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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses three myths in pelvic health surrounding pelvic health demographics, urinary incontinence, and sexual intercourse.

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

ALEXS MORGAN
Good morning, PT on Ice Daily Show. My name is Dr. Alexis Morgan, and I am so happy to be with you all this morning to talk about some myths and bust them. So there are so many myths in pelvic health. I narrowed it down to three. I might sneak a fourth one in. But there are so many myths that need to be dispelled in this area of pelvic health. And so this morning we are going to talk about a couple of misconceptions in the topic of pelvic health and then what the actual facts are. So thank you all for joining me so much this morning. At the end, we'll talk about some courses upcoming in the pelvic health division if you are interested in joining us. So top three myths. Number one, only women need to worry about pelvic health. Number two, urinary incontinence is a normal part of aging. And number three, pain during sex is normal. Three myths that are pervasive in this space.

MYTH #1: ONLY WOMEN NEED TO WORRY ABOUT PELVIC HEALTH
So let's start with myth number one. Only women need to worry about pelvic health. This is absolutely not true. All people need to be considerate of pelvic health. All people can have pelvic floor issues, no matter what your anatomy is. So whether there is a penis or a vagina, you may have issues that are because of your pelvic floor. So some common issues that we treat are chronic prostatitis, slash chronic pelvic pain. And that is, um, that is what a topic that we discuss in our level two course, as well as erectile dysfunction and so many more. these issues can absolutely be addressed with a pelvic floor physical therapist, a pelvic floor therapist altogether. And it's really important that people understand that these issues can absolutely be addressed And so often, of course, you'll have to take our course to learn a whole lot more about it, but so often these lifestyle things that we discuss like eating well and exercise and getting blood flow, all of those are so incredibly important for all people. And in particular, issues as we just discussed, like chronic pain and even erectile dysfunction. So of course, big solution being when we kind of shift the gears and talk about how all people may benefit from pelvic health, then all people have an equal opportunity to seek that care. that's a big part of why in the ice certification for pelvic health we go over all anatomy and all diagnoses surrounding any and every pelvic floor issue that can arise here because We want to provide health for all. And if you are ICE certified in pelvic, then you know exactly what I'm talking about. You have the abilities to provide that care to all people. Speaking of, congratulations to our individuals, our very first individuals who are ICE certified in pelvic. We just completed our first level two course and we have several who are now ICE certified in pelvic. So congratulations to you all.

MYTH #2 - URINARY CONTINENCE IS A NORMAL PART OF AGING
Moving on to myth number two, urinary incontinence is a normal part of aging. It is absolutely not the case that incontinence is inevitable with age. And again, this kind of goes back to myth number one, this occurs in all can occur in all people. So incontinence might occur with, um, males and females, and it does not have to happen just because someone is aging or just because someone had their prostate removed. There's a lot of different types of urinary incontinence, but these can all be addressed. A big one that we talk about a lot in sport and kind of in function is stress urinary incontinence. and this is where there's an increase in intra-abdominal pressure and the pelvic floor musculature either doesn't know how to, can't coordinate enough, or is not strong enough to withstand that pressure up above and the leaking occurs. There could also be urge incontinence where you have the urge to go pee and then it's really difficult to hold it in because of that urge. And we even have functional incontinence as well where it is difficult for an individual to get to the bathroom in time because of some type of physical impairment or cognitive impairment. And because of that, there is incontinence. So for all of these individuals, there are absolutely solutions for them. And because of that, we don't accept the myth, we don't accept the statement that it's normal to Pee your pants as you age. It is absolutely something that can and really should be addressed to improve the quality of life for all people.

MYTH #3 - PAIN DURING SEX IS NORMAL
Myth number three. Pain during sex is normal. That is a very pervasive and difficult myth that we hear quite a bit. Maybe that is surrounding menopause, maybe that is surrounding postpartum, or just in general. But pain during sex should not be expected. Sex should be pleasurable, should be enjoyable, and should be enjoyed by both or all parties involved. And unwanted pain during sex is something that can and should be addressed to improve pleasure in a very important aspect of life that is sexual health. There's so many reasons why someone might be experiencing pain, and just like in all areas of the musculoskeletal system, when we experience pain, it's not always straightforward. Wouldn't it be nice if it were? But with pain with sex, we talk about in all of our courses, we layer in all of the different aspects of pain with sex and begin to separate these issues out. It is our job, it is our duty, it is our honor to help individuals decrease pain and increase pleasure with sex to improve their quality of life. And we do this from some simple ways like lubrication maybe more complicated ways like can referring someone to counseling to mental health therapy to assist in maybe some prior traumas and we also can do some manual work as well as exercises in order to fully address the full person and address the full picture of the reason why someone is having pain with sex. So again, if you want to learn more about that, we do talk about it in all three of our courses, our live, our online, and level one and level two, but we really take a deep dive in level two. So if this is something that you're interested in, yay, join me. This is one of my more recent more recent interest in pelvic health, and we would love for you to join us in any of our courses.

SUMMARY
So to recap, pelvic health is absolutely important for all people. Incontinence is treatable. Let's help these individuals get treatment. And lastly, pain with sex should be addressed. Let's have Our job is to get individuals to understand that we are available for them to help them address their pelvic concerns. And let's reduce those barriers as much as we can for them, talking about them, letting people understand that you are a resource for them. And by all means, take this information, create some reels about it, create some posts, but get those myths out there, and most importantly, get the truth out there. Thank you all for joining me this morning. Before I close up, I just wanna let you all know, our Level 1 course, it's about to sell out. There are still a few spots. We have one week left before we officially start, so that's July 8th, if you're listening on the recording. And so sign up for that if you are trying to get that in soon. It will sell out. Same with level two, but that one starts in August. So August 19th. And then our next three courses that we have live are in Ohio, July 20th and 21st. in Wyoming, July 27th and 28th. And then Tennessee, right here in my hometown, Hendersonville, Tennessee, September 7th and 8th. So we hope that you will join us. If you're already signed up, can't wait to see you in person. And thank you all for tuning in this morning. Have a great day, have a great 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 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. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com 

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty member Julie Brauer discusses how fitness equipment is not necessary for older adults to reach fitness goals, how fitness equipment is not feasible for older adults to obtain or use, and that older adults likely do not want to use this fitness equipment because they can't correlate how using it translates to functional activity

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses addressing shoulder mobility in wrist pain patients. 

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

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.