who don't respect your livelihood, who are trying to overwork you and underpay you. That's all we have for today's episode. I hope you found this helpful. I'd love to hear any discussion you all have about this. You can leave a comment here. I'll be back tomorrow. We're gonna talk about Fitness Athlete Friday, how to develop really brutal strength in a way that translates to improvements in your Olympic weightlifting. So we'll see you again tomorrow morning. Have a great Thursday. Have fun with Gut Check 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 the ins & outs of daily life as an acute care physical therapist.

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
Welcome to the PT on ICE Show brought to you by the Institute of Clinical Excellence. My name is Julie. I am a member of the older adult division. Thank you for spending some time on your Wednesday morning with me. Let's dive right in. So one of the most common questions that I receive from students and clinicians is is asking me about acute care. Should I go into acute care? Should I choose home health over acute care? And I'm having a lot of conversations with folks about pros and cons. and sharing my reflections from having been in acute care and home health and inpatient rehab and outpatient and private and home with older adults. So I figured I would do a podcast and bring all these thoughts that I've been having in these individual discussions to all of you. Okay, so what I'm going to do is I'm gonna go through a list of five to seven things that I believe are the most important characteristics of acute care and will help you decide if acute care is the right setting for you and if you are going to thrive in that setting. Okay, so number one, this is what I believe is the most important characteristic that sets acute care apart and will be the biggest factor in helping you determine if you are going to thrive in this setting. All right, number one is that in acute care you have complete autonomy over your day. You have complete autonomy over your schedule. This ended up being The reason why I feel like I thrived the most in acute care is because I wanted full autonomy over how I structured my day. So let me explain what that means. So when I was working in the hospital, I would walk into work, you clock in, and you are more than likely going to be given a list of patients. It is then up to you to decide which of those patients you're going to see. Are they appropriate to be seen? So you're doing some triaging there and you have autonomy to make that choice. And then you get to decide, most importantly, what your day looks like. When do you go see those patients? And this was so key for me. I don't like to be in a box. I don't like to be back to back all day. I like to create my own day. And so I would look at my list and depending on how intense or complex the patients were, depending on my energy levels for the day, I would decide, like, okay, I'm going to knock out a bunch of my patients in the morning. Back to back to back, get it done, and then go eat lunch, and then in the afternoon when my energy stores are down, that's when I do the majority of my documentation. So my afternoon, I wouldn't really have to see any patients, maybe one, and the majority of it was documenting. Or if sitting around and documenting for a long time is something that fatigues you, you can do a system where you go see a patient, then you document. You see a patient, then you document. So if you are someone who really needs that energy reset after pouring into a human, typically one that's very sick and there's lots of complexities and you need a little bit of a break and a breather, you can set your day up so that you get that break after every single patient or perhaps after two patients. So you really have a lot of flexibility there. I remember I was the type of person who I would love to knock everyone out in the morning. I would go find a quiet room or a room that was near some natural light. I would put my music on and I would just sit there and document. So you have full flexibility there. When you look at other settings like inpatient rehab, you are back to back to back to back. It's one of the things that I liked the least about the setting is that I did not feel like I had autonomy over my day. And I realized that that was professionally a big core value of mine. And then if we think about home health, you do have a lot of flexibility. You schedule all of your patients yourself. However, I learned my experience was that that was a big burden for me and I never really knew what I was walking into. I didn't get the choice of who was on my schedule. Scheduling patients was typically fairly time-consuming and frustrating when you're trying to reach out to all these people and they may not be answering and you're trying to very efficiently, Tetris them into your schedule so that you're not driving all around your region. Trying to schedule patients became just this extra task that really stole a lot of my energy. So after having been in multiple settings, I think that was the biggest plus to acute care. And if you are someone who likes to have that flexibility and you feel you can be efficient and effective and productive by making your own schedule, then acute care may be the setting for you over other settings. Okay, that's the biggest one. Number two, When you work in acute care, you learn how to be a master of scale. You have to learn how to come up with unique and creative loading strategies because you are in an environment where you don't have weights. You are in an environment where maybe you are just stationed to the edge of the bed because your patient is, they have tons of lines and tubes attached to them. So you have to figure out how to do a lot with a little. And that skill right there has become, it became my superpower going forward into every other setting. I never encounter a time where I'm with a challenging patient, they're complex, or we are in a less than ideal setting, for example, someone's home, and I have never felt I'm stumped. I don't know how to bring a fitness forward approach to this person. I can't come up with an idea. I don't have weights, and so I just don't know what to do. That has never happened. And the reason for that is because over several years, I learned how to get incredibly creative. So in the acute care setting, that could be as easy. I carry around dumbbells in my backpack. and I'm like rucking through the hospital, I bring my own equipment. We paused, we paused, we're back. That could also look like the, this is my favorite hack, the toiletry buckets that are typically filled with shampoos and soaps. I dump those out, roll up towels, soak them in water, put them in the toiletry bucket, and now that becomes a little bit of load, I would have folks deadlift that toiletry bucket, press it over their head. That was one of my favorites. I would use the tray table for a sled push. I would turn the hospital bed into a total gym and put it at an incline and have them reach at the bar above their head and they're doing pull-ups or I'm having them basically do a leg press with the hospital bed. I just was able to always find a way to bring that fitness forward approach and the acute care setting really forces you to get creative. And that was just such an amazing skill that has carried me through every single setting with every single patient that I've had throughout my career. So that's number two. Okay, number three. You do not, for the most part, have to take any work home with you. Yes. How nice does that sound? So for a lot of you who are in other settings and you typically at night, you get home from work, you maybe go to the gym, you eat your dinner and then you're like, well, here's my glass of wine and I'm going to sit down and I have one to two hours of documentation to do. That is not something that is typically happening when you are in acute care. Now in the very beginning as a new grad, a hundred percent, I was taking documentation home for me. But the vast majority after that learning curve, you know, after I got through that steep learning curve, I was not taking any work home from me. With me. You actually get to leave work at work. The administrative burden is very, very low. The EMR is very easy. It's a very low, low, low documentation burden. Something that I didn't know and I learned when I went into home health is that my god, documentation burden was enough for me to, was a big reason why I quit home health. I truly was so frustrated and cognitively overloaded by how extensive the documentation was that I could not even be present or enjoy the time with my patients. And for me, that was enough to say this setting is absolutely not for me. So if you are someone who you're really trying to create a barrier of when I'm at work, I do my work and I do a fantastic job. And then when I'm out, I'm off, I'm done. You go home and your energy stores go to your partner, they go to your friends, they go to your family. Acute care is definitely a setting where you can more easily create those boundaries. Okay, documentation burden low, that's number three. Number four, you are gonna do a lot of things in acute care that don't look like traditional therapy. Okay, so what I mean by this is that your role beyond improving someone's mobility and getting those sick patients, those, you know, individuals who need to get out of that bed and trying to start to get them stronger. Beyond that, I would say The majority of my time was actually spent being a fierce patient advocate, a fierce patient advocate. That is truly what my role became. And I actually evolved to loving that part of the role even more sometimes than going in and doing the functional mobility strengthening stuff. I thought it was such a beautiful opportunity to be able to advocate hard for my patients. So in MMOA, we call that significance over sexiness. You're not always going to get this patient doing squats or deadlifts or bringing in weights, but what you can do is you can fight to the end so that your patient can get over to inpatient rehab. I will never forget one of my first patients that I experienced working on the trauma floor was an individual who had a spinal cord injury. He fell down the stairs, ended up in the hospital. He did not have insurance. And he worked hard every single day with us. I worked with him for months. But because he didn't have insurance, acute rehab was saying, no, no, no, we're not going to take him. Even though everything else made him the perfect candidate to go to rehab. And we know that his outcomes were going to be so much better if he was able to go over and get that intensive rehab. So me and my colleagues were able to just hammer on that goal and we brought it up to the physicians and we got them to do an appeal and face-to-face peer review and we worked closely with case management and we were able to get him over to rehab because we went after that so hard. and that was more beneficial than probably anything we could have done in a more traditional therapy sense. So you have this awesome ability to really dictate the outcome of these folks and it doesn't look anything like PT. Another example is if you have an interest in working in the ICU you have an amazing role there to advocate. Meaning you're going around with the physicians and case management and the nurse manager and sometimes higher up execs in the hospital and you're looking at these folks who are on sedation and on the vent and you know that you want to get that sedation down so you can get these people up and start that early mobility. and you get to look at their settings and look at what's going on and say, look, can we get this person off Propofol and put them on Propofol? Or sorry, the opposite, take them off Propofol and put them on Procedix so that we can try and decrease the sedation burden that's going on with our patients and get them mobilizing faster. That is so cool. I thought that was amazing. I loved feeling like I was like this mama bear trying to protect all of my patients and get them to the next best. setting and really improve their outcomes. And much of that did not look like teaching them how to do sit to stands or deadlifts. So if that's something that you feel you would love to do, acute care is a really wonderful setting for that. Conversely, if you are an individual who, you know, I talk to a lot of clinicians and students who love the fitness part, like their core values when it comes to their professional career are that They want to be able to work with someone when they are in the stage of being able to load them up. That's what brings them value. They want to work more from a sports performance perspective. And they want them to be at a level where they're able to do all the exercise. Like that's what you love to treat. And so I give them the, you know, I let them know, acute care may not be the setting for you. You really may belong more in outpatient instead. So something to think about just the how dynamic of the role can be in acute care. Okay next you learn how to communicate and you learn how to be on a team. All right you will hear all the time that in acute care you have to have really solid interprofessional communication. 100%, you've heard that word over and over again. But what does interprofessional collaboration actually mean? You learn very quickly that the world does not revolve around you and your therapy plans. These patients are so complex. They have so much going on with them. You are one small piece of the puzzle that actually helps them move on to the next level of care, or helps them get home and be safe. You learn it really quick. You cannot operate in a silo. You start to learn what the nurse's roles are, what the nurse tech's role are, truly what your OT partners and your speech partners can do. And you learn how to work with case management. You learn how to have conversations with physicians. They're all right there, and you have to figure out You have your patient's health and mobility, and you want them to get stronger. That's the forefront of your mind. But you've got to deal with all of these other individuals who have their own priorities when it comes to the patient. the physicians or the surgeons, like I'm trying to keep the lungs and the heart alive, or I'm just trying to keep that brain alive. Like that's what their focus is. You know, the nurses are, Hey, I got to get these meds into my patients and they're overloaded. And you start to learn to have grace for people when maybe they're not fitting the idea of what you think should be done for the patient because you're thinking about your bias of mobilization and strengthening. So you start to understand, how to create allies with individuals who have various priorities when it comes to your patient case. You learn how to argue, you learn how to be direct, but you learn how to respect everyone else's role and everyone else's time. And that can become a really beautiful collaborative effort where you can work together and move people forward. And you just don't get that opportunity in other settings. When I went into home health, I really missed the fact that I could easily collaborate with my OT partners or my speech partners, or I could easily, you know, talk to a physician. In home health, a lot of the time it feels a lot more siloed and My goodness, if I was able to get even just a PA on the phone to tell them about a concern I had with a patient, that was a big win. So if you are someone who values and loves the fact that you're surrounded by a team constantly, acute care may be the setting for you there. Okay, only a few more, I promise. Let's do two more. Okay, next, the emotional toll slash connection is very high in acute care. Now, every single setting you are going to be emotionally connected to your patients, right? You could be in very vulnerable situations with the patient. However, I do believe acute care has the highest amount of emotional connection and along with that emotional toll because you are with folks that are dying, that have been through catastrophic accidents, that are, you know, I will never forget the day where I was working in trauma and a patient came in, terrible car accident. That individual lived, but her spouse died. And you are pouring into this human, they don't even know that their spouse is dead yet. I mean, you are going to face these situations so often, especially if you work more in the ICUs. You are surrounded by death quite frequently, and you're surrounded by a lot of sadness and loss and grief. And that can take a significant toll on you. I think it's beautiful that you are able to be someone who can support your patient, your patient's family during an incredibly tough time. But that can also be something if you are, um, if you are an empathetic person to a fault, sometimes like I am, that you can take on a lot of that grief and that can end up being incredibly heavy for you. So something to consider if you love to be in those vulnerable positions with your patient and you want to help them through dying and sickness and grief and loss, it may be a great setting for you. And that's not to say you don't experience intense joy as well. You can. see folks who were minimally conscious after a stroke or traumatic brain injury, and you can see them, you know, spontaneously start to recover. And that's absolutely incredible as well. But the emotional roller coaster is incredibly high. So if you are prone to taking on a lot of energy and emotion, and that's something that you know is not necessarily a positive for you, then maybe acute care isn't the place for you. Okay, last one here, last one. you do not get to see the sexy outcome. You do not get to see the sexy outcome. In acute care, you truly have to be okay with being the person who sees this person once, you plant a seed and you hope that that grows and that ends up changing this person's trajectory. But you don't get to see that outcome most of the time. And that's really hard for individuals. Many clinicians, they want to build that relationship and go along that journey with someone and see discharge day, see how far they've come from the amount of effort and work and progress that you've been making together. That longer term relationship is so important. This is one of the, um, this is definitely one thing that I didn't like about acute care as much is that I didn't have the ability to see this see this outcome. On the flip side of that, I definitely adopted the perspective that, hey, I've got maybe one or two chances to work with this patient. I'm going to do everything possible to set them down the right path. I'm going to pour into this human 200% to try and make sure that I can hand off the baton to the next person and it's a fitness forward individual and I can continue to keep them in that lane. And I was okay with that. I loved knowing that as a fitness forward professional, when I walked in those doors of my patients' hospital rooms, I knew, I just felt that their outcome was going to be different because I was coming into their room. And I loved being able, I loved being able to have that impact with them, even if it's for a very short amount of time. If that is something that you feel like you can get on board with and you can really learn to value and you can be okay with planting the seed and not seeing the outcome, acute care could be a really wonderful setting for you. If you are someone who knows that they want to go along the journey over a long period of time, they want to see discharge day and know what those efforts look like at the end and what the outcome was, probably not the setting for you. Okay, all, that's my list. It's not an exhaustive list by any means. I would love for you all to add to this list to kind of let more folks know some pros, some cons, some other considerations. Please add to this. Put it in the comments. Send me a message. I'd love to post other thoughts about all the things that go into acute care and whether it is going to be the right setting for you. Okay. So I will end with talking to you all about what we have coming up in the older adult division. So in August we, Oh, first let's talk about July. My goodness. So this coming weekend, we, uh, the whole team is in Littleton, Colorado. And then once we go into August, we are in California, Salt Lake city. in Alaska, as well as our Level 1 online course, that starts August 14th as well. PTINice.com, that's where you can find all of that info. If you're not on the app already, make sure you get on there and get into our community. We're on the app so much more now, so if you have questions or comments, find us in there. All right, team, 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. Miller Armstrong // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Miller Armstrong makes his debut on the podcast discussing what separates the top 5% of physical therapist from the rest of the profession.

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

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

EPISODE TRANSCRIPTION

MILLER ARMSTRONG
Good morning, everyone. My name is Dr. Miller Armstrong. I am a lead faculty for cervical and lumbar spine management, and I'm out of the Nashville, Tennessee area, and super excited to talk about today the topic of clinical success, one choice being required. So what I mean by this, and I'm gonna do a few parts here, so I'm gonna be on over the course of the next couple of months talking about this, but it starts here. What is that one choice? And at ICE, we are quite literally obsessed with thinking about what makes the top 5% of our population and of our profession, what makes them the top 5%. Like what is different about those people that are the best? What do the experts do differently than the rest of us that make them the experts? And so to frame this, I really have to tell you a little bit about my background so that you're able to better understand where I'm coming from. A side note, I couldn't resist hopping on the back porch. It's a rainy day here in Nashville, so it's a beautiful morning. So I couldn't resist jumping on the back porch today. But I was born in this area. I was born and raised in Nashville, Tennessee, actually just south, about 30 minutes, in a town, and now it's a city, called Murfreesboro, Tennessee. And in Murfreesboro, there's a university. And that's where, I mean, throughout my entire life, and throughout my entire childhood, I was in Murfreesboro. Elementary, middle school, and high school. I was down in Murfreesboro, and the college down there is called Middle Tennessee State University. So if you're not familiar with MTSU, they're a mid-major Division I when it comes to sports. So Conference USA, they play schools like Western Kentucky. Conference has switched around a ton since I've been there. When I was there, it was like Marshall, Western Kentucky, Florida Atlantic, Florida International, UAB, things of that nature, kind of in the southeast region of the country. And so I played football throughout my entire childhood and growing up, and then I eventually played football at MTSU. And team, after my second, or after my first year, heading into my second year, we had a coaching switch. And so my first year there, I was playing quarterback and I was on like scout team, practice team quarterback. But going into my second year, we had a defensive coordinator switch. And so the new defense coordinator, of course, brought alongside with him a lot of other staff. So we had a lot of new faces on the other side of the ball. And in that offseason, I got switched over to So I ended up playing linebacker the last few years that I was at MTSU. But you have to imagine that it was not only a new room, like in the college sports world, especially football, I knew a lot of those guys that I was playing linebacker with, but I didn't know them that great. So it was a little bit of a new feel as far as walking into a position room. What was even a newer feel was now we had new staff. And so it was not only a new position, it was a new linebackers coach that I had to get to know. And this guy's name was Siriki Diabate. And Sariki, he's one of my favorite people on the face of the planet. And he was a younger guy. So for the college coaching world, being in your late 20s, early 30s is really young to be a position coach. So Sariki was leading the linebacker room. And Sariki had such a fascinating story. Almost so much so that we couldn't really relate to this guy. So, Sariki was from the Ivory Coast, and he came over to America in his late teens. The dude was like 17 or 18 by the time he showed up in New York, and he experienced a lot of unrest. growing up. Growing up in the Ivory Coast, like, there was a lot of civil wars, there was a lot of unrest in the town that he lived in. So much so that there would be times where, like, militias would come into the town, and he would have to get out of there with his dad for days at a time, just in order to stay safe. So it was a really tumultuous time growing up for Seriki. And so his family saved up some money, and they sent Seriki overseas to America to have a better opportunity. And so Siriki showed up in America, didn't really know any English, didn't really know any direction, but he found American football. And through American football, he found that he had a really nice talent for it. And as he started playing a lot and getting a lot better, he ended up at a juco down in the Bahamas, where he eventually got recruited and ended up playing for Syracuse up in New York. And so as he's playing for Syracuse, Siriki was an undersized guy for the ACC. So the ACC is one of the major conferences across the country. So a lot of big schools, Florida State, Clemson, a lot of these teams. And so those humans are huge. These people are massive. Siriki was about 5'10", 5'11". And at the time he played at Syracuse, He was only about 215, 220 pounds, which is sounds big to the normal American, but for a division one power five conference middle linebacker, that's a small size. Most of those guys these days are walking around 6'1", 6'2 plus and well over 230, 235 pounds. We would watch Siriki's tape. So we would find his highlights basically as a linebackers group and we would watch him when he was playing at Syracuse. Sometimes the GA that was in our room would watch or would bring it up so that we could watch it all together. Because when you watch Sariki run around the field, there was something different about this guy. There was something different about what Sariki looked like on film. So just to give you a little bit of context, in the world of football, especially on the defensive side of the ball, players are graded, a lot of times, individually and as a group, and as a defensive group, they are graded according to how many people are in the frame on film when the play is over. So when the ball carrier is tackled, how many defensive players are in the frame. So if you only have like two guys in the frame that the camera captures, that's not very good. It doesn't show a lot of effort. It's a way to grade effort versus if you have like nine or 10 guys out of the 11 on the field that are in the frame at the end of the play. Coaches, defensive coaches love that. Defensive coaches love that. Individually, they will grade these guys based off of how many times or what percentage of times that an individual is in that frame. So if you're not in the frame at the end of a play, 40, 50% of the time throughout the game, the coach is saying, hey, you're not giving enough effort. Like you're not showing up around the ball when we're watching film. So knowing that, when we would watch Siriki's tape, when we would watch film on our coach, he was literally in the frame every single time. You couldn't find a play where this guy was not in the frame. It was so impressive. He was all over the field making plays in the backfield, making tackles, and if he wasn't making tackles, he was near it. He had the epitome of what good effort looked like. And so it was really interesting to watch, and it was really interesting to hear his mindset. And what he would talk about, team, he would walk into the room, and then he would watch our tape, or we'd be on the practice field, and he'd be all over us as far as trying to get us to make plays. And he would say things like, hey, run through that guy's chest. Like a pulling guard, and if you're not familiar with football, a guard is an offensive lineman. Those guys are usually 315, 320 pounds or more. A pulling guard coming around trying to put hands on you, Siriki would just simply say, run through him. The ball carrier is behind him. So run through that guy. And we would look at him and almost laugh. We were frustrated, but we would almost laugh. We'd be like, Siriki, what does that even mean? Like, what do you mean run through this guy? So much so that throughout that offseason, throughout the first few months that Siriki was there, even through the first few games, like game three, game four, we're watching film, he's still on us, like just decide, just get in there and make a play, run through that pulling guard, whatever it might be. We had such a hard time with this as a linebackers group that eventually we were like, coach, like shoot us straight. What do you actually mean by this? And team, what Sariki was saying next quite literally changed the way I view everything that I do in my career and in my life because of the mindset that he portrayed. What he said was he said, Miller, well, he said, team, crew, he said, guys, what we have to understand is that you really only get one decision. You get one decision. And that decision is whether or not you want to be successful. That decision is only decided by you, and it's really the only decision that you get to make, is whether or not you wanna be successful. Okay, what do you mean by that? And what Seriki said was, if you, and this is in the context of college football, but he said, if you want to be a good college football player, if you wanna be one of the best in the country, you watch film. you learn the playbook. You not only learn the playbook, you show up early. Maybe you get a good stretch in, maybe you get your body warm before the workout, and then you're the first one going as hard as you can in the workout. Even school, you can't get on the field if you have bad grades. So you show up to class, you do your work, you study, you take your tests, you perform well on your tests. But all of that is just what follows making the initial decision that you want to be successful. And that's what he was trying to get across to us. So making that play is just quite literally making the decision that you're going to do what's required. He said that this also comes down to doing everything that the coach says. He said, if you fail, but you're doing every single thing that I'm telling you to do, it's not on you. Your success is determined by your decision. that really started to broaden the way that I viewed a lot of different things because I started to think of, okay, now that I'm in the physical therapy profession, what does that mean? What does being successful look like in physical therapy? And that's what we obsess with here at ICE. In our cervical and lumbar spine management courses, we talk about that. Like, what makes the top 5% the top 5%? And at the end of the weekend, we share a slide. But we talk about a lot of different things throughout the weekend about what makes those experts the experts. Some of those things are like doing the basics really well. not making bad decisions because you don't have bad data. You're not sloppy in your physical exam or your straight leg raise or things like that. You're about it. You lead from the front. You have competency across multiple domains. All of these sorts of things is what attributes a great physical therapist. And so what we have to realize is that that That is preceded by making the decision to be successful, to be the top 5%. It's not like the top 5% or the experts have some magic pill that they take and then they become this great physical therapist. What they've done is they've decided on the front end that I'm gonna be successful. And what that looks like is eradicating all of their weaknesses, making sure they have four asterisk signs that they can chart and that they can track over time. making sure that they, in the first five minutes of every single session, making sure that they never forget to retest their asterisk signs, doing trial treatments, adhering to the test retest model, having a nice hypothesis list because they do their symptom behavior first, like all of these sorts of things that we talk about at ICE, it's all preceded by the experts making the decision on the front end. Because Siriki would argue that if we are not, say you're not rechecking asterisks after a trial treatment on day one, He would argue that that's not getting sloppy, that's deciding to not be successful. Once you make the decision to be successful or be the top 5%, every single thing else, everything else follows. Everything else follows. It's extreme ownership. This guy got to that mindset before the book came out, right? But I love that idea of, Okay, if I don't feel like I'm getting good outcomes, it's probably because I may have woken up that morning and not decided on the front end to do what it took. So whether or not, the fork in the road is whether or not I want to be successful. Once I make that decision, you just do whatever is required of you. And what is required of being a successful PT? All of the things that we preach here at ICE. So if you're not being about it, maybe then you actually didn't decide to be successful. All of those sorts of things. So team, chew on that for a little bit. So excited to be able to jump on here with you all. I love talking about those things. I love sharing a little bit about Sariki, and he had a lot of other sayings throughout three or four years rolling around with that guy, but yeah, it was a lot of fun, a lot of fun. We do have some courses coming up here soon. So, if you want to get into a lumbar or cervical spine management course, August is your month. We're coming in hot all of August. So, August 3rd and 4th, I'm going to be up in Aspen Mall, Pennsylvania, just outside of Pittsburgh, rolling with lumbar spine. The next weekend, August 10th and 11th, in Longmont, Colorado, Brian Melrose is going to be out there in Colorado. And then the following weekend, August 17th, 18th, I am going to be out in Grass Valley, California, over at Body Logic PT with that crew. If you're looking to get into cervical, August 3rd and 4th, if you're in the Cincinnati area, we might only have one spot left or so. It might even be sold out by the time I'm saying this, but cervical management was Zach Morgan. And then the last weekend of August, August 24th and 25th, over in Bend, Oregon with Brian Melrose as well for cervical spine management. So quite literally every single weekend of August, if you want to take a spine course, we're somewhere in the country doing it. Lumbar or spine or lumbar or cervical team. Thank you so much. I can't wait to see you next month talking about the next thing here and have a great day.

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

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

In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jessica Gingerich discusses pushing strategy during labor.

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. Today's Monday, so you know that we are kicking off our week with some pelvic content. So today I'm going to talk about a question that I got from a client. So I wrote this down because I didn't want to get it messed up. And so She asked me, she said, if my uterus contracts to push my baby out during birth, then why do we as women feel or need to push during that second phase of labor? And I love this question because she has, she's done her research, right? She read that the uterus contracts to help push her baby out. And sometimes there are some nuances to our patients that we want to make sure that we clear and explain, and especially around birth, because we can decrease that fear around birth. Or if she wasn't having fear, at least empower her. So the uterus plays a key role during labor. So it expands during pregnancy to accommodate the growth of the fetus. There's also a thick muscle called the myometrium that expands to hold the baby, but it also contracts during labor, um, in this wave like pattern, starting from the top of the uterus down towards the cervix. And it helps to open or dilate the cervix. And it helps to thin or efface the cervix to allow the baby to move towards the birth canal. The contractions become stronger, more regular and more frequent as labor continues. So that is the role of the uterus. The pelvic floor's role is to be in a relaxed position. I like to think holes open, and I even say that to my clients. So it gives this really nice kind of internal cue. Now, while the uterus has a lot of work to do during labor, the role of pushing just helps descend the baby towards the birth canal. So it's just something that helps. And that's all we can that's what we can explain to our patients if they have this question. Now, this is kind of outside of the scope of this podcast, but I want to mention this is Because we do push during labor, we can imagine that the stronger our cores are, and really from an endurance and aerobic capacity, this can be a huge advantage, right? The stronger we go into labor can be a huge advantage to help with this. And so we want to make sure we're encouraging exercise in specifically core work, and even programming that as accessory work for our clients. So let's get into pushing. And there's two specific ways to push, and I'm going to talk about those today. This happens during the second phase of labor. I want to also mention that when we talk about pushing, we've got an open glottis and a closed glottis. The closed glottis is very similar to what athletes do when they are lifting weights. And so we really want them to practice how to push, especially those athletes that when they hold their breath, down below there are holes closed. And so as we talk about these strategies, I want you to be thinking about your clients who would really, really benefit from this. So the first one we're going to talk about is the closed glottis push. This, you think about your canister, so you've got your diaphragm at the top, your abs at the bottom, or excuse me, in the front, you've got your pelvic floor at the bottom and your back muscles in the back. You've got holes in the top and you've got holes in the bottom. And so as we create that intra-abdominal pressure by either tensing our core and holding our breath or tensing our core and exhaling, these are different strategies that create a different amount of force with each. So the first one is closed glottis or closed glottis pushing. This is going to be where we close our mouth, we close our nose and we bear down or strain putting the base or putting the pelvic floor in the basement or in that descended position. This creates a lot of force. This is going to be very helpful if mom is right at the end of that finish line and she can feel maybe she reaches down and she can feel the baby's head. or she, um, someone's telling her that her baby's crowning. She can close her mouth, close her nose and push. The second one is going to be an open glottis push. And so you can imagine we are creating a force through our abdominal muscles as air is coming out of our mouth and our noses. This is typically going to be really noisy and really loud. Maybe mom's screaming, maybe she's, making some really loud mooing faces, maybe noises, or maybe she's cussing because it hurts and that's okay. So this is gonna be a little less powerful, but it can be a really wonderful technique to help control their heart rate and help mom hold on longer, especially if she's got that marathon birth going on. Both of these pushing strategies can be influenced whether mom has an epidural or not. There's going to be less likely them to feel what they're doing. And so they're going to need coached pushing. That's going to be a nurse telling mom when to push. This is important to talk about because they need to practice. Practicing these birthing these pushing strategies for birth prior to birth can help mom come back to that and remember, Oh, this is what I did. This is what I did to prepare for this. I had a client tell me that she was in her second phase of labor. So she was pushing, she was so confused because she could not figure it out. She also had had an epidural. And then she remembered, she was like, wait, I remember that we practiced this, that you, you had me every day practicing how to do this. And so she went back to what she had been doing and she ended up being really, really proud and really, um, happy with how her birth went. But it took her a minute to like, remember, Oh wait, I did this. I knew going into my birth, how to do this. So she came out of that. She was really empowered, felt really good. So that is what I've got for you today. Um, we have our last cohorts coming up. So if you head over to ptonice.com, our last L one is kicking off on September 9th and our last L two of this year is going to be kicking off on September 15th. So head over there, snag your spots. Um, we'd love to have you have a great Monday.

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the differences between front and rear mount bike trainers, which is preferred for different bike types, as well as budget options. 

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

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

EPISODE TRANSCRIPTION

MATT KOESTER
What's up everybody? Good morning and welcome to another episode of the PT on ICE Daily Show. Today I'm going to be your host. I'm Dr. Matthew Koester. I'm one of the lead faculty in the endurance athlete division with a specialty in bike fitting. I am super stoked to hop on here today and talk about probably the most popular question that we get in every live course and one of the most important things when you're getting into fitting for the first time as far as equipment goes. But before we dive into those topics, I want to talk about the opportunities that y'all are going to have to come and find us on the road. with number one being in Denver next weekend. We've only got four seats available for that course, so if you're interested in popping in, it's gonna be in South Denver in the Denver Tech Center area. We are really, really stoked to be heading out there soon, but if that's not gonna work out for you, we have another option, which is gonna be in Bellingham, Washington again, because the last time we were out there, it was completely sold out, the wait list was filling up, and we decided we'd run it back and set up a second course in Bellingham, Washington later this fall. There's gonna be another opportunity as well to see Jason London, who's the original content creator for this course, which is an absolute opportunity in Park City. That's a really cool location. We're gonna be out there in October as well for that course. So if you're looking to get a jump on some of this education and use this stuff in the clinic, the live course is the best way to get through it. So by all means, come find us on the road and check out one of those course options. Now, I said I was gonna talk about probably the biggest question in the course. The biggest one is really the thing that gets you into this. And it's what type of trainer do I need? We have two options in most cases. So to my left and behind me here, we have a front mount trainer, which offers a whole lot of options as far as what bikes can go on. And then we have the tried and true rear mount trainer. And what I want to do today is talk about probably like the biggest pros and cons of each. I want to talk about which one is probably the most appropriate for you and your clinic, depending on what type of bikes you're typically seeing. And then the ones that kind of have, I'd say, more budgetary constraints and or are just limited in availability sometimes. So, to start off first, I want to talk about the rear mount trainer because that is the one that is tried and true. That is going to be, in most cases for us, this green guy here. This is the Curt Kinetic trainer. Now, if I slide that thing forward, You'll see we've got the rear roller, which is basically what compresses the tire and allows you to kind of go through resistance while you're pedaling. You've got this rear cup that basically compresses the back axle of the bike and allows you to keep the bike nice and steady. And then we typically put something underneath the front wheel. Sometimes it's a custom wheel block. Sometimes it's an adjustable wheel block that allows you to lift that thing up and down and change the positions. But with this trainer, one of the things that people really, really love about it is that it's been around forever. They're used to it. When somebody comes into your clinic for a bike fit and they see something like this, they're like, ah, I know what this is. This makes perfect sense to me. I even brought my training skewer, which is typically the axle that they have to replace in the back of the bike if they're going to get on this bike. Because these metal cups here that compress the rear axle when they're tightened up are gonna basically act to lock the bike in place only on the contact points they get to touch. So if those contact points are plastic, which is pretty common as a way to save weight, save money on a bike, you have to replace that either with a training skewer, which just has metal cups on the sides, or in many cases nowadays with how bikes have gotten, these new through axle skewers. So the through axle skewer is typically a lot thicker, it's a lot more robust. It's common on bikes that allows them to put disc brakes on the bikes, which is really more and more ubiquitous these days. So having these options for different through axle skewers allows you to put metal on metal and compress it in the rear end of the trainer. Now depending on what types of bikes or what brands of bikes you're seeing more in the clinic, the skewers that you're going to need are going to change. So they all have various thread types that go on them. Some are very fine, some are medium, some are coarse. Now the Other kicker to this is that even though you might have the thread type dialed in, the distance, so the width of the actual screw itself might change. Last time I checked on the Kirk Kinetic website, which is the name brand for these guys, they had somewhere between, I think, five different options. I think it was like five different ones, three that were the different thread types, and then two more that were XLs for different distances. And each one was running about 50 bucks. So there's a bit of a financial investment to have all the options so that folks can come to see you and have all the options available to them. If you don't have one of these available to you and their bike doesn't have that, you're going to be kind of stuck in a place where you don't have an option with this style of rear mount trainer to throw them on and do the fit appropriately. That could be a bummer. got to have all the pieces. I'll say there's one other option out there, or not one, but two other like styles of these that are completely adjustable. CycleOps makes one, and I'm forgetting the other brand right now, but they basically have plugs and things that you can change in and out to put on. In my experience, they can be a little challenging to work with. They don't always match up exactly the way that I want them to distance wise. I like the tried and true nature of these ones from Kure Kinetic, but if you're in a bind, and you can only afford to grab like one adjustable through axle, I think you can figure it out. You just have to spend more time with it and go through the trials and tribulations of working through it. So, to recap real quick. This guy, tried and true, everybody knows it, everybody's used to it. It's a trainer they spend their entire winter on. The adjustability in terms of having different through axles is definitely a key. You gotta have them, especially nowadays as bikes have gotten more and more modern, going to disc brakes. These through axles are just like almost a non-negotiable So you gotta have all the different types so you can match the different brands and the different bikes that they come in. So, tried and true. Now, we step into one thing that Jason and I have been seeing over probably the last few years that's really become more popular is this front mount trainer. It really started to make its way in probably like a couple years ago in staging areas or like warm up areas for cross country cycling and downhill cycling. Specifically in downhill cycling, you'll see these guys everywhere when it comes to just getting through warmups. What this guy has to offer is two pieces that basically slide together. These two pieces include the front end triangle here, which allows me to remove and add the front fork of the bike. So we take the front wheel off, slide the forks over top of this guy, and snug it up nice and tight. The next piece from there is the rear rollers, where we have to get the tires centered in the rollers so they can smoothly pass back and forth as it's rolling. Cool part about this, they only have one adjustable piece as far as the actual front axle goes. So, and they send it with them. So when you buy this piece, you have everything that you need in order to do the fit. You can put any bike on here, because the front mount options will work for a standard fork, so they'll work for through axles. You can often put their own through axle back into the same bike. When you're talking about the distances here, there's a little track here that allows you to work with different size bikes so that when you overcome that issue, you can even separate them or buy the extenders. It just has to get, you have to make sure they're nice and perfectly aligned. Otherwise the back wheel might want to roll off one side or the other as you get started. So the rear trainer here offers a whole lot of options for being able to just throw a bike on quick. Now, the challenge that comes with that, as you start to get into like, oh, this thing works for everything, is that it kind of has that jack of all trades where it's not quite really any good at one thing. The challenge behind this thing is that it's not near as stable. It kind of sacrifices the stability and the tried and true nature of the rear mount for something that can be a little bit tippy if your patient or client gets on it and you're not paying attention. If they just throw a leg over it, it can kind of pull the weight with it, I'll say I've never had anybody fall off one. I've never had an actual incident, but I can definitely tell you that when I am with a client in the clinic and we're setting up to do a bike fit, I talk to them about getting on and off the bike carefully. I talk to them about how, like, when they're going to transition on, I'm going to grab ahold of the bars just to create that element of stability. But then even once they're up and on, an experienced rider, so I would say a good example of this would be a triathlon athlete. So somebody who's in the Madison area for me, who's doing Ironman Wisconsin and is coming in for a fit, If I throw them on this guy, it will work, and it will be fast to throw it on, but it lacks some of the stability and control that they're used to having when they're on the rear mount trainer that they spend all their time on. So they might hop on this, and they might notice that they just don't feel as confident. They don't feel as great. So they're more thinking about the experience of being on the trainer than they actually are thinking about the fit as they're going through it, which can be a negative. Okay. So there's the negatives to it, and there's the positives to it. From a financial standpoint here, if you were in a clinic where you were going to have to buy things new, and I'm going to kind of make that a subject for a moment, you can't just go on Facebook Marketplace and buy new stuff and throw it in at your organization. This guy's going to run you somewhere between $400 to $500, but it's kind of that jack of all trades. You can put anything on it. There's no bike you need. There's no custom pieces that you have to go through. You can just get any bike on here. The rear mount trainer, gonna be a similar ballpark. In many cases, it'd be like 250 to 450, depending on how nice you go, you can certainly spend more. It's gonna be limited in some ways because you're gonna have to have all of the different through axles to accommodate any different bike that walks in the clinic, but you're gonna have that stability and just steadiness that people really rely on and like when they're riding a trainer at home. So it's familiar, so that's kind of a nice option. If we take a step away from the idea of having to buy new, and you're like, okay, I'm going to budget my way through this in my clinic. And I know that if I buy something used, I can just make sure that it's good quality and it's broken. We started to get changed the tone here a little bit. These are harder to find use, but they are definitely. Hmm. They're harder to find used, you can get a hold of them, but they definitely have deals all the time on new ones. So you can find the ballpark, if you go on Amazon or various websites, you can get anywhere between that $400 to $500 mark. And this is where I would spend the bulk of the money, because you're going to have almost no scenarios in which you can't get the person's bike on the trainer. That is going to get you through more fits, even if it's a little bit less ideal of a setup. On the flip side, if I've invested in this one right here and I've got the money spent, I'm probably going to start looking at Facebook Marketplace because these guys are a dime a dozen. There were so many folks during COVID that were buying up bike trainers and they were going to spend more time on them at home. We saw the same thing with Pelotons and indoor bikes. These things are on Facebook Marketplace, Craigslist if you still go down that rabbit hole. They're everywhere for sometimes like under 100 bucks, maybe 50 bucks sometimes. And then from there, most of your investment on this guy goes towards the actual, through actual skewers that allow you to get all the bikes on. So your investments kind of change a little bit as you go through this. This guy's going to be the most money up front. This guy's definitely going to be cheaper as you go through it. But you got to get more components, more pieces. If I only had one in the clinic, which is kind of the question that people boil it down to, if I only had one, it would be the front mount trainer. and that comes with one more layer to it. I love the ability for a private practice or a clinic to be able to get out in the community and showcase the things that we do on a high level. If I want to go out to our local high schools here and go talk with them about mountain bike fits and making sure they get the best performance, injury rate reduction, all of those things, I can pop out to the local high school on one of their opening practices, which is actually coming up in a few weeks. I can throw up the front mount trainer, and in a very short time, take out their front wheel, put that thing right over top of this guy, pull the back up, and go right through things like seat height, have a quick look at their reach. I can make adjustments to small things on the bike very fast and make quick transitions to the next bike and not have to fiddle around with various components and other changes. So the, not only in the clinic does this kind of become the absolute jack of all trades, getting it on, It also makes some of those like community events that much more approachable and that much easier to go through. So I am always going to lean on this guy, but I will tell you it's nice having both for that occasion when somebody comes in and I'm like, Ooh, I really want the stability of the rear mount trainer for this person to throw it on. But I would say nowadays as I've gotten more and more comfortable with this, those things are few and far between. There are a few more nuances that would definitely go into this. There's more questions that surround them about the live courses. but deciding between which one is right for you. Hopefully this is a helpful conversation, a helpful talk to get you through that decision. Feel free to drop a comment, ask us questions here, send me a DM, but we will be in Denver next weekend. If you're ready to join us, we'll talk this stuff through even more. Thanks, y'all.

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

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses reimaging the objective examination for patients presenting with low irritability, especially only in specific positions or under specific loads. 

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

JORDAN BERRY
What is up? PT on ICE Daily Show. This is Dr. Jordan Berry, Lead Faculty for Cervical Spine and Lumbar Spine Management. Today we're chatting about a topic called Low Irritability Equals Function First. Okay, so I hope you're having an awesome Thursday. We're about to break down just a concept that I think matters when you're thinking about the novice versus the expert clinician and how they're efficient during their initial evaluation. This key concept of when you're thinking about going into the objective exam and you know the irritability is low or at least moderately low, we're always gonna test the functional movements first. Okay, so a few concepts that we talk about during our live cervical and lumbar spine management courses, when we're thinking about the objective exam and what the expert clinician does different as opposed to the novice, one of those things is that they have a very long, detailed, subjective exam, and they have a short, clear, and crisp objective exam. and how as you gain more experience and more pattern recognition, typically that will sway even more lopsided towards being a longer subjective while having a shorter and more dialed objective exam. And then another concept we talk about is that when the patient irritability is low, you have to be really aggressive during the physical exam testing in order to recreate the symptoms, right? Because if you under test, then you might not actually recreate those familiar symptoms to know that the treatment that you're about to apply is going to work and that you're moving in the right direction. And so, one way that you can accomplish both of those things, right, with keeping a short, clear and crisp objective exam, and then making sure that you're going to be aggressive during the physical exam testing when the irritability is low, is always thinking about testing the functional movements first. Okay, so let me give you a clinical example with this, and then we'll break it down and talk about why it matters and why it's important. So, Imagine that you're in an initial evaluation and you've done your body chart and you know that the symptoms are somewhere around the area of the lumbar spine, like we'll say low lumbar into the right glute wrapping around towards the right hip, maybe even like anterior lateral right hip as well. But you know there's some vague diffuse symptoms that are somewhere in the lumbar spine and somewhere in the hip as well. And during this objective, you also gather that an aggravating factor is squatting anything over 95 pounds. And so day one, during the initial eval, you know you're gonna be trying to differentially diagnose if the symptoms are coming from the lumbar spine, or if they're coming from the hip, or maybe both. But primarily, again, the initial evaluation, day one, during the objective exam, we're trying to tease out What is the primary symptom generator? We have to nail that down day one. What a novice would do is as they're going into the objective exam, they would likely just hammer through a battery of tests for the lumbar spine and the hip. So they'd probably have that person hop up and you're going through all the basic stuff, right? You're going through active range of motion, your joint exam, your segmental exam, potentially neurodynamics, your test and hit PROM and strength testing and palpation. You're essentially just working down this battery of tests to try to see if anything recreates the familiar symptoms. And so let's say that you go through that 12, 15 minutes of objective exam testing and you figure out that hip passive range of motion, like internal rotation or fader recreates that familiar hip pain. And so now we have an asterisk sign, right? We've got our, um, let's, let's call it internal rotation is what we're going to retest and we've recreated the familiar symptoms. So you've done a good job, right? You haven't done anything wrong, but I would argue that that is not expert level because number one, it took us a fairly long time to get to that answer of what is recreating the symptoms. And honestly, the patient doesn't really care about any of the stuff that you just tested. So, an expert here is going to look at function first. So, we might do some of the same objective testing that we did just a minute ago with the novice, but the first thing that we're going to do if the irritability is low to moderate is look at function. So, if the subjective exam we found out that anything over a 95-pound squat recreates the familiar symptoms, well, I'm going to look at a 95-pound squat. So I get that person out in the gym, maybe we do a warm-up set, and then we load up to 95, and right when they drop down, right when the patient drops down into the bottom of the squat, they get that familiar hip pain. Now, right then, you have one of your asterisk signs, but we could also modify that movement or try to tease out in real time if we can change the symptoms or affect them in any way. So let's say that person drops down into the squat, bottom of the squat, they get their symptoms, and you grab a big mobility band. wrap it around the hip, and give a big lateral distraction, a lateral pull, while they go down into a second rep of the squat, and the symptoms are completely gone. So think about what you've now done. Number one, you have a better asterisk sign, I would argue, because it's something that the patient actually cares about. It's functional, it's very easy to retest, but you've also clued yourself in on your differential diagnosis. Because if I can do something to the hip, right, do a self-mob to the hip or do a lateral distraction for the hip and immediately change the symptoms that we got with squatting, then I know when I go back to the table and I do my more traditional objective exam testing, I'm going straight to the hip. So maybe on day one now, I can leave all of the lumbar spine testing and maybe hold it off until day two. because now I know that I can affect the hip. Now we go back to the table. We do some of the objective testing and I go right towards PROM and I jam that hip up into IR and fader and recreate those familiar symptoms. Boom. Now we've got our two objective asterisk signs. We've got one passive range of motion. We've got one that's functional, the squat. So now when I apply it to some sort of treatment, I've got two ways that I can retest.

SUMMARY
So number one, why this matters so much of testing function first when irritability is low is differential diagnosis. It's just a fast way to identify oftentimes where the symptoms are coming from or at least cluing you in as to what direction you need to go in instead of just testing all the lumbar spine stuff and all the hip stuff. Now I've clued myself in that I'm probably going to focus on hip day one. So the second thing why it's important is efficiency. We always say during objective exam testing, as little as possible, as much as necessary. So I only want to test the stuff that's absolutely necessary so I'm efficient, but also I don't risk flaring up the patient with doing a bunch of tests and measures that aren't necessary to begin with. And if I can eliminate a few things right off the bat from that functional testing, why not start there? And then lastly, it's way better buy-in. It's way better buy-in. So day one, you're always trying to have the patient walk out thinking, man, I'm finally in the right spot. This person totally gets my issue. And they're definitely going to be walking out saying that if you're first off testing the functional stuff, the stuff that they actually care about that you pick up in the subjective. No patient cares about hip IR, cares about lumbar AROM, cares about palpation. They don't care about that. They care about the thing that they want to get back to that they love. And if you're including that in the physical exam, the buy-in is going to skyrocket. So think about that over the next week or so. About maybe changing the order of your physical exam if this is not typically how you order things. When the irritability is low to moderate and you pick that up during the subjective exam, then when you go into the objective exam, you make sure that you're testing function first. It's gonna help with differential diagnosis, it's gonna help you be efficient, and you're gonna get way better buy-in. All right, so think about that this week. Next week in the clinic, I'd love to hear feedback on that as well. Just to leave you with a few upcoming courses that we have with cervical and lumbar, this coming weekend, we've got cervical management in Oviedo, Florida, few seats left for that. And then also this weekend, we've got lumbar spine management in San Luis Obispo in California. And then coming up August 3rd and 4th, we've got cervical in Cincinnati, Ohio. And then also August 3 through 4, we've got lumbar spine management in Aspinwall, Pennsylvania. All right. Thanks so much for listening. Have an awesome Thursday in the clinic. And if you're going to be a cervical or lumbar spine management course coming up soon, hopefully I will see you there. All right. Have a great day. Thank 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.

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 as he compares & contrasts the different roles of heavy & light lifting in the scope of geriatric rehabilitation.

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
Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dr. Dustin Jones with the Older Adult Division and today we're going to be talking about heavy versus light loads, particularly in geriatrics. Which one is better? Is there a certain time, place, person that we may want to use heavy versus light? I want to take a dive into the research and some of the themes that we're seeing in the literature and also just from experience in clinical practice and in fitness. of how we want to think about these different types of load because to be very honest we have a big bias here at at ICE I would say and then definitely in the MMOA division where you will hear us talking about the need to push for higher intensities right especially with our professional pandemic of under dosage where we have individuals that are not being challenged and have the ability to change right like this is a big big issue and something that we really need to speak to and it's very easy to mix that message with that higher amounts of load heavy load is the only way to go and that could not be further from the truth all right so let's kind of get into the pros and cons of you know heavy resistance versus lighter resistance and when we may want to use these because it's really important to be very thoughtful in your approach of applying load to individuals I wanna start with talking about some of the advantages of lighter resistance training. That's the one that we typically associate, oh, that's under dosage, or that's too easy, or that's not gonna be that effective, right? That's not necessarily the case. So when we think about light resistance training, lighter loads, you know, maybe 40, 50% of someone's estimated one rep max, if you're doing those types of calculations, Those loads are really, really great for introducing movement. I think we can all agree that if we have individuals that haven't exercised before, that are relatively new to a movement, have a lot of fear on board, maybe a lot of irritability, that a lighter load is going to be easier to get the party started, if you will, with those individuals. And for some, it may be first set where you're doing a lighter load, check the box, things are looking good, and then we're going to progress to a heavier load. But in some settings, and I'll speak for home health at least, that's where most of my experience is, is that takes weeks and sometimes even months with individuals where we are doing somewhat of a lighter load before we really have a green light to really progress to a relatively heavy load with certain individuals. So introducing movement, I think light resistance training is a great place, a great tool and time to use that. I also mentioned irritability. When we have folks that are highly irritable, A heavy load is not necessarily a great situation, right, for those individuals. They'll often increase irritability and the behavior of those symptoms. They want to be respectful of that irritability and often lighter loads can allow us to introduce movement and helpful movement and activities without causing a big increase in their symptoms or a change in the behavior of their symptoms. So introducing movement, high irritability, those are great places. Another great place to introduce or use lighter resistance training is when we're really focused on movement velocity, of really creating speed with a particular movement, which in geriatrics, oftentimes, it's very helpful when we're working on reaction timing, for example, or performing movements that require a lot of speed, like stepping strategies to regain balance, for example. the lighter loads are gonna allow them to move quicker than if they were bogged down with the super heavy loads. We can use that in our training. Light resistance training also improves strength and hypertrophy as well. There is a lot of kind of mixed literature of showing that, man, heavy resistance training is kind of the gold standard, right? If we're wanting to get people really strong, if we're wanting to improve muscle mass as well, like we gotta lift heavy loads. but particularly in older adults and deconditioned older adults that they can see improvements and significant improvements in strength and hypertrophy with relatively lighter loads, 40, 50, 60% of their 1RM. Now, oftentimes you have to adjust the other variables of dosage, right? Typically higher volume, but we can see an improvement in strength and hypertrophy in older adults, particularly deconditioned older adults with light resistance training. And that's really good news. I think it's really helpful, especially if you're in a more acute setting, you're in home health, acute care, SNF, Those types of settings, the lighter resistance is typically more accessible to these individuals and we can still get benefits from it. So I hope you can see some of the value of lighter resistance training. There are certain times and places and people where we are going to want to use light resistance training over heavy resistance training. Now let's talk about heavy resistance training. What's some of the evidence showing and theme showing of where that really stacks up? What are the benefits? The obvious one is strength and hypertrophy. Most of the literature It's going to be looking at improving strength, improving hypertrophy is with heavier loads, you know, usually that 80-85% of someone's one rep max, you're going to see really good results with a lot of the individuals if you can be able to apply that. One thing that is not often discussed and why you'll often see the MOA faculty use, give a little bit more preference to heavy resistance training is the stimulus it will give to bone mineral density. that heavier loads are going to be a greater stimulus to improve bone mineral density than lighter loads. Most of the research that's showing pretty significant changes or a reduction in decline in bone mineral density are usually doing resistance type activities in higher percentages of someone's one rep max in the 80s, 85% for example. So bone mineral density is a huge one and that's why we'll often use it somewhat preferentially with folks when we can apply it. Another big one, and this is purely anecdotal and from what I've observed working with lots of folks, is the confidence piece. Introducing light resistance training can help build confidence, right? It can get people moving. They can start to do things that they didn't think were possible or what they thought they'd be able to do. initially, but once we get past a certain point, heavy loads are going to be the only tool to really change people's perceptions of themselves. There is nothing like, and this is in my experience so purely anecdotal here, but there is nothing like lifting a relatively heavy barbell off the ground and doing a heavy barbell deadlift with someone that perceived that they are weak, that they're old, that they're fragile, that they're slow, that they can't improve, they can't change. That is such a powerful tool for these people to improve their confidence, but change the perceptions of what they're truly capable of doing. And this has so many ripple effects, right? If I am able to deadlift my body weight, for example, and I'm absolutely shocked and surprised, usually for a lot of members of Stronger Life, a gym for folks over 55 in Lexington, that's where I'm working, it's usually the 100-pound mark. If people can deadlift over 100 pounds, it just blows their mind, and many of us know, like, 100 pounds, that's okay, cool, awesome, but can you do your body weight? Can you do two times your body weight? But for 100 pounds, for some reason, for these individuals, it just, like, kind of, flips the switch, and then they start to think of other activities in a different light. They start to see, well, if I could do that, a hundred pound deadlift, man, going to Lowe's and getting my own bag of mulch is no problem. I don't need help. I can handle that myself. I don't need to go ask Bob across the street to do this for me at my house. I can handle that. Oh, that trip that I wanted to do, I may be strong enough to do that now. I may be able to do X, Y, and Z. Oh, I'm more confident in maybe being able to take care of my grandkids because I know I can pick up 100 pounds off the ground. It has a ripple effect of how they perceive all kinds of different situations. And what I've observed is that behavior often changes, hobbies often change, leisurely activities often change, and overall their life becomes better and more rich and more lively all from an exercise, right? I shouldn't say all, but it's a very profound moment. So heavy resistance training does a great job of achieving that. Another reason heavy resistance training is very, very beneficial, especially in the context of rehabilitation, is it minimizes a detraining effect. So if I'm performing light resistance training over a period of six weeks, eight weeks, for example, I will likely have more of a detraining effect. I will likely lose more of the gains that I've received over that eight week period. I will lose more of that after I'm done, as opposed to if I were lifting heavy weights the whole time. So if you are working with individuals where you're not sure what's going to happen upon discharge, What are they going to do? Are they going to start that exercise class down the road? Are they going to watch that YouTube channel, fitness channel that you recommended? You don't know, right? Are they going to do that home exercise program? It's all up in the air. You're not really sure. We can use heavier loads. to typically get more results, especially related to strength, especially related to functional capacity, related to transfers and independence, we can use heavy resist strain to get more progress over that period of time and they're going to have less of a detraining effect upon discharge and they will maintain their gains for a longer period of time. For me, in the context of home health, this was absolutely crucial, that if I was pretty sure that whenever I discharged Doris, and I was probably gonna see Doris within five, six months, I needed to account for that five to six month period. Doris, I need to get you as fit as possible in this eight week period before we're gonna discharge. So I'm gonna give preference to heavier resistance training as soon as I can apply it with her situation. It'll minimize that detraining effect, all right? So there's lots of different reasons, but I hope you can appreciate the benefits of light resistance training, of when you may want to use it, what situations is it really helpful, but then also for heavy resistance training. There's certain situations where, yeah, we definitely need to avoid light weights and stick with heavier weights. It's very nuanced. There's a right time, there's a right place, there's the right person. We're going to apply these different types of load or amounts of load. We can also appreciate that oftentimes it's overlapped, right? There's going to be times where I'm doing heavy load and lighter load in the same program. They can coexist. And this is why at any ICE course, you're often going to hear us talk about and not or. That we're not here to be dogmatic. We're not here to polarize. We're not here to say, you know, this is absolute garbage. You only need to stick with this particular intervention. That is very rare in our profession of rehabilitation and fitness that oftentimes it's an and not or approach. And that's definitely the case whenever we're talking about the amount of resistance that we're applying to our individuals.SU

SUMMARY
So let me know your thoughts. Any other scenarios, situations I didn't touch on? I didn't even talk about tendon health, soft tissue, related adaptations to resistance training. Drop some of your thoughts and some of your experiences while using light versus heavy resistance training and geriatrics in the comments. YouTube, hop on Instagram, we'll talk there. But we appreciate you all for watching, for listening. I want to mention a few MMOA or Modern Management of the Older Adult courses that are coming up. We have our certification that is for folks that have taken all three courses. Our Level 1, which is going to be starting August 14th, that's eight weeks online. Then our Level 2 that's starting October 17th, that's eight weeks online as well. And then our live course. So all three of those culminate in the ICE certification for older adults. Our live course is coming up too that I want to mention. This weekend, Victor, New York is going to be going down. Jeff Musgrave is going to be leading that one. It's going to be an awesome crew up there in upstate New York. And then the following weekend is our big MMOA Summit. This is where all the MMOA faculty descend. In Denver, Colorado, we do this one time a year where we all come together, have an absolute blast. We do a lot of activities, hikes, we'll have a big cookout pool party with all the students afterwards. So if you're in the Denver area looking for something to do next weekend, we'd love for you to join that course. All right, y'all have a good rest of your Wednesday and I'll talk to you soon.

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses the benefits of icing prior to exercise for patients dealing with arthrogenic inhibition. 

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

LINDSEY HUGHEY
All right. Good morning, PT on ICE Daily Show. How's it going? I am Dr. Lindsey Hughey, one of the division leads of our extremity management here at ICE. Welcome to Clinical Tuesday. It is awesome to be with you all here to share a little clinical tip. I'm going to try to keep it short and sweet this Tuesday. about arthrogenic muscle inhibition, and specifically after surgery like ACL or a total knee replacement, not things we get to usually talk about on our weekend extremity management. So really the big question I want to tackle today is should we ice for this? When you come to our class, we talk a lot about peace and love principles, and this came out of the British Journal of Sports Medicine in 2020 by Dubois and Escular. And they really highlighted that when we're managing soft tissue injuries, we actually don't want to ice or use NSAIDs anymore. And so the question comes up weekend after weekend. Well, what about after surgery? Should we be icing still? Well, because of arthrogenic muscle inhibition, it's kind of a completely different animal. And the evidence would tell us actually, yes, we should be icing for this. And so I'm going to discuss a little bit about that research briefly. But let's just briefly talk about before that, what is arthrogenic muscle inhibition? Well, what happens after surgery, what we see is that the normal activation of the sensory receptors within the joint and its surrounding structures, think ligament, tendon, joint capsule, and even muscle, And these are all responsible for detecting change in joint position, tension, compression. They send signals to the central nervous system. But in response to injury or controlled trauma like a surgery, these processes get disturbed and interrupted. So what happens is after a surgery like that, the central nervous system kind of goes into protective mechanism mode. And so a lot of inhibitory signals get sent to really protect. Big picture, if we step back, this inhibits our quadriceps activation. So after an ACL repair or a knee replacement, we see a lot of the quad swollen, it shuts down, and this leads to sequelae of functional deficits, big ones being like knee extension deficit, which means we miss our terminal knee extension, leads to quadricep atrophy. if we don't quickly regain that knee extension and proper activation, we'll tend to see persistent knee pain if this is not rehabbed appropriately and poor function in our stability as well. So what does ice do? Like what, why is icing potentially beneficial here? Because just to review one more time, that arthrogenics, inhibition that is happening, arthrogenic muscle inhibition, what is happening again is that we see that abnormal joint afferent input, which will decrease excitability of the spinal neurons controlling that quadriceps activity. And so that decreases motor unit recruitment and then even our firing rate. And we see this time and time again in our folks with ACL and it becomes persistent and people after total knee replacement. So what is icing doing? Like why is ice potentially helpful? And then I'll share two articles and point you in the direction to read to share how ice has been beneficial. What icing cryotherapy is thought to do is that it may prevent the activation of those inhibitory synapses that are happen in response to that arthrogenic muscle inhibition or AMI. And By disinhibiting, it actually increases the excitability of the anterior horn cells. We're getting a little nerdy this clinical Tuesday. And so what happens then is that there's less supraspinal control over the reflexive activity of like guarding. And so the icing serves as a strategy to just basically overcome and create disinhibition, right? Prevent that inhibition from happening. two articles specifically in the ACL literature that I want to share. And what's really, I want to give a shout out to Jonathan, because it was actually a course participant that asked this question. And, you know, I said, I actually need to do a lip search because I don't know the answer for sure. And he was so awesome. And he like sent me these two articles. So shout out to him for doing so. So what we see out of the British Journal of Sports Medicine in 2019, there was a scoping review by Sonnery Cotlett et al. And this included 20 RCTs that had moderate quality evidence where they looked at the efficacy of cryotherapy in combination, so let's consider not just alone, but in combination with exercises that activate the quad after ACL. And so what they saw is improvement in activation. These folks tended to do better when cryotherapy was a part of their care and those that had that AMI present. In addition, We see another article I want to point you to, and I'll tag these links for you. We see another article specific to ACL, but that timing might even matter. So there was a study done in the Journal of Orthopedic Surgery in 2019 where they actually compared putting ice on folks before they did quad activation, and they had a sham environment where they It was actually kitty litter that they put on the knee, and then they put ice on the knee. And they did this so that the person measuring output and torque was blinded to know whether they had ice or not. And what they found is the folks that actually had ice prior to had better firing in their quad because what happened is it had disinhibition effects, meaning it stopped that inhibition that usually happens and shuts the quad off. So consider, and that really surprised me, that the timing of our ice in combination with exercise or stim might be the thing we also need to consider doing it before we start a bout of exercise care after surgery.

SUMMARY
So as promised, keeping it short and sweet today, I wanted to give you all an update that we are, in fact, advocating for cryotherapy for our folks after surgery because it helps with long-term, down the road, better quad activation because of its disinhibitory effects. I'll put those links here for you today. I hope everyone has a wonderful Tuesday and that you'll consider cryotherapy still for your folks post-operatively, which is contrary to our peace and love principles. If you want to learn more just in how we manage knee pain, rehab in general, please join us at an extremity management course. What's coming up is July 20th and 21st. Cody will be in Hendersonville, Tennessee. That course is filling up, so join him there. And then I'll be in Bend, Oregon with Hannah, which is sure to be a blast. We're going to go visit Justin Dunway, our Total Spine Thrust faculty that weekend. It's going to be a blast. That is July 27th, 28th. And then we have two opportunities in August across the country, 24th and 25th. I'll be in Bismarck, North Dakota. Never been there, so join me there. And then Cody, again, will be putting on a course, but this time in Greenville, his home base, the same weekend. So opposite spectrums on August 24th and 25th. I hope you'll consider joining us as you end out your summer. Thanks for your time this morning, everyone. Take care.

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

In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett takes a pragmatic approach discussing variations we see in practice and physiology and acknowledges where we still have work to do.

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

CHRISTINA PREVETT
Hello everyone and welcome to the PT on ICE daily show. My name is Christina Prevett and I am one of our lead faculty in our pelvic health division and I'm coming to you from a cottage on my 35th birthday because I had a Wonderful husband who surprised me but that does not mean that I'm not gonna get excited talking about all things pelvic health so We had a really interesting conversation come up over the last several weeks, and it's funny because it's come up in a variety of different circles around defining normal. What is normal when it comes from a pelvic health perspective? Because when we are trying to make diagnoses of different conditions, urinary incontinence, pelvic organ prolapse, diastasis recti, we have to know what the realm of normal is so that we know when we deviate from it. And so we had a question come up in our app about, what is the amount of normal voiding, the number of normal voiding episodes that an individual should have during the day? Because some of our literature says 5 to 8, and some of it says 8 to 13. And then if you leak a little bit when you're really tired, does that actually consider you to have a condition? Do you have urinary incontinence? If you have a kind of a spasm in your shoulder, you wouldn't say that your shoulder was injured, but you would say that you have urinary incontinence. And it's such an interesting question, and I kinda wanna dive into it a little bit today. So last week, as many of you know, I'm a postdoctoral research fellow at the University of Alberta. And so what I am looking at in my research, I am an interventional researcher, specifically looking at resistance training and its impact on health. And what my studies are looking at specifically right now is on resistance training in pregnancy and its impact with pelvic floor dysfunction. What I was doing was I was learning from physiology researchers. I was looking at individuals who were looking at pelvic floor assessment and measurement. And up in Ottawa, I was at Linda McLean's lab, they are doing data taking on what is normal force production of the pelvic floor and what are things that we can expect to see as differences in the pelvic floor on ultrasound, on EMG force activation, and on dynamometry, which is force production. in a younger cohort of individuals and an older cohort of individuals. And this sparked a lot of conversations because we know that with age, for example, pelvic floor dysfunction goes up, but what are normal wrinkles on the inside of the pelvis? And what are things that we would consider abnormal or needing to seek some intervention for? So I'm gonna try and take you through a couple of different examples in the literature of what we know, what we don't know, and what we have to acknowledge is just areas of gray. So we're gonna talk about the bladder first. So some of our literature is saying, you know, five to eight Ps during the day is normal. Some individuals have pulled that up to eight to 13 as a top end of normal. And then some people will say that you shouldn't ever have to pee at night, or it should be rare, like you shouldn't be getting up consistently to pee at night. And others say that that is true if you're under the age of 65. But if you're over the age of 65, getting up once to pee is considered within the realm of normal. So let's talk about why there is that variability. When we are looking at data sets and we are trying to incur where that normal distribution is. So we think we have an average if it's normally distributed and 95% or 97.5% of our data is going to swing within plus or minus two standard deviations of the mean. And I'm getting kind of in the weeds of statistics here, but that's kind of our normal distribution. And our P of less than 0.05 on a two-tailed test are the ones that are below that two standard deviations on either side. And what that's saying is like when we have this big group of individuals who are kind of distributed across this arc, and we are seeing that this other group of individuals is well below that, then we can say that these are probably different populations or there is something different going on. When we are looking at trying to characterize normal, There is so much that comes into human behavior that creates differences in a person's lived experience. And when we're trying to capture that descriptive data, it depends on a lot of things, right? If we are looking at normative data and we're trying to describe it, it is going to be very specific. to the data set that we are capturing that information from. What do I mean by that? I mean, if we have an individual who's an athletic group of people who are very conscientious of hydration, their normative values for how often they're going to pee is probably in that higher end between eight and 13. If I am working with a sedentary population who doesn't take a lot of care in their hydration, or it's not something that they think about, five is probably on the top end of that. And so we know that this hydration status is largely going to dictate frequency of urination. Similar to things that we know cause liquid to filter through the kidneys a lot faster, things that we call bladder irritants. So if I am working with an individual who has a higher caffeine or alcohol intake, right, that's gonna make it flow through the urine. Caffeine is not a diuretic, it's a mild diuretic. It does make us have to pee, but in the morning, we're oftentimes drinking caffeine that's simulating that the kidneys and the bowels to start functioning. We are peeing more in combination with having caffeine. Alcohol is another one where it increases filtration rate because alcohol is a toxin, our body is trying to get rid of it, and so it can change our frequency of urination. timing of when we drink water can dictate are you a person who gets up every night to go to the bathroom or not. So all of that can be in the realm of normal variation and that makes it extremely difficult then to diagnose things like nocturia or frequency issues where urination is over a threshold where we consider this to be a quote-unquote pathology or a condition. And so what that has done in our bladder consensus statements is that we have added a second part to this. We have said that when you're thinking about healthy bowel and bladder habits, you should be able to defer going to the bathroom as needed. Your urge to go to the bathroom should increase as the amount of bladder filling hits a more critical threshold. We're getting to the top of our bladder fillage. and we should be able to empty our bladder when going to the bathroom and have complete emptying of our bladder. And frequency of urination, we have like, you know, multiple studies that have tried to characterize normal, but the big asterisk sign on this is that frequency should be at a level that feels okay for you. You should not be stressing about your bladder. You shouldn't have anxiety about bathrooms because that's showing that there is issues with being able to defer going to the bathroom, being able to hold going to the bathroom, or you're going to the bathroom so often. that it's disrupting the cadence of your day, right? But that's really difficult because we can't necessarily say there's this cutoff, right? Where if you're going to the bathroom less than five times, you're probably dehydrated. That's pretty consistent. But if you're going to the bathroom six times versus 10 times, It depends on you and on how you are feeling, and if that is okay for you, or if that's something that is all right for your day. And so we don't really have these normative values, and it's why there's inconsistency in the literature about it, and we can't really give you a hard and fast number, and we really don't want to, because you're a human being. It depends on your day. You're not doing the exact same thing every day. So these healthy bladder statements that we have that are in our research and that are in our course are trying to give an idea, right? So if you have a person who's really underneath that or really above that, then it can almost introduce the conversations around frequency and work on things like urge suppression to potentially bring that frequency down or modulate liquid intake to maybe help with some of those concerns. A second example where we're not really sure about normal is when it comes to diastasis recti and pelvic organ prolapse. And this I actually see as almost a bigger problem because it really bottlenecks our research. It actually makes a huge difference in terms of the way that we are educating on normal conditions and normal changes, and how we create a threat response oftentimes when potentially we don't need to. Let me kind of dive into what I mean. When we are looking at our frequency of pelvic organ prolapse, so pelvic organ prolapse is a movement of one or more of the vaginal walls towards the vaginal opening, and it is assessed on a Valsalva Beardown Maneuver, which is done on a relaxed pelvic floor. Okay, that is where we are doing our assessment. We know that our vagina is not a hollow tube, our bits touch, and we do not have our vaginal wall as a cartilaginous ring, right? It is smooth muscle. And therefore, it should be moving, right? We should see some movement, but it is the degree of movement that we have tried to create a cutoff score for in order for us to have clinical care pathways that give us some idea about what is the next step for individuals who are experiencing signs and symptoms of pelvic organ prolapse, right? We can have individuals who have high amounts. So where are some of the issues come up? We can have individuals with high amounts of movement and low symptom burden and vice versa, right? We can have individuals with high symptom burden with low movement. So here comes the first hole in our argument is that there's discordance between subjective complaints and objective symptoms of prolapse. The second concern that we have with using our grading system as it is currently is that depending on, again, the study population that we are pooling data from, and this is gonna be especially true with our individuals who are post-menopause, we can have over 50% of individuals studied in a normal data set where individuals may not even have signs or subjective complaints of prolapse experiencing grade two movement. So not at or past the level of the hymen. And so they can have that movement. And so if greater than 60% or greater than 50% rather of individuals are experiencing grade two movement, can we truly say that this is an abnormal finding? Because that would mean that 50% of our female population or 25% of our population in general is experiencing a condition. and in combination with the fact that they're lacking symptom burden is a concern. The third thing when it comes to prolapse literature, and this is something that I've been thinking about a lot lately, is that so many of my clients who have really high symptom burden are most concerned with their standing and resting position of their pelvic organs. So for some of my clients with higher grades of prolapse, thinking stage three, stage four, it's standing and feeling that bulge around the opening of their vagina in the introitus. And our assessment is on an active bear down, which really is something that other than birth, we should not be doing a max bear down. So the clinical, the jump to this is how we assess pelvic organ prolapse to this is where my symptoms are most prevalent is missing. We're missing a step. And that is why in our pelvic division, we are such huge advocates for the standing assessment, right? We're not doing a max bear down, but I'm seeing where are your tissues resting especially for some of my postmenopausal individuals or those who have a larger vaginal opening, it's very easy for me to appreciate and I get a much clearer picture of the posterior wall at rest in a standing evaluation. And so when we were doing some of our work up in Ottawa, it was really interesting because when we look at individuals who are parous, those who have given birth vaginally, what we see is that our perineum is going to have more up and down movement. We are going to see post-delivery, an increase in range of motion, and it's been most characterized in the anterior wall. And we are going to see a shift in some of our pelvic structures, right? This is normal physiology. And so when we haven't done a great job of characterizing normal variation and then add in individuals who have had multiple vaginal births who have now gone through menopause, some of that shift in structures are wrinkles on the inside that we maybe don't need to pathologize. And so because we have so much of this variation of normal, again, now our definitions for pelvic organ prolapse are an objective sign of descent in combination with subjective symptoms and subjective complaints. And that's wonderful because what it means is, is that people are gonna have different range of motion. Just like some of our individuals from a musculoskeletal perspective are more bendy and can bend over and their elbows can touch the ground. And some people, they can barely get their fingertips to touch because of hamstring length. We're gonna see variations of normal in vaginal wall length. And this is not something that we need to pathologize. It's the combination with subjective complaints that is going to be our important distinguishing factor to potentially modifying or working on the anatomy, whether that's conservatively with pelvic floor muscle training and pest reuse, or that's surgically with a vaginal mesh type of surgery going into prolapse repair. The third where we don't have a very good understanding of normal is with diastasis recti. So two years ago was the first time that we had taken a big representative sample who were not coming in for core complaints and giving them an idea of what is a normal interrectus distance, right? And over 50% of individuals coming in had greater than two centimeters, which is typically our cutoff score for diastasis recti. And what that shows is again, this bell curve of normality is centered around two centimeters. So if our average is two centimeters or 50% of individuals on this normal distribution are experiencing a two centimeter gap, then again, we've had a failure to recognize normal variation when slapping on layers of pathology or conditions. And again, this is alarming because what it does is it halts a lot of our progress. Because until we've been able to characterize what is normal, recognize when subjective complaints come in, and then be able to create care pathways and algorithms that allow for normal changes, but acknowledge and treat the subjective complaints, it makes it difficult for us to take the next step forward. And that was something that I've learned so much from the researchers that I was working with last week who were doing so much work on the basic science level to characterize normal variations and look at anatomical differences between those that have complaints of pelvic issues and those that don't. And what this does is it allows us in pelvic health to understand the physiology and etiology of the conditions that we are treating. And we do a really good job in other areas, like in cardiovascular complaints. But honestly, it's frightening sometimes how little we know about why individuals are leaking. I did a reel where we talk about exhale on exertion, about how that reflexively gets our pelvic floor to work, because our pelvic floor kind of pumps in and out with inhale and exhale. And on EMG, for me, when I was exhaling on exertion and doing an isometric lifting task, my pelvic floor activation was the exact same as when I was balsalving. And this makes a lot of sense, right? Because what the biggest thing the exhale does is it brings down inner abdominal pressure by about half. And so it makes sense that it works for us when we're trying to get people to have a lower threshold before they start leaking, but we have used physiology that is based on anatomical plausibility and we do not have the evidence to back us up, right? So anatomical plausibility is when we take theoretical thoughts about how things work and use them to justify our outcomes. That is where we start. But until we create this bridge where we understand variations of normal and then understand from a physiology perspective what our interventions are doing, we're always going to be a little bit behind in our creation of these care pathways. And so it made me think a lot about my research in resistance training in pregnancy. because we have some acute studies on what the Valsalva Maneuver does, but we have nothing on bracing mechanics when it comes to a female pelvis and heck no on a pregnant female pelvis. And so it really did create so many conversations that were so fruitful and so incredible. And I'll leave you with the final example. So we know that there are some people who are going to experience urinary incontinence a lot more readily or a lot sooner than other individuals. And what we are starting to see is that some individuals have more urethral hypermobility than others do. And it tends to be a non-modifiable anatomical risk factor for incontinence with exercise. What that means is that yes, we can absolutely see improvements with pessary management. It's going to tack up the urethra, prevent some of that hypermobility. We're definitely going to see improvements, right? But we may have a subset of individuals that are not going to have a complete resolution of symptoms because of their genetics, because of the way that their anatomy is. And that to me, like just learning about this physiology research, it makes so much sense for me as an interventional researcher, but also as a clinician, that I have some people where I have hit them with everything and I still can't completely resolve their symptoms. They get a lot better. But it's okay to have those conversations that there is going to be some individuals who have small amounts of leakage. And then the next part of that is when do we actually consider that a problem, right? When is that becoming an issue? And we don't have that answer. Like I can squat and I can have a cranky hip before I warm up, but I'm not injured. I just need to warm up, right? So maybe if I have a drop or two of urine linkage, I don't have incontinence, my body just needs to warm up. And so we just have so much more that we need to understand in terms of normal variation and genetic makeup and anatomical differences between individuals of different parity states, different ages, stages, different disease history, different injury history. And when we do that, it's really going to open up from a research perspective and a clinical perspective to us to get truly a better understanding of what it is we're trying to modify, how we are doing what we're doing, and it's going to get us to gain credibility in a lot of different spaces. All right, that is my rant for today, 20 minutes. Alan's going to be like, yep, this is Christina, she's on the podcast. But I hope that makes a lot of sense to you. I get so passionate talking about this because I think it's so important and it has been a blind spot for me. And so it's very cool to fill up a known blind spot and just work to think about things a little bit differently, which is really neat. If you all are trying to come and see us live on our two-day course, we have two courses left for the summer. I am in Cincinnati this weekend, July 20th and 21st. Alexis is in Wyoming next weekend, the 27th and 28th. And then our live courses start up again in September. If you are looking to get into our online cohorts, September 12th is when our next L1 starts. If you have already taken our L1 online and you wanna jump into our level two cohort, that is starting August 19th and it is filling up very quickly. All right, have a wonderful week, everybody. I'm gonna ring in 35 by the lake and I will talk to you all soon.

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the different deadlifts variations and who may best benefit from their performance.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Good morning, everybody. Welcome to the PT on ICE daily show. It is the best day of the week, Fitness Athlete Friday. My name is Guillermo Contreras, here with you today from the Fitness Athlete crew, talking all things deadlift. So this is an exciting topic here. We just finished up our level one course last week and we just had our fitness athlete summit a couple of weekends ago. One thing that we know that throughout the one course as well as the live courses is that deadlift is typically going to be one of the most spicy topics. Should everyone be deadlifting? Why should we, why should we be deadlifting and why should we be deadlifting heavy? One of the questions we most commonly get both in the live course as well as the online course is the question of all the variations we see. The conventional deadlift versus the, you see back here, the trap bar deadlift versus the sumo deadlift. What is the best position? What is the setup? How do we coach it? How do we look at it? And if you want to dive into all that, that nitty gritty, that really deep detail stuff, highly recommend you jump into the L1 course or you join us on the road for a live course. But today, all I'm going to be talking about are the different types of deadlifts. And the topic title is a deadlift for everybody. Right? So not everybody, but everybody. Because there are instances where individuals will be using a different setup or a different variation of the deadlift to be able to move the greatest amount of load in the deadlift movement. So the ones we're going to specifically talk about today are the conventional deadlift, the one we see the most often and the one that we coach typically in the L1 course, you see in CrossFit gyms, you see done all over the place. The sumo deadlift, which we see a lot more in competitive powerlifting where they're trying to lift the heaviest amount of weight humanly possible off the ground. We trap our deadlift because we see it a lot in athletic sports and individuals using it in different ways and we'll talk about the differences there. That'll be more of like an end of the conversation discussion there. And then lastly, some variations known as kind of the hybrid deadlift. And that is just going to be a slightly different for individuals who maybe can't get into position for conventional but don't need to go sumo, we find something in the middle. So first things first, we're going to talk the conventional deadlift. we look at the conventional deadlift we want to ensure that we are set up in such a way where that bar is close to our bodies. So when I coach this out I'm telling athletes that they want to set up hip width apart so their feet are right underneath their hips for this conventional deadlift setup. From there the bar should be lined up closer to my shins. I typically will tell athletes when they look down, they should see that the bar is lined up over their shoelaces and not too far forward, because now that barbell is far away, which makes moving a heavy, heavy load a little bit harder, because it's going to pull you out of position. So we want that bar nice and close. From here, with the conventional setup, what we tend to see is my hips are going to go back. And when I'm set up in this double overhand grip, my hands are outside of my shins. And when I get all that tension on board, my knees are below my hips, my hips are below my shoulders, and I have this really nice stacked set of position in which, again, my shoulders are above my hips, my hips are above my knees, and that bar is nice and close to my body. That is going to be our conventional setup. That is the most common variation you're going to see in the CrossFit gym with any athlete that walks in, someone that's just a recreational weightlifter and is doing deadlifts on a day-to-day basis. The second most common variation we're gonna see is something called a sumo deadlift. With a sumo deadlift, that barbell, and I apologize, if you're listening on the podcast alone, some of this won't make any sense, so I'll try to talk as much as I can, but the video will give you a lot more detail on this. With a sumo deadlift, we set up with a much wider stance. So my feet, if this is hip width apart, This is shoulder width apart. This is just outside of shoulder width apart. With a sumo deadlift, we are going wider than that wide stance. The reason for this, the reason we see this in power lifting is because we are essentially just decreasing the amount of work being done. Meaning that the amount of distance the bar has to travel is less because now, rather than having to go from here to here, the motion turns into here to here. so it's a much shorter distance to travel or a much shorter distance to pull that barbell off the ground. The other big differences we see with that sumo deadlift outside of that much wider setup is gonna be that the torso angle is more vertical. So because I have this wide stance with a slightly more toed out position, or sometimes excessively toed out position, I can now set up with a much more vertical torso, and that bar can stay right underneath me. This means my erectors can be locked in a good position, I can stay nice and tall, and I'm driving through my thighs, boom, to lock that barbell out and overhead. Because I'm so wide with my legs, my grip is now just inside of my hands in this nice narrow position. Because again, I'm trying to decrease the amount of work being done by reducing the distance that bar has to travel. So that is our sumo deadlift. The points of performance still stand when I set up for a sumo deadlift here. my knees are still below my hips, right? It's just a slightly much less difference there, and my shoulders are still way above my hips, but I am much more vertical and I'm driving straight up off the ground. So it's a very different looking movement. The emphasis on load is going to be moved to different muscle groups, but it's a way to do essentially less work because you are moving a shorter distance and you can move much, much greater loads typically if you train it enough. So that is your sumo deadlift. The one here that most people don't know about, that most people don't do, is the hybrid. The hybrid is typically only given for athletes who might struggle to get into position with a conventional deadlift, but want to still be in a more narrow stance position because it's going to translate more into Olympic lifts or other type of lifts from the ground. And what that is, is if this is our conventional stance, this is our sumo stance, we break the difference and we are just slightly wider. So we're no longer just under our hips. We're now maybe just outside of our shoulders and our grip is just inside of our legs there. That setup mimics that conventional deadlift a lot. So I'm still in that hybrid deadlift. I'm sorry, I'm still in that hybrid deadlift stance here. The bar is still lined up nice and close to my shins. I'm sitting back, I'm getting over that bar, my hips are still above my knees, my shoulders are still above my hips, my hands are still nice and close to my body, and I'm pulling there, sitting back and tapping down. That one is most commonly given to athletes who just might not be able to handle that position of hip flexion in a conventional deadlift for one reason or another. or that just slightly wider position, allows them just enough room to sit comfortably into that setup for the deadlift. You'll see athletes, especially longer, taller athletes, when they go to set up in conventional deadlift, they set up here and they can only get there with this kind of nice, kind of rounded position because of how long their femurs might be, or their limbs might be, or if they have a shorter torso. So by just giving that little bit of clearance in that hip, they can sit there in that same deadlift stance, pull, and then get back down. So that would be your hybrid. So again, to recap, we have our conventional deadlift here, slightly wider for our hybrid deadlift, even wider and more upright for our sumo deadlift. That is how we pull heavyweight off the ground. Regardless of how you do your deadlifts, we know that the deadlift is one of the best ways to improve low back pain, to reduce low back pain, to reduce kinesiophobia, to build strength, resilience, and just overall good quality life and function because of the way that you're moving a heavy load off the ground, training every muscle group, strengthening your grip, strengthening your back, strengthening your hips, strengthening your posterior chain. So the deadlift should be something we should have in our arsenal. The one thing I want to give some love to is the trap bar, right? So this behemoth bar over here, we see this a lot. and it's shaped like a, what would that be, a hexagon, I think? Hexagon. We see this a lot in sports, a lot more in like, you'll see it in like football, basketball, because they just want to reduce risk. So they claim that the bar being out in front is just too unsafe. But in reality, what happens a lot of time when you have a lot of athletes, the time it takes for a strength and conditioning coach, if they don't have a large strength and conditioning staff to really coach, cue, and ensure good quality movement with a barbell deadlift, it's hard. So the trap bar takes away a lot of those things that you would normally coach by allowing an athlete to set up with the bar at their sides here and be in a more squatty position. You can get more hingey with it if you'd like, but most people are going to tend to falter back towards that more squatty movement pattern when it comes to a trap bar. There's nothing wrong with using the trap bar. The trap bar is a great way to load up that hinge pattern, that deadlift pattern, get comfortable pulling weights off the ground, even like jumping or heavy farmer scares. You can do a lot of different things with the trap bar, but it's not going to be the same thing as loading up that barbell, having good quality coaching, ensuring that that back is being nice and strong and holding that really stiff, strong position as you hinge forward. And that's where a lot of that magic happens with the barbell deadlift. So again, trap bar, a wonderful tool to use. It also, if you're dealing with crossfitters, it's not going to translate to literally anything else besides maybe some loaded carries, heavy carries, sandbag carries, jerry can carries, things like that. But it's not going to transfer over into strength for Olympic lifts such as the clean and the snatch. So we want to really try and work and improve on that deadlift. So again, one final recap. What do we see? Deadlift, one of the best things we can do for low back pain. Improved kinesiophobia, just get rid of it all together. Improved strength, resilience, quality of life, everything there. This is the health lift, what it was normally known as back in the 20s, I believe. We have a conventional deadlift in which our stance is around hip width. Bars close underneath our shoelaces, hips above our knees, knees, hips above our knees, shoulders above our hips, and that really nice pattern there. We have that hybrid, we'll be slightly wider stance, and now our grip, instead of being outside our knees, goes inside our knees. and we are still driving with that same shoulder above hip, hip above knee position of our body. And then lastly at that sumo deadlift, that really wide stance that again allows us to reduce the distance that bar has to travel so we can do more load typically. the hips are still above the knees, the shoulders are still above the hips, we have a much more vertical torso, and we are driving straight from the ground, standing tall with it. Sumo deadlift, hybrid deadlift, conventional deadlift, and special shout out to the trap bar deadlift as well. So there's a deadlift that anybody can do, we should be deadlifting in the clinic with our athletes, especially if you're dealing with fitness athletes and crossfitters, they're gonna deadlift, so be really good at coaching it, understanding these different variations that they can use to train in different ways. If that's just a little bit, and you're like, oh, I want to learn a little bit more, please, please, please join us on the road. We are not traveling a whole lot in August and July, but starting in September, we are on the road right away. 7th and 8th, we are in Austin, Texas with Fitness Athlete Live. Then the 14th and 15th of September, we are in Longmont, Colorado. And then the 28th and 29th, we are back in Texas, in Springs, Texas, which I believe is down on the coast near Houston, I could be completely wrong, so I apologize for anyone from Springs, Texas if I got that wrong, but please come check us out, we're on the road. If you want to see, learn a lot more, be able to dive into it a lot more, into the science of everything a lot more, the level one, the fitness athlete level one starts back up on July 29th, so that'll be in about three weeks. We're starting up our next cohort of the CMFA L1. And then the CMFA L2, if that's the one course you are waiting to finish up to get your CMFA certification, that starts up on September 3rd. That course is only twice a year. That course always sells out. So please, if you're thinking about getting your CMFA cert and you want to take that L2, dive into all things programming, movement modification, some business aspects, high-level skill, gymnastics, and Olympic weightlifting, Sign up for that one on the PT on ICE website. CMFA L2 starts up September 3rd, CMFA L1 July 29th, and we are on the road in Texas on the 28th and 29th and the 7th and 8th of September, and then out in Colorado on the 14th and 15th. Gang, thanks so much for tuning in this morning. Have a wonderful weekend, and we will catch you Monday on the PT on ICE Daily Show.

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

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

In today's episode of the PT on ICE Daily Show, Older Adult lead faculty member Jeff Musgrave discusses how choosing pain now can help you avoid pain of regret later in your career.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Welcome to the PT on ICE Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy, currently serving in the Institute of Clinical Excellence in the Older Adult Division. It is Thursday, so it is Leadership Thursday. Super excited to be bringing to you a message that I think a lot of people are going to relate to. Pain now or pain later? When thinking about this topic, it really came very organically out of a class that I was coaching. So I get to coach people 55 and up, we're all about pushing high intensity, we celebrate sweating, we celebrate heavy weights, and really pushing things in a business called Stronger Life. But we were finishing up class, it was a really tough workout, and I was talking to our members and I said, you know, the reality is, team, you can have a little bit of pain, a little bit at a time, or you can have some uncontrolled pain later in life, maybe years from now, maybe decades from now, but that pain, you're unlikely to get to choose. And we all know this, if you're listening to this podcast, you know that we're all about being fitness forward. We're all about choosing that little incremental consistent pain to avoid greater pain later, right? Whether we're talking about building reserve for not even just older adults, but all people, right? The stronger we are, the fitter we are, the less likely we're going to have those uncontrollable pains through health complications, whether we're thinking about heart attacks, type 2 diabetes and amputation, strokes, Those type of things, for the most part, are very avoidable by choosing a little bit of pain, a little bit at a time. So this really just resonated with me, and as I was reflecting on it, not that I have that many great quotes, but this one, I was like, this one kind of lands. It connects a little bit. And then it made me think about my career. It made me think about people that, in scenarios that I've been through, as a clinician, and my journey in my career. So I think this not only relates to us from a physical standpoint, but thinking about our career, where we're headed, having big dreams, like what do you want out of your life? Who do you want to serve? And how are you going to get there? And the reality is, I truly believe you've got to choose some discomfort. You've got to choose a little bit of pain if you want to reach your goals. Likely, if they're worthwhile at all, they're going to be hard to obtain. They're not going to be easy to get to, and you're going to have to push yourself. And you're going to have to seek some pain. If you're choosing comfort in your career, you're unlikely to reach any big, meaningful goals. That's just the reality of it. So I'm gonna give you some examples, thinking about the perspective if you're an employee and if you're a business owner, if you're an entrepreneur. So for these, really we're just gonna talk about two scenarios. So the first trap that can lead to you not choosing pain is really just seeking comfort, career comfort. And it can be a career comfort as an employee and as an entrepreneur. So the way I see this is if you're early in your career or maybe you're later in your career, it doesn't really matter. But if you were choosing comfort as an employee, it could look like choosing prioritizing a paycheck over growth. right? And I've been there too, right? Student loans, debt, paying the bills, that's a reality. We all have to pay the bills, right? And the more financial margin we have, the easier our life is from that perspective. But that's not always the path to a meaningful career. Those two things can coincide. You can make great money and you can be serving your life's passion, the mission, the thing that you are here as a clinician to do, you can get both. But oftentimes, there are so many more opportunities to choose a paycheck and comfort over growth, over meaningful growth. Some signs, because I've worked at these places before, I've been there, team. Some signs that you are in the wrong place and you're choosing career comfort over growth or that small incremental pain is you're working with a bunch of burned out clinicians. They've been there for a long time. Their interventions are ancient, right? They're not up on the research. They're the ones doing shake and bake with heat and e-stem. They're using the ultrasound machine, whether it's plugged in or not, right? We know it's going to work. Not to say we won't do that to meet a patient's expectations. If they believe that's what they need, we'll do that and then we'll get after it later, right? Another sign you're in a place of just comfort, seeking a paycheck, is all of your clinicians or maybe you have gotten into the habit of using handouts. There's like, here's my older adult knee program. Here's my shoulder program. Here's my hip program. Team, we know if it works for everyone, it works for nobody. Right? Care has got to be individualized. We've got to meet people where they are, do an individualized assessment, and then we can dive in and really bring them the goods. But there's a good chance if you're in a work environment where everyone's super burned out, they're there for the paycheck, it's probably a pretty good one. and the expectations are probably pretty low. No one cares what the quality of care is. All they typically care about is billing units. If billing units is more important than quality, if you're not getting your sword sharpened by the people you're working around, you may be choosing career comfort over growth. I think another area where people can fall into a trap, there are lots of different companies that are gonna offer mentorship. This happened to me. I was switching settings early in my career. I was promised mentorship. What I got? Super full schedule, no help, no supervision. I wasn't even treating during the time my mentor was supposed to be there. No conversations about mentorship happened until I told them I was ready to leave and put in my 30-day notice after I'd been there for five months. No mentoring, didn't execute on the schedule they said they would give me to slowly on-ramp and sharpen my skills. Look around. If your mentor is not available, if your mentor is not someone you want to emulate, that's at the cutting edge, that's constantly growing, that hasn't reached the peak of their career, if you've peaked and stopped, you're done. You're learning or you're growing. So that's another trap that I typically see. So if that is you and that is what your situation is like, you need to run. If you're interested in growth, you're interested in being the best, you can't hang around in a work environment for very long with people that are burned out, that aren't trying, that are doing the minimum, that are there for the paycheck, it will crush you eventually. You can swim upstream for a while, but you need people to go with you. And if you're in that scenario and you can't change your scenario right now, stay connected with us. Listen to the podcast, go to good content courses, and we can help you get through that period. But long-term, if you want solid growth, you've got to find a solid mentor. You need to be surrounded by like-minded clinicians that are going to push you You want people that are gonna point out the things that you're doing poorly. You need a mentor that's gonna say, you know what? I think you can do better. I know what your capacity is. You're smarter than this. You're better than this. Let's get better. Let me show you how. And that person better be someone you're ready to follow. Okay, so that's if you're an employee seeking career comfort. If you're an entrepreneur or a business owner, one of the traps that I see with seeking comfort is you probably busted your tail to get started. I hear Jeff Moore talk about this all the time and it's so true. Getting that boulder, pushing that boulder at the beginning to get some momentum is so hard. It's so challenging to do that. Once you get it going and get some momentum, it's easy to just be like, oh man, I did it, like this is good, I'm making money, I like this, and it's easy to get comfortable there. When really, there's so much more that you could do and I think Sometimes that is not bringing on someone else to help you. You're seeking comfort through just doing it all yourself. Not trusting someone else with things maybe you're not great at. relying completely on yourself. And basically you've turned yourself into an employee for yourself. You don't have time to work on the business. You don't have time to expand. You don't have time to bring on more business or new employees that are smarter than you or better than you in a certain area to really grow your business, to have a big impact. If you're really good, bring more good people with you. Serve your community well. Push yourself, push your business. If you are seeking comfort and you're an entrepreneur, this is my challenge to you, to grow your team. Find something that you suck at and find someone better than you at it. Offload some of those things, a little bit of time if you can. You don't have to go all in. I'm not saying cancel your schedule. What I'm saying is bring someone on that can help take on a little bit of the burden that's better than you in a certain area. That can help shake off the comfort. That'll make you feel a little uncomfortable. It'll be a little harder to teach someone else. It's gonna take some time investment, but it'll pay huge dividends. So that's one of the main ways that I see that happen. But you've got to free up enough time that you can work on the business, not just in the business. That quote I pulled from the EMF Great Book. If you're an entrepreneur, you've never read it. That's a trap that I fall into. I wanna do the work myself, but I've gotta get comfortable giving other people tasks that I'm just not that great at. We can't be good at everything. We can be good at a lot of things, but if we're gonna grow a business, we're gonna have a big impact. We've got to share the load. We've got to share that burden. The other, on that same note with hiring someone, another thing that we see, is if you get too disconnected. So the one extreme that I see with entrepreneurs that you can fall into this trap and I tend to fall into is I want to do too much work and not delegate or let other people do things I'm not good at. The other extreme that I tend to see is we have people that then continue to micromanage really talented people. You give them a job, you give them tasks, but you're upping their grill all the time. You're checking up on everything. You're not giving them the space to be creative. You're not giving them the space to spread their wings and do their thing, to let them fly out of the nest. You're hovering over them, micromanaging everything. You've got to find smart people. You've got to set some clear expectations. You've got to give them good support. Be clear. Just as a side note, when you think you're being clear, you're not being clear. I fall into this trap all the time with not having enough clarity. But the biggest key, once you get someone talented on board, is get out of the way. There's a reason you hired them. Give them the space to do their thing. Okay, so that's part one, career comfort. The second piece, risk little, gain little. If you risk little, you're likely to gain little over time. So if you're interested in growth, being the best in your area, being the go-to in anything, you gotta risk a little bit. You've gotta throw some money at your skills in an efficient way. You've gotta go through the discomfort of getting real feedback. If you're not getting real feedback on your skills, whether you're in the clinical or you're doing some type of mentorship or you're continuing education courses, people should tell you when you do something wrong. They should be bold enough to tell you, hey, that's not great. You can do that better. Here, let me show you and have a trusted source for that. But you're going to have to see some incremental pain and discomfort of being told that's not great. The other thing is if you are one of those people that were like me, you're in a career, you're ready to make a jump, you want to do your own thing, you're gonna have to suffer some pain. You're gonna be on the bubble for a while. You're gonna have to have some revenue streams to help support that jump as you're getting things going, and you gotta be prepared to not make money for a while. For most scenarios, there are very few scenarios where you can just hop straight over, go completely from being an employee into being an entrepreneur. So you need to have a period of time to build an on-ramp for yourself, and this is going to be uncomfortable. You're going to have to have revenue streams that are going to help support you through the period of time that you're working on building a business or building up your referrals so that you can make enough money to sustain things. That period of time will not last forever, but you need to have a solid plan. and you need to have a long runway. The longer the runway you can create financially, the more reserve financially you can create before you start doing a second thing or a third thing. Whatever it takes to be able to build your dream, build your business, you gotta do it. There's no path forward without some pain, without some discomfort, without some extra hours. I've just never seen that happen. If you've been able to do it, please share in the comments. I'd love to know how you pulled that off. So that is the second piece if you're an employee and you're trying to move forward. and you want to start your own thing. If you're an entrepreneur, I think another big mistake through being comfortable and not not risking enough is not risking to make yourself an expert in one area. I see this a lot too where clinicians are well-rounded. They can do a lot of things and that's great. You need to be able to treat all of the things that you want to treat, but eventually, after you become successful, you've got to niche down. You've got to find that specialty area. You want to be the go-to for this. When their friend says, oh, I've got someone that's got pelvic floor dysfunction, you need to go see Amy. Amy is the best at it. No one's going to do a job for you like Amy will. That's who you want to see. That is so clear. The message to your customer is so clear. You need to niche down. And maybe you've got a couple different areas. That's great. Crush it with those. You'll still get word of mouth referrals, but you want your clinic to be known for something in particular. This is great for getting people active. Maybe you're the older adult go-to. If you're over 55, you really want to go see Sally. Sally is the best in the world. She gets it. She understands what's going on. She's going to treat you with respect by challenging you as you're ready. I've got a friend who did X, Y, or Z, or those are the type of stories you want to hear. But you can't be too broad. If you want to grow, eventually you've got to niche down. You've got to be the best at things. Or maybe you're growing your team so that you've got a team of people that are the best at things. The only exceptions I can think of here is if you're in a super rural area, you kind of have to be a jack of all trades, but you want to hit those things that are the most common. And then people are going to trust you by proxy too, right? If you crushed it in this, it's like, well, I'll trust them with that too. And that can be helpful as well.

SUMMARY
Team, I hope this was helpful. This is something that I'm really passionate about. I found in my own life. personally, professionally, in the gym, seeking some discomfort early is going to help avoid pain later, uncontrollable pain later. So seek that little bit of pain for the growth, for your dreams, the things that you really want to do in life, and you will be much better off for it. Team, if you've got thoughts or questions here, I would love to hear your thoughts. I hope this was helpful. So we want to avoid seeking career comfort and if you risk little, you will gain little. Team, enjoy the rest of your Thursday. We'll see you next time.

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

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 reframing the conversation around post-operative guidelines for physical therapy treatment.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in our geriatric division. I'm coming to you from the University of Ottawa, so if there's a little bit of background noise, that is exactly why. But today, what I wanted to talk to you about, and the reason why I'm on here a little bit early is because I feel like this is gonna take me a little bit of time to get through, is to start reconceptualizing our post-operative guidelines when we're thinking about not just musculoskeletal injury, but many of our post-operative protocols when we're thinking about early healing and early recovery. in the post-operative window. And so I just posted a reel on our ICE Instagram account that's talking about hip precautions and how we have research going back from as like synthesis of research systematic reviews of research going back as far as 2015 to show that these precautions that were intended to reduce risk of early hip dislocation actually don't do that and what they actually do is they exacerbate post-operative deconditioning and they increase fear of movement. And we see this all the time in clinical practice, right? Individuals go for surgery. They're given these restrictions. These restrictions are not evidence informed. They're never discharged. And what it does is it causes people to disengage with activities of daily living, with sports, with activities that they enjoy. They become more sedentary. And then downstream, we see that the amount of postoperative deconditioning is greater and their capacity to engage back into the things that they enjoy before surgery is less. You know, I've had clients that have said to me, I'm so much worse. Like, my pain is better, but I feel worse than when I went in for surgery. Like, why did I even get this done if I could have dealt with this surgery? And so over the last couple of months, I have really been thinking and noodling on this. I did a podcast on the pelvic section on our Mondays around how our pelvic restrictive guidelines around lifting are not evidence informed at all either. And that when we remove those guidelines, and we have now multiple RCTs that have said, you know, other than don't have penetrative intercourse for six weeks, when we say here are your buoys, and here's how you can progress based on how you feel. not only do you not see an increased risk of postoperative complications in those individuals with liberal restrictions, but they actually have a reduced pelvic floor burden in that postoperative window. And so that early recovery is actually enhanced. And so we have to kind of understand where some of these guidelines come from and how are we as a profession in allied health going to start pushing the narrative and where is our role in that because I think we have a really massive role. So the first thing that needs to be acknowledged that is really front of center when it comes to post-operative guidelines is that when we do research and we take surgeons and we have done cross-sectional surveys, not we other researchers, and asked, you know, where did these lifting restrictions come from? Like, where is your evidence? Or do you believe that your restrictions are evidence-informed? In our pelvic literature, we saw that 75% of urogyne surgeons recognized that the reason for their restrictions is because this is what they have always done. And only 23% of the surgeons surveyed believed that the restrictions that they were giving were evidence-informed. Now that is a massive problem, right? We so often in medicine come through the lens of let's avoid bad outcomes that we don't acknowledge that the lack of doing something by restricting a person's movement can actually lead to adverse outcomes down the road, right? Because yes, they're not saying we did X activity and caused X outcome, but the removal of activity, now what we know in all of our accumulated literature on the effect of deconditioning on trajectory of aging, clinical geriatric syndromes, and post-operative deconditioning that can lead to changes in independence, that deconditioning also needs to be acknowledged in our algorithm of what we are thinking when it comes to our post-operative guidelines. And so what we are acknowledging first is that one, we have evidence that does not support restrictive guidelines in many different examples, right, our arthritis literature, not sitting in bed post cardiac surgery, our lifting restrictions post pelvic surgery, we now have a variety of different areas across different organ systems, musculoskeletal surgery, cardiovascular surgery, urogyne surgeries where we are acknowledging that our restrictions are overly restrictive and that that restriction does not create better outcomes. The step forward that I want to make is that not only are they not leading to better outcomes, but that subsequent deconditioning by overly restricting a person is an adverse outcome in itself in the opposite direction. And what this is highlighting is that we have a big knowledge translation gap problem. We acknowledge in many areas of medicine that this exists, but this is front of center for our allied health clinicians around what we are allowing in our practice or what we are acknowledging in our practice. And so you're gonna say Christina, okay, where are these restrictions coming from and why as a clinician am I hesitant to push back on these guidelines despite the fact that I know that these are not evidence-informed, right? So because there's a hesitancy on the side of the clinician and We want to acknowledge those. Those are the elephants in the room, right? So the first thing is around the fear of an adverse outcome, right? When we don't do anything, we don't have that same feeling of responsibility if something was to go wrong, right? Because I didn't push them. So it wasn't me that caused that adverse outcome, right? And we can't always avoid adverse outcomes, but what we do a lot at MMOA is we try and flip the script of, you know, we think about the harm of loading people, but what's the harm if we don't load them? And that's a slower churn, a slower burn, but it's important to acknowledge that that's relevant too, right? So that fear. But the fear also comes from going against the surgeon and liability and referrals. And so I want to acknowledge that piece and I want to acknowledge it on a couple of different stances. Number one is that our messaging is never to, you know, speak negatively to the surgeon and speak about the person. We speak about the concept. And so the way that if I'm trying to remove restrictions that have been placed on somebody or deviate from a protocol, which I tend to do a lot, when the surgeon has outlined this, I will say where your surgeon was looking at was this is their scope. They're looking for lumps, bumps, infection, early complications. Where my lens is here. based on their assessment of you two weeks ago, they may have felt X from where I am assessing you today. Here's where I think our steps are going forward. So it is not bashing the surgeon. It is not going against the surgeon. It is using my scope as a doctorate level clinician to be able to make further recommendations going forward. And as a newbie clinician, the thought of going against the protocol set out by the surgeon used to terrify me, right? I'm a rule follower and our medical system has placed medicine at the top, which, you know, they have the brunt of the liability. I understand where that is coming from. But as I get into my research degree or when I get into my research career and I acknowledge the level of the evidence when I see the outcomes that are so much better when I ditch these protocols and load people more aggressively earlier and I recognize that a surgeon has never never actually rehabbed a person after their surgeries, it changes my mind, right? I would never go up to the surgeon and say, you know, you are going to go with that anterolateral approach for that hip replacement. I really think you should take a posterior approach. It would be better. Because that's not my scope of practice, right? That's not what I do. That is not where my skill set is. So why are we so shackled by a surgeon telling us what our job is, who has never, never rehabbed a person after their surgery, has not actually seen them for more than 15 minutes in an appointment after their surgery. And so I I would never take continuing education from a PT who has never treated the condition that they are teaching about, right? Like you would never go to see me and teach in geriatrics if I have never rehabbed a person who is over the age of 65. So why is our system created in a way where we are taking rehab advice from someone who has never done rehab, whose medical degree does not actually have an exercise prescription component in a lot of cases. And so that acknowledgement has really shifted my perspective on this is maybe foundational work that they are giving and they are catering also to the lowest common denominator, right? Like when I am working with a person and they are trying to give a blanket statement guideline that has exercises on it, they have to cater to the person with the most amount of deconditioning in order to believe that this protocol is safe for everyone. And we acknowledge as clinicians that that blanket statement never ever works, including blanket protocols, because our people come in with a variety of different chronic diseases, comorbidities, positions, supports, biopsychosocial considerations, motivations and drives, and musculoskeletal reserve around that postoperative joint. And so what we have to acknowledge is the flaws in the system, but I'm not saying that as a bad thing, I'm saying that as this is where I come in. High five me in, this is my job, and I need to advocate for my profession in making an opinion on this, right? And this is where we need to lock shields with medicine and surgery, not blast each other with swords and acknowledge where our scope is and where their scope is. The final thing is around liability, right? And I think the post-operative guidelines around joint replacement are a really good example of where the liability, we have to be acknowledging liability, but we also want to make sure that we are thinking on the other side of the equation, where when we are working with individuals post-operatively, we are worried about post-operative dislocations. And what we see is that those with low musculoskeletal reserve going into surgery and have a fall in the early postoperative window are the ones who are more likely to dislocate or those that have a size fit issue or get a deep infection in the early postoperative window. So what we are doing by deconditioning is we are impacting one of those risk factors in a positive way. If we are creating more deconditioning, if we are lacking reserve around that joint and we are not supervising them, potentially in the early post-operative window, that is where we can have liability on creating an adverse outcome. But we don't have any evidence around pushing individuals too far from an exercise perspective early on, creating adverse outcomes. Now, if that was to change, sure, we're gonna change our strategy, but we want to really be thinking about this from a clinical and critical lens, because it's really important that we acknowledge these things. So, What do I think we actually need to think about with our post-operative guidelines? Or what do I think we are missing with our post-operative guidelines? I feel like we are missing our confounding variables that are going to dictate how quickly we're going to be able to progress individuals. So what do I mean by that? We acknowledge as clinicians, because we do this all the time in our assessments, that there is going to be different things in a person's background that is going to allow us to be more aggressive in rehab or is going to cause us to take a slower approach. Those are not acknowledged in our postoperative guidelines right now. So what are some of those things? One is our level of frailty, burden of clinical geriatric syndromes or complex comorbidities. Secondary is musculoskeletal reserve going into surgery or the amount of deconditioning we are able to stave off with early postoperative mobility. And so what we are acknowledging or what we want to acknowledge is that some individuals, we obviously have that early protective phase around a graft. I'm not saying that we're just going to blast that out of the water, but we know that after two weeks, most of our collagen synthesis is there and now it's remodeling in order to get stronger. And that remodeling requires load. But then we create a brace around an individual for six weeks where we're actually not creating a lot of loading through that joint or we're not actually having pulsing forces from our muscles that are acting and contracting to start creating tensile forces in order for our collagen fibers that are coming down or our healing fibers that are needing that load in order to get stronger. And there's a huge amount of variability in our in vivo studies around the strength of collagen resynthesis and that range is probably related to musculoskeletal reserve. And so, one, we need to acknowledge that yes, we have that early protective phase, but their amount of reserve going into their surgery is going to be a predictive factor of how aggressive we can potentially be post-operatively. Their complexities with respect to comorbidity are going to incur a higher or lower inflammatory load that is going to dictate how fast we're gonna be able to progress exercises, right? When we really step back from all of our comorbidities, a lot of them are related to inflammatory cascades, depending on the organ system that is impacted by the disease. And so when we have individuals with a high comorbidity burden, they are gonna have a higher inflammatory load, and that higher inflammatory load is going to impact how fast we're gonna be able to get individuals working, but on the flip side of that, exercise is anti-inflammatory. but it's going to slow down our progressions. So all of this to say is that one, we need to be confident in our assessment skills that includes early postoperative management. We need to acknowledge that our role is one of critical thinking that allows us to take information medically from the surgeon and some of their early protective phase issues, and then be able to progress them as we see fit, because we're the ones who are seeing individuals that are progressing and we are responsible as well for their wellbeing and their capacity to return to activities of daily living. And that baseline musculoskeletal reserve going into surgery is going to be a big confounding variable or a big protective variable in order to think about their postoperative reserve. And so where I see our postoperative guidelines hopefully going in the next several years is one, blanket statements are gonna go out the window, right? We are going to remove these lifting restrictions. We are gonna give individuals buoys, okay? We're gonna say, hey, you just had surgery on X joint. This is what I want you to think about. I want you to be thinking about gradually returning to movement within your comfort zone, and I want you to look for X, Y, Z. And if you are experiencing X, Y, Z, that is your body telling you that you've probably pushed it a little bit too far today, okay? You're not hurt. sore is safe, but it's your body telling you that you just had surgery and we need to stay within these buoys and those buoys are going to change. And as you get further from surgery, you're going to be able to experience more and more of life and you're going to be able to come back to more and more things and that is going to be okay. And we're going to be able to guide you along that process. In rehab, what we tend to do is think about things very linearly, where we say, okay, we're going to do range of motion passively, range of motion actively, maybe in combination with some isometrics, and then we're going to load through range. I think that's a huge mistake. And you guys can give me your thoughts on this. I feel like, you know, Ice talks a lot about and not or, that we need to be strengthening through the range that individuals have in that moment. And then as they gain more range, we're gonna continue giving them strength in the upper ranges that they are now gaining, right? I think waiting to exercise through range or strengthen through range actually deconditions the joint more, and it ends up being a huge issue. We see this all the time in rotator cuff post-op management, right? There's a protective phase that now, thankfully, a lot of the surgeons in my area are not prescribing to, thankfully. And then we go range of motion first, and then we go strengthening through range, and then getting that strength in those upper ranges, especially over 90 degrees, is a bear in rehab. And where I have seen a shift in my practice, and I've seen better outcomes anecdotally from it, is that I am strengthening through range and with weight bearing earlier, and they're gaining their strength back a lot faster. And so I think this and not or approach to orthopedic post-operative rehab is going to be important. Now, I acknowledge that I'm in an outpatient setting and I'm going to be seeing people who probably have a little bit more musculoskeletal reserve going into surgery than others who are in skilled nursing facilities, et cetera. But that means that your deconditioning effect is going to be that much more detrimental, right? When I have a person who doesn't have a lot of reserve going into surgery and then I see that dip postoperatively, that is going to be very, very impactful for them versus my person who has more reserve going in. And so it makes me not change my stance, but actually be more diligent about my loading principles in that early postoperative period because that deconditioned individual cannot handle more deconditioning. And we see this all the time, right? It's why our hip fracture research is so poor. You know, we have those statistics that if you break your hip and you need a, or if that your 50%, 50% of people who have that surgery end up in a nursing home or don't end up making it over a year or whatever that may be. And that's likely because they have a period of deconditioning on a deconditioned person that creates a lack of reserve around that joint. And then they aren't able to come back from it. So our role in rehab becomes even more urgent where we need to prevent that from happening, right? We, we can't wait. on a lot of those things. Obviously weight-bearing status is going to be one of the things we have to be mindful of, but being able to strengthen a joint around non-weight-bearing status in order to try and reserve as much capacity around the hip and pelvic musculature as we can is going to be really, really important. So I hope all of that made sense, right? We have this gap and I want us to have so much strength in our convictions around how important it is for us to push back against these guidelines. Yes, it's scary, right? We don't like pushing back against medicine because sometimes I think we are not as confident as we should be in our doctoral level education and our evidence is on our side. And so we don't have to be jerks about it, but we have to acknowledge that our outcomes could be so much better. And I want to let you center in on the fact that you are the expert here. The surgeon is the expert in the actual surgery. You are the expert in managing them after. That handoff should be seamless. And it is important for us to advocate. And until we advocate and have respectful conversations that, yes, are scary, yes, your heart rate is going to be up, yes, you're going to feel like you have that adrenaline going through your system, but have the evidence in your back pocket Acknowledge your scope of practice and your skill set and make sure you are there to best serve your older adults. All right, that is my rant for today. If you were trying to see us live in person over the summer, Julie is in Virginia Beach, July 13th, 14th, so this upcoming weekend. Jeff Musgrave is up in Victor, New York, July 20th and 21st. And the entire crew is up for MMA Summit in Littleton, Colorado, July 27th and 28th. So if you were looking to see us on the road in the month of July, you have a couple of opportunities. If you're hoping to get into our online courses, our next MMOA level one starts August 14th. We are just finishing up our last cohort and we have a bit of a break for the summer. And then our advanced concepts level two course is starting October 17th. So I hope you all, I want to know your thoughts around this. Am I going crazy? Am I on the same boat or same page as you all? And what can we do collectively to make this a little bit better? All right, have a wonderful week everyone and we will talk to you all soon.

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses details that can be easily missed when treating out tendinopathy!

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Good morning, PT on ICE. My name is Cody Gingerich. I'm one of the lead faculty in our extremity division. And I'm coming on here today to talk about the hidden details of tendinopathies. Um, so in our extremity management course, we cover tendinopathy. We have an entire lecture on day two, as detailed as we can on tendinopathies. But what we know is tendinopathies in general are incredibly difficult to treat. Um, they last a long time. There are a lot, a lot of different variables that you have to constantly be playing with in order to really treat these people out and get them all the way back better and feeling good. And sometimes in an hour, hour and a half long lecture, we still can't cover everything that we, uh, possibly know about tendinopathies. And so I want to cover some today, just some of the hidden details of tendinopathies, things to look out for, and just a couple like additional clinical pearls, um, that may help you next time you're working with someone that has some tendinopathy going on. And there's a couple of different areas that I want to specifically address, and that's going to be more so like elbow tendinopathy. So think medial lateral epicondylalgia or tendinopathy in general. Um, and then patellar tendinopathy as well. Those just tend to be some areas that are pretty common. And so the first thing that I want to really emphasize with tendinopathy is looking at why the additional stress is happening to that tendon. So what we know about tendinopathy up front is that it is a chronic overuse injury, right? It could be acute, but typically it's gonna be in a chronic situation. And that means that that tendon is not doing the capacity or the work that you are asking of it. Okay. If it is an acute situation, a lot of times that is just negligence on that human and saying like, let's say, you know, for an Achilles tendinopathy or a patellar tendinopathy, let's say, you know, they haven't played basketball in 10 years and they decided that over one weekend they wanted to play, you know, two days straight of basketball. And it's pretty reasonable in that situation to be like, well, yeah, your patellar tendon couldn't handle all of that jumping and running that you were doing all at once. And so it's reasonable to think that a tendinopathy could accrue. And that's not necessarily something where you have to really look at like, all right, well, why is this happening? That's just pretty clear on like, well, that person just, you know, blew past their acute to chronic workload ratio. But oftentimes that's not how these things pop up and it's over time and they are long lasting and they are lingering and things like that. And that's the point where we need to really look at, okay, we definitely know that that tenant is not able to keep up with what we're asking of it. But why is it doing so much work that it is getting overused, right? Is there a movement pattern that they are doing that is potentially faulty? Is there a weakness somewhere else that we need to address and that tendon and that those tissues are just taking up more of the slack for a weakness elsewhere? And that's really where I want to hone in today. Because the other thing that we know about tendinopathies is it's pretty much a bullseye when those people come into your clinic and they say, hey, I have pain right here, or they point right to their patellar tendon. That can very quickly tunnel vision us into saying, okay, cool, I need to do wrist extensions, we need to build up that tendon, we need to do isometrics, we need to do eccentrics, we need to do heavy, slow concentrics, we need to really go after that tendon. And that can just pigeonhole us at that spot because it is such a bullseye when those patients tell you, this is where it hurts. And you're like, cool, I know where that is. I know what's happening. We need to get that tendon stronger. And that is true. But there are also other factors involved as to why that thing got pissed off in the first place. So we have those isometrics to help pull pain down and we need to address the tissue that hurts. but additionally addressing why it's doing that, right? And so in the fitness space where there is a lot of like grip heavy things and we see tendinopathies at the elbow, what I see frequently, there's two real things that we need to look out for as far as like those hidden details. One of those is shoulder capacity. How much shoulder capacity do they have? And are they trying to make up their lack of shoulder capacity with hanging on for dear life onto the rig, onto a barbell, onto a dumbbell or whatever, because that is now where they feel like their power is coming from. And that is causing some overuse because their shoulder capacity is not at an ability to really handle all of the things they're doing. And so that leaks down the chain to the elbow, wrist or hand. The other thing that I see very commonly, specifically when dealing with medial elbow tendinopathy, is that a lot of times people with generally weaker grip tend to try and make their grip stronger by doing this like false grip. And that is what is taught and what is appropriate in weightlifting. If you're doing dead lifting, cleaning, snatching, we want knuckles down. And that puts us into a position like this. If we are hanging or doing gymnastics movements, we want knuckles over the bar like this. What that does is every then movement, they then grab a kettlebell for a farmer's carry. They're gonna hook grip it like this. What happens is they're always using this, rarely getting the actual capacity to the other side of their forearm and those gripping muscles. We know the strongest grip is going to be in a little bit of wrist extension as well. And so then we can start pulling out like, well, in your workouts or in your day-to-day life when you're gripping things, I want you to actually start to pay attention to some of your traditional grip and let's see if we can't utilize some of our wrist extensors a little more when you're going to grab a door, when you're going to pick up things like hey let's get our knuckles back a little bit and now all of a sudden instead of just consistently trying to like hammer this tendon and get it stronger, we got to get it stronger, it's like well Yes, we can get it stronger, but we can also help to pull some of that tension and some of that irritation and overall use back to help it calm down. And that's the big thing is like tendinopathy, we want to improve the capacity because that's what overall needs to happen. But if we can improve the capacity while also taking away some of the work that that tendon overall has to do, now we're going both directions at the same time and pushing them forward faster. Right? And so that then leads to like, we're asking less of the tendon and it's getting stronger at the same time. So then that tendon can start that healing process a little bit faster. Okay. A similar thing can happen at the knee. where we have patellar teninopathy. But if you watch that person move, and they are trying to squat, and they are trying to push press, or power clean, or things like that, and they have a bit of a muted hip, where they are not using their hips effectively, and most of that work ends up coming through the quads, that's another situation where Yes, that patellar tendon needs some work and it can improve the overall capacity, but if you don't help that person and coach that person's overall movement pattern, they're going to consistently continue to aggravate that tendon. Whereas their hips should be the most powerful thing that is producing force, right? So get them into a little bit more of that posterior chain, get them using their glutes out of the bottom of the squat, get them using their hips when they're doing it in a power position, when they're doing push press. The examples are numerous where we want people to start using the hips and take away some of the stress from that patellar tendon while you are doing all of the additional isometrics, wall sits, Spanish squats, heavy slow concentric, cyclist squats. These are all great. But sometimes we also want to pull down some of the stress that those tendons are taking on and relearn some movement patterns that could be contributing to this longstanding tendinopathy. Sometimes that might mean adjusting their squat stance a little bit or their deadlift stance, just getting them used to using their hips a little bit more effectively while you're treating out that tendinopathy. So that's going to be one of the really big ways is like, don't get tunnel vision on. We need to strengthen, strengthen, strengthen, strengthen, and don't look elsewhere. Because a lot of times with these chronic tendinopathies, there is a reason there is a weakness in the chain somewhere. There is a weakness in movement pattern where that is causing the overuse of that tendon to happen. So simultaneously, while you're trying to decrease pain at that tendon via some strength training, some isometrics, building that tendon capacity, we also want to be working and trying to figure out, well, what is the underlying cause of why we're overusing this tendon in the first place? So I really want to emphasize that today. The other factor that sometimes gets overlooked in tendinopathy is going to be compression and speed of the tendon and what it is doing and in what space is it operating. So every tendon is going to pass by a bony prominence. That is where the bony attachment is going to be. And anytime we are working through tendinopathies, we want to appreciate that compression that happens in whatever exercise you choose to do. So if we're talking about a patellar tendinopathy, the deeper that person gets into their squat position, the more compression that patellar tendon is going to go under. Same thing when we are doing, if we were doing elbow or wrist exercises, the more that we stretch that tendon, if we straighten our arm, that will, and then extend or flex our wrist, that will put that tendon over more compression around your epicondyles. And that exists for pretty much every tendon in the body. And so Being able to navigate that variable and pull some of those different exercises out or changing exercises, it's not always necessarily that the exercise is wrong, but maybe the range of motion can be adjusted because that tendon can't tolerate the current compression that it is under. Okay. Finally, the speed. The speed is where tendons really hit kind of a fork in the road on what can it tolerate. So we like to live up front with isometrics, concentrics, heavy, slow building blocks of the tendon, but ultimately most tendons get aggravated under speed. So if you think you're runners and you're jumpers and you're throwers If you're crossfitters, where they're pulling a lot under speed on the bar, that's usually where those tendinopathies occur. Quick wrist movements, all of those type of things. And that ends up becoming the aggravating thing. So if we don't end up building in more speed, we aren't going to end up being able to get them all the way through their plan of care. And so that can start with using a metronome, right? So you can track how is this tendon tolerating speed. So you go a 60 beats per minute on whatever exercise you're trying to do. Then you go to 70 beats per minute or 80 or you start, you know, that's where you can very easily track and then you can start getting back into their actual functional movement with speed and knowing that it can tolerate certain levels of that speed. So overall, I saw a question here, stretching the tendon equals compression. Essentially, yes. That is a good way to think about it. If you are stretching the tendon, you are pretty much adding compression around those bony prominences most times. That's gonna be a pretty accurate statement for most of those tendons. Wrapping it around whatever bony prominence is adding compression, and most of the time that's gonna be if you're stretching it. And that becomes typically a more aggravating position for most tendons.

SUMMARY
So overall, the three really main things that I want to point out as far as additional details to tendinopathies that you don't want to forget about when you're treating tendinopathies. The first one is why specifically is that tendon getting irritated and getting overused in the first point? That is oftentimes going to be a weakness up the chain somewhere or potentially a movement pattern fault that you want to coach out. You want to look at, get your eyes on how they're moving and can we decrease stressors and get change some of that movement pattern while we are treating out the tendinopathy. Number two is going to be really paying attention to the compression around that tendon. Can we change or adjust range of motion of that exercise to help improve some of that compression or potentially add compression if they can tolerate it? finally is going to be speed. If you need to really truly know we are building them out through that full plan of care, getting them back to functional sport activity, you have to get them into speed. And I would track that with a metronome or something like that. So, you know, for a fact that that tendon is able to tolerate more speed, that's going to be more likely to reflect the activity that they are doing. Okay, that's all I've got for you today. Just wanted to touch on a couple different points of tendinopathy. As far as catching extremity management on the road, we've got a couple courses coming up later this month. So we have a course this coming week, looks pretty full out in Kent, Washington. Next weekend, we are in Henderson, Tennessee, couple seats open there. And then in July 27th, 28th, Bend, Oregon. So pretty much all across the country, we've got courses coming to you. from the extremity management. Would love to see you out on the road. Thanks for watching.

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, #ICEPelvic faculty member April Dominick shares how YOU can make a huge impact on the quality of life of a client with an upcoming prostatectomy simply through education on pelvic floor muscle retraining, lifestyle changes and physical activity AND learn the ESSENTIAL clinical pearls to include in a pre-operative physical therapy session when working with this population.

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
This is Dr. April Dominick. I am on faculty with the ICE Pelvic Division. Today we are chatting about prehab for a prostatectomy surgery. Why is prehab important and what should be included in your PT session with that pre prostatectomy client? This topic, it is so near and dear to my heart. it's because these humans just don't have the treatment or education that they deserve prior to going into these surgeries and afterwards when they come out. And if I can convince you why it is so important to be able to connect with these humans and to even just educate them on, hey, there is Help for you. There's pelvic floor muscle training that can be done education about behaviors whether that is you actually doing the PT session or you referring them to someone else it can have incredible outcomes for them post-op just because they are aware of pelvic floor physical therapy for their surgery the prostatectomy so Let's dive into what a prostatectomy surgery actually is. It is something to treat prostate cancer, and that's going to be by removing part or the full gland of the prostate. They're also going to remove surrounding tissues and seminal vesicles. The gold standard for surgery is a radical prostatectomy where they remove the entire prostate gland. I didn't have a walnut, so here's what we're working with. This fig represents the prostate. So let's run through some real estate of where everything is situated in someone with a prostate in terms of the pelvic floor and the organs. So we have our bladder here and then we have the bladder neck with the urethra that goes through our prostate. and this is going to be representative of the urethra itself. So the urethra goes from the bladder neck through this fig or the prostate and then down into the penis and that is how everything is set up. With a prostatectomy, after the prostate is removed, that extra support around the urethra is now lost, and the remaining bit of that urethra now needs to be reconnected back to the bladder. This reconnection, we can think about it like a bridge, or a fancy term is the anastomosis, and that anastomosis needs time to heal. So a Foley catheter is placed in for about five to ten days. That means that the bladder is or the urine is emptying passively. The bladder is not doing its job. It's off on vacation. And then once the catheter is removed, the bladder acts like it forgot how to start or how to store urine. It doesn't know what to do with it. And so we have a lot of urinary leakage. So among other things, this is why urinary incontinence or urinary leakage is a major side effect with these prostatectomy surgeries. post-op, the external urethral sphincter is relied on for maintaining continence. So good news for us, the pelvic floor muscles help to close that sphincter and keep pee in until it's appropriate to release it. And that's why pelvic floor muscle training with physical therapy can be so important pre-op and post-op, at least from the bladder side of things. So who does the prostatectomy surgery affect? Well, obviously those diagnosed with prostate cancer. It is the second leading cause of death from cancer in males. It's going to affect our individuals who are older than 50 years old and who are African-American. So if you think about who you are treating currently, if you're treating individuals who have prostates who are older than 50, one in eight of them are probably gonna have some run-in with prostate cancer, whether that's treated with a surgery or not. That's where you come in. You could have such a profound effect with these individuals just by educating them that pelvic floor muscle training exists And whether you're again, whether you're doing the treatment or you're referring out to someone else, you can have such an incredible impact on their post-op outcomes potentially. So, We talked about with a post-prostatectomy, we talked about that surgery can result in urinary incontinence or leakage. It can also affect sexual function. There can be reduced physical function. Think about it. If you're leaking all the time, is that really going to convince or motivate you to go work out? For some, no. And then it'll also affect the overall health-related quality of life. Take 65 year old Phil. You've got a Phil in your clinic. You're already treating him for low back pain, um, with his hikes and his weightlifting, say. And he went in for his annual physical, and then he walked out with a date for a surgery for radical prostatectomy. Besides being in shock that he now has this potentially life threatening diagnosis, Phil comes in and is like, this happened. He's like, am I, am I ever going to be able to hike with my hiking group and not be the person that smells like pee? Am I going to be able to be cool with being in the changing room in the, in the locker room after my weightlifting session, like removing this soggy pair of underwear, or am I going to be able to enjoy sexy times with his partner? Well, since you're here and you intently are listening to this podcast, You, your first line of question is, hey, Phil, did they recommend any sort of physical therapy for you? Um, whether it's pre-op or post-op. And of course, Phil's like, no. So you teach him that pelvic floor muscle training can be so effective and helpful, um, and play a huge role in those side effects that he's worried about. Y'all, what if we could have an incredibly bigger impact, building the foundation, setting the stage for what to expect post-surgery, just with PT sessions? Clinically, I've been treating this population, hopefully you can hear my passion behind it, for about seven years. I've interacted with so many fills that come in, if they even get to me, right? and they are just slapped with that surgery date, and the side effects are kind of breezed through during their appointment, it seems like. And their concerns aren't really heard, their well-being and their questions, they're just kind of like not given a lot of attention. I didn't always do pre-op sessions, but once I started, hoo-wee, I was just blown away by how different the clinical outcomes were in terms of improving, whether that was decreasing the volume of urinary leakage for some or having them return back to their ADLs exercise a little bit sooner. The biggest thing, which was so powerful for me, is these people came in extremely uncertain, having no idea even why, if their doctor did send them to PT, why they were there. And they were just uncertain about these really scary side effects, about how maybe for the first time they were going to experience some sort of losing control of their bodies, from peeing unexpectedly to changes in their erections. And they walked out of that first session feeling a little more confident, a little more certain. And that is the power, I believe, of these pre-op sessions. And then from a research side of things, what's shaking out in the few RCTs that we have for these pre-op sessions and their effects on prostatectomy, some may be helpful in improving quality of life. they may affect a shorter hospital stay. They may reduce post-op urinary leakage in the short term. So some studies find around month one, three, or six, that the individual is leaking less, meaning they're drier faster. Now, when you compare someone who had some pre-op PT to someone who did not around 12 months, they are about the same with their rate. But I would argue that I bet folks are going to be a lot more satisfied if they did that prehab and they are drier sooner, right? So let's go into what a prostatectomy PT session entails before that surgery. We've got these sessions already in place. for folks who are going in for surgery for their ACL repair, for their hip replacement. But just like we're fighting with our pregnant and postpartum population, we are somehow having to fight for someone to have a pre-obsession for something like a prostatectomy, and that impacts so many daily functions. Let's outline what is involved in that pre-op PT session. Again, you can educate someone on what to expect if you're referring them to someone to do this. So we'll go over subjective, objective, and the treatment. From an assessment side of things, from that subjective piece, what you can be talking to your patient about is what are their current bladder and sexual habits? How many voids do they have during the day? How many times do they go pee? Do they have an urge? Do they have urinary leakage or hesitancy? And there are some outcome measures that go over these things. The International Prostate Symptom Score goes over those things. Plus they ask about nocturia or nighttime urination. And then the NIH Chronic Prostatitis Symptom Index is another outcome measure. And I love it because it asks about the impact of these symptoms. How is it affecting your quality of life? Then you want to also ask about their sexual function. How would they rate their erection strength or their satisfaction with their sexual life? From an outcome measure standpoint, you can give them the International Index of Erectile Function. This is something that asks them to rate qualities of their erection from the past four weeks. Then you want to also get a good idea of their current physical activity regimen. What a wonderful time to, if they're already a little physically inactive, hey, let's like plug in for, here's why it would be really great if you could up that physical activity. Not just for that immediate post-op surgical outcome, but also, hey, we can lower all cause mortality. And then from an objective side of things, so we went over the subjective, objectively speaking, we want to get a pelvic assessment. Whether that is over the clothes, external, near that midline, or it is a visual or tactile palpation, or an internal rectal assessment, if that's what you're trained in. So we're looking for, what's their awareness? Do they even know that they have this group of muscles that they can control? called the pelvic floor. We want to be looking at their coordination, timing of the pelvic floor, and then also getting an idea of what is their breathing and bracing strategies for things that increase interabdominal pressure, like fitness activities or functional lifting of the groceries, coughing, running, weightlifting. Typically, this population tends to be a breath holder. So we're gonna spend some time, there's just so much that we can do to help them in this area, to help them have improvements in their methods with that. And then we also wanna be doing some sort of general orthoscreen because what if their hips are cranky? Obviously that's gonna affect pelvic floor, low back, and all those surgical outcomes. From a treatment side of things, so we went over subjective, objective, highlights from the treatment side of things. where we'll talk about education, what to expect post-op, and some homework for them to work on. Education. I cannot stress this enough. The education piece here is vital for affecting their outcomes and well-being. Let's educate them on the pelvic floor. Here's what it is. Here's the anatomy and physiology. Here's how it affects your penis. whether that's for sexual health or for the urethra for urination. Here is what happens during the surgery. Get to know the surgeons in your area and which methods they use. What are their outcomes, right? And then you want to be explaining the risk factors for these side effects like urinary leakage and sexual function. dysfunction. Non-modifiable factors. If you're older, it's not going to help you as much. And if you already have some reductions in urinary function, like you're already leaking, that is not going to help you on the backside. Modifiable factors, tons. So things like smoking, poor nutrition, That is gonna delay healing post-op. Can we identify some current bladder irritants and reduce those immediately post-op? What about poor mental health? Things like low self-efficacy or if they're experiencing anxiety or depression, helping them ID these things and finding them some psychosocial support to have upcoming for the surgery and post-op, so key. and then reduced physical activity. Hard health is heart health. What do I mean by that? Erections, ejaculation, is related to vascular health. Hard health is heart health. So what affects our vascular system? Aerobic and resistance training exercise. If we can have them and talk to them about how it's important and how increasing that physical activity is going to improve their physiologic resilience to the surgery itself and any complications that come up, that is gonna be having such a huge impact on their quality of life. Regarding physical activity, in a 2014 RCT by Mina et al, they found that men who were meeting physical activity guidelines prior to surgery had greater health-related quality of life at six and 26 weeks post-op compared to men who were not meeting those physical activity guidelines. So, from a post-op perspective, we want to tell them what to expect. Urinary incontinence and sexual dysfunction. From the urinary incontinence side of things, they will have a Foley catheter in for five to 10 days. Remember, the bladder doesn't work during this time. Once that catheter is removed, we gotta retrain that neural pathway to help control the bladder so that they know, oh, my bladder is filling, or this is how I'm gonna stop that leakage from coming out, and how to fully empty the bladder. Another huge tip, have them bring a hygiene product, whether that's a pad or a diaper or something, with them to the hospital so that when they are discharged, they have something to help protect them on their way home or on their way to the store to grab their meds. And then urinary incontinence could be present from a couple of months to a year post-op. We see a significant improvement in that three to six month range, but it could be affected by things like, hey, it gets worse at the end of the day because the pelvic floor muscles are tired, or with transitional movements like sitting to stand. So working on these movements with them is gonna be super helpful pre-op. And then maybe talking to them about how, if you're not going to see them for 10 days or so post-op, we may be using the pad weight or the number of pads in a 24-hour period as a marker for our progress. So just having that in the back of their mind. When it comes to what to expect from a sexual function standpoint post-op, it can take up to two years to recover to baseline function from an erection standpoint. We want to set these expectations from an ejaculation standpoint. Dry ejaculate is going to happen now because those seminal vesicles were removed, and that's what helps produce that ejaculate. There may be some changes in their orgasm sensation. Erections, it could be dependent on surgery outcomes. How much nerve sparing was there in that procedure? They have the potential to get better with this, especially with pelvic floor muscle training or things like pumps. And then loss of penile length. This is something that we want to let them know can happen so they don't get a little surprise. Homework wise, we want to address any of those pelvic floor deficits we found from that objective piece, especially that breathing and bracing strategy. We can do that with biofeedback, whether that's with a mirror, with a palpation from the therapist or from them, and just to really improve their awareness and coordination there. And then giving them cues that connect them to the pelvic floor. Evidence supports, hey, pelvic floor contractions with the following cues, like shortening the penis, though I've been told nobody wants to have that. So something like nuts to guts or stopping the flow of urine is great for that. One side of the range of motion, the contraction side of the range of motion of the pelvic floor, and then something for the relaxation side, like let the testicles or base of penis hang loose. I did an Instagram post recently, so you can check that out on the ICE or Revitalize Pelvic Physio page. And then we wanna be, for homework, modifying their poor lifestyle habits. Can we reduce those bladder irritants, process sugar? Can we increase your physical activity and mental health? And then finally, we want to be scheduling their followup visits on the calendar. So whether that's for pre-op, a couple more sessions, or as early as 10 days, once that catheter is removed, they can pop back in to your office.

SUMMARY
So, I hope you found that information helpful. We reviewed how prevalent prostate cancer is, especially for those who are 50 plus. We know that radical prostatectomy is the gold standard for treatment. Two major things that are affected post-op are urinary incontinence and erectile dysfunction. Pre-op PT sessions are fairly new, but we have some evidence that says, hey, those who partake in pre-op sessions are drier sooner than their counterparts. And then from a PT session standpoint, thinking about asking what their current bladder and sexual function is, asking them about physical activity, mental health, objectively getting a measurement of the pelvic area, and helping them connect with that area a little bit more. Treatment-wise, we want to really harp on that education. about what the pelvic floor is, how it can help with their function, and also what to expect, possible side effects, modifiable risk factors, and then giving them homework to work on those deficits, and then finally scheduling that additional follow-up before surgery and then getting their post-op session on the calendar. My next podcast, I'm going to go into detail on what a post-op session post prostatectomy looks like. So tune in for that. And then if you want to learn more about pelvic floor examination, join us live. We have our next two courses. One is July 20th, 21st in Cincinnati, Ohio. And then July 27th and 28th, we are gonna be in Laramie, Wyoming. If you're wanting more of a virtual option, we have our two different courses that are eight weeks, L1 and L2. And in L2, we go over the male pelvic health conditions as well. Thank y'all so much for tuning in from my prostate slash walnut. Happy Monday, and I'll see you next time.

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

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 uphill & downhill running, the differences between flat running, and how to progress into vertical running with patients & athletes.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
All right. Welcome everyone. Happy Friday. Welcome to another episode of PT on ice daily show. Uh, hope everyone had a wonderful 4th of July holiday and have a great weekend ahead. My name is Jason Lunden. I am the lead for the endurance athlete division. Uh, so teach rehabilitation injured runner live and online as well as a professional bike fitting course. And what I'm going to cover today is. what vertical adds to the equation. So talking about uphill and downhill running, both hills and in the mountains, and what the differences are compared to level running, why that matters, and then how to safely progress that training for yourselves and your patients. So uphill and so Adding vertical to one's training obviously means adding some uphill and downhill running, and those are obviously different than running on level ground. So uphill running is characterized by a lot more mechanical work, meaning there's a huge increase in the load on the muscles, as well as changing the biomechanics of running so that one is landing in more of a flexed position at the hip and the knee as well as more dorsiflexion at the ankle and that the amount of hip flexion, knee flexion, and ankle dorsiflexion is much higher in uphill running than level running and or certainly downhill running as well. Stance times are longer, the amount of time in flight is lessened, and impacts are overall less. As far as contrasting that with downhill running, downhill running is characterized by landing with a lot more, the knee in a lot more extension, a lot less hip flexion. And then depending on the experience of the runner for running downhill, If it's more of a novice runner, they're going to be characterized by striking with a rear foot strike pattern or heel strike pattern. If it's a more experienced downhill runner or trail runner, it's going to be characterized by more of a mid-foot strike pattern. Here, downhill running is basically characterized by negative work, so it's all eccentric work. So a lot of more impact to the runner and a lot less load specifically on the muscles, just more of an eccentric load. And so why does this matter? So, you know, thinking about your patients that you might be working with, if you have someone with a high hamstring tendinopathy, that's likely going to be loaded a lot more and potentially irritated more. with uphill running, right? Because that hip is going to be in more flexion. There's going to be more muscle work, particularly on the posterior chain with that uphill running. And that repeated high hip flexion angle is going to also cause some compression at that hamstring insertion. Whereas if someone is dealing with patel femoral pain or maybe medial tibial stress syndrome, Downhill running is going to really increase the stress on those areas with that increased impact and eccentric load and definitely irritate those symptoms. And so you want to be thoughtful when prescribing or getting those runners back into dealing with a vertical that, you know, if it's a high hamstring tendinopathy, you may want that runner to be hiking the uphills and then running the downhills. And then conversely, if it's someone with patel femoral pain, you'll want them to be running the uphills and hiking or walking the downhills. And in addition, If someone is running, whether it be on the road or on the trail, and they have a race that has a vertical profile with some elevation gain and loss, you definitely want them to be implementing hill workouts or running in varied terrain. early on in their training so that they have the time to adapt to those new loads on the muscles and on the joints, as well as, you know, adapt their running mechanics appropriately too. So typically, you know, if it's someone who's new to trail running and, you know, they're going to be running their first trail race and there's, you know, 5,000 vertical elevation gain and loss, they're going to be wanting to implement that training far out in their training. So months ahead of time, again, because of the differences in the mechanics and the loads on the muscles with uphill and downhill running. As far as ways to, you know, implement this safely, there really isn't any scientific evidence on this. It's mainly anecdotal, you know, a lot of kind of looking at a lot of the advice that coaches will give is really based on the 10% rule or the literature that we have on progressing training volume in running. So, you know, no more than 10% increase in vertical per week or certainly no more than 15% over the course of two weeks is a common piece of advice that you'll hear. So what does that look like? You know, if someone is running 10,000, or sorry, 1,000, vertical in the first week, uh, you wouldn't want to increase by more than another, um, a hundred the following week, if you're doing that 10% rule. And that's going to be really more for your novice runners. Um, and generally for your, your novice trail runners or novice runners that are, or novice runners running hills, um, it's going to be looking like, you know, probably being able to add a thousand feet of vertical. in their first week and then progressing from there with that 10% per week or no more than 15% for two weeks. If it's a more experienced trail runner that you're working with who has had a lot of experience of doing a lot of vertical, start at approximately 50% of what their vertical was prior to dealing with their injury. And then the last thing to consider is, okay, so we're talking about vertical, but how are we progressing that in the space of also progressing just running volume as well as intensity? And so a good rule of thumb here is to not, ideally, the safest way is to not progress all three of those elements in the same week, but realistically that's probably going to have to happen. And so the best place to start out is not increasing all of them combined by more than 15% per week. So what that would look like is, you know, I am running, you know, 50 miles a week. I'm doing a thousand foot of vertical a week. And then also within that week, probably, you know, adding in a speed workout as well. And so for the next week, I would want to not increase my weekly volume by more than 10%. So we keep that at, you know, 10% and then not increasing the combined vertical and amount of intensity work by more than 5%. So that would get us our 15% total there. So again, just to recap, you know, adding vertical or dealing with vertical with endurance athletes, uh, is going to be very common. Um, especially if, for those of you living in more mountainous regions, um, where trail racing is, is King. Um, but even for your, your road racers too, if they're going to be running a race with, you know, a vertical profile, so not Chicago marathon, but, um, you know, maybe Boston marathon. where there are some hills, you really need to be thoughtful of how to, one, implement that training, as well as how to progress that training, and how running uphill is going to stress their body differently. how it's going to change your mechanics. So again, uphill running is going to be a lot more load concentric on the muscles, especially on the Achilles, the glute, the hamstrings. And it's going to be characterized by a lot more, a much deeper angle of flexion at the hip, knee and ankle. Whereas downhill running is going to be characterized by a much larger eccentric load with potentially being at a rear foot strike versus a mid foot strike and adding a lot of impact. To progress that, we want to kind of draw on the information and experience we have from both coaching and the literature, which is going to be drawing on just level running. So not increasing vertical by more than 10% per week, or not increasing vertical volume and intensity for a sum of more than 15% per week. And wanting to implement this early on in their training so they have time to adapt to the stresses of training. I'll leave you with just one really cool article that came out more recently, which was looking at downhill running and adaptation to that. And really as little as one bout of 30 minutes of downhill running on a 20% grade results in what they call the bout effect, or it's really a protective effect on eccentric muscle damage and delayed onset muscle soreness. So after that one bout, the next time the runner runs downhill, they're going to have less eccentric muscle damage and therefore less delayed onset muscle soreness. So that's pretty cool. So definitely wanting to implement that downhill running as soon as you can into their training so they start getting those adaptive effects.

SUMMARY
All right. Well, thank you everyone for listening. We do have some endurance athlete courses coming up. of coming up right around the corner on July 8th is when our next cohort of rehabilitation injured runner online starts. So that is the last one for the summer. So we'd love to see you online for that. Our next professional bike fitting course is going to be in Denver at the end of July. And then our next rehabilitation injured runner live is going to be in Sparks Glencoe, Maryland. in September. So we'd love to see you at those courses. Reach out if you have any questions. Have a great weekend. Get outside. Do something fun. See y'all.

OUTRO
Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning 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 how to approach helping patients who don't want help

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Good morning, everybody. Welcome to the PT on Ice Daily Show. My name is Alan, happy to be your host today. I currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member in our Practice Management in Fitness Athlete Divisions. It is Thursday. We talk all things leadership, business ownership, practice management. Leadership Thursday also means it is Gut Check Thursday. It is the 4th of July, so we have a gnarly hero workout planned for you all this week. The workout, I just finished it. It is called Glenn. Glenn is named for former U.S. Navy SEAL and CIA operator Glenn Doherty. He was killed in the attack on the U.S. Embassy in Benghazi back in 2012. And so this is a very long Very kind of moderate intensity piece with a bunch of different stuff thrown together. So the workout starts with 30 clean and jerks Recommended weight there for guys 135 95 for ladies that should be a weight that you can hit for smooth consistent singles getting done somewhere between maybe three to five minutes out the door for a mile run a 2k row for guys 1600 meter row for ladies or a 4k bike for guys 3200 meter bike for ladies After that cardio piece, you're back in the door for 10 rope climbs. That also looking to be done in maybe 3-5 minutes, a rope climb every 15-20 seconds or so. If you can't rope climb, we have some scaled options for 20 pull to stands. or 30 strict pull-ups, whether that's with actual strict pull-ups or with a band, but some sort of challenging vertical pulling motion that's going to get you done in three to five minutes. Back out the door, repeat that mile or that row or that bike, and then come in the door one final time for the coup de grace, 100 burpees. For a lot of folks, this is going to take maybe 45 to 60 minutes. It's going to depend obviously a lot on your mile run time, your ability to cycle that barbell, and your ability to motor through, more importantly, those 100 burpees at the end. Treat this workout just like a run where you're maybe aiming to decrease your split time, start slow, build up speed. The worst thing you can do is race through those clean and jerks in that first run. and then crash into a wall on those rope climbs that second mile and definitely you can hit the wall if you're not careful on those burpees and turn that into a really miserable end to the workout. So just pace yourself, go slow, get faster kind of mindset. So that's Gut Check Thursday. Today is 4th of July. We're kind of talking about a topic related to the 4th of July in the United States of America. The American mindset, the cultural mindset that we can and we should and we have to save everybody, right? We have to be the world's police and the world's diplomat and inside of America as healthcare providers and physical therapists, we have to save every patient. So the title of today's topic is You Can't Save Everyone. I don't want this to be a pessimistic episode where you leave feeling discouraged and like you should give up. I hope you actually leave this episode feeling maybe a little bit more relaxed, a little bit more empowered in your practice. This topic came from a question we had from a student at the Fitness Athlete Live Summit a couple weeks ago. So, on Sunday mornings of Fitness Athlete Live, we take Q&A. We get some really good questions, we get some really good discussion points. And a student named Trevor, Trevor Purcell, who's nearby me here in Clarkston, Michigan, had a question. He said, hey man, you know, you're doing the thing, you're using the symptom behavior model, you're finding out what's wrong with people. you're giving them manual therapy and exercise that's reducing their symptoms, you're trying to get them into loading and higher intensity exercise, you're figuring out what music they like, you're pumping the jams, you're trying to high five, like you're bringing it, right? In every aspect of your practice, the clinical reasoning, the manual therapy, the exercise, the personable skills, the DJ skills, you are bringing the heat And that person is just straight up not feeling it. Like how, what do you do, how do we get those people to get more serious, to get them to maybe transition to doing a maintenance program with us at the clinic, or maybe transitioning to a fitness program out in the community with a resource that you may have associated with your clinic. Like what do we do with those people who seem to, no matter what, no matter what value we're showing them, just really don't seem interested in picking up what we're putting down. And so my answer back to Trevor was be careful, right? Be careful that we don't try to save everybody, even people who don't want to be saved. And so today I want to talk about that. I want to unpack that answer in a little bit more detail. I want to talk about the numbers behind the physical therapy profession and how many people were expected to help. I want to talk about what I call the lie, how we learn to help people in physical therapy school. And then I want to finish and talk a little bit about the reality of what it actually looks like in practice to work with those people and some tips and tricks for that.

THE NUMBERS
So let's start with the numbers. Numbers are boring. As Jeff Moore, our CEO, would say, data doesn't change behavior, but I'm a firm believer that even though data doesn't directly change behavior, telling somebody they're going to die early if they don't lose weight or stop smoking or sleep better or exercise more, all that stuff, we know That just doesn't flip a switch in people and all of a sudden they change all of their less than optimal health behaviors. But that being said, even if data doesn't change behavior, I'm a big believer that data does inform decisions. And so knowing the data going into any situation can make us better prepared for that situation, even if it doesn't directly influence a decision in that situation. And so stepping back on a macroscopic level and looking at analysis of our profession, there are about 300,000 licensed physical therapists in the United States of America versus a population of 330 million Americans. So if we were to pair up one physical therapist with patients and say, this is your charge, this is your crop of people that you need to help every year, get moving, stay moving, stay with whatever fitness program they've been turned on to, you would need to help 1100 individual people per year. Now, the truth of that 300,000 is that those aren't all full-time practicing physical therapists. We have about 90,000 full-time physical therapists in outpatient. We have about 60,000 in acute care, skilled nursing, inpatient rehab, sort of the hospital side of the equation. and we have about 26,000 folks working in home health for a total of 176,000 full-time licensed practicing physical therapists. People getting up every day, putting on the uniform, and going out to man their post on the trench, right? So automatically that cuts our profession in about half. All the rest of those people are in academia, they are in management or ownership, they're no longer practicing, they are part-time, or even many of them are retired and they just want to keep their license because once you let it lapse, it's a lot harder to get it back than if you just keep it renewing. So that changes the equation a lot. That means every physical therapist now has to help about 1,900 patients, right? Almost double the amount of patients. And if we take a hypothetical scenario where you are an outpatient physical therapist, your productivity is maybe moderate. You see a patient every 45 minutes. You see about 12 patients a day, 60 patients a week. We know those are all highly unlikely to all be unique visits, each with a different patient, that a lot of those folks are coming maybe two to three times a week. And so if we assume that those folks are coming twice a week, then you're probably only interacting with 30 unique people or so per week, and then if the average plan of care is about 10 visits, or about five weeks of care, that we probably only interact with somewhere between 250 to maybe 500 unique patients per year, and that would be a very high volume productivity model. That would be a model where maybe you are seeing a patient every 15 minutes or so, or maybe even more. And so just thinking that statistically already the math doesn't add up, right? That puts us at about 20%. We're helping about 20% of the people we need to if our belief is that we should be helping and saving everybody with getting them moving, helping them stay moving, musculoskeletal rehab, performance, that sort of thing. It's not surprising to me that that number is exactly where physical therapy is at for utilization each year. Only about 20% of Americans seek the help of a physical therapist per year. So all things considered, we're at where we should be for the size of our profession. That if we wanted to reach more patients, we would somehow need to get even busier than we are, which I don't know how that would be possible. If you're only working with 500 people a year, seeing a patient every 15 minutes to see 1,900 people a year you would need to see 6 to 10 patients an hour you would have 3 to 5 minutes with each patient and so obviously that does not seem logistically possible and so the real truth is we either need more physical therapists or we just need to recognize not everybody needs the help of a physical therapist at any given time or wants the help of a physical therapist at any given time and that's okay.

THE LIE OF ENTRY-LEVEL EDUCATION
So moving away from the numbers and moving into the lie of why doesn't everybody need our help and why do we feel this disconnect between wanting to help everybody but maybe perceiving that not everybody is, again, picking up what we're putting down. We're bringing all the noise in the clinic and they're just not receiving it. In physical therapy school, we were shown a facade, right? We worked with a lot of paper patients, right? A lot of case studies and scenarios on a sheet of paper. We worked with a lot of mock patients who were usually our fellow classmates, our professors, or maybe paid actors who were likely just students in a different program at the college that we took PT school at. And the thing about these folks is that they always got better, right? We did an intervention, a manual therapy, or an exercise intervention, or both, or whatever. and those patients always got better. Not only did they get better, they were completely adherent with their home exercise program, and they miraculously restored their function, sometimes within minutes of care, right? And so the smack in the face is entering those clinical rotations and entering early practice and realizing, That's not how the majority of human beings respond to physical therapy treatment at all. And we get this buzzword that flies around social media as a result, imposter syndrome, right? I feel like I don't belong here. When in reality, I think imposter syndrome is this belief that we're not good enough and we have nothing to offer our patients and that we're not doing enough to save these people, right? If we could just shackle them down and force them to exercise, they would feel so much better And damn it, why don't they just do that? But in reality, what we're probably experiencing is this interaction of higher volume care than we were exposed to in school, right? I remember my mock exams being 90 minutes or two hours. I've never had that long for an eval in practice in my life. And we also had a lack of basic clinical reasoning coming out of school. and a lack of exercise prescription skills. So we're interacting in this high volume model where maybe we're not able to quickly figure out what's going on, correctly dose manual therapy and or exercise for that person to show them a symptom reduction, and also that they just tend to not get 100% symptom relief, even if we do nail it on the head. And so we leave the clinic every day feeling defeated, like we're not helping anybody, like we can't possibly help everybody, and then we come with questions like, What do you do when people just won't accept the treatment that we know is the best choice for them?

THE REALITY OF PRACTICE
And so that brings me to my final point, the reality, the reality of practice, that not every person needs or wants our services, especially in the span of an entire year. I think often of my own mother, who is a very unhealthy person, has been unhealthy her entire life, who is really a testament to the resilience of the human body, has never exercised, has never picked up a heavy thing, has never got her heart rate above baseline, who I don't think has ever eaten meat or anything that's not packaged or processed in a piece of paper or a piece of plastic, right, lives off Twinkies, and Ho-Ho's, and 7-Up, and lunch meat, and kind of the typical baby boomer diet of nuclear family processed food. Has been healthy her entire life, has done nothing about it, and this past December, having a string of three hospital admittances in about a month of being so sick that it was tough for even the doctors at the hospital to figure out what was wrong, having septic shock, having COVID, just really kind of decaying in a hospital bed. And me going down to that hospital, a two-way drive each way to get her some physical therapy, 10 to 15 minutes of movement, and seeing the kind of miraculous change that she made just doing 10 to 15 minutes of higher intensity exercise a day, right? Function restored, no longer needs a walker, no longer needs oxygen, standing on her own, back to kind of her baseline before she started to get sick and go in the hospital. And thinking that finally, by gosh, this is it. This is the light bulb moment where she's going to connect that the exercise she's doing is related to how much better she's feeling, how much more function she has, the realization that she can probably continue to live independently and she just has to keep doing this stuff. And then again, that lie, right? That getting smacked in the face moment of going back home and hearing, I don't want to keep doing that, I hate that, I'm never gonna do that again in my life unless I have to. And feeling that disappointment, right? Of gosh, why won't you let me save you? And finally, coming after a really bad failed intervention to say hey, you need to turn your life around, you could die, we don't have the time and money to continue to do this with you, I can't keep driving here four hours a day to make you do 15 minutes of exercise. And that moment of, oh, I don't want you to. I don't want to do this exercise stuff. I only did that because I had to. And that's really kind of what we hear a lot from our patients in the clinic, isn't it, right? We hear a lot of the reasons sometimes that they come to see us are extrinsically motivated. They have to come see us in order to get that image they want, in order to get an extension on that pain medication. maybe they're coming to see us so their spouse or their kids or their grandkids or their friends or whoever stops nagging them about going to get their elbow pain seen or their knee pain or figure out why you're falling. So a lot of times Patients can show up without the necessary intrinsic motivation on board that we know we need to see to really have a person make a significant lifestyle change. And understanding that real people don't behave like the fake patients we interacted with in physical therapy school. They don't always 100% get better all the time. They don't miraculously buy into our care. They aren't lifelong proponents of physical therapy just because we treated them once. That's not how real people behave. They have a number of different expectations, a number of different barriers, and a number of different motivation reasons to or to not come to physical therapy. I'm a big fan of the 90-10 rule. This is something I learned from our CEO Jeff Moore. Don't spend 90% of your time helping 10% of people, right? Do the opposite. Spend 10% of your time helping 90% of people because they have the motivation on board that you need to see, that they can make those changes we want to see them make, but they are also voicing and they are showing you and telling you that they want to make those changes. And now that's not to say that we abandon those other people, we abandon the 10%, but rather we reserve ourselves, right? We don't beat ourselves up that we haven't convinced a person who is maybe 85 years old, who has never exercised in their life, who has never eaten something that hasn't been processed, is not probably going to make a miraculous life change after coming to see us for physical therapy for just a couple visits. And so, letting yourself off the hook a little bit. The sooner you learn to recognize who those people are, again, you're not banning those people, you're not going to give them less care, you're not going to say, hey, you can't come here until your attitude turns around, but you're just a little bit more reserved. You're understanding that if you continue to dump a lot of energy and passion into a person who's not reciprocating it, it's unlikely that you're going to see that behavior miraculously change until something else changes in their life and there's no harm in that and there's no reason to feel bad about that because I would argue that you have cemented yourself as a resource in that person's life that if in the future they encounter another injury they're probably going to come see you which is great because it's better to come see PT 2.0 than PT 1.0 or surgery 0.0 or whatever, it's better for you to be the resource in their life for when that pain does pop back up. And if they are ready to make a change, they are ready to lose weight. get fitter, get stronger, stop falling, stop smoking, stop drinking, sleep better. Whatever might change in their life, once they get their own life figured out on their own time, they have you as a resource, and I think that's very, very, very important, and that's very, very, very noble and good work to be doing in your community, while you continue to pour the majority of your energy into the people who are reciprocating the things that you are trying to teach, the things you're trying to show, and the lifestyles we're trying to change and shape.

SUMMARY
So, you can't save everybody. The numbers support that it's not possible anyways. Recognize that we were kind of set up for failure from the start with school, of never encountering patients who didn't get better, patients who didn't want to come to physical therapy, patients who were soul-sucking sometimes in their physical therapy session. and I think it's a normal and natural reaction the way that entry-level schooling is currently run for us to get that smack in the face feeling when we leave school of, oh boy, this is much different than those fake actor patients and those paper case studies. And the reality, the reality of what can we do We can't dump our energy into those folks and expect them to change on their own. It doesn't mean that we abandon them. It doesn't mean that we discharge them. It means we continue to be a resource for whenever they're ready to change and we pour the majority of our energy into the folks who want and are currently trying to make those changes and need and want our help to do so. That's all I have for you all on this wonderful Thursday. I hope you have a great 4th of July. I hope you have a nice long weekend. Hopefully you have tomorrow off work. Have a great weekend. We'll see you all next week. Bye everybody.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty member Jeff Musgrave discusses how to help older adults understand the value in practicing falling as well as tips for increasing confidence & helping older adults set positive expectations for a meaningful experience.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. Proudly serving as part of the older adult division and super excited to be bringing you some more conversations, some more topics regarding older adults. In particular, I think a big swing and a miss oftentimes for older adults when we're thinking about balance and falls training. So much of our time is focused on falls prevention, preparing someone for falls prevention and trying to keep someone from having a fall, which is awesome. We need to do that. It's very important. There's a lot at stake for older adults and we want to prevent as many falls as possible. but we really should not stop our falls training there. So there is a lot of great research to show that we can help improve confidence and reduce injury risk if we can actually prepare someone to fall. And there are two big steps there. So if we're going to go beyond this falls prevention into falls preparedness, there's two pieces. One is getting someone up and down from the ground is a key thing for building confidence and something we need to do if we're planning to do any falls landing with anyone. So just so we're clear, I'm not gonna be covering floor transfers today. I am gonna be talking about strategies. If maybe you've learned how to do these things and you're not sure how to create a successful session regarding falls landing. So I did mention that there is some literature showing benefits for falls landing, because maybe that's new for you. You're like, yeah, I'm not so sure about that. There was a study that came out in 2019 by Moon et al, where they took older adults and they taught them a tuck and roll strategy. So the reality is everyone that got exposure to falls landing using a tuck and roll strategy were able to do two things. One, reduce the acceleration speed of their head hitting a cushioned mat, but also the impact force, the ground reaction force is on their hips. So when we're thinking about trying to reduce head injuries, head, neck, spine injuries, as well as reducing fracture risk. We can do that successfully with a tuck and roll strategy. They found that older adults, after only just two sessions of learning a tuck and roll strategy, were able to reduce their head acceleration speed by more than 40%. 40% slower of their head hitting the floor, or in this case, a crash pad. The other thing they were able to do was reduce that hip ground reaction force by 33%. That's huge, and I especially want you to think about, we know that 30% of adults fall each year. We don't wanna say you're older, so we know that you're going to fall, but we do want them to be aware that there are things they can do to reduce their injury risk. We can teach that, and we want to keep in mind that a lot of our older adults, because of deconditioning, have become frail. They've lost muscle mass. They don't bounce back from injuries as quickly as they should because they've lost reserve and don't have that extra beyond what they need to live daily life physically or within their balance, so they are more likely to fall, and they're more likely to get hurt when they fall, causing a catastrophic injury. So we think about the people in our caseload that are the most frail, they probably, in a lot of ways, have the most benefit from these fall landing strategies, because they're the most likely to have a life-altering fall. Because I think most of the time we think, well, this is just for the people who are super healthy, super strong already. But those people are the ones that are more likely to be okay if they have a fall. The people that really probably need this the most and need it most urgently are those who are the most frail, the most weak. They have the most to lose and are the most likely to get injured in a fall. So I really want to advocate that we find the right strategy for the right place to start these strategies for older adults. And I've got a few tips to try to create a successful session for older adults if you're teaching fall landing for the first time. So I'm not going to be going through the mechanics of how to do that. That is something we go through in depth in our in our live course and teaching that, but I do want to help you set the stage for how to make this a successful session, first time teaching fall landing strategies.

VALUE IN PRACTICING FALLS
So the first thing is value. Your patients are probably gonna need to be sold on the value, like why in the world would we practice falling? Because it sounds risky and you as a provider may be perceiving risk too. And there is some risk involved. We need to have a very calculated mindset of risk versus reward that's also gonna help us dictate at what place do we start these fall landing strategies. So what's the game? We can prevent head, neck, and spine injuries. We can prevent those hip fractures, likely, if we can teach an effective falls landing strategy. So I wanna let them know that they can learn they can reduce their injury risk. They need to know that it's really possible, it's been studied, people have done it, and if you've already been doing this with your clients, you can share success stories of how you've done this with other people, that it went fine, but you also need to keep in mind the individual characteristics of the person in front of you. I'm not saying carte blanche, like take these people, drop it like it's hot, hit the mat, hit the floor with everyone. If you have taken our live course, you know that there are lots of ways to scale this to make it really easy and very non-intimidating, very low risk. And I'll share a couple of those at the end. So first thing you've got to do is you've got, they've got to know the value. Why would I want to learn this? What could be made better? Reducing their injury risk is the biggest sell here. And even if they're not having lots of falls at this point, we do want to keep in mind with populations that have degenerative neurological conditions that we know are progressive in nature, whether it be MS or Parkinson's disease, falls are frequent. They happen very often. And if they've got the motor control and the ability to learn and do those things now, we want to teach them early rather than later. And get those grooves nice and deep. Get those motor patterns. so that they can access them when they need to. So value is the first thing. What's the value to the patient? You're gonna have to sell them on this. Should be a pretty easy sale because our older adults are thinking about falls and the consequences all the time, whether they've had a catastrophic fall or they've had a friend or family member that's had a catastrophic fall. So that should help set the stage.

SET POSITIVE EXPECTATIONS FOR A MEANINGFUL EXPERIENCE
The second thing is you wanna set positive expectations. They're gonna need to borrow some confidence from you. You have got to come in confident. You've got to know where you're going to start with the person you're planning to teach fall landing. What is going to be a positive experience for them? Where is it reasonable for them to do this? How many reps? How irritable are their symptoms? We gotta think about those things, but we also wanna share the positive experiences we've already had with others. Hey, I've done this with lots of people. I know it sounds scary. Meet them where they are. They probably wanna hear that you know that they're scared. Or they may be a little concerned. Maybe we don't want to say fearful or scared. But, hey, I realize this could sound scary, but I want you to give this a shot. I'm confident you can do this. We can do this without irritating your symptoms. It's not going to be as exciting as you're imagining. I know what you're imagining in your head. We're not going to be just dropping it like it's hot. We're not going to be hitting the floor. We're not going to hit a hard surface. We're going to teach you all the mechanics. We're going to do it nice and slow, and we'll progress as you're ready. So set those positive expectations, let them know kinda how the progression's gonna go, and that you're gonna be starting very simple, very easy, with just learning the positions, and then from there, you can scale it up and make it more challenging. So value first, positive expectations, and then the last piece, which if you've been following the older adult crew for a while, you've probably heard, but is a huge key with older adults for building their confidence, and that is intentional under dosage. You may have someone who's super active. independent, relatively robust, but you still wanna start fall's landing in a scenario that's gonna set them up for success. We want those successful reps early on to build their confidence so we can invite them along on this journey towards more challenge and more challenging options for fall landing. So we can add complexity, we can add more height to these fall landings so that they can really build their confidence, and take this journey with us. So to give you, I think it's gonna make more sense to give you some examples of how to do this. So intentionally underdosing for something like a backwards fall could simply be done from a recliner. You're a home health clinician, you've got a patient who tends towards backwards falling. You can get them at the edge of the recliner and you can have them tuck their chin and then fall back into the recliner. With the recliner up maybe. Maybe it's completely upright, They are seated, chins tucked, and we're gonna have them slowly work on landing from there. From the recliner, you could tilt it back a little bit and do the same thing. You could progress it all the way from an upright position, slowly falling backwards, to 45 degrees, to all the way flat. You could do this in home health in their favorite spot, which for a lot of our clients in the home health setting is in their recliner. Maybe you're in a clinic setting and you want to introduce a backwards fall landing. You can do that from a seated position with a big wedge. So you imagine that 45 degree wedge, their butt is sitting at the edge of it. You're going to have them tuck their chin and then work on landing backwards, sending the arms out. But they're only doing a very small range of motion. They're not in the floor. They're not Worried about being in the floor, you're not having to teach that getting up and getting down, you can do that from a seated position, which is beautiful. I don't know too many of our clients that would not be successful from a seated position, even our older adults who are pretty frail and are medically complex. If they can go from a seated position to a lying position safely, they can work on a backwards fall landing, and they'll be successful. For our clients who are more advanced, say that goes really well. Maybe we have them go from a standing position and just have them sit and then rock back with their chin tucked. That would be a very easy progression. Once again, not getting them in the floor. They may have had a traumatic experience in the floor. They may feel like the floor is lava, just like the game we played as kids. So we wanna keep in mind, we can scale these things and make it very easy, but you should intentionally underdose your fall landing strategy. Give them options that are super easy. I'll give you a couple examples for forward fall landing. So if you're gonna work on forward fall landing, at least the way that we teach it in the older adult division, there are lots of ways to teach fall landings. But a couple of the key things are, dispersing the load across the forearm and turning the head. You can work on just the motor control of tying these two movements together, getting onto the forearms and turning the head, or even just getting in that position from a seated position, just the mechanics. This is what we're gonna do. This is not scary, this is not hard. You can do this with someone who's super fearful, just working on the mechanics. Then from there, you could do it from a standing position to an elevated mat or some type of soft surface. So even just from a standing position, very slowly working on getting the forearms down and turning the head. It's not complicated. It's not scary. There's basically no risk there. And it could be as slow as you're ready for. After that, once you're comfortable with that, you could speed it up a little bit. Let them try to get very, a little faster down to their forearms with a head turn. From there, you could work on a quadruped position. So hands and knees, maybe on a mat table, super soft mat table, firm enough that they're not having difficulty with their wrist being in that fully extended position. But a mat table could be a great spot, or if you're in the home health setting, You could do this onto a countertop. You could put your Airex pad on top of the countertop and work on that forward fall landing. Once they're good there, you could move this to a bed. And we've not even talked about going from standing all the way down to the floor. So just keep in mind, fall landings are very scalable. Our older adults need to know how to fall, especially if they're frail. It's our job to figure out what's a correct scaling option. They need to know we need to do three things. They need to understand the value. They need to also know that this can be done successfully, that you have been successful doing this with others, that you have maybe practiced yourself based on their specific scenario. And then the third thing is you're gonna intentionally underdose this. You're gonna make sure those first reps are very easy, very easily digestible in small steps, going very slow, and you're gonna progress it gradually as they feel comfortable. And it's really that simple, team. You just have to know all the scaling options and start super simple. I hope that was helpful. I hope you didn't hop on here expecting that I was going to show you step-by-step the fall landing piece. That is something we teach in our live course. I would highly recommend if that's new for you to hop in a live course and we'd love to teach you. But that's an idea of how to set up a session for success. First time someone's learning fall landing techniques, those are the steps you want to take. If you've got experience with this, I would love to hear from you. Are there other strategies that you use that have been helpful for that day one fall landing?

SUMMARY
Team, if you're interested in what's going on in the older adult world, we've got our next cohort of MMOA level one, our eight-week online courses starting August 14th. We still got some seats there. So if you've not taken online level one, that will be happening soon. Level two course, just want to warn you, it does not come around as often in the last cohort sold out. So if you've taken level one, you're preparing to take level two, you're interested in our next spot, that's going to be October 17th, get your spot. They're probably going to sell out again. If you're trying to catch us on the road, maybe this fall landing thing really struck a chord with you, that's something you would like to add to your toolbox. We'd love to teach you how to do this across a continuum of the spectrum of older adults, their functional ability and whatever setting you're in. We can teach this stuff in any setting and we'll show you how to do that. The next live course is gonna be Virginia Beach. That's gonna be the 13th of this month, and then I'm gonna be in Victor, New York on the 20th, and then after that, the entire older adult team is coming together for MMOA Summit. You'll see almost our entire faculty teach this content, be together to ask us questions, pick our brains. You're gonna have tons of value there because you're gonna have so many people to help you answer your questions and go through these different techniques, and that's gonna be on the 27th in Denver, Colorado. Team, I hope this was helpful. I would love to hear your questions, comments, thoughts on this. And other than that, team, have a wonderful Wednesday and we'll see you next time.

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

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

In today's episode of the PT on ICE Daily Show, Dry Needling Division faculty member Ellison Melrose discusses the benefits of utilizing dry needling as a treatment for sexual dysfunction in women.

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

ELLISON MELROSE
Good morning PT on ICE Daily Show I am coming to you live from Durango, Colorado this morning in my truck so excuse the background, but we are here to talk about First of all, my name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of ICE. I am coming to you today to talk about dry needling in the pelvic health space, particularly for sexual dysfunction in females or in women. And I wanted to highlight two common diagnoses we have, which is vulvodynia and vaginismus. So let's dive right into that. First, I want to highlight in 2018, there was a joint report done by both the International Urogynecology Association and International Continence Society that overviewed sexual function and dysfunction. They did a deep dive into things like the proper screening, what proper history or physical subjective objective exam would look like. And then they had a huge section on the prevalence of pelvic floor dysfunction in folks that had sexual dysfunction as well. So that's what I wanted to highlight today. We, in the pelvic floor practice or pelvic floor space, we see it often where pelvic floor dysfunction and sexual dysfunction is highly linked and correlated. what I, what this report, um, highlighted is that there's actually 37 different diagnoses of sexual dysfunction that can be attributed to some form of pelvic floor dysfunction. And that's a lot, right? So, um, there granted, I mean, if you look at all of the, the nitty gritty diagnoses, um, we may be thinking maybe we're over medicalizing this, patient population a little bit with specific diagnoses, but it highlights the fact that there's so many people out there that have pelvic floor dysfunction that is contributing to a form of sexual dysfunction. 45% of women that have urinary incontinence will complain of sexual dysfunction at some point in their life. Of that 45%, 34% of that is hyposexual desire disorder. Um, and 44% of those are a brand of sexual pain disorder, which is either dyspareunia or a non-coital, so a genital pain that's not associated with intimacy. And that's what I wanted to highlight. Two most common diagnosis that we see in the clinic that can be challenging for us as pelvic floor PTs often are both vulvodynia and vaginismus. And we'll kind of get into potentially why these can be challenging diagnoses for us.

DRY NEEDLING FOR VULVODYNIA
Um, but for vulvodynia, the clinical definition of this is anyone that has had pain in or around the vulva region for at least three months without a clear ideology of symptoms. So they don't have, They've had negative cultures, so they don't have either fungal or bacterial infection going on here. And so there's this idiopathic pain presentation in the vulva region. And then vaginismus is a recurrent or a persistent muscle spasm of the pelvic floor, which inhibits any form or enables penetration and there's different forms of vaginismus and different diagnosis underneath that umbrella of vaginismus. And we can kind of dive into that when we talk about vaginismus specifically. I wanted to highlight these two diagnoses particularly because without a proper diagnosis, oftentimes the internal assessment can either be very challenging or it can be very non-therapeutic and actually traumatizing to some of these folks. So if we don't have a particular subjective exam that allows us to understand what is going on with our patients, the whole pelvic floor assessment may be not therapeutic. So for both of these diagnoses, everything starts in the subjective exam. Let's start with vulvodynia. So vulvodynia, oftentimes folks may have symptoms similar to that of a yeast infection or a UTI that then kind of snowballs from there. They may have actually had recurrent yeast infections or UTIs in the past and are familiar with those symptoms, but, and so they do their normal treatment with that, which a lot of times is either over-the-counter medication or they might phone up their OBGYN and say, well, let's get some of these either antifungals or antibiotics on board ahead of time while we wait for the culture. Well, culture comes back negative and the symptoms are still persisting. Sometimes they may get taken away with some of the medication a little bit, but the symptoms overall typically will persist past that. Um, and for folks that have this at this point, it is no longer a, um, you know, bacterial or yeast causing these symptoms. There is a brand of neuropathic pain going So a lot of times they have either had this for quite a long time, at least three months, they've seen other providers that have either provided a medical treatment or something that has been ineffective. And so symptoms have continued. When we think about neuropathic pain and the chronicity and the persistent pain or the chronic pain side of things here, this actually heightened symptoms typically. Um, other subjective things that you might see in these folks is that they may have, um, some sensitivity to, uh, like touch in, in the vulva region, right? So wearing specific type of clothing may be uncomfortable where they may have other brands of, uh, nerve related symptoms like itching or burning. Um, which oftentimes are two symptoms that we think about for either a yeast infection or ATI. And so that's why they get mismanaged in their medical treatment. So it all starts in the subjective exam. And while an internal assessment in these folks isn't out of the question, it can definitely be helpful. It doesn't always, it's not the most efficient way to go about treating this pain presentation. when we think about neuropathic pain, we need to think about, okay, why is this nerve so irritated? And a lot of times in vulvodynia, they see that there is either a irritation of the nerve. Sometimes there can even be, you know, some, some changes in the myelin sheath of these nerves. So there's actual nerve damage associated with it. Depending on maybe what the original cause of the, nerve irritation was. And so when we dive into, we've highlighted their subjective complaints, we know what's going on here, where do we go from there, the internal assessment may be valuable in order to see is this maybe a hypertonicity issue. So if we have tight pelvic floor musculature, can we teach them to relax their pelvic floor and allow for improved blood flow to the pudendal nerve that could be contributing to some of these symptoms. So there is a lot, there is value in that. And I believe that there is, um, oftentimes in the pelvic health space, we are so used to, um, you know, trying to treat, the patient's symptoms ourselves, whereas we can teach our patients to help themselves with learning how to relax their pelvic floor. So there is a benefit in the vulvodynia patient population to utilize the internal assessment. But when we think about efficiency, so how can we treat a neuropathic pain presentation the most efficiently in our in our clinical setting? I am in the dry needling space, and so we use dry needling a ton outside of the pelvic floor world for treating various different brands of pain, one of which is neuropathic pain. So dry needling can be a super efficient tool to improve, to talk to the nervous system and do a nervous system reset to the nerve in question, which oftentimes is the lupudendal nerve. So dry needling is a very efficient tool in order to improve those neuropathic symptoms. With that being said, everything we do physically, manually, we need to highlight that this is a persistent pain diagnosis at this point. And so we need to be utilizing our pain neuroscience education. um, educating these folks about, um, what, what happens to our nervous system when we have had pain for a long period of time. Um, and, and that pain doesn't necessarily equal damage at this point or else everything that we do with our, our manual skills or dry needling, uh, will only get us so far. Right. So, um, vulvodynia again a lot of times these patients come in to us with chronic symptoms so they've been going at this for a very long time they've had typically a medical mismanagement where they've been having some medications on board that weren't helping their symptoms they have a lot of sensitized nervous system and so we want to make sure that we are using the most clinically efficient tool to treat these symptoms. Oftentimes as well, you might actually get some reproduction of symptoms with dry needling when we're approximating the pudendal nerve or getting close to that pudendal nerve, which can be helpful in almost diagnosing, right? So using our tools to help with localizing their symptoms. So that is how we would use dry needling in a case for vulvodynia and in a patient population where we would still likely be able to utilize the internal assessment.

DRY NEEDLING FOR VAGINISMUS
Now let's pivot to vaginismus. Let's talk a little bit more about different diagnoses under the umbrella of vaginismus and then how we would and why we would use dry needling in this patient population. So, Vaginismus, there's two different diagnoses and underneath that we have two other subdivisions. So we have both primary and secondary vaginismus. So again, a reminder vaginismus is either a persistent muscle spasm of the pelvic floor. It's either persistent or it's associated with something and we'll get into that. Primary means that this has been forever. So this has always been an issue. Um, sometimes there may be a congenital malformation of the genital track on board with this patient population as well. Um, and if that is the case, even things like typically their first, um, like, uh, association with any form of penetration, uh, is oftentimes a, when they get their menstrual cycle. So, um, having a tampon and they're unable to actually insert a tampon into their vagina. Um, from there, then they, they often with this congenital, um, malformation or having it be a primary diagnosis is they, they often are treated fairly medicalized in that state and, and they may require some form of surgical procedure to, widen the vaginal canal. So that's primary vaginismus. Secondary vaginismus is acquired. So it wasn't always an issue, but it could be acquired from a form of trauma. So either an emotional or a physical trauma that then caused muscles in the pelvic floor to spasm. And this can be either global. So what I mean by global is that it's every time anything is enters the vaginal canal, there is a muscle spasm associated with that or it's situational, meaning that things like inserting a tampon may be possible, but physical intimacy with, um, or sexual intimacy is not possible. So there's no, uh, penetration available during, uh, sexual intimacy. Um, so those are the different kind of clinical or, diagnosis we find under the umbrella of vaginismus. Oftentimes in pelvic floor PT, we will see, um, a lot more probably of the secondary vaginismus in that they've, you know, they've never had, they hadn't always had issues, but then something caused or something triggered an issue, which causes the pelvic floor muscles to, um, to spasm, right? And that could be a traumatic birth of vaginal delivery. It could be a sexual trauma. So a, um, yeah, a sexual assault or something of the sort. It could be a, uh, traumatic pelvic exam by their OBGYN, uh, which we've, I see a ton in the clinic and, um, so it could be, a natural physical trauma with that. And then it could also be heightened with a, um, an emotional trauma as well. So a lot of times, I mean, this is a very intimate part of our body. And so there's a lot of times a very, uh, pertinent, uh, or very prevalent emotional, well, um, 70%, I would say probably about 70% of your initial evaluation evaluation, is going to be a subjective exam. Understanding the why behind these patient symptoms is crucial to dictate the course of your treatment or even the course of your assessment in that initial evaluation, right? Like, are we going to be doing an internal assessment on these folks? And a lot of times, probably, probably not, right? So what does day one look like or our initial evaluation look like with folks that have vaginismus? and how and what does our course of treatment look like for them. So typically education goes a long way with folks that have had either a physical or an emotional trauma that has caused muscle spasms here, right? So teaching folks about the anatomy of the pelvic floor musculature uh, why they feel like there's a brick wall when they try to insert a tampon. Right. Um, how, uh, what a Kegel is. Right. So anytime people have any association with the pelvic floor, they are often just think, Oh, I should be doing Kegels. Right. Um, and teaching them what, what a Kegel or what a pelvic floor muscular muscle contraction is and educating like the benefits of relaxing the pelvic floor. And this is just all done through education. So no even physical touch or assessment has been done at this point, but just educating folks around the anatomy of the pelvic floor. Anatomy and physiology of the pelvic floor can go a long way here. We also want to educate about vaginismus itself. So vaginismus is another brand of chronic pain, right? So these folks have typically had pain for an extended period of time, Um, there's not a diagnostic criteria for, for duration of symptoms like there is for vulvodynia. Um, but there is a pain cycle on board here, right? So it all starts in the brain. So it, it either the, the brain perceives an emotional trauma due to either a physical trauma or, or purely emotional that registers discomfort or, or fear associated with, uh, penetration either from a previous, uh, you know, exam with a speculum from a previous sexual encounter, um, from a trauma traumatic birth, right? So the brain remembers those things, which is then going to be causing, it causes muscle guarding. So public for guards, the tight muscles in the public for cause the penetration to be painful. or impossible at sometimes. And then this difficulty in pain reinforces that alarm, the amygdala alarm that's going on up in the brain, right? That reinforces that this is a threat, right? The nervous system then remembers this pain, and so every time our brain is their, their brain is thinking about, you know, either having to go to the OBGYN or having a sexual encounter, anything like that. Um, it is going to remember that and we are going to get the same physical symptoms as the, the tight muscles, um, which is often going to lead to, you know, decrease blood flow to the nervous system, which is going to cause potentially, you know, perceived as pain by these folks. And so they're going to avoid those, uh, you know, avoid whatever is causing this pain cycle, right? And those folks, which ultimately, especially if this is a sexual nature is going to, um, reduce the desire to either have sexual intimacy with their partner or, um, and it's, it's going to reduce that, that overall desire, which is then going to, again, any thought of that intimacy is going to be threatening. So discussing that, that pain cycle with these patients can be very therapeutic and, and helpful in that this isn't their fault, you know? So the nervous system, I like to say it's smart, but dumb, right? It remembers things and not always for the right reasons. And so education about anatomy, physiology, about the vaginismus pain cycle, can take up a majority of your initial assessment with these folks. I also like to do, again, a guided pelvic floor relaxation series with my folks, even if we're not doing an internal assessment. So on day one, these folks, we may not be getting into an internal assessment. We may never get into an internal assessment, but we do want to teach them how to um, feel their pelvic floor muscles and, and learn how to relax them. And so sometimes, um, I will educate them on how to do some self biofeedback either with tactile cueing, um, just medial to their ischial tuberosities sitting on, um, you know, a yoga ball or something like that, where we have some, uh, tactile cueing to the, um, perineal region or the pelvic floor area. Um, and, and teaching them about, again, the anatomy and that when, We're breathing. We're trying to make some of these muscles move. Increasing movement in these tissues is going to increase blood flow to the tissues, which is going to reduce irritation to the nervous system. So teaching them how to relax their pelvic floor without even doing any physical touch yourself can also be helpful. This is a patient population where after we kind of break down and help them understand the why, I like to highlight other tools we have in our toolbox as physical therapists, right? A lot of times when these folks, um, come to pelvic floor PT, they, they've done their research. So they know often that pelvic floor PT equals an internal assessment, which they've had done by their OBGYN and it's maybe been traumatic in the past or Um, they know any form of penetration is, is traumatic. And so, um, right out the gate, I'll say, you know what, that is a tool we have in our toolbox. The internal assessment's a tool. It is gold standard for assessing how the pelvic floor muscles function, but is not everything that we do here at pelvic floor PT. And I introduced dry needling. And I know that seems like for folks that have, don't have vaginismus or don't have trauma associated with penetration, they're like, Isn't dry needling more of a threat than an internal assessment? And for folks that have vaginismus, oftentimes it's not, right? So dry needling the pelvic floor muscles can be an amazing tool as we don't necessarily need to do an internal assessment. on these folks, we know there's likely not going to be anything therapeutic initially with that initial internal assessment. So if we can utilize dry needling in the earlier stages of our pelvic floor PT with these folks, it can be an amazing tool to talk to the nervous system, you know, put a break in that pain cycle associated with the muscle spasms or the tight pelvic floor musculature. It's a beautiful kind of what I like to say control or delete to the nervous system and so it can really help with Retraining that cycle of you know, these muscles Have more control other than just muscle spasm, right? and so if we can take some of the the heightened neuropath or the heightened symptoms down with a tool like dry needling, it may allow us to either ourselves or them do a form of stretching or manual therapy where they can improve the tissue's mobility as well, right?

SUMMARY
So I could probably talk about this stuff all day. I've already been on here for almost 25 minutes, so I'm going to stop it here, but I want to kind of summarize everything we talked about today. Um, I, we kind of went into a recent report done in 2018 that dove into some pelvic floor dysfunction in, um, sexual function and sexual dysfunction. And we dove into two specific diagnoses today. We looked at vulvodynia and vaginismus clinically and how we can utilize things like dry needling for either treatment or even, um, diving into a little bit of some diagnostic, uh, with, utilize with dry needling as well. Um, and so, uh, while we're, you know, dry needling, the pelvic floor is a fairly unique, um, skill. Uh, there's a lot we can do with dry needling outside of the pelvic floor as well for these folks. And so, um, for those that are in this space, I highly recommend taking our lower body dry needling course if you haven't already, We go into needling for the lumbar spine, the glutes, muscles that surround the sciatic nerve. And so again, taking those principles and utilizing them in the pelvic floor space can be really helpful as well. So we have some courses upcoming this fall. We have, let me pull it up right here. We have a lower body course, I believe in Scottsdale, Arizona, in the beginning of September. We, for those that have taken lower body or upper body, we have two advanced courses coming to you this August. So we have our, our juggling summit up in Seattle and the second weekend in August. And then we have one down in Longmont, Colorado at the second to last weekend in August, um, right before Labor Day. Uh, we have a ton of lower body courses coming to you this fall. So hop onto ptlnice.com and check out what courses we have, um, coming to you. Um, if you guys don't see something in your area, feel free to reach out to us and, um, we can look at getting something booked near you as well. Well, hopefully you guys have a great rest of your Tuesday and enjoy the holiday this week. Bye.

OUTRO
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