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Jun 17, 2024

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

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

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

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.

Jun 14, 2024

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

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

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

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.

Jun 13, 2024

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses 5 tips to begin to get more comfortable with technology & improve your productivity

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

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.

 

Jun 12, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett as she discusses experiencing loss, processing grief, and its impact on being a geriatric clinician.

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

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.

Jun 11, 2024

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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.

Jun 10, 2024

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

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

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

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.

Jun 7, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the anatomical & clinical considerations of the deltoid muscle in functional fitness, as well as the best ways to begin to train the deltoid in the gym.

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

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

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

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

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

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

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

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.

Jun 6, 2024

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

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

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

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

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

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

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

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

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.

 

 

Jun 5, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses three tips to give older adults permission to succeed in physical therapy: acknowledge their concerns, craft experiences that ensure success, and focus on belief change.

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

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.

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

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

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

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

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

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

Jun 4, 2024

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

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

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

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

EPISODE TRANSCRIPTION

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 slash 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.

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

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

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

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

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

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

Jun 3, 2024

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

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

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

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.

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

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

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.

May 31, 2024

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

May 30, 2024

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

 

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses three different variations to load the lateral shift: side plank variations, RNT side bends, and unilateral carries.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

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

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

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

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

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

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

May 29, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses the management of urinary incontinence in the older male, implications for function, and quality of life.

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

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

EPISODE TRANSCRIPTION

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

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

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

May 28, 2024

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

May 28, 2024

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

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

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

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at signup to receive a one month free grace period on your new Jane account.

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

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

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.

May 24, 2024

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

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

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

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

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

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

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

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

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

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

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.

May 23, 2024

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses three things to consider when changing positions: transparency, pay, and communication.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane, an 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, PT on ICE Daily Show. Happy Thursday morning. We hope your day is off to a great start. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness, Athlete, and Practice Management Divisions. Today is Thursday, Leadership Thursday. We talk all things small business management, practice, ownership, and management. But more importantly, it is also Gut Check Thursday. This week's Gut Check Thursday, coming up on Memorial Day weekend, we have Murph, the infamous hero workout performed by CrossFitters and functional fitness enthusiasts across the planet. This is a very long, grindy, aerobic bodyweight workout. If you've done this workout before, I don't really need to tell you anything about it. a one mile run, 100 pull-ups, 200 push-ups, 300 air squats, and then finish with another mile run. You can't manipulate the order of the mile runs at all. You can change and partition or not partition the pull-ups, push-ups, and air squats in the middle any way you want. As long as you get 100 pull-ups done, 200 push-ups done, and 300 air squats done, you are good to go with that work that you get done in the gym. Typical times are going to be 40 to 60 minutes and obviously a little bit slower if you wear that 20 pound or 14 pound vest. A lot of different ways to approach this workout. We have a lot of scaling options over on the Gut Check Thursday post on our Instagram account. But there are numerous ways to modify and scale this to get a really good workout in on Memorial Day before you head off to hopefully celebrate some barbecues, some beers, that sort of thing. Today, Leadership Thursday, what are we talking about? We are talking about things to look for if you are considering changing your job position. So we're gonna talk about transparency, we're gonna talk about pay, and we're gonna talk about communications and leadership presence.

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

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

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

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

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

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

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.

 

May 22, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses a framework to begin to better assess balance & tailor focused interventions for patients, including assessing risk factors, understanding inputs that affect balance, and how to measure outputs from balance.

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

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.

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

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

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

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

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

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

May 21, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses assessing, treating, and loading the upper traps when suspecting their involvement in neck or headache symptoms.

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

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

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

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

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.

May 20, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the benefits of birth control and when we should be thinking more positively about these medications and methods

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

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

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

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

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.

May 17, 2024

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

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

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

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

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

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.

May 16, 2024

Dr. Ellen Csepe // www.ptonice.com 

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

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

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

EPISODE TRANSCRIPTION

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.

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

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

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

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

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

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

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.

May 15, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how environmental factors influence all aspects of the aging experience, including movement, nutrition, and social interaction.

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

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 signup to receive a one-month free grace period on your new Jane account.

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

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

May 15, 2024

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

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

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

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 P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

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

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

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

OUTRO
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