Info

The #PTonICE Daily Show

The faculty of the Institute of Clinical Excellence deliver their specialized content every weekday morning. Topic areas include: Population health, fitness athlete management, evidence based spine and extremity care, older adults, community outreach, self development, and much more! Learn more about our team at www.PTonICE.com
RSS Feed
The #PTonICE Daily Show
2024
April
March
February
January


2023
December
November
October
September
August
July
June
May
April
March
February
January


2022
December
November
October
September
August
July
June
May
April
March
February
January


2021
December
November
October
September
August
July
June
May
April
March
February
January


2020
December
November
October
September
August
July
June
May
April
March
February
January


2019
December
November
October
September
August
July
June
May
April
March
February
January


2018
December
November
October
September
August
July
June
May
April
March
February
January


2017
December
November
October
September
August
July
June
May
March
February


2016
December
November
October
September
August
July
May
April
March
February


All Episodes
Archives
Now displaying: Page 3
Feb 1, 2024

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

In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses how to subjectively & objectively identify patients presenting with acute back spasms, how to treat spasm, and how to follow-up treatment with appropriate homework. 

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.

ZAC MORGAN
Alright, good morning PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty in the cervical and lumbar division, here to bring you a Technique Thursday talking about myofascial decompression or cupping for an acute back spasm. For those of you all who work with acute back pain, so this is something that early in my career I did not see an awful lot of, but as I have kind of entered the market of seeing more and more acute low back pain, you will see these people walk through the door that are clearly in a spasm. And I want to talk today about why cupping has kind of become the treatment of choice here for that exact presentation.

ACUTE BACK SPASM PRESENTATION
And let's just kind of narrow in on why we're focusing on back spasms to start. And the real thing is, this is one of those diagnoses you don't read a ton about in the literature, but it's one of those things that you know it when you see it. So it's fairly empirical. So every so often, people kind of walk through the door, and they're kind of in that shape of a question mark. They're really off to the side, and you can tell as they walk through the door that the severity of their situation is really, really high. Even just watching them move about the world, their activities of daily living are extremely challenging when they're experiencing a back spasm. They're not able to freely move through space and move that spine around because their erector or QL or some of that posterior musculature is in a full spasm. So this is something you will see if you're seeing people day of within a couple of days of a back pain episode. So it's certainly one of those acute low back pain scenarios. Now the issue is, you'll see a lot within our profession of people sort of argue about, well this is just going to regress to the mean. And I don't disagree. A back spasm is going to go away on its own, for the most part. So generally speaking, untreated, in my experience watching these things happen around the gym, having some of them myself, a lot of times people have some movement limitations for ten days or so, seven to ten days, maybe a week, maybe a little bit longer, but then they're usually back to normal life after that point. So it's not one of those conditions that sticks around for months the way like a radiculopathy would. It's just something that's acute, but while it's present, it's very severe. I think it's important for us to say We know it regresses to the mean. It will get better on its own.

WHAT IF REHAB CAN BEAT REGRESSION TO THE MEAN?
Here's the thing. With early treatment, what I'm about to show you all, I think we can take several days off of the episode. And I think that because of empirical data here in the clinic. So I'll watch people walk in in that situation that we just described. Very put off to the side, huge spasm in that erector. You can almost see it through their shirt. and they're unable to do much, and we treat them with some cupping, we treat them with some relaxation techniques that we're going to unpack here in a moment, and often that person feels tremendously better, tremendously quickly, so within a couple of days, maybe three max, versus that seven to ten. Now that's a difference, right? That's almost a week of time different that that person is going to end up walking around with pain or not walking around with pain. Why does that matter? When you think about how influential this spasm is to their activities of daily living, they can't do much. Now deconditioning is going to set in, even on healthy people. If healthy people move around the world for a full week without really flexing their back, without allowing it to move, they're going to have some deconditioning on board. And if we could have gotten rid of that a week earlier, we've given them more of an opportunity to maintain or even gain fitness during this period of time that they have some acute pain. So I think it's really important that we focus in on this because while it's not a usually a long-term disabling diagnosis, it is a short-term disabling diagnosis. And when people are in that disabled period, they're looking for short-term help. And I think we can be helpful with that.

IDENTIFYING CANDIDATES FOR CUPPING
So let's talk a little bit about identifying these before we actually get into the treatment. And from an identifying standpoint, you want to start with that body chart. So if you've been to cervical and lumbar management, you know we always start out with quantifying where are the symptoms on this person's body. When someone's in an acute back spasm, it'll be a little complicated to find the exact spot of symptoms. They don't usually point to one thing. They often kind of talk about that whole erector side. They might even point to that whole area of their low back and say it just feels locked up. I've certainly had plenty of clients who reported just like local pain sort of at the waistline, like right where the waist of your pants are. I've had unilateral, bilateral, it bounces around a little bit on the body chart, but typically whatever muscle is in spasm is where the pain is. And often the person has a hard time describing it because of the severity. They just say my whole back is out, my whole back's out of whack. So it's not one of those focal diagnoses on the body chart. Subjectively, you're going to see some common aggravating factors. The biggest one's flexion. The person probably won't even allow their back to flex. And when you look at that from the active range of motion standpoint, you see it's just hip flexion. The lumbar spine is not actually actively flexing. The person's just kind of absorbing into hip flexion. Any quick movements are often painful subjectively. So they talk about transfers, they talk about when they've been lying down to get up. Really anything where they have to move quickly will often be an aggravating factor. And then things like bending, sneezing can also be pretty painful for these folks. In their history, they'll usually tell you about some sort of fatigue-based activity that onset this. So this won't usually be like a one rep max deadlift. That makes me more think of a strain. Where this presents itself is in a workout with a bunch of deadlifts. So when somebody's, you know, several sets in and their back is already tired and then it just fully locks up and kind of worsens throughout the evening or worsens throughout the day, that's more of the spasm presentation. It's not just in weightlifters or competitive athletes. You'll see this really with any human who has exceeded their capacity. So I've definitely had plenty of folks that were gardening all day or mulching all day and just using their back a bunch and then it wound up in spasm. So it's really whatever over challenges that musculature tends to create the spasm. So subjectively, you'll see those common ags and then you'll also see that history where the person was either fatigued entering an activity or did an activity so much that it created enough fatigue that eventually created a spasm. Objectively, again, their lumbar spine, it's not going to reverse. When they flex, it's going to stay very flat. You're going to see a lot of guarded movement. The person's probably going to be very hesitant to move, and you'll notice that quite a bit through this active range of motion exam. You will even often see cervical flexion. bother that person's symptoms because the erectors, they attach all the way up in the neck, in the suboccipital spine. So you will see cervical flexion be bothersome, but then it's not like a sensitization thing from a neurodynamics exam because the ankle won't make any difference. So, when you see that cervical component create a lot of discomfort in that acute pain scenario, and then you dorsiflex and plantarflex the person's ankle, and it doesn't make any difference, that's ruling spasm higher on my list. So, objectively, that'll often be how it presents, and then a lot of it's just observation. You'll just look at this person's back, and like I said in the beginning, they'll be twisted off to one side. They may even be kind of in the shape of a question mark. Like you can see that that erector on that side has just shortened in the area of the lumbar spine. And so the person is fairly obviously uncomfortable. A lot of times the erector itself is swollen or hypertonic or larger, whatever you want to call that. And it'll be tender to the touch. So just palpating that region, a person is going to report most of their symptoms. So like I said, a fairly obvious diagnosis. And again, it's one that I didn't see a lot of until I got that really acute back pain person in the clinic. So that's sort of how they present.

TREATING BACK SPASMS
Let's talk about treatment. There are a lot of things that jump into my head that I would like to do. Like if you have acute non-radicular low back pain, the first thing that jumps into my mind is spinal manipulation. But often moving these people's backs through space is just not a realistic possibility for you on day one. Team, over the last couple of years I've spent a lot more time learning about cupping and doing a lot of cupping with clients and this is the one thing that whenever you see this presentation show up, whenever we drop the cups on that region, get it nice and relaxed and it doesn't even have to be all that vigorous. The person often gets off the table stunned at how much better they feel. So cupping has definitely become the treatment of choice and I like to just keep it really really simple. Now the biggest issue from a treatment standpoint when someone's in spasm is it's really challenging for you to get that person comfortable most of the time. They don't like laying in supine, they often don't like laying in prone, and then on one side or the other they're often really uncomfortable. If you can get them in side-lying, which is typically the most successful for me, you want the erector that is in spasm up. So I have Caitlin here behind me, and you can imagine in this situation, her left erector would be the one that would be in spasm. So that's the one that I'm going to target with treatment, and that side's up. You also want to prop a pillow between the person's knees just so that hip doesn't adduct and create even more tension on that lower back region. Instead, let's keep those hips nice and neutral and get this person in a relatively comfortable position. This will often be the position they've told you in the subjective exam that they like the most. So we're going to go right to that position and then treat in that position. So I'm going to move to the other side of the table, show you sort of where I put the cups, some of the verbal cueing alongside of that, and then we'll wrap this thing up. and summarize at the end. So anytime you're doing cupping you always want to use a little bit of cream. It's just a lot easier to glide the cup around and it's a lot more comfortable for your client. So make sure you add a little bit of cream to that region that you intend to cup just so that that way it's more comfortable for your client. You're then going to grab your first cup and localize it to the region that you think is in spasm. It doesn't have to be directly over it. Reminder, these muscles are literally all the way across the spine. So if the person's too pressure sensitive, you could certainly move away from it. But you want to be in that basic region. And then you're just going to get these things on. with a little bit of tension. So a couple of pumps to start is plenty. So I don't have this thing cinched all the way down where she's in a ton of a stretch feel. Instead, I just have a little bit of air out of the cup and a little bit of domed tissue within that cup. this gives you that nice decompressive feel if you're the client a lot of times they'll be a bit uncomfortable when you first do this but they're uncomfortable anyway they've been in spasm for a few days and so it's no major deal to them these cups are probably only like 30 to 40% pulled out. So typically if I'm being more aggressive with cups, I get it a little closer to that full capacity of vacuum. But for this, I've got a very severe patient in front of me, they're very fear avoidant, they're not moving all that much, and I've just got a little bit of tension in those cups. I start out just like this, like you all are seeing. So the person just kind of gets comfortable, relaxes, feels that pull. But after they've sat here for a couple of minutes, I'm going to start to try to cue that person to do a bit of a posterior pelvic tilt. The point of that posterior pelvic tilt is just to access a little bit of their lumbar flexion while they're in this nice, friendly, non-weight-bearing position. Anytime they're in weight-bearing, that erector tends to want to be in spasm. So I'm going to get them to just relax things a little bit here in sideline in a nice comfortable position. So I might have them move through 10-20 reps here, maybe even cueing some deep breathing in between if they're very severe. So 4-7-8 breathing pattern is often a helpful one, that physiological sigh. Either one of those are typical go-to's while we're in this position and the person's nice and relaxed. Now, for those of you all who treat human beings, you know a lot of times our female clientele is a little tougher than our male clientele. Sometimes the men are already sweating in this position and they're already having a lot of challenge. If that's the case, I'm going to stay right here and just have them work those pelvic tilts. If I do perceive that the person, if they're telling me, hey, this feels quite a bit better, you know, it seems like they would like a little bit more treatment, the next move I'm going to have them carefully make is getting into the position of quadruped. So they don't like prone and supine, so I'm going to leave the cups on and the person is going to ease their way to quadruped. And then from this position, they're just going to do some gentle angry cats. So I'm going to cue them up into some spinal flexion, telling them to separate the cups. They do have a tendency to pop off, so you want to keep that gun handy. But I'm essentially just going to cue her through 10, 15 reps here of angry cats, thinking about really elongating this whole erector. If you want to make it a little bit more vigorous, you can have them gently flex their cervical spine as they go into the cat position. That's going to give you even more stretch across the erectors and often feel pretty tight for the person, but quite good. Once we're done with that, I'm going to have them just lay back down in sideline in the original position. And this is where I think a nice little bit of massage can be helpful. So just popping the cups off, you may have some light bruising, but then getting in here and just showing that area some love and getting a little bit of massage going to that region. Team, I realize what I just showed you is quite simple. and I'm not trying to be overdramatic, but simplicity often makes this person pop off the table and feel dramatically better.


FOLLOW-UP TO CUPPING
I think what we follow it up with is very important as well. Earlier in my career, it was always, hey, let's load, load, load. Let's make sure we're getting this person moving. This person is overloaded. That's why they ended up in spasm. So what I'm actually going to target these days is a lot more relaxation techniques. So maybe that breathwork pattern we did with the cups on, I assigned for homework. I need five minutes of this a day minimum. Convince that person to give you some breath work. Convince that person to up their hydration by a bottle or two of water over the next few days. Hey, I really think this is going to help. If you're in a little bit more hydrated state, I think that muscle can relax more. Convince them maybe to add some electrolytes. Heck, I'm fine with a warm bath at night with some Epsom salts. It doesn't matter to me. I'm going to get this person to relax. I'm not going to go have them do more deadlifts. Their problem isn't necessarily that they're weak with deadlifts. It's that they got fatigued. Do we need to build the endurance of that region? Possibly. Maybe that's why it contributed to a spasm. But for right now, my main goal is relaxation. And team, I'm always going to argue for more treatment in this scenario. Earlier and more treatment. The reason being is imagine Kaitlyn is that person who has the back spasm. And she then loses 7 days of not just training, but also moving around like a normal human being. We only have 52 weeks in a year. I don't want to sacrifice an entire week of that person's life to fear avoidance, to lack of ability to move like a normal human being just because it's going to regress to the mean. Not when I could simply get in, assess it, help that person feel like, you know what, I think I'm going to be better in the long term. get them gently moving, teach them some relaxation techniques, and get rid of this thing seven days faster. It's gonna be hard to convince me that that is a harmful approach, even though we are utilizing passive tools to help that person relax. I think this is exactly why we need those tools, is to help put that fire out, and then in that process, convince this person to start addressing some of their lifestyle factors, to start addressing that ramped up nervous system, getting them to calm it down, to start addressing hydration. Some of the basics, right? Just the basics of what it means to be a human, people mess up quite a bit. So, we want to make sure that we check those basic boxes, and often you're going to follow up with this person in 48 hours, and they're going to say, Zach, feels tremendously better. Can't believe how much relief we have. and now we can perhaps get after some of that loading or regional interdependence or anything that you think might have contributed. But team, I think it's a simple approach and I don't think you should feel bad about treating people with acute back pain even though you know that they're going to regress to the mean. It's worth it to save them that week in my mind. I'm always going to opt towards more treatment.

SUMMARY
So team, that's all I've got for you this morning. Last couple things I want to leave you with is just the upcoming spine courses. So if you're looking for cervical spine this weekend in the DFW area, make sure you jump over to Hazlet, Texas. That course will be right there near Dallas-Fort Worth Airport, kind of north of Fort Worth. If you're looking a little bit later in the month, Simi Valley, California, that one's getting closer to a sellout, so don't wait if you're in that region, you want to take that course. There's not too many seats left. And then March 9th and 10th, will be in Kuna, Idaho. If you're looking for Lumbar, March 23rd and 24th, Brookfield, Wisconsin, that's right outside of Milwaukee, that'll be at Onward Milwaukee. And then April 6th and 7th, we have two courses going on, one on the west side of the country over in Carson City, Nevada, and then one right here in Hendersonville, Tennessee. And again, that's April 6th and 7th. So we hope to catch you at some of those on the road. We'd love to catch up with you, talk more shop like this, talk about the main patterns that show up in the back of the neck and how to best utilize them. Team, I hope you have a great rest of your Thursday. Crush it in clinic today and I will see you soon here on the podcast.

SPEAKER_00: 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.

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.

Jan 31, 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 to discuss recent research evaluating the efficacy of high-volume vs. low-volume resistance training for older adults as it relates to facilitating muscular hypertrophy. Jeff breaks down the research but also offers practical implications for the clinic.

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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JEFF MUSGRAVE
Welcome to the PT on ICE Daily Show. I'm gonna be your host today, Dr. Jeff Musgrave, Doctor of Physical Therapy, currently serving in the Older Adult Division, trying to demolish things like underdosing, ending frailty, and I am super excited to bring to you a very interesting research study that just dropped January 4th of this year. So the title of this article we're gonna be digging into today is Higher resistance training volume offsets muscle hypertrophy, non-responsiveness in older adults. So, trying to dig in to figure out if someone is not responding to resistance training, what can we do about it? So, obviously if you're listening today, if you're following in the world of ICE, you know that resistance training is paramount. Getting people strong is how we're going to break the cycle for people that are coming in with pain and dysfunction, musculoskeletal disorders. There aren't any conditions where we can get people too strong. And we know specifically through the lens of working with older adults, when we've got things like frailty, adults who are pre-frail, who are very vulnerable to external stressors, or maybe one rep max living, we've got to bring them quality resistance training. We need everyone to have a path back to load. As quoted by Lindsey Huey in the extremity division, we love to say that load is our love language and all paths lead to load.

HIGH VS. LOW VOLUME RESISTANCE TRAINING
So let's dig into this a bit more. So higher resistance training volume offsets muscle hypertrophy, non-responsiveness in older adults. So what we've got, we've got 85 subjects. over 60 years old male and female that had 14 dropouts and everyone was required inclusion criteria included they could not be doing any formal aerobic training or resistance training prior to being included in the study. Their nutrition was actually analyzed by a dietician, which I thought was really cool for this study that they were looking at that. They also acknowledged that variations in sleep patterns are going to impact people's ability to recover. They weren't able to control for sleep, but they did figure out that by and large, there weren't any huge variants in nutrition, but they did have everyone supplement protein So they did a 20 gram protein supplement in the morning and in the evenings in between meals. The purpose of this study was they were trying to figure out, can we identify strategies like what's gonna happen when we adjust volume at a set intensity for older adults? and then figuring out like what do we do with non-responders so we do have people that are going to respond to resistance training but maybe we may have some people in our caseload and you've probably seen this clinically that don't respond as quickly to resistance training and they were just isolating out the variable of volume, not intensity. So what they did is they had each participant was a study in themselves where one leg was identified for lower volume and one leg was identified for higher volume. What they did is they were looking at the quadriceps muscle They got a baseline cross-sectional area from an MRI, and then they did one rep max testing on a single limb knee extension machine. So single limb knee extension machine to get a baseline one rep max, and then they did an MRI to look at the cross-sectional area of the quad muscle. And then the right or the left leg was assigned randomly to a higher volume program and a lower volume program.

METHODOLOGY: WHAT IS LOW VOLUME AND WHAT IS HIGH VOLUME?
So when we dive into the methods here a little bit, what we find is for the first couple weeks of the program, they were, the low volume group was doing one set. Okay, one set, trying to hit an eight to 15 rep max. And then the higher volume set did four sets at that eight to 15 rep max. So we got one set versus four sets. So that's what they're calling low volume, and that's what they're calling high volume. And that was for each person. So they were able to like kind of control for a lot of factors by testing the low and high volume on the same person, which I thought was really cool, a really cool way to test this. So after the first two weeks, they amped up the intensity a little bit and they were asking them to hit a eight to 12 rep max, still one set on the limb that was identified for low volume, and then four sets on the side that was for higher volume. So they continue that from weeks three to 10. So 10 week duration of intervention, we've got a low volume side and a high volume side. So what they did is they analyzed the results and they were looking to figure out who are our non-responders and who are our responders. So they're looking at cross-sectional area of the quad and changes in one rep max on knee extension. So what they found between all the subjects between the right and the left limb, they found that 60% went into their non-responsive category where they did not make statistically significant changes in their one rep max and or their quad volume. So those were 60% were deemed as non-responders. And then the responders, about 40%, it didn't matter, the low and the high volume side, both improved in their quad size based on the MRI and their one rep max. So really interesting here that they found that the responders, it didn't really matter the volume as long as the dosage was there and that maximal effort. And when you look at the literature for older adults, it is all over the map. And in general, this is a wide brush stroke here, okay? So not for every study, but a lot of the studies will say the more deconditioned someone is, the less, Intense a dosage needs to be to make change. So if you've been doing absolutely nothing Something is going to be beneficial But then the dosage for true strength training, you know, there are lots of studies Landmark studies for older adults like the lift more trial that's looking at you know hitting percentages of 80% for a five by five five sets of five repetitions, but when we you know dig a little deeper into this dosage and you know, based on the rep ranges for their intervention there, because they were doing eight to 15 rep maxes, sets of that. So we're looking at a 60 to 80% rep range, not rep range, percentage of a one rep max. So, pretty decent on dosage, but typically we're going to start people at a minimum of a 60% and then we're going to amp that up to 80%, maybe 80 plus, and then be adjusting the rep scheme. But this is just looking at maximal volitional output to muscular failure in that eight to 10 rep range. And what they did is if they hit more than that number of reps, then they would add a little bit of weight in increments of one kilogram. some weight away if they were doing multiple sets like on the high volume side.

CLINICAL IMPLICAITONS
So really interesting to really think about the impact of volume but this isn't typically what we're going to do clinically right so if we're going to add a higher percentage of one rep max we're going to drop those sets and reps and not be doing these AMRAP sets for each set. Not a great experience, causes lots of soreness, can produce symptoms. And these were all non-symptomatic patients. These weren't people having pain like what you're going to see in the clinic. So there's one caveat there, but just keeping in mind like rep ranges and kind of these basic rules that we try to use for programming strength training. When you look at something like Perlepin's chart, for example, that's been used in the strength and conditioning and Olympic lifting world for years, you're going to see that Rep ranges are going to vary, but you know, if we're in that 70 to 80 rep range, we're going to be doing sets and reps of three to six. So add a total volume of about 18 reps total. And same thing for our 55 to 65% of a one rep max, we're gonna be doing sets of three to six, not these eight to 15 rep maxes, which I understand for the study design and to try to equalize this, that was necessary to be able to compare apples to apples. But clinically, we're gonna be doing smaller sets and reps, and we're gonna be, as we increase a one rep max, not this 8 to 15 maximal effort. So when we're looking at this through the lens of Prolepin's chart for the low volume to be doing one set of an 8 to 15 rep max, you're maybe not going to hit the minimum threshold on volume to make strength adaptations.

IS LOW VOLUME TOO LOW FOR SOME PATIENTS?
And I know there's some studies that say, that are leaning into one maximal effort being enough for strength gains, but I would say clinically, that's not typically what we do. If we're gonna be using that 60 to 80% rep range, we're gonna be breaking that up into smaller sets and reps, and we're gonna be adding more volume than that. So I would question that the low volume group because we did not adjust the intensity up, it's not apples to apples here. Because if we're going to increase that percentage, we're typically going to be doing smaller sets and reps, but also going to be hitting more volume. So I feel like the low volume group probably didn't really hit threshold. And I think that probably impacted, this is all opinion of course, but I think that impacted the low volume group's ability to make changes. And I think that's why we're seeing 60% non-responders. But if we were going to dose this out at that volume, we would have been doing much higher percentages. And the high volume group is probably more a normal rep range and percentage that we would use if we were just going to create a program for someone. So I think that's a weakness in this study, but I still think there's some things we can take away from this.

USING RESISTANCE TRAINING DOSAGE TO OVERCOME BARRIERS
So if we're thinking about training with older adults, we know that there are often lots of barriers. So our older adults come in typically with lots of fear. They may have beliefs on board that are going to limit our ability to be able to really push that intensity or push the weight because of fear, bad experience, or maybe just lack of experience with weight training, that they're scared, there could be histological barriers where maybe someone's coming in and their primary concern is they've had a fragility fracture or they've got low bone mineral density. And knowing the timeframes for healing on bone, we're gonna make muscular adaptations much faster than we're gonna make changes in the bone. So we may actually hit what's appropriate at that point we're going to be adding volume which goes in line with what this study is telling us is if someone's not responding to lower volume up the volume and we're not looking at high intensity and the other thing this study is not testing is it is not comparing low and intensity to high intensity resistance training it's moderate intensity and high volume or low volume which is not typically what we do but it was just looking at the impact of volume is all it's doing at a set intensity so for those people that we hit barriers where we can't go heavier then we're gonna have to add more volume. But keeping in mind that there are specific benefits to higher volume or higher intensity, higher load training that we will not get with moderate or low load training. But we will, if we want the strength adaptation, we are gonna have to adjust that total volume up. So our people that aren't responding or we've got barriers, then we need to up the volume. So I know all this digging in to say, If we hit barriers in hitting that higher load, then we're going to have to add more volume. But that's a reality of what we see in clinical practice, especially with older adults. And I think that's something that's valuable to keep in mind if we're working around injuries or belief systems or fear or time frames for healing. of tissue, especially like bone or cartilage that may have a longer duration of time, that we're going to have to supplement with more volume. So really from a clinical standpoint, I think that's helpful to keep in mind. But still keeping in mind that if we can hit high load, we want it because we're going to get strength adaptations, adaptations to the bone and other tissues faster and create more margin. Because with older adults, it's all about building as much strength and as much margin in the tissues, whether we're talking about strength or fitness or bone density, we want as much margin as possible. And the only way you're gonna get that is with high load. But if we can't, the next best option is to add volume.

SUMMARY
Team, I hope this was helpful. I found this article really interesting. I'd never seen a study put together quite like this. If you have maybe taken our online courses and you want to get into live, where we do lots of practical labs, you've got some great opportunities coming up. So we've got MMOA Live in Kearney, Missouri, January 27th and 28th. We've got Oklahoma City, Oklahoma, February 17th and 18th, that same. And then the weekend after in February, we've got course in Connecticut and Minnesota on February 24th and 25th. Team, I hope you enjoyed this talk. I would love to hear your thoughts on this article or your experience with older adults with adjusting volume and maybe what you've seen. Other than that, team, have a wonderful rest of your Wednesday and we will catch you next time.

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

Jan 30, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses the current literature around best practices for degenerative meniscal issues, including graded manual therapy, self-relief at home, and loading. Mark also discusses how to begin with the highly irritable patient & progress through the full plan of care as symptoms reduce & tolerance to load increases.

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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

MARK GALLANT
All right, what is up PT on ICE Daily Crew? Dr. Mark Gallant here, lead faculty of the Extremity Management Division alongside Lindsey Huey. Happy to be here today, coming at you on Clinical Tuesday. What I'd like to talk about today is degenerative meniscus tears and what is the best path going forward to treat them. So what we'll get into today is a few things of overall arching research and philosophy about degenerative meniscus tears. So those are those tears that person's around the age of 40. There's usually no relevant recent trauma. So we'll get into again, general research philosophy. And then what we're going to talk about is what do you do when that tissue is really irritated? How do you move them forward clinically? And then what do you do when it's, when it's less irritable and we're really trying to get them back to all the things that they love the most.

GENERAL RESEARCH PHILOSOPHY
So what we see with these degenerative meniscus tears in the research, a few interesting points. So first is, that when Horga et al in 2020 took 230 asymptomatic knees, ran them all through the MRI tube, what they found in their research is about 30% of those folks had a meniscus tear or some sort of meniscus degeneration. So even in asymptomatic folks, having some tissue changes to the meniscus tissue is quite normal. Then Thorland et al in 2018, they had a surgeon who went in and did a scope of arthroscopic surgery to over 600 knees and while the surgeon went in there determined is there damage to the meniscus or is there no damage to the meniscus. What they found was an equal number of folks with no damage to the meniscus reported signs of mechanical knee pain that we typically associate with meniscus injury. So things like catching, locking, and lack of extension of the knee, we have historically associated those with a damaged or torn meniscus. And what Thorland et al found is, no, this really is more of a sign of that the knee is not doing well, that the health of the knee is not at its max capacity. and that's likely why they're getting those catching, locking, lack of extension, not that one specific tissue or a couple of specific tissues are to blame. And then finally, over the last decade, we have study after study, systematic reviews, randomized control trials showing that if you compare someone who had conservative care like physical therapy versus having surgery to their meniscus, that after a year, the outcomes are the same, if not better, favoring the physical therapy side with far less medical cost. Last year, what came out is we now have Cochrane-level review evidence, a Cochrane study showing that scoping these meniscus knees, or knees that supposedly have meniscus damage, is no better than placebo. So again, many asymptomatic knees are gonna have changes to the meniscus, whether that's degeneration or tears, Most knees, whether they have a meniscus tear or not, if they are unhealthy and not doing well, they're going to show signs of mechanical knee pain such as catching, locking, and lack of knee extension. And when we take it even further and we look at who gets better if we treat them out for a year, again, Cochran level review evidence saying that we should not be scoping those knees, which has led my partner, Lindsey Huey, to often using the phrase, stop the scope. There's a couple podcasts here a ways back if you want to check them out where Lindsey went into more depth of the all the research showing why we should not be scoping degenerative meniscus tears or at least not scoping them as a first line of treatment. She also has a episode on our virtual ice where she goes in depth to the scoping the knees.

STOP THE SCOPE: THEN WHAT?
So what I want to talk about today is stop the scope, then what? Then what do we do after that? So how are we going to effectively treat these people to get them back doing the things they love? So Let's start with the highly irritable patients, someone who comes in, their symptoms are at that 7, 8, 9 out of 10 symptoms. How are we going to treat them? Well, modulating their pain is always a good place to start. So can you use your manual therapy, your joint mobilizations, your dry needling, your myofascial decompression, or your soft tissue techniques to take their symptoms from that 8 and get their symptoms down to a four, a three, a two, something that's a little more manageable. When we're doing our joint mobilizations for these folks early on, what we're going to do is we want to do them in more of a open pact or positions that are not challenging the end range as much. So both flexion mobilizations or knee extension mobilizations. Again, at this point, we are not trying to get after knee stiffness or range of motion limitations. We're trying to create fluid exchange. We're also trying to pump any chemical irritants out of the area. And really the biggest thing is we are trying to get a positive stimulus into those tissues so that the central nervous system will calm down a bit and allow us to load the knee, which will effectively improve its long-term health. So again, very mid-range, open-pack joint mobilizations. With your dry needling, what we typically see is it works well to go distal from the knee. So putting your needles in hamstrings, quads, glutes, tissues that relate to the knee, but are not going to create fear for that patient by putting the needle directly into the area or tissue that is sensitized. Same with your soft tissue mobilization or your cupping. When you, after you do your joint mobs, your dry needling, they're feeling a little better. Then we're going to give them a self-mobilization to follow it up when that person is more irritated. Again, we want that to be more of that open packed, less challenging end range. If they have a flexion deficit, we like to go on the floor doing a heel slide, but having a thick band provide an anterior tibial glide, which will further modulate their symptoms and allow them to get through a nice comfortable range of flexion. If their deficit is more knee extension and the pain and symptoms are high, we're going to have them do a quad set but put a towel behind their knee so that they know there's an end range and they're not going to bottom all the way out into their symptoms. You can also add a band to distract the tibia and that sometimes can be an added benefit for those folks. So you're going to do your pain modulation technique in the clinic You're going to give them some sort of self-mobilizLation to help further modulate pain at a fairly high volume, 15 to 20 reps to really pump that tissue.

LOAD AROUND THE KNEE
And then as early as we can, we want to load the tissues surrounding the knee. So the quads, the hamstrings, the gastroc soleus complex early on when things are irritated, it's going to be challenging to get a lot of tensile load through these, through these tissues. It's also going to be challenging to get them at an end range. So, we're going to do mid-range knee extensions and we're going to do Knee flexion, so either banded, monkey feet, whatever you can do to challenge those hamstrings with a light load and a mid-range at a high volume. And then whatever way you want to load the gastrocs and soleus, but again, going low tensile load, high volume. And then what sort of functional thing can you get that person into? A lot of times those folks have challenge with loaded knee movements. We want to get them back to that as early as possible. without stirring up their symptoms. Early on, what we find best is to go double leg activities that don't have a lot of shear involved with them. So not a lot of twisting and rotation. So we love a body weight squat and even a body weight squat to limited depth to keep that person comfortable early on. So again, symptoms are high. You're gonna go manual therapy, more for challenging symptoms, not challenging their end range. You're going to go self-mobes that have the same type of style where they're more mid-range, really creating a pump to that tissue, giving some positive input. You're going to start to challenge the knee extensors, the knee flexors, and the gastroc soleus complex with lighter tensile load. higher volume again thinking pump and getting positive positive stimulus in the system and we want to get them used to doing their functional activities double leg body weight squat with a depth that they feel comfortable with is a really nice way to do this now then that person is going to come back and their symptoms are going to be lower so they're going to tell you know what i was at an 8 out of 10 but over the last couple weeks, I've been hitting all the stuff we talked about. The manual therapy felt good. Now my symptoms are more in that two out of 10 range. I feel like I can get after it a little bit more. So now when we're doing our joint mobilizations, we are gonna go straight down to the end range and really challenge the end ranges of these tissues and make sure we facilitate that they can restore full flexion, full knee extension. For our dry needling, now we are gonna get much more direct at the tissues of the knee. So we really like to needle the popliteus, the hamstrings, the gastroc soleus, tissues that are right there interacting with the intra-articular knee tissues. For your follow-ups, now again, we want to get them right into those end ranges of tissues and really start to challenge them.

CHALLENGE END-RANGE
We love the classic terminal knee extension with a really thick band. Spanish squats can be another way to get after this. We also, for the knee flexion after the mobilization, we're gonna get into a child's pose position with a towel behind the knee. I'll come on tomorrow on our Instagram feed and demonstrate what this looks like. So they're gonna have a towel behind the knee with a band keeping it placed, and they're gonna rock all the way back into deep end range knee flexion to really challenge the end range of that motion. Now, loading up the local quad, loading up the local hamstrings and gastroc soleus at that point where they can tolerate more tensile load, we're going to go long arc quads, really loading that up, whether that's a classic knee extension machine, your monkey feet, banded long arc quads. you can hit spanish squats in this position to really load the quads up for our hamstrings we're really going to start to challenge the length tension relationship of those by doing things like nordic curls You can also do Nordic curls or bridge walkouts to really challenge those hamstrings can be another nice one. And then in this phase, we are really getting into the concentric eccentric in functional activities. We really like transitioning to single leg activities in this phase. your split squats, your kickstand RDLs, your single leg RDLs are very nice for this phase, really challenging that knee overall from both a proprioceptive balance and load perspective. When you're doing your squats and your deadlifts in this phase, really starting to load them up, how heavy and how much stress can that tissue take during this phase. Step ups are another really nice one to add in. So again, during that low irritability phase, now we are challenging end ranges of tissue. We're really trying to put positive stress into the quads, hamstrings, calves, Our functional activities, doing single leg, whether that's split squats, RDLs, heavier on the double leg squats, deadlifts, step ups, all work really well. Once they can tolerate that phase, with 2 or 3 out of 10 or less symptoms, then we've got to really get them back to their more dynamic activities if that's what they choose to do. Here's where we're going to do things like box jumps, rebounding jumps where they jump from one box height to the floor up to another box height. We're going to hit things like jumping ropes so they get their plyometric endurance up. single leg hops for distance, running for distance, cutting. This phase we really want to focus them on getting back to the activities that are challenging them and some pivot rotation movements that are going to challenge that sheer force to the knee.

SUMMARY
So overarching themes. For these degenerative meniscus tears or degenerative meniscus damage, surgery is never the first line of defense for these folks. When they're more irritable, our manual therapy is gonna be much more mid-range, calming things down, giving a positive stimulus to the nervous system. Our follow-ups are also gonna challenge more in this mid-range, again giving positive stimulus, mid-range knee extension, banded or monkey feet hamstring curls, low to the gastroc soleus, and typically double leg functional activities. Once they can handle those things where symptoms drop below that five, now our manual therapy gets much more into the end range of those tissues. Our follow-up MOBS are also gonna get into the end range of those tissues. I'll show that, Child's Pose Rock Back tomorrow on our Instagram feed. Our knee extension, our hamstring activities are gonna be much more higher tensile load. Our functional activities will switch into single leg or much heavier and stressful double leg activities. Once they can tolerate that at a two or three out of 10, then we're really gonna start getting into their running, jumping, cutting, dynamic motions overall. Hope this helps as far as treating out those alleged meniscus tears and avoiding them from going into an unnecessary surgery. If you'd like to catch us on the road, I'm gonna be in Highland, Michigan, just outside of Detroit this weekend. Lindsey will be in Scottsdale, Arizona this weekend. And then the next opportunity to catch us will be Lindsey will be in Carson City, Nevada, February 17th and 18th. Hope to see you all soon. Hit us up in the comments if you have any questions or things to add to this conversation. Have a great rest of your Tuesday.

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

Jan 29, 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 how to get patients performing more fitness in their plan of care, as well as suggestions on how to help patients transition to becoming "everyday athletes" with a wide variety of home & community fitness programs.

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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

RACHEL MOORE
Good morning, PT on Ice Daily Show. It is 8 a.m. on a Monday morning, which means we are here tuning in for our ice pelvic. We are hanging out here today. We are gonna be talking about building the bridge to fitness in the pelvic floor PT space. So we talk a lot at Ice about being fitness forward. We've had Jeff Moore on the podcast a few weeks ago talking about what fitness forward means. and we really pride ourselves on being fitness forward right sometimes that can create this like mindset of if i'm not seeing athletes quote unquote how can i bring this fitness forward um style of therapy into pelvic floor pt

WHAT DOES BEING AN ATHLETE MEAN?
And first I want to talk about what athlete means, like define what that means in this space and kind of dive in from there. So when we talk about like athletes, quote unquote, in our space, that's anybody that's like intentionally moving their body for exercise. That doesn't mean that they're CrossFit Games athletes. That doesn't mean that they're super competitive. It just means that they are moving their body intentionally to get some effect. I would argue that every parent that is chasing after kiddos is an athlete in that case. And so if we take this term of athlete and broaden it out, we can apply that concept to everybody that walks into our clinic. This is a really huge key point in the pelvic space because there are so many people that are coming into pelvic floor PT that maybe have not ever exercised before or maybe exercise like back in high school played sports and since they graduated high school haven't done anything in the gym intentionally or haven't done any sport. So this season of life of pregnancy and even postpartum is a fabulous reintroduction into potentially the world of exercise. And that's where we come in. So when we have people coming in that are pregnant that want to get out of pain, maybe their goal isn't even anything to do with staying in the gym or getting back into the gym and their entire goal is to get rid of their back pain in pregnancy or get rid of their pelvic girdle pain in pregnancy. We can help not only accomplish that, like we know that. We talk about it in all of our courses, in our live course and in our online course, how we can use resistance training to mitigate pain and get rid of pain in these populations. But we have a fabulous opportunity here to literally change somebody's life. We can help them fall in love with fitness and fall in love with that feeling of being strong. a lot of times people are coming in and again maybe they haven't resistance trained ever and we put a barbell or a dumbbell in their hands and they kind of look at you like I'm not really sure who you think I am but there's no chance I can do this and so having conversations with them about like look this is a 20 pound dumbbell and your toddler weighs 30 so yeah you can and I know this looks scary because it is this little metal handle with two big old heads on the side But in reality, you're already lifting more than this. Let's just build your capacity by doing it intentionally at a higher volume. And then they start feeling those effects of that. We can have so many downstream effects from resistance training, not just getting them out of pain, not just giving them a new hobby. We can shift the trajectory of their life and impact things like metabolic diseases in their future. So this really is a powerful thing that we can do. And we have to recognize that every time somebody comes into our clinic, whether or not they've exercised before, we have a lot of opportunity to help build this capacity for them, not only physically, but also emotionally and mentally. In our PT sessions, we do a lot to help build confidence and rapport, right? Like we're in there with them. We're going over form. We're talking to them about like, okay, this is how you do a deadlift. This is how I want you to brace. This is what a brace means. Now we're going to practice it. Let's go apply it. Like let's actually lift heavy things while bracing. And when they're in the clinic with us, that can be incredibly empowering and amazing. And we love that, but sometimes that doesn't translate over into the next step. So great.

WHAT TO DO AFTER FORMAL PT HAS ENDED?
When I'm in the clinic and you're watching me do the things, I feel awesome and I feel like I can knock that out of the park, but I'm just not really sure what to do when I leave here. A lot of the times the way that I'll program HEPs is I'll do like our rehab EMOM style and I'll give them two or three workouts, if you will, and they cycle through them. But I think we all can agree that if you're just doing the same thing like three times in a week, so like A day, B day, C day, and do that for a few weeks, it can kind of start getting stale. And we kind of like crave that variety, right? Especially as people are starting to get a little bit more confident. So there's kind of this like gap between I'm done with PT, informal PT sessions. A lot of clinics are now coming out with like once a month or like once every other month kind of like check-in style appointments where you come in, you get a progression of your exercises, you get maybe some updated programming, and then you go off for another month or so on your own again. And those are really the two big things that we see. And then the third option is like, okay, you discharge and you're done. I'm here to talk today about another option, right? So when we have our person who's coming in and they've been coming to us for several weeks, they're feeling really great or maybe a couple months and they want to continue working out, but they want something a little bit more than once a month. and they don't really want to do like a full blown PT session. Like they just want to come in and work hard. We've got two options. We can create a program within ourselves and within our clinics, or we can get really, really good at helping find a home gym or a home space for them. If we're talking about the creating a program route, this is something we're about to roll out in my clinic. We're calling it like the bridge. Feel free to take that same concept. But the whole idea is when you're done with PT, quote unquote, like you're not in pain anymore, all your symptoms are gone. You're feeling really solid. You want to work out, but you're just not sure where to go and you're not sure if you feel like you can confidently take the things that we've done in our sessions. and apply them across the board, this is the spot for you. So we're doing it as a couple times a week and obviously this depends on what the capacity is within your clinics. We're rolling it out starting out two times a week and these are group HIIT style classes, where we're going to have a cardio component, we're going to have a strength component, we're going to take them through different movements, and so there will be a variety of movements that they can increase their comfort and their confidence in while they're in our classes. They're also building community here. They're meeting other people that are in a similar stage of life as they are. Not only are they maybe pregnant or postpartum just like they are, but they're people that are wanting to get into exercise and wanting a little bit more, but maybe haven't really known how to do that up until this point. So we're taking these people and we're bringing them together and then we're lifting heavy things together. So powerful. If you've ever set foot in a CrossFit gym or any type of like group fitness setting, you know how powerful these connections are that get built in under like shared suffering, if you will. This class, though, isn't meant to be forever. Like, its whole goal or the whole purpose is to build capacity, increase confidence, so that these people can go from working out a couple times a week, doing their PT exercises, and then coming to these bridge classes. But I want you getting to the point where you're like, let's send it five days a week, or whatever that looks like in your schedule. And truthfully, I want you to have more variety. Like I want you to get out and do different things and try new sports.

BUILDING A NETWORK OF FITNESS PROFESSIONALS
And so that's where option two comes in, where we as professionals need to have a really reliable, strong network of fitness providers. So we need to know not only the CrossFit gyms in our area, Because truthfully, not everybody vibes with CrossFit. That's OK. There's the whole phrase, like, CrossFit is for everybody, but it's not for everybody. So CrossFit gyms in your area, knowing those coaches, being comfortable with, like, if I send you there as a newbie, I know that you're going to be in really solid hands and be taken care of. But also the other types of workout spaces, too. So we're thinking things like F45 or burn boot camp, maybe having some options for, like, Pilates studios, where you've taken some classes there you understand how they teach the bracing piece of it and if it isn't maybe what the way that you've taught them you kind of have that conversation beforehand or you have an opportunity to educate those Pilates instructors on like hey this is how we do things from a pelvic floor PT side you've got somebody coming in that's postpartum or pregnant So this is kind of the messaging that we have. We also really love things like PureBar. We've got actually evidence for PureBar helping reduce stress urinary incontinence, not even full-blown pelvic floor PT, but just going to PureBar classes. So having a variety, knowing who these people are, knowing what these spaces are like, and knowing what the environment is like. It is powerful to be able to have your hands directly on give the people the thing that they need as far as improving their fitness and improving their form. But it's also powerful to then watch them take that and go off into the world and utilize it. And then you're seeing them maybe on Instagram months later, or you run into them at a workshop, and they've been going to these gym classes for like a year. And now maybe they're competing at different things that they're in CrossFit. And you can see this like spark ignite. And we have the opportunity to start that spark at our very first visit, our very first appointment when somebody comes waddling into our office because they're in so much pain, they can't even take a full length step because their pubic bone pain is so bad. We can be the ones that not only knock that pain out, because I know we can, but also create this bridge into a completely different life for this person. Increasing their capacity, increasing their confidence, helping them find community and support, and having that far reach outside of the realm of what our typical plan of care is. This is huge. This is a massive piece of the puzzle in the pelvic floor PT space. So if you are not somebody who has the ability or desire, totally understand, to create a group class within your own setting, whether it's in your clinic or your gym or whatever, start reaching out and start making those connections with providers, fitness providers in your area. Meet those gyms, take those classes, get out there and build that network. Have some cards on hand when your patients are talking about, hey, I just really think I'm ready to get out there and do more. Lay them all out. Here's everything we know about all the gyms in the area. Let's talk about all your options and help you find the perfect home for you. I hope that kind of lights a fire under you guys if you have an eval coming in this afternoon on the ways that you can really implement all of these strength training principles to change their lives and also to get out there and make some connections in your community.

SUMMARY
If you are looking to join any of our pelvic classes, we've got our live courses. We actually have a ton coming up in the next couple months. We've got one in February, February 3rd and 4th in Bellingham, Washington. And then we've got three rolling out in March. Our first two are gonna be March 2nd and 3rd in Newark, California, and March 9th and 10th in Bismarck, North Dakota. Our next online cohort comes on March 5th. If you're interested in that L1 online cohort, hop into it, because we are, man, we're getting full. So grab your spot before there's not one, because if so, you've gotta wait another nine weeks after that March 5th cohort to hop into the next one. I hope you guys have a great Monday morning. Absolutely crush it. Thanks for joining.

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.

Jan 26, 2024

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses the prevalence of runners returning after joint replacement, risks of returning to running, and how providers can set these athletes up for success on their return.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JASON LUNDEN
Hey, good morning, everyone. Welcome to another edition of the PT on ICE Daily Show. Happy Friday. My name is Jason Lunden. Uh, I am the lead for our endurance athlete division, and I am very excited today to talk to you about return to run following total joint replacement. So this is a topic that has held great interest to me for a number of years. Um, and really hasn't been a lot out there. Until more recently, there's still not a lot out there, but there have been some really neat studies that have come out in the past year that can help guide us with that. So today we're going to cover, one, do runners return to running following total joint replacement? Two, what are the risks that we and they need to be aware of? And then three, How can we set them up for success if they do indeed want to return to running?

DO RUNNERS RETURN TO RUNNING AFTER JOINT REPLACEMENT?
So first, answering the question, do runners return to running following total joint replacement? The short answer is yes. I think we've all probably heard anecdotal stories of runners who've had a total joint replacement and returned to running despite being told that they should never return to running from their surgeon. Furthermore, a study from 2018 just looking at the prevalence of osteoarthritis in marathon runners made the observation that out of their cohort that they were studying, there were seven marathoners who were running with total joint replacement. So, you know, are these unicorns, you know, people who are going against the advice of their physicians and maybe their PTs and you know finding some success? Is it that they're finding very short-term success and then having to go on to you know early revision of their total joint? You know really didn't have any of that data until until recently. So a really cool study in 2023 came out by Antonelli et al looking at the return to run rate for runners following total joint replacement, namely total hip, unilateral knee, and total knee arthroplasty. And what they found is that yes, runners do indeed return to running following total joint replacement. And depending on the type of joint replacement they had, some of them return at a very high rate, while others return at a pretty modest rate. But overall, one of the interesting things out of that study is the number of people going into total joint replacement that classified themselves as a runner is actually really small when you're looking at the whole population out of the study. And that really, you know, reinforces our knowledge that we've been gaining recently that, you know, running is not a precursor to osteoarthritis and perhaps it may be chondroprotective. So that's one kind of neat takeaway from that study. The other really cool thing is that for patients following a total hip arthroplasty, if they're a runner prior to total hip, 75% of them returned to running after getting a total hip arthroplasty. With knee replacements, the percentage is much lower at around 10 to 15%. of those runners who were running, runners, and then going on to get a knee replacement, only 10 to 15% of them returned to running. And then even more surprising is a certain number of patients who did not run prior to joint replacement actually picked up running following joint replacement. About 1% of patients studied in the study. So yes, patients, can and do return to running following total joint replacement.

RISKS OF RETURNING TO RUNNING AFTER JOINT REPLACEMENT
But what are the risks? I think we all have heard the narrative that you definitely should not avoid impact and avoid running following total joint replacement. And there are concerns for periprosthetic fracture, so fracture around where the orthodesis is or where the implant is. you know, concern for dislocation for total hip replacements, as well as polyethylene wear and loosening of the implant. Those are the kind of the four main concerns that surgeons have. And I think there, you know, is probably some validity to those concerns. And we do want to be thoughtful in having those discussions with patients if they are looking to return to run following total joint replacement. But another really neat finding out of the Antonelli study is that there was no difference in revision rates between those patients that went on to return to run following total joint arthroplasty and those that did not run at all. So the revision rate is around 5%, which depending on how you look at it, is either pretty small or still a pretty large number if we're thinking of 5% of people are having to go on to get a revision following the first total joint. And unfortunately, as with most surgeries, the second time around, the outcomes just aren't as good. So we definitely do want to avoid revision of a total joint if we can. And one way we can think about doing this is being really smart and methodical in how we're helping these patients return to running. Keep in mind that You know, following most lower extremity surgeries, patients actually see a decrease in bone mineral density, typically for the first year or maybe even up to two years following surgery. And that seems to peak in total joint patients at around three months, and then not actually improve, but the amount of loss peaks at about three months. So right around when we would be thinking about implementing a return to run program with a total joint patient, realize that their bone mineral density is probably at the lowest that it's been recently. And particularly if they are osteopenic patient or osteoporotic. You really want to go slow with them with implementing impact just to avoid periprosthetic fracture. So that also is making sure that you as a practitioner have knowledge of what's going on with the human in front of you, not just that they've had a total joint, but what's the bigger picture? Do they have a history of osteopenia or osteoporosis? And is there anything that they can do to help combat that?

SETTING PATIENTS UP FOR SUCCESS TO RETURN TO RUNNING
So setting up our patients for success that do want to return to run following total joint replacement. One, we want to have a good idea of what's going on with them as a human and on a global scale and making sure that we're being specific to that. Two, regardless of that, we do want to have a slow progression with return to running and return to running volume. So this is a patient population where we definitely want to start with more of our walk, jog intervals than just going into straight jogging or running, making sure that they are able to tolerate a good walking program first. So being able to walk, you know, certainly 45 minutes or an hour without any issue, implementing impact in a controlled setting. So having them do stomping, um, you know, jump rope, uh, and, and things of that nature and making sure that they are tolerating some impact before we really get, uh, have them get to a lot of repetition, which running is a lot of repetition, um, for that. And part of doing that is really making sure that they are regaining and probably even gaining more strength than they had going into surgery, particularly with, if we're talking about the knee and the hip, quad strength, hamstring strength, and then global hip strength. So really making sure that they are, have had a good program with that and that they are at you know, 80 to 90% of what their contralateral leg is before even thinking about implementing a return to run program. And also making sure that what we're comparing their operative leg to with the contralateral leg isn't just comparing to, you know, crap numbers. So making sure that they do have a certain level of strength and fitness going into a return to run program. A couple things that we like to use as quick screening tools in the endurance athlete division are the ability to do single leg squats and the ability to be able to do at least 20 single leg squats with good form and with maintaining balance, as well as being able to do single leg heel raises and the ability to do at least, in this older population, 10 to 15 single leg heel raises to full height if possible. So we're really being methodical about how we're implementing that return to run program and progression of volume. We're making sure that prior to doing that, we have maximized their strength gains around the hip and the knee. And then we also want to make sure that they have the mobility to have, you know, the best gait mechanics that they can. So really making sure that they are getting, particularly with total hip patients, that they are getting hip extension, that they have good mobility of the rockers of the foot and ankle. So good ankle dorsiflexion, good, great toe extension, et cetera. And if they don't, working on that, either using your manual techniques or giving them some mobility drills to work on with that, And then bringing it all together with when we are implementing that return to run program, really trying to set them up for success by looking at their gait mechanics and then implementing some drills to help decrease impact at the hip and knee. Namely, if they do have decreased rockers, you know, and even with working on it manually and with some mobility drills, they're just not getting that back. getting them in a shoe with a rocker bottom to help with that can be extremely helpful in our older adult population. So something like, you know, Hoka has several shoes with a rocker bottom, as do other brands. And then if they're really limited in their, they're not able to get that hip extension or you're not observing hip extension at toe off, getting them to have a little bit of a forward lean, a forward lean not a forward bend so that they're basically just leaning their center of mass further forward to prevent over striding which over striding really increases impact at the hip and the knee and probably even more importantly it increases the the loading rate at the hip and the knee so those would be kind of two things to to really look for in your total joint patients that are returning to run. So in summary, you know, return to run for total joint replacements, yes, patients do and can, can and do return to run following total joint replacement. Much higher rate with, if they've had a total hip replacement compared to a total knee, but overall, those patients that we're working with that have had a total joint are likely to not be a runner to begin with. Two, we do want to be aware of what the risks are. There is no difference, at least in Tonelli's study, in revision rates between those patients that went on to return to run and those patients that did not return to run following total joint replacement, but those risks still are you know, I think valid with paraprosthetic fracture, risk of… hip dislocation, particularly if they were to fall, polyethylene wear, and implant loosening. So just really having a good understanding, particularly the bone health of the patient in front of you. And then lastly, set your patients up for success. Get them strong, work on their mobility, have all that tie into good gait mechanics, and slowly progress their volume. That's all I got for you today. Uh, thank you for listening.

SUMMARY
If you are interested in treating endurance athletes, um, or you do treat endurance athletes and are looking for some CEUs, uh, we do have a variety of offer offerings within endurance athlete division. Uh, for coming up first is our second cohort of rehabilitation of the injured runner online, um, starting in early March. Also in March, we have our first offering. of the year of professional bike fit in Texas. And then we have a bike fitting offer, the professional bike fitting course offered also in April in North Carolina, and then in May in Minneapolis. And then our first rehabilitation of the injured runner live is going to be early June in Milwaukee. Come join us for those courses. We have a lot of fun and I think you pick up some really good skills and clinical pearls with treating endurance athletes. Have a great weekend, everyone. Get outside, do something fun with friends and family, and we will catch you later. Bye.

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

Jan 25, 2024

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses how friction opposes the momentum of starting a business but offers different solutions on how to overcome the initial friction encountered when starting. 

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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JEFF MOORE
All right, team, what is up? Welcome back to the PT on ICE Daily Show. My name is Dr. Jeff Moore, currently serving as the CEO of Ice, and always thrilled to be on the Daily Show, Mike, and always happy to be here on a Leadership Thursday that is a Gut Check Thursday. As always, let's start with the workout. It's gonna be a little bit rough. We got five rounds for time. It's just a simple couplet, but there's no rest to be found. The workout is five rounds for time, you are gonna do 30 calories for the gents, 25 calories for the gals on the rower, and then you're gonna do 15 burpees over that same rower. and you're simply going to, I say simply, but ouch, going to repeat that for five rounds, okay? So thinking a little bit about time domain as always, you got to think about maybe that row is going to take you what? Maybe up on two minutes and then a little bit over a minute for those burpees. So a great target would be 15 minutes. Try to keep it inside of 20. I think that would be a reasonable goal for the workout. It was a qualifier workout. It's gonna hurt. The heart rate's gonna be peaked. There's just nowhere to hide during those five rounds. So enjoy that. Make sure you're tagging Ice Physio. Make sure you hit Gut Check Thursday with that hashtag. It's so fun for us to be able to follow along with you. So enjoy that workout today.

"IS IT WORTH IT?"
Let's talk about friction in your business. Specifically, Let's talk about friction coefficients and how it relates to your business. So I get to talk to a lot of people who are in the process of starting up their companies, kind of in that early phase, okay? And many of them engage with me when they're in the harder part of that phase, right? Where they're starting to wonder, is this worth it? Like maybe the excitement of starting something new and all the fervor that comes along with that has legitimately turned into the daily grind and some real questions about, is this going to turn over? Is this going to catch some momentum? Is this gonna work? Are really starting to come to the forefront? Is the ROI there? The first thing I want to say is don't shame yourself. If you're in these shoes, don't shame yourself for asking that question. I think that this latest generation of business gurus, this mantra of everything is going to work as long as you keep going is the most ridiculous mantra of all time. That makes absolutely no sense. I can list off an innumerable people who have hit dead ends and pivoted and had drastic levels of success because they were willing to say, this route, the way I went about it, this approach, this area doesn't make as much sense. Now that I've seen around the corner a bit, that does not make sense. I'm going to pivot. I'm going to pull back. I'm going to redirect. And those people have a huge amount of success. So don't feel like It's not logical or you're less than because you're asking the question, is it gonna be worth it? It isn't always. That being said, if you've hit that spot and you've thought, is it worth it? Do I really wanna be in this space? And the answer is a hell yes. You say, I love serving these people. I know it's what I'm called to do. I know I bring some unique value to this area. I know that I've got something to share in this space. I wanna keep going. I want this to work. If that's you, then I want to share with you what I think is both an accurate and helpful analogy from physics that correlates beautifully with the business journey.

OVERCOMING FRICTION
So, in physics, If we can get you to think way back, right? When an object is stationary and you want to move it, to do so, you have to overcome static friction, right? And this is really hard. You know this because you've encountered it in plenty of places on a daily basis, maybe even in your workout. So if you're in the gym and you're trying to push a box, right, you're trying to do box pushes across the floor. You can all picture how agonizing that is. You know the worst part is getting the box started, right? It's that initial setting into motion. Once the box is sliding across the ground, I'm not saying it's easier, but it's certainly better, right? The same is true for plate pushes. Like when the 45 pound plate is on the ground and you're trying to push it across the floor, it's getting it started that's the absolute worst. Keeping it moving isn't nearly as hard. Mathematically, The reason for that is that the coefficient of static friction is larger than the coefficient of kinetic friction, right? When you're doing equations, the thing you multiply the forces against is larger when you're talking about static friction, things that are not yet in motion. Now, you don't have to, if you're not a math person, you don't need to gravitate towards that part of the conversation. It's best illustrated visually probably that, let's imagine that you had two hand saws, okay? We're talking about like the saw that you would cut a Christmas tree down with, right? Let's say this is one hand saw. These are all the teeth of the hand saw. This is the other hand saw, okay? So you're putting teeth to teeth on these two hand saws, yeah? Like this, okay. If they're sitting stationary, the one on the top, settles into the one at the bottom, right? And they've been sitting there for a while. And now you wanna move the top saw relative to the bottom saw. This is gonna be tough, right? Because you've gotta break all of that and get things moving. However, once the top saw is moving across the bottom saw, as long as there's decent speed here, there's not enough time for the top saw to sink and settle into the bottom saw. Thus, you kind of click across the top significantly easier than it was to break that original static bond. Once something is in motion, it's not settled into the other object. Keeping it in motion is not nearly as hard. Team getting a company going and keeping a company going is the exact same scenario.

BUSINESS IS PHYSICS
The business rules follow the physical world. It's why we use all the same terminology all the time, right? How often do we say, oh, it's an uphill battle, right? I've got the wind at my back. We've got momentum, right? Momentum. We're talking physics all the time because the same mechanics happen. They're in different environments, but the same terminology, the same laws apply. Okay, so if what we're saying is, you gotta get some speed going, because that is significantly easier once built up to keep it going, well, what do we mean by the speed of our business? We gotta break that down, because that's where the action item lives for today. So, the speed of your business, getting the saw moving over the other saw, is best looked at as a compilation or an aggregate or a sum of the speed of all the different parts of your business. And this is where it can get actionable. First of all, appreciate that at the beginning, they all start at zero. They are settled into one another. Each part of your business has to break the static friction to get things into motion. For example, idea or concept generation, right? The hardest thing is thinking of that first original concept that's paradigm shifting. It's got static friction. It's hard to create that first great idea. But once you do it, once a unique and valuable concept has been created, building off of it seems effortless, right? Then it's like, once you've done that, you're like, oh, now we should do this, and now this opportunity becomes available. Once you get that first great original idea, Building off of it seems effortless. Team building has significant static friction. Think about it. People want to join a great culture. Well, you need a team to have a culture. So in the beginning, there is no culture, which is why there's so much static friction to team building. But once you get a couple great people on board, they naturally attract a bunch of other great people. Once the saw is moving, it's really easy to keep it moving. You just got to get it moving. It's all about finding those first couple people that will then attract other great people almost effortlessly.

ATTRACTING BUSINESS IS OVERCOMING STATIC FRICTION
Attracting consumers or customers has significant static friction. Think about when you walk by a restaurant and there's nobody in there. Do you want to be the first people to go in, especially if you're not familiar with the area? Absolutely not. But once there's a few people in there and they seem to be having a good time, other people just naturally come in. Why do you think happy hour is always so discounted, right? People want their restaurants to look full and bustling, so people will come in and actually have dinner. That's what draws them in. Consumers attracting them has significant static friction. When there's none, it's hard to get one. But once you have a few, it's easy to keep the saw blades moving. This is how I want you to think about your business. And your action item is to realize that you can get each of these going, or any of these going, and the beauty of getting them going is you can use them to nudge the other one. This is where you got to get clinical with it, right? So when you've got that box for that box push that you know is going to be tough to get moving, right? The best, the hack would be, could there be another moving box that you could slam into this one just to break that static friction? So then you could then push it from there once it's already in motion. The answer in business is yes. You could choose any of those boxes if you will. Idea generation, team building, attracting consumers. Those are all individual physics scenarios that you could focus on and get one of those in motion and I promise you it'll ram into the next one. If you break the static friction of team building and you get a couple of great people, I promise you, you'll get more great ideas, right? So that one box that's now moving will slam into the other box and you won't have to do quite so much work to break the static friction of the other one. So you can use success or momentum in any of these individual areas to nudge into the other one and make it easier to get it into motion.

FINDING THE LOWEST BARRIER TO ENTRY IN BUSINESS TO BUILD MOMENTUM
The key then is to figure out which one for your business has the lowest barrier of entry. Which box, if you will, can you get moving the easiest? Is it team building? Is it attracting consumers and getting social proof? What area in your business can you get moving so it can slam into the other boxes and get them moving for you without quite as heavy of a lift? That's what I want you to really think on today. Before I let you go though, there's a couple other thoughts that go along with this topic that I've got to share, especially because I think they give you a lot of hope. And the first one is, you only do this once, in most cases. There's exceptions, things happen. But in most cases, you only get it going, if you will. You only get the box moving or the saw blades rubbing. You only do it once. Once you've got momentum, once you've got speed, once you're only dealing with kinetic friction, you just keep it moving, right? You don't have to start and stop again. So realize that if you're feeling like, my gosh, this is a heavy lift, it gets lighter, because the boxes, once moving, are easier, but they also slam into each other, and overall, the momentum builds and it does get easier. You don't have to keep facing that your entire career. So if that's you and you're in that spot, hold onto that. And number two, to get even more exciting, to think a little bit bigger this morning, soon, it's not that one component of your business bumps into the next one. A couple of years down the road, what begins to happen is your businesses begin to bump into each other, right? If you're playing this game right, if you've got one business that's really humming, Oftentimes, that can help to create an offshoot business that doesn't have nearly as much labor required to break the bonds of static friction because you have so many resources from the first one. So pretty soon, what you realize in the game of business is that every time you create, it's a little bit less effort and a little bit more impact. If you're watching this and resonating, you're probably at the hardest part right now. But if you can think about how to use one box to bang into the other, you can get this thing moving. If you can realize that you only have to do it once, hopefully that can help you have the effort you need to build the speed. If you can really dream and realize that soon one of these lifts can make all the other ones happen almost for free, you can realize this game becomes, you never want to say effortless, but you do want to say a return on investment that you probably never imagined. when you were first starting off and maybe sitting right now in a bit of a tough trough looking at a big mountain, right? The top is brighter than you could ever imagine. So think a little bit about how the physics of friction in your business work together and think about the upside of that, not just how hard it is to get that damn box started to begin with. I hope that gives you a little bit of hope this morning on Leadership Thursday. Team, There are so many courses going on. I'm in Reno, Nevada right now. I'm doing all the logistics for Ice Sampler. Ice Sampler is sold out for this year. It's been sold out for a long time. Those of you coming to the event, this is going to be an absolute banger. Carson City is so beautiful. The gym is so beautiful. Carson City CrossFit. So if you're coming to Sampler, get excited for that. Other than that, we have some online courses that are almost sold out. Essential Foundations Level 1 only has a handful of seats left. We are more than half sold out for Pelvic Level 1, which starts in March. Point is, a lot of these online courses, especially, are selling out like crazy. So get on ptinex.com, jump in, grab what you need, get it done, break that static friction. Cheers, team. Have an awesome day.

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

 

Jan 24, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses workout ideas for acute care patients, including those who are confined to bed, able to move at the edge-of-bed, and those who can transfer & ambulate with assistance.

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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JULIE BRAUER
Good morning crew. Welcome to the PT on ICE daily show. My name is Julie. I am a member of the older adult division. Excited to be talking to you all this morning about a few workout ideas for your hospitalized patients. All right. So what we're going to dive into this morning is first, we're going to talk about why it is so incredibly important to bring a fitness forward approach to our medically complex sick older adults in the hospital. and then we're gonna dive right into how to do it. So I am going to give you three different workouts. They're simple. They only consist of three exercises and they're going to be for three different individuals.

FITNESS FORWARD ACUTE CARE
So the individual who is the bed level patient, so they are not ambulating, they are not transferring. Then I'm going to give you a workout for the individual who can sit edge of bed, so who can tolerate those positional changes, but again it's not someone who is transferring or ambulating. And then lastly for the individual who is able to transfer out of bed. Okay, Let's dive in. First and foremost, team, what I think we can all agree on is that patients are being sent home sicker and sicker and sicker. Insurance is denying acute rehab left and right. And once patients do make it to acute rehab, if they're lucky enough to get there, they're only getting enough days to just barely make them functional. We have to agree that these patients need to get as strong as possible and they need to do it as quickly as possible. If we can agree on that, then we have to realize the massive opportunity we have in the acute care setting to bring a fitness-forward approach. Now, I know what a lot of you are thinking. Fitness in the hospital What the heck? No way. It doesn't belong there. I don't have the equipment. They're too sick. That's for down the road. I want you to come along with me and get a little curious. I want you to be open minded and perhaps shift that perspective. Think about it this way. You are a fitness forward clinician. You are working in the hospital setting. You have hundreds and hundreds of patients handed to you on a silver platter. All these patients are in one place, door after door after door, literally right in front of your eyes. And they are just waiting for you to walk in, inspire the hell out of them, and guide them to the land of wellness and fitness. You do not have to hope that these patients who need you walk into your clinic doors. You do not have to hope that your Facebook marketing or your Instagram post is seen by your target avatar. They're all there waiting for you. You literally have a captive audience. Literally, these patients are in their hospital rooms. They are in their hospital beds. They have alarms on. They are tied to lines and tubes, et cetera. They're all there at your disposal. Team, the patients who need you the most, the ones who are medically complex and sick, They are waiting for you. They are handed to you on a silver platter in the hospital. Do not waste this opportunity. We have to realize that ankle pumps and glute sets, walking to the door and back, doing 10,000 tenettis a day, are not going to get the job done. Those are not going to increase our patient's reserve and resiliency, so they don't end up back on your caseload in a week. Fitness forward therapy is absolutely critical for these sick folks. Okay, so we've gotten curious. We're starting to shift our perspective. The most important thing that comes next is, well, how the heck do we do it? So let's dive into three different types of workouts we could do.

WORKOUTS FOR BED-LEVEL PATIENTS
Workout number one, this is going to be for your bed-level patient. So this is an individual who is in the ICU, perhaps, or they are in inpatient rehab. They cannot tolerate positional changes. Maybe their vitals go totally wild when they try to sit up. The alarms are going off, the nurses are running in. Vitals go wild, you gotta lay them back down. Perhaps they're incredibly orthostatic when they do sit up. Their blood pressure absolutely tanks, and you have to lay them back down. or they may have significant fear or pain. They just refuse to get out of bed. Hell, this could be the patient who, you know, your last session should hits the fan. You went way over time and now you have barely any time with this human. You do not have the time that it's going to take to get this person up and out of bed. Okay, so think about a couple of those scenarios that you may walk in to your patient today and this perfectly fits that description. This workout is for them. Okay, so what are we going to do? This individual supine is pretty much all they got. The bed is all they got. What we're gonna do is turn that bed into a workout machine. The hospital bed turns into a home gym. What do you need? You need a Sally tube slide. So what is that? You've seen them if you've been in the hospital. They're yellow, they're plastic. Individuals and the staff will use them to transfer patients because it decreases friction. You need that and you're gonna need a wedge or a slide board. and a gait belt. So three pieces of equipment, sally tube slide, a wedge or a slide board, or and a slide board, and a gait belt. Okay, so what are the three movements that we're going to do? We are going to do a modified pull-up, we are going to do a modified leg press, and we are going to do a modified rope climb using the gatebell. Okay, so how do we set this up? You get that sally tube slide underneath them. For our modified pull-up, you're going to tilt the bed. They are going to reach to the bed rail that's above their head and they are going to pull themselves up. That sally tube slide is going to allow them to slide and we're going to add some gravity onto them so we get them to a degree of a vertical pull. For our leg press, you're going to set that on the slide board, sometimes the wedge on top of the slide board at the bottom of the bed. We're going to tilt that bed again. They are going to kick and press to do a leg press, and then they'll slide back down, and then they push again, slide back down, etc. For our rope climb, you're gonna use that gait belt. You're gonna tie it to the foot bed rail. You're gonna tie that gait belt on there, and then they are going to grab onto it. They are going to pull themselves as much as they can to get to an upright, long sitting position, and then slowly let themselves down. Okay, so that's how those three exercises with the equipment are gonna be set up. Now, how do we dose this? Remember, this is an individual who has very low tolerance. We are just trying to get that blood flowing. We are trying to do very short bouts of activity and they're going to need a lot of rest. So how I would set this up is an EMOM, maybe an EMOM for six or nine minutes. Minute one, we're going to do that pull-up. I'm going to have them work for 20 seconds, and then I'm going to give them a full 40 seconds of rest. What am I doing during that time? Taking their vitals, right? Watching to see that they are responding okay to the exercise. I'm going to want to know what their blood pressure is, their heart rate, their oxygen saturation. Minute two, they're going to do that leg press, 20 seconds, and then they get 40 seconds of rest. And then lastly, they're going to do that rope climb for 20 seconds, 40 seconds of rest. What is beautiful about a workout like this is that many times what you will find after you're able to increase the intensity with them in the bed where their vitals are staying at a reasonable level, they're not going wild, then you sit this individual up and you will find all of a sudden their blood pressure actually stabilizes here. And now they're someone that you can safely get out of bed. Okay, there's your bed level workout for that individual.

WORKOUTS FOR EDGE-OF-BED
Next, now you have someone who can tolerate a little bit more. We're going to do a combination of a bed level exercise and sitting edge of bed. So they can tolerate positional changes. This is for that patient who can transfer out of bed, but it totally exhausts them. One rep and they're absolutely toast. This is for the patient who you know would thrive at acute rehab, but you really need to build their tolerance. You need to be able to say to those acute rehab liaisons, hey, this patient can tolerate multiple sessions of therapy per day. So we're going after endurance here. All right, so what do we need for this one? We need a heavy TheraBand or a resistance band. And that's it. One piece of equipment. So what we're going to do is we are going to do a AMRAP here. A 15-minute AMRAP. As many rounds as possible. Three exercises. Why are we doing that? Because we want to show, hey this individual tolerated 15 minutes of non-stop work. What are our three exercises? First, we are going to do a resisted bridge. How do you set up a resisted bridge in a hospital bed? You take your TheraBand and you anchor it one side of the bed rail to the other side of the bed rail. Now, when they go to bridge up, they have some resistance there. You can do it double leg, you can do it single leg. Exercise number two, we are going to do repeated supine to sideline to sit transitions, all right? And then exercise number three, while they're sitting on the edge of the bed, they're gonna scoot laterally to the foot of the bed and then to the head of the bed, okay? So those are your three exercises. How are we gonna dose this? Again, the goal is endurance. So we want them to be doing only enough repetitions to where that RPE at the end is only like a four to five. We don't want them to be seven, eight, nine. Remember this is endurance we want them to be able to sustain for 15 minutes total because that is going to be the buzzword that helps get them to acute rehab. So for that entire 15 minutes you're going to do as many rounds of those three exercises and you're going to try and keep the rep scheme to as many that keeps that RPE about four to five. That you're going to go ahead and document about why this person is perfect for acute rehab because they can tolerate 15 minutes and then you are going to progress them from there, try and get to 18 minutes the next time you see them and then get to 22, etc. Okay, that's your second patient.

WORKOUTS FOR AMBULATORY PATIENTS
The third patient, this is an individual who can transfer out of bed all right so they only need a little bit of help they can transfer out of bed but when they get really fatigued their can their performance is really inconsistent so this may be where the physicians or the case managers are like hey they can transfer out of bed like they're high level, they can go home. But you know that when they get fatigued, their knee buckles, or they really lose that eccentric control, their balance starts to go out the window. You know they need acute rehab in order to improve their tolerance so that they are able to do safe transfers throughout the day. Mimicking when someone throughout their day is going to have high and low levels of fatigue, you want to know that that consistent performance is safe. So, what are we gonna do here? In this workout, what we're gonna do, three exercises, we're gonna do an overhead press, a standing march, and then a stand-step transfer, okay? So that overhead press, what do we need? You are gonna get that toiletry bucket that every patient is given, you're gonna dump all the crap out of it, you're gonna take a towel, you're gonna roll it up, you're gonna soak it in water. That makes that toiletry bucket now have some load. This is what we're going to use for the overhead press. It's going to be done sitting on the edge of the bed. Next is going to be the standing march. This can be a standing march that doesn't have any load to it. You can have your arms on the walker for upper extremity support or you can use something like a bedside commode bucket. clean that you put a bunch of weights in like ankle weights load it up and they can do a one-handed uh carry or a hold while they march okay and then with the stand step transfer you just need their assistive device and a chair set up next to the bed all right so in This type of workout, what we are wanting to do is we are wanting to really increase the intensity of those first two exercises, the overhead press and the standing march, and then have them do the transfer because we want to show Hey, this is what it looks like when this person is under fatigue and then tries to do a transfer. You want to prove to those acute rehab liaisons, balance gets really poor. I have to jump in and I have to give them some support in order for them to not lose their balance when they do that transfer. So you're showing the deficit here. So in those first two exercises, you want intensity to be really high. So comparatively to our first imam, it's going to be the same exact thing, but work and rest is going to be reversed. So you are going to have them work for 40 seconds, and then you can give them only 20 seconds of rest. and that 40 seconds, you want it to be sprint effort, okay? You want them to be working at RPE 789. You want them to really, really push it. So similarly, you can do this for 6, 9 minutes, 12 minutes, 15 minutes, and the goal here is that when they get to that stand-step transfer, they're under fatigue, you are going to see what happens. Then you can document and show acute rehab, hey, This is all the assist that they need. This is how their technique breaks down when they are under fatigue. That is going to be the buzzword that you're going to be able to use to advocate for them to get to acute rehab. You're going to also use that and progress them to just try and build that endurance. So let's say acute rehab is still like, screw you, we're not letting you in. Now you have a baseline workout. You continue to hammer in on improving their endurance so that when they get to that transfer, they have stability.

SUMMARY
All right, three workouts for you. That bed-level patient who cannot get out of bed, supine's all you got. You turn the bed into a workout machine. You got your second workout for that individual who can tolerate transfers, transitionals, and can get to that edge of bed. And then the third, you got a workout for someone who is able to get up and transfer out of bed. I have multiple reels that I've made about each of these individually. I'm going to put them together and post it. You will have that soon so you can get a visual of what all this looks like with my actual patients. And I cannot wait to hear how you guys use some of this stuff out there in the clinic this week. All right, to finish this off, we've got courses coming up. We want to see you guys out on the road. We would absolutely love to see you. We got tons of spots left in Missouri. That is this weekend. Alex will be out there. That course is going to be absolutely amazing. We got multiple courses coming up in February. I will be in Minnesota. It's going to be a freaking blizzard. I cannot wait. And then our online courses are going to be starting up in March. So we'd love to see you online or on the road. All right, y'all, that's all I got for you. Get out there, bring that fitness forward approach to your hospitalized patients. I cannot wait to hear about it.

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.

Jan 24, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses a modern approach to carpal tunnel syndrome (CTS), including when central findings are present. Lindsey discusses examination and treatment, including the use of the rehabilitation every-minute-on-the-minute style (rEMOM) exercise dose.

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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

LINDSEY HUGHEY
Good morning, PT on ICE Daily Show. How are you? Welcome to Clinical Tuesday, my favorite day of the week. I am Dr. Lindsay Hughey from our extremity management team, and I am here to chat with you today about an ortho-cert approach to carpal tunnel syndrome. And what do we do when it's not just the carpal tunnel, when we also see some central symptoms? So I am going to unpack what a fitness-forward approach looks like, how we will use our manual therapy to modulate symptoms, and then what psychologically informed looks like for this condition when we think about combining all the courses from our OrthoCert and putting that all together in an integrative way, how we can approach this condition. and then I'll leave you with a couple rehab e-moms at the end, so stay for that.

CARPAL TUNNEL SYNDROME OVERVIEW
So first off, let's briefly review what the subjective and objective presentation with someone with carpal tunnel syndrome and then possible central considerations that are present as well. Think double crush is kind of a common medical term present. So for that CTS, that carpal tunnel syndrome, we'll see classic sensory anesthesias or paresthesias in those first three fingers and then possibly that radial half of the ring finger. There may be motor deficits in our first and second lumbricals, opponent's pollicis, abductor pollicis brevis. So think about in your objective exam, thub abduction and thumb flexion may be weak. We'll also see, from an objective perspective, locally we'll see a positive phalanx and tonels, and then our carpal compression test. Patients will complain of interruption in gripping and daily tasks. They may even drop objects or have to shake out their hand to ameliorate symptoms. Often symptoms are worse at night, and then when they first wake up in the morning, and then tend to improve as the day goes on. When we also consider there might be some central things going on, it's that person that not only complains of what I just told you and had objective exam findings, but they also say they have some numbness tingling along that C5, C6 dermatome. They may complain of some local neck tightness or achiness in that mid to lower cervical spine area. on exam, you will find a UPA or central PA will elicit those familiar symptoms when you're around C5, C6. In addition, that dermatome distribution will be impaired and then reflex changes in that biceps reflex might be abnormal compared to that uninvolved side and we really understand the whole clinical picture when we use a body chart right and we really listen to that subjective and dial in their ags and eases so you find out when all of that's on board that there's two things going on at the same time and here's where we'll need our ortho hats where we need to put into practice what we know in our cervical class and what we know from our extremity class.

APPLYING FITNESS FORWARD
So first off what is fitness forward? when that's one of our primary pillars. So what does that mean for this condition and in general? Well, we are going to approach the whole human in front of us. We know that this typically affects females later in that fourth and fifth decade. they are two times females are two times more likely than males to have this condition and so appreciate that in that decade that's either you know a career focused time or family focused or a mix of the two so consider the stressors for that human that may or may not be involved in that decade. And then we see some links to obesity as well. So thinking about the whole human holistically, we see worsening symptoms for those that have higher BMIs. So not only will we consider the whole human from a fitness forward perspective, but we're going to think about how can we attack local tissue getting irritability down. So think about local tissue in the hand and even in that C5, C6 area of cervical spine. And then we'll start with local treatment but then eventually we're already thinking about how globally will we make this human more resilient and robust in their grip strength and their overall upper quarter strength. So even day one when we're trying to just calm symptoms we're thinking fitness forward. How fit will you let me get you? We're gonna consider those system influence that I already mentioned, sex and possible stressors in life. We're gonna consider mindset, the physical activity levels of that human, because again, I said there's links to increased BMI and obesity. So we're dealing with an underlying systemic inflammation probably on board as well. We'll think about what's that sleep hygiene like? Are they getting the eight to nine hours of sleep? How's their diet and hydration? Are they getting half their body weight in ounces? Are they eating colorfully? That is all a part of fitness for it. So it's not just loading them up locally, globally, making tissues robust, but really we want a whole system-wide robustness.

MANUAL THERAPY FOR CARPAL TUNNEL SYNDROME
And the way we'll first approach these humans is through symptom modulation, through our manual therapy techniques. This is how we'll really get trust and buy-in when we're dealing with carpal tunnel syndrome, or CTS, and then there's central possible involvement as well. double crush, whatever kind of terminology makes you comfortable. I tend to think labels limit. And if you've been to our extremity course, you know that. So symptom modulation locally first looks like bracing, actually. So an over-the-counter splint at night is first-line defense because that's when symptomatology is worse because we're sleeping in that phalanx position. And if there's worsening symptoms in the day, we'll even recommend a wearing schedule during the day. But we first start with night. We'll educate on any ags and easing postures, right? If moving in and out of postures is really important. We don't want someone hunched over like this all the time, and we also don't want someone being perfectly erect. So depending on their job and life and family functions, we'll give some advice there as well, as our education starts to dampen irritability and symptomatology. Our manual therapy perspective though, so here's our second pillar coming to play. is that we are going to target the CT junction and then an upper T spine. And we're going to use manipulation. You'll hear at our course that if you have any upper quarter symptoms and you have a pulse, you are going to get some kind of thoracic manipulation. for that neurophysiologic effect. So what you learn in your cervical and total spine thrust courses, you're going to bring forward here. And this is going to help dampen pain, not only centrally right in the cervical spine, but also we see pain dampening and increase motor output in our upper quarter when we use those techniques. So those will be our go-to techniques, prone CT junction, and then our upper T-spine manip. In addition, doing some lateral gliding for a pumping action in those higher irritability stages targeted at that C5, C6 area. Follow up for that will be some cervical retractions to get a pumping action centrally. And we may or may not combine that with some traction. a manual therapy perspective from extremity management local to those carpal bones and that wrist, we'll actually start doing some wrist mobilization. Extension's often a common impairment here, so we'll work into progressive extension, mobilizing those carpals, and we'll even do this nice soft tissue splay technique. If you've been to the course, you know, and if you're on the fence, you'll join us to learn this, but a splay technique to just open up right where that median nerve travels through where all of our flexor retinaculum is, it gets tight in there when there's inflammation on board. So just doing some soft tissue mobilization and splay. And it's interesting is this is a tech, the technique we teach is one that was actually used in that PTJ study in 2020 from De La Penas and crew, where they looked at four-year follow-up of those with carpal tunnel syndrome that did conservative care, which was only three bouts of PT, and this splay stretch was included in the 30 minutes of manual therapy that these folks got, and they compared this group to those that went on to get surgery, and they followed them over four years. What was similar about both groups is both groups got education and they got tendon and nerve glides. And what we saw is similar similarities. So meaning pain and function was the same whether you got surgery or conservative care, which lets us know that our conservative care, our manual therapy techniques like this splay technique can be a really powerful resource for our patients to modulate symptoms and to lower that irritability in their tissues. In addition, not only will we do some wrist extension mobs, do that splay stretch, but we'll also work locally at that thenar eminence. And we will target our wrist flexors with myofascial decompression, soft tissue massage, and or dry needling. So targeting wrist flexors, forearm pronators, and the thenar eminence anywhere where that median nerve could be compressed. So those are our manual therapy targets.

PSYCHOLOGICAL CONSIDERATIONS FOR CARPAL TUNNEL SYNDROME
Moving on to our next pillar, psychologically informed, how do we address psychological considerations for this human that has CTS and then symptoms along that C5, C6 dermatome with reflex changes as well? Well, we're going to have a conversation about lifestyle, about what we call meds health. Simply that is M is mindfulness, E is exercise, D is diet, and sleep. And this is a nice framework to address lifestyle behaviors. Now we might not address them all at once and we'll choose our education and dose it wisely, right? We don't want to fire hydrant lifestyle behavior modification to patients, but we do want to make sure all the pillars and how they're functioning are in the background of our mind. So consider M mindset. or mindfulness what we're thinking here is what can we give this human that's kind of stressed and in pain to just calm their system and one really great way to bring them into a more parasympathetic state is doing breathing so breathing in just five minutes a day physiologic sighing right, where you do that two inhalations through your nose and exhale has been found to be beneficial in reducing physiologic factors like heart rate and just calming our system. So consider that can be an easy thing to integrate into a patient's life that is stressed or maybe suggesting some green space, go out for a walk and or journaling if that is their thing. from an e-perspective, exercise, what I want you thinking about is just what's their physical activity like? Are they getting their 10,000 steps daily? Are they meeting the daily requirements of physical activity, which is 30 to 60 minutes every day, right? We want a total of 150 to 300 minutes a week. Is this human getting that activity? And if we consider some of the common profiles, which is obesity and being female in that later decades of life, we need to consider what is that like and how can we influence them to move more to help with this inflammatory state that's going throughout their body. D is diet, so education on what is your diet like? Are you eating enough protein to support healing and function? Can you reduce that sugar intake to calm inflammation? Can you eat colorfully, eating more plants, again, to help control inflammation? How's your hydration? Are you getting half your body weight in ounces? These are additive behaviors that we can help, always trying to add first and then take away if necessary. And then finally that final pillar, sleep. How is sleep hygiene? Talk to this human about maybe very dark in the room an hour before bed, no heavy big meals or your phone or TV. This can help just with quality of sleep. So consider that psychologically informed piece is so important. And you'll kind of notice that there's always a synergy between our pillars, right? You can't be fitness forward, right? And build up local tissue and global tissue robustness if you don't first symptom modulate through manual therapy, right? And our manual therapy needs to be excellent and executed well with the right dosage so that we can be effective in symptom modulation, which gives us this modulating window of opportunity to then load them better locally and then globally when we think about the upper quarter. And then the psychologically informed piece, we need solid education and lifestyle counsel to help this whole human, this whole system be more robust in their world. And that's why the trifecta and the synergy of the pillars is so important.

USING THE rEMOM FOR CARPAL TUNNEL SYNDROME
I want to leave you with two rehab EMOMs inspired by exercises that we learn in our cervical course and then exercise that we prescribe in our extremity course. So, and if you want to write it down, feel free, but early in our care with high irritability, I would suggest a 12 minute rehab EMOM that looks like this. We're thinking about someone that has lots of numbness, tingling, lots of inflammation on board. All ADLs and IADLs are limited. their sleep sucks, right? They need a massive blood pump. Minute one, we're going to do a UBE, a salt bike, or echo, or rower, whatever the patient loves. Minute two, we're going to do tending glides because we see tending glides in some of our RCTs being superior than our nerve glides and helping create a local pump to our flexor tissues. Number three, minute three, is nerve glides, right? We're going to do a slider glider for that median nerve and even try to get that cervical spine involved. And then number four, we're going to do cervical retraction with or without traction. So we put that band on a secure surface and there's this traction environment where we're offloading the lower to mid cervical and then doing some pumping action cervical retraction. We'll do that three rounds and that's why it's a 12 minute rehab EMOM, early in care, high inflammation on board. I'm going to leave you one more EMOM, and then we'll call it a day for PTL Nice. But later in care, when irritability is dampened, right, and we more are at that lower irritability stage, there's no longer numbness and tingling symptoms. We're thinking about robustness of local and global tissue, and we're working on resilience, we want to layer in more volume and intensity. So we'll use that same structure, 12 minutes. Minute one, we're going to do grip training. So we are going to specifically target doing a spherical grip. So you would turn that kettlebell upside down and work on carries, which works on the whole upper quarter, arm at side or arm here. So we get that cuff firing up as well. And we'll work on that. You can even work on your tip grip or palmar grip as well to really target median nerve and the muscles that feeds. That's minute one. Minute two, we're going to do some wrist flexion and wrist extension exercise. Recommend rehab dose if you've been to one of our courses, you know, that's 8 to 20 reps 3 to 4 sets Anywhere from 30 to 80 percent intensity, right? You'll meet the patient where they're at minute two again just a repeat wrist flexion extension exercise and then minute three will be pronation supination and then finally minute four we'll actually do prone cervical retraction off the table to start building up robustness of the cervical extensors. These are just two examples of how when you take our ortho cert courses specifically our spine courses and then our extremity courses it's helpful to prepare you for management for something like cts when there's also that double crush right there's involvement um centrally and distally.

SUMMARY
Our author's cert, we would love you to be a part of it and learn more about it. If you're interested or the first time you're hearing this, check us out on ptlonice.com and it'll tell you all the courses required, total spine thrust, cervical, lumbar, extremity management, and testing for this is free. You just take those courses and you test out at the end. It's been a blast kind of talking to you about how we integrate our classes. From an extremity management perspective, class is coming up. Mark and I are both on the road this weekend, and there's still, there's one spot left in Mark's course in Fayetteville, North Carolina. There's lots of spots left in Burlington, New Jersey, if you want to join us. And then the following weekend, we're at it again. We will be in Highland, Michigan, and then Scottsdale, Arizona, and we have spots. So again, ptonice.com to check out OrthoCert, and then check out extremity management courses. Thank you for your time this morning and in listening to that OrthoCert approach to CTS. Happy Tuesday, everyone. And if you think about it, wish our CEO a happy, happy birthday. He'll love that. See y'all later.

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

Jan 22, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses a case study where external pelvic floor treatment was beneficial for a patient presenting with complaints of low back pain.

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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JESSICA GINGERICH
Good morning. Welcome back to the PT on Ice daily show. My name is Dr. Jessica Gingerich and I'm on faculty here in the pelvic division here at ICE. So I'm going to talk to you today about when back pain isn't coming from the back. So what I mean by that is that we have done our lumbar screen. The active range of motion, combined motions, overpressures, segmental exam, neural exam, and the neuro exam, if symptoms are passing the gluteal fold, are negative. I'm talking about when the hip screen, passive range of motions with overpressures, combined motions, palpation, and strength testing is also negative. So nothing is revealing the symptoms consistent with a subjective exam. In the pelvic space, it may be common for the general population to not correlate symptoms of pelvic floor dysfunction with pelvic pain or back pain or hip pain. Therefore, they may not disclose one of the symptoms, likely whichever is not bother or is least bothering, right? So if they have back pain, but they also have pelvic floor dysfunction, they may not disclose the pelvic floor dysfunction because the back pain is more important to them and they're not connecting the two. So for the internally trained PT, we're gonna assess the pelvic floor as well. We do this by looking at different tasks that the pelvic floor is doing. So we tell them to contract, we tell them to relax, we ask them to bear down. We do this with an external visual assessment. So there we're looking at their total range of motion. And we also palpate internally to see if we can Provoke any pain per the patient's consent. Screens for the non-internal pelvic floor PT will include subjective asterisk signs. So toileting behaviors. Are they bearing down when they have a bowel movement? Are they bearing down when they're voiding? Are they peeing just in case? Do they feel like they pee all the time or is the urge really sudden? Do they have pain with insertion, whether that is a penis, a tampon, bedroom toys, a speculum, all of these are important. What are their stress levels like at home, at work? Heaviness in the vagina, leakage, and also pelvic pain. So pelvic pain being pubic symphysis pain, tailbone pain, SI joint pain. Of course, we are gonna be grabbing ags and eases around back pain. But now you may be adding pelvic floor agonizes. So everything we just talked about above. And remember that the general population may not correlate their pain with pelvic floor symptoms, unless their pelvic floor symptoms may be pain, then they may connect them. But it's our job to connect the two. So from here, we need to dial in our hypothesis. Is it weakness of the pelvic floor? Is it a proprioception awareness? Where are they in space? Is it a behavioral issue like toileting? Can we change how they're going to the bathroom to make this something that is normal? We need to potentially teach them about the squatty potty, the NAC, general strength training, and even nutritional guidance around pelvic floor dysfunction. So I have a patient right now that I wanna talk about. And so she's this wonderful human. She stands all day for work and she came in with complaints of painful intercourse. From here, I asked her about if she had any pain and she disclosed that she also has back pain. And so she came in wanting pelvic floor PT. That was her main complaint. She did not correlate necessarily that her back pain and her pelvic pain or dyspareunia was the same or was correlated. So when I was asking her about her symptoms, it turns out that her back pain and then the time she noticed that intercourse was painful, it came on around the same time. So we decided between the two of us that we were going to stick with an external exam. We weren't going to do an internal exam for comfort reasons. So when we dialed that in we found that the octorator internus was painful upon external palpation. She denied any bearing down with bowel movements or urinating, which I will encourage you guys to, if you ask someone if they're bearing down with toileting behaviors, go back and ask them on their follow-up visit if they do that. Because chances are, they've been going to the bathroom the same way their whole life, that they're not necessarily paying attention to it. And you may notice that they actually do bear down, even though they thought they didn't. So for her, what we did was we started with the pelvic floor. We treated the pelvic floor first. For her, we started with the squatty potty, teaching her how to have a bowel movement where she can sit down and relax. We started by giving her exercises where she was actually thinking about where her pelvic floor was in space. Was she lifted really tight or was she able to relax? And it turns out that she was not able to. She did not know where her pelvic floor was in space. So that was her homework. She came back two weeks later and told me she knew where she was in space, that she actually felt her pelvic floor drop the more she practiced it. Now, before that two-week follow-up, she had emailed me 24 hours later and said that her following day at work, she had zero back pain. no back pain. This was something where she was carrying around a stool so she could sit down when she needed to. So from place to place she was dragging a stool around and she didn't have to do that. That's pretty powerful. So in my exam I didn't provoke her back pain. I didn't know that her back pain was potentially coming from her pelvic floor. I had my suspicions. So I treated what was important to her in that moment, thinking that maybe her back pain would respond, and it did. So from here on out, we are still treating the dyspareumia. However, we are also now loading the spine. And that has been really powerful. So we're about a month in, and she has had pain-free intercourse. and she's having pain-free days at work when she is standing. So, I'm gonna encourage you guys to go out there, try to correlate the two, whether you're an internal pelvic floor PT or a non-internal pelvic floor PT, or you don't consider yourself a pelvic floor PT at all, you are. So start asking the questions about leakage, pressure, heaviness in the vagina, any pain with insertion, and just following that up with the, hey, this may be related to your back, and I just wanna make sure I don't miss anything. If you are uncomfortable, speaking of this, please, please let me know.

SUMMARY
So I'm gonna end today with where we will be, the pelvic division. We will be live in Hendersonville, January 22nd, or excuse me, 27th, and our level two course will kick off April 30th. Here you will learn about advanced pelvic floor dysfunction, pelvic floor syndromes, managing pelvic issues post-op, sexual health, birth control and fertility, and birth prep for the athletic population. So we look forward to seeing you. Hopefully you guys sign up and we'll see you around. Have a great Monday.

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

Jan 19, 2024

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the role of the lat and its importance in functional fitness as well as his top three exercises to strengthen the lats.

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

If you're looking to learn from our Clinical Management of the 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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

GUILLERMO CONTRERAS
Good morning, PT on Ice, Daily Show. Welcome to the Best Day of the Week Fitness Athlete Friday. I am Guillermo Contreras on the teaching team within the fitness athlete division of the Institute of Clinical Excellence. My basement gym here. Today's topic at hand is lighting up the lats. One topic that we see most often discussed or looked at within the fitness athlete division, whether it be in the live course or the online course, is the idea of lat weakness. And also, right, we talk about very heavily how to cue engagement of the lats, right? We never wanna say engage the lats, but squeeze oranges between your armpits, pretend I'm not gonna tickle you, don't let me tickle you. And in essence, we want to be able to teach individuals how to better utilize, use, and strengthen their latissimus muscles. The best way we can do that is not only using the pull-up, which we teach in the live and online courses, but also giving some accessory movements. And the accessory movements are where most people tend to have the greatest amount of questions. What movements do we do? What can we actually use to strengthen it besides a standard lat pull-down machine or a seated row machine? Especially when in the fitness athlete realm, we don't have those pulley systems. We don't have a giant cable pulley machine. We don't have a big lat pulldown, seated lat pulldown, or a seated row machine. So being able to give really good accessory movements that individuals can utilize in the gym to improve that lat strength, that awareness of what their lats are doing, is really pivotal. in helping improve the quality of movement, the strength of movement, and the ability for our fitness athletes to complete what they want to be doing in and out of the CrossFit box.

STRAIGHT ARM LAT PULLDOWNS
So, quick anatomy review for you all, right? We know the lat originates right here on the front side of the shoulder, wraps down around into the low back, and then attaches itself through to the lumbar spine via the thoracolumbar fascia, which is why the pelvis can play a part in the position of the length of the latissimus as well. So with that, I'm gonna give three of my favorite or three of the best movements or exercises that I give, that I prescribe out for a home exercise program or within the clinic to help improve individual's lat strength and lat activation. Number one is a direct strengthener of the lat. It's just gonna target it, it's gonna help people feel it really, really well, and that is right here. It's a straight arm lat pulldown. And I'm gonna show two variations that this one can be performed, depending on, I would say like the level or the strength of the individual you're working with. We start simply by anchoring that band onto a pull-up bar or anything just above head height. We then take that band, we can hold it in both hands here, back away there so there's some tension. We get a nice forward lean, keeping that nice neutral spine. And then I simply keep my elbow straight and pull that band down to my hips. By keeping the arms straight, we ensure we are hitting that lat muscle by performing that shoulder flexion all the way to end range. And in this upward position, we are hitting that end range position of the lat overhead when it's fully lengthened like we would see at the bottom of a pull-up. A way that I progress this for individuals is by adding hip movement or combining that shoulder flexion with hip extension. Because as we extend the hips, we change the length of latissimus by letting the thoracolumbar fascia can relax a little bit more, contract a little bit more, and we get up to the top. This movement is called a lat prayer. Again, I don't know who named it, who comes up with the names of it. It's simply what I know it as, a lat prayer. And what that looks like is a very similar setup. I am here in this forward flexed position, hips back, arms at that end range. As I pull down on that band, I am bringing my hips up towards that band and come into a full contracted position of the lats. as I descend back down, I'm going to that fully lengthened position once again. So it's just a combination of movements. We can do this both as a smooth kind of movement, all occurring at once, or we can segment it as a pull to the hips with that straight arm pull down, and then a stand, return to the hinge, and then come back up. So that is your straight arm lat pull down. dosing that with some good amount of volume right this is just a a rogue blue band i think it's like a half inch or a quarter inch band, but it's got a nice amount of tension on it. I can do anywhere between like 15 to 20 reps, really feel that nice active muscular pump as I'm doing it, and it creates a lot of awareness in that shoulder. The lat is huge when we think of pull-ups. When we're doing kipping pull-ups, chest-to-bar pull-ups, butterfly pull-ups, whatever it is, we wanna have proficient strength in the lats to be able to maintain a stable shoulder and protect us from injury when we're dropping down to the bottom. So number one, again, straight arm pull down or lat prayer. However you want to do that, you can dose it out in different ways.

BANDED KETTLEBELL ROW
Number two is a unique one in which we use a kettlebell and then a band anchored to the rack or a rig. Here, we take that band and we put it around the handle of the kettlebell. It can also be around our wrist or something like that, or you can actually like attach it onto the kettlebell itself. Easiest way for me to set this up for my athletes is just to have it right around the handle there. And then we set up in the same way we would do a bent over row or a single arm row. So it can either be supported on a bench or a box. It can be in this kind of double leg hinge position here, or we can be in just our standard staggered stance position here. From here, forearm goes on the knee, take a hold of that kettlebell, pick it up. We then row back towards our hip. So I'm here and I'm pulling back to my hip and then letting it pull me forward. So the motion is more of a J. So I like to think of it that way. It's a J back up to the hip and then bringing it back down. So more of a curved motion of that row versus the standard kind of straight vertical row. or I guess you could say horizontal row. What this does is because it is now anchored, as I do that row, it's not a simple horizontal row where I'm just doing a little bit of an upright motion there. I am now getting a bit of a vertical pull force as well, where I have to actually pull against that band, up to my hip, and then back down. Up to my hip, and then back down. This is a really nice one because you can load it different ways. You can load it with a heavier kettlebell going 35, 45, 53, whatever weight you want to use for that weight. Or you can make it much tougher by going with a much heavier band. This is like the Rogue quarter inch band. This is I think like 15 pounds, 20 pounds of force, stress. But you can go much heavier attention on that band, make it much tougher. There, maybe you probably are bracing on something so you don't get pulled over. But this one, if you've never done it before, if you've never prescribed this for your athletes before, this works wonders. It hits that so much better than anything else you've seen. And it feels great. I think it feels really good. It's a very strong movement there. So that is a banded kettlebell row. Again, think of a curved pull towards the hip rather than a straight vertical row. And you're going to get much more of that lat activation as you come back.

BANDED LAT SWEEPS
The final movement, because we know that the lat is responsible for much more than just doing vertical pulling, It's also responsible for maintaining tension on the bar when we're doing deadlifts, Olympic lifts like the snatch and the clean. We want to make sure we're also training it to do those things. So this here is my favorite exercise for those athletes who struggle to find their lats, to find that armpit squeeze, that pinch, and we can cue it with something called a sweeping deadlift. This here is just a five pound kids bar, it's my daughter's, but we can also use a PVC pipe or a dowel, anything works fine. we take that bar or that PVC pipe, it goes in the band as well. So again, once again, it's anchored on a rack or a rig, something that's not gonna fall over on top of you. We move back away from that anchor point, so now we have some tension on that band. We then pull that bar towards our hips, and then we begin our movement. So here I'm going to bring my hips back, maintaining tension the whole time, bend at the knees, down to the bottom, And then as I come back up, I am maintaining tension, so I'm scraping my shins to my thighs, pulling through, and maintaining that tension there. And back up. We can obviously do this with different grips, right? So this would be more of like my deadlift or clean grip. I can go much wider, as wide as this bar lets me go, and go with more of a snatch grip, and then really focus on more of a snatch setup, or more upright torso, and really think, of going through that first and second pull as I come there, as I come here, getting tall with it, and continuing to use that tension to train how that should feel when I'm pulling that bar towards my body. So there it is, right? A nice recap. Three movements that I love to give my athletes who are struggling either with getting pull-ups or with shoulder pain because the lats might be weak and they're kind of dropping and crashing down in their kipping pull-ups or their butterfly pull-ups. One here, that straight arm pull-down, pulling down to the hips, keeping the elbow straight. Can I add in some hip motion to just really increase that tension and that full range of motion for it? that banded kettlebell row with a vertical and horizontal pull that's working together at the same time to really hit that lat musculature there. And then that sweeping deadlift for maybe my athlete that just really struggles to understand what it means to use their lat to be able to hold that bar close to their body to create more tension through their spine, through the thoracolumbar fascia to maintain a neutral spine when deadlifting, Olympic lifting with the clean, the snatch, et cetera. So there again, three movements that I love to prescribe out to my athletes for that there.

SUMMARY
If that was good, if you enjoyed learning those, or you're like, oh my gosh, I've never seen those before, never heard of those before, and you want to learn more, please join us on the road, please join us online. We have a number of courses coming up. We have our next course of Clinical Management with a Fitness Athlete, Level 1 course, or what used to be known as the Ascendant Foundations. That kicks off on January 29th. We would love to have you join us there. We do all things squat, front squat, back squat, deadlift, press, pull-ups. We learn how to program for CrossFit. We understand what it looks like to do a Metcon. It's a great experience, great course, especially if you're new to this area and you want to get more involved in the fitness athlete realm. And then our live courses, we have a handful coming up. Next week, we're going to be in Portland, Oregon, January 10th and 11th. We're going to be in Richmond, Virginia, February, I said February 10th and 11th, February 24th and 25th down in Charlotte, North Carolina, so hitting that East Coast. And then in March 23rd and 24th, we're going to be out West in Meridian, Idaho. So if any of those are near you, if you've been looking to take a live course, please head to PTOnIce.com, go to our live courses, check that out. And if you have taken these courses, and you're interested more in kind of just the exercise prescription realm, what do movements look like, these ones right here, there's a resource we have in our self-study courses section of the PT Honors website called the Clinical Management of the Fitness Athlete Exercise Library, over 150 exercises all different realms for deadlift, for squat, for pressing, for pull-ups, for gymnastics. Myself and Kelly Benfinger, the TA, worked really hard to send that out. We just came up with a new version 5.0, fully updated, that we'd love for you to use to help your athletes and have a really great resource for you. So gang, thank you so much for joining this Friday morning. Hope you have a wonderful weekend. And again, thank you for tuning in. We will catch you next week on the PT on ICE Daily Show.

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

Jan 19, 2024

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the various types of taxes encountered in personal & business finance, how tax liability is calculated, and how to use tax deductions/tax credits to reduce how much tax you pay.

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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

ALAN FREDENDALL
All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Hope your Thursday is off to a great start. My name is Al. I'm happy to be your host today. Currently have the pleasure of serving as our chief operating officer here at ICE and a faculty member in our fitness athlete and practice management divisions. It is Thursday. It is Leadership Thursday. That also means it is Gut Check Thursday. So today is Gut Check Thursday. A little bit kind of heavier and slower. We have a workout. 15 hang power cleans, 9 wall walks, 12 hang power cleans, 7 wall walks, 9 hang power cleans, 5 wall walks. The barbell weight for this week, 135 for gents, 95 for ladies. That should be a moderate weight barbell that maybe you even have to break up. Maybe you deadlift it up to the hip. Maybe you break those cleans into maybe 2 or 3 sets. and then you're really just kind of grinding through wall walks. It's going to be a very shoulder, upper body heavy workout designed for maybe the 10 to 15 minute time domain. Any modifications you need, suggestions on how to approach the workout, you can check out the post from last night on our Instagram page and see a bunch of different scaling and modification options. So that's Gut Check Thursday.

TAXES
Today it is the middle of January, which means it is tax time. Hopefully you have already started to wrap up 2023 finances, personal and maybe also business if you happen to be a clinic owner. So I want to take some time and talk about different types of taxes, especially for those of you who are maybe dipping your toe in the water and thinking about What I might do if I were to open my own clinic, maybe you're somebody who is in the process of opening your own clinic Maybe you have a side hustle Treating folks from your CrossFit gym or your run club or whatever and a lot of this stuff is all brand new to you so we're going to break down the different types of taxes that you'll encounter and We'll talk about how tax actually works as far as how does the government decide what you owe them. And then most importantly to all of you, we're going to talk about different types of tax deductions and credits, the difference between a deduction and a credit, and a bunch of different things that you're probably not doing to reduce how much tax you owe the government, whether through your personal finances or through your business finances.

DIFFERENT TAXATION TYPES
So let's start at the top and let's talk about all the different ways that we can be taxed in the United States of America. So very common that we all pay federal income tax. That's something you can't get away with unless you happen to make very little or no money. We also have payroll taxes. Inside of payroll taxes are two different taxes. That's our Medicare tax and our Social Security retirement tax. We talked about those two weeks ago when we talked about changes in Medicare for 2024. We talked about how we pay into the Medicare and Social Security system from our paycheck, and that is the payroll tax. If you're a W-2 employee, you pay half of those taxes. Your employer pays the other half. If you are self-employed or otherwise you work as a contractor, you the individual taxpayer, you pay all of those payroll taxes. Now some of these that I'm going to talk about may change based on where you live. So depending on the state that you live in, you may or may not pay state income tax. Depending on the state you live in, you may or may not pay state property tax if you happen to own a home. depending on the state you live in. You may or may not encounter sales tax. We're very familiar with sales tax. Anytime we buy something, we typically pay a tax. And then getting into kind of some more advanced taxes. If you do happen to own a company, you may or may not be paying corporate income tax. And hopefully if you're a larger company, you're not doing that. And if you have questions about how to avoid that, we have a whole course for you that I'll tell you about at the end of this episode. And then finally, if you do have any sort of investments in the stock market or retirement or whatever, if you receive any sort of money back from those investments, dividends or whatever, you will pay capital gains tax. So just about 15 different types of taxes that we encounter in our life that results in our paycheck being smaller than maybe we would like it to be. So that is types of taxes.

HOW ARE TAXES CALCULATED?
Now, how does the tax burden that we owe get calculated? In the United States of America, specifically with federal income tax, we have a bracket system. A range of income, zero to $10,000. $10,001 to $19,999 and so on and so forth. You get the picture. As you move up those brackets, you can kind of think of it like ascending a staircase. As you move up that staircase, as you move into different income brackets, your amount of income that you are taxed on changes. So the percent of tax that you owe changes. Now that is essentially the name of the game when we're talking about how to pay less taxes over time both again for our personal finances but also for our business. Our goal as individuals and as business owners is to push ourselves back down those brackets reduce the percentage of tax that we pay, reduce the amount of what is called taxable income that's going to be calculated to determine how much tax we owe. How do we do that? We do that through a series of deductions and credits. Now, these are not the same thing.

TAX DEDUCTIONS VS. TAX CREDITS
What is a tax deduction? A tax deduction may be commonly called a write-off or an expense. It is something that reduces your taxable income, which may potentially push you far enough down in that bracket system that you now enter a lower bracket for your taxable income and pay less of a percent of your income as tax. That is very different from a tax credit, which at the end of the day when you finish your taxes and you get told you owe X amount of dollars, A tax credit will reduce that amount owed one to one. So the key difference is tax deductions do not reduce your tax bill at the end of the day in a one to one fashion. They cumulatively push you back down those tax brackets. which hopefully results in you potentially paying less taxes. But that's not guaranteed. You can certainly have a lot of deductions, a lot of expenses, but maybe not enough to push you down a bracket, which means your tax bracket does not change, which means there's really a minimal impact on the tax you owe. Very different from a tax credit where you have a tax bill, you know how much you are owed, and the tax credit is going to reduce how much you owe in a one-to-one fashion. So now let's talk about what you probably all care about are what are all the different ways? What are all the different deductions and credits available? There are for most of us around 15 ish different deductions and credits. Some of them depend on if you have children or student loans or if you own a business. But let's rip through all of those and talk about them and see which ones may apply to you that maybe prior to this podcast, you didn't even know were a thing, which can maybe hopefully result in you paying some less taxes this year. So the first one is called the Child Tax Care Credit. Again, tax credit reduces your tax bill in a one-to-one fashion. This is about $2,000 per kid for the 2023 tax year. So if you don't have kids, you can't get this. The more kids, the more tax credit you get. There's also a Child Care Tax Credit, which is not as well known. This will allow you to get a credit for 35% of $3,000 of childcare cost incurred for one kid or 35% of $6,000 for two or more kids. So if you are sending your kids to daycare or you're otherwise paying out of pocket for childcare, you can reduce your tax bill by a little bit, 35% of whatever you spent up to three or $6,000 depending on how many kids you've had. If you are still in school or maybe you have college age kids, there are a couple different tax credits that are mainly going to apply to the person in school. So we have the American Opportunity and the Lifetime Learning Credit. Those are geared towards college students. If you're listening to this and you're not currently a college student, I would not recommend going back to college just to get these tax credits. That's definitely not going to work out. But if you are listening to this and you're a student or you know a student or you have a student in your family, then these may apply to them. This next one applies to almost all of us. You may not know that you can deduct, so again, not a tax credit, but you can deduct up to $2,500 a year of your student loan interest. So some of us may not have paid interest the past couple of years with the COVID forbearances for our student loans, but if you have been paying on your loans through the past couple of years, you have accrued interest and definitely at least this year going forward, with everybody's payments resuming, you will have interest and you can deduct up to $2,500 of that interest. So that is information available from whoever services your loans. They should send you an email or something in the mail telling you how much you paid in interest and you can deduct up to $2,500 of that. Adoption credit is another tax credit available. Again, probably not for most of us, but if you do happen to adopt a child, you should know there's a tax credit for that. You can get up to 60% of your gross income in deductions for donating to charity. So whenever you are donating to charity, you should keep those receipts. You should keep a record of that because that can be a very significant deduction for you on your taxes. Medical expenses saw a big change over the past couple years. You can only deduct medical expenses if that expense happens to be 7.5% or more of your gross income. So a medical expense that's probably going to be in the thousands or maybe tens of thousands of dollars. Again, probably not applicable to all of you, but possibly someone out there, this is relevant to you. You should know that you can deduct your property tax and any state sales tax that you may have paid. This obviously is going to require that you've kept a lot of receipts. And for many of you, this is going to be an automatic deduction that you take in lieu of needing to provide a receipt for literally everything you may have purchased in the past year. If you own a home or you're currently in the process of buying a home, you can deduct your mortgage interest. You can deduct any sort of contribution to a retirement account, IRA, 401k, HSA, whatever. And then these last two deductions and credits, I think are widely underutilized in general, but especially in the field of physical therapy. You should know that you can take a home office deduction if you do any portion of your work from home. This is very relevant to us. A lot of you are doing notes at home outside of clinic hours. Maybe you're not given time in the clinic. Maybe you choose to have a flexible schedule and instead of doing notes at the clinic, you peace out and go home and change into your PJs and you do your notes at home. Whatever you're rocking, if you're at home and you're doing work, you should not feel bad about taking that home office deduction, right? Especially in the era of so many people across the country working from home, you should not feel bad one bit about taking that home office deduction. And then the final tax credit I want to talk about is called Form 8826. We've talked about this specifically on the podcast. We've had some posts on our social media about this. This is a tax credit designed to improve access. through the Americans with Disabilities Act, the ADA Act, designing with the intent of improving access, essentially, to rehab and there is a limit on this credit every year and that limit is a $5,000 tax credit, which means if you have spent up to $10,000, half of $10,000 is $5,000, you can have a $5,000 tax credit. this year if you have justified spending that much money. So what qualifies? The tax credit is very vague. We love vague laws here at ICE. What does that mean? Things like high-low tables that I'm standing at right now. Maybe things for adaptive fitness. A wide base ski machine for wheelchair users. Maybe lap mats so that seated patients can perform dumbbell, kettlebell, barbell work in the clinic. Anything that you can justify as improving access. Maybe you got the push button door to your facility. Whatever. If you widen the door frame, you've made a bathroom ADA accessible. If you can reasonably justify that you have made your facility more accessible, you can grab that credit and that's a credit that you can use every year, year over year. So if you're out there, you're a clinic manager, you're a clinic owner, maybe you're thinking about becoming a clinic owner, start to think strategically about equipment purchases such that you can maximize that tax credit every year. So I'll leave you with this. We've talked about different types of taxes, how taxes are calculated, common tax deductions and credits.

WHEN IN DOUBT, HIRE IT OUT
I'll leave you with this. If this stuff drives you crazy, if it makes you nervous, if you truly know in your heart of hearts that you're bad at it, when in doubt, hire it out, right? You can very easily get access to a high quality accountant who would love for sure to do your bookkeeping, but would love to help you with tax prep as well. I think often of accountants and lawyers is they are doing this stuff every day. To them, you coming in with whatever you have going on with your personal or business finances is as easy for them as when somebody comes in and they have low back pain, right? You will know what to do just like they know what to do. with your taxes or the law. So when in doubt, hire it out. Let the experts handle it. You can certainly do your own bookkeeping throughout the year. Keep track of your credit card statements or whatever and just hand it over for tax prep. There are also a lot of accounting firms that will do all of your bookkeeping for you. They'll go into your bank account or your credit card account every month, every quarter, once a year, whatever. pull out all of your expenses itemized for you and help you prep for taxes. I recommend, again, if you're not strong at this, if you don't want to become strong at this, if it makes you nervous, if you get worried about getting in trouble with the government, it's in your best interest to shed a couple hundred bucks and pay an expert to do it for you. So when in doubt, hire it out.

SUMMARY
So if you'd like to learn more about opening your own practice, we'd love to have you in our Brick by Brick course. Our next cohort starts April 2nd. We talk all things incorporation, taxes, getting a tax ID, a type 2 NPI number. We talk about the differences between insurance and cash and hybrid. We talk about working with Medicare. We talk about budgeting. We talk about different types of EMRs, everything you need to go from maybe a pipe dream of opening your practice all the way to potentially launching your practice by the end of that eight week course. So the next cohort starts April 2nd. We'd love to have you. So taxes, complicated, but a lot of good information hopefully that maybe you didn't know about to save you some more money this upcoming tax season. So have fun with Gut Check Thursday. Have a fantastic Thursday. Have a wonderful weekend. We'll see you next week. Bye everybody.

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

 

Jan 18, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses how to navigate a pelvic PT eval when a “hands-on approach” for assessment & treatment may be off the table due to an individual comfort level with pelvic examinations or when trauma is on board.

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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

APRIL DOMINICK
Good morning, everyone. Welcome to the PT on Ice Daily Show. This is Dr. April Dominick here from the Ice Pelvic Faculty Division. And today we're discussing how to navigate a PT eval when hands-on treatment and assessment isn't an option. Psychiatrist Jacob Marino once said, the body remembers what the mind forgets. Why should we consider a hands-off approach during an eval for someone with pelvic floor symptoms? Maybe the client has some trauma, maybe they experienced nervousness about what a pelvic floor assessment is, or maybe they've had previous discomfort during other pelvic examinations with other medical providers or in a different setting. So for some of these folks, that hands-on assessment and manual treatment just is not going to be the best go-to during the evaluation and maybe even for some subsequent, if not all, follow-up visits. The idea that an internal or external exam is a requirement to make pelvic PT a success is just not true. Is it helpful? 100%. But we are the detectives of the musculoskeletal system. And we take into account the cognitive and emotional state into consideration of the human in front of us. just like all great sleuths like Nancy Drew, she's not making her next move based off of palpating the person in front of her, but she's taking cues from the person in front of her. So I'll give you some tips today for how to go about a hands-off assessment for an eval specifically, from the subjective to the objective, through the treatment, and then post-session. Pre-session, We want to make sure that your intake form has an area for a client to share some trauma or abuse that may have happened to them, whether that's current or they have a history of it, whether it's physical, emotional, whatever the case is. Whether they mark something on that intake form or not, as pelvic PTs, we are dealing with an extremely intimate part of the body. And that means that someone may not even realize that they're holding on to some trauma until maybe in session. They have some sort of trauma response because you palpated their low back, right? Or because you brought up during discussion or during subjective, um, a certain word and that was triggering to them like, um, anus. And knowing that their executive functioning is probably not working optimally in that moment is very helpful for us to make that session for them the best experience possible. If someone has a trauma response, just thinking before we even dive into the subjective, just having that in our head is important. We want to be non-judgmental. We want to be compassionate. in our responses, we should be patient and supportive of a pause that that person may need to take. They may need to take a breath or ground themselves or stretch. I have these little small animals like a llama, this one doesn't have any legs, just for them to hold on to and little fidgets as well. So know that that may happen in session and later on, You could ask them when they're not in that traumatic response or in the next session. You could ask them, hey, what would be appropriate for me to do to help you through that? Do you know? They may not have any thoughts on what to do if that does happen again. During the subjective, let's talk about that. With these clients, I tend to rely heavily on the subjective. We want to be looking at the verbal and nonverbal communication from our clients. These can cue us for the need for a hands-off objective and treatment session, even if the trauma was not shared on the intake. From a nonverbal perspective, when you're looking at your client, do they have knees to chest? Are they folded in super flexed? Do they have minimal eye contact? Are they wringing their hands and fingers throughout the entire session? From a verbal perspective, type of words for pain. So in the pelvic setting, we hear a lot of really scary sounding words and words that sound harmful. Things like, it feels like there's a chainsaw in my vagina or every time I sit, it's like a hot poker is going up my butthole. So listening for those intense words when they're describing their pain, as well as a tremor in their voice, are they shaking? And then any sort of non-specific description of their pain. Oftentimes I'll be like, yeah, tell me, can you show me, or can you tell me more about where your pain is? And if they show me, they kind of like, point in this giant circle of like from sternum to mid-thigh is where their pain is, and for some that is where their pain is. But for others, their pain is at the tip of the penis, but they just aren't comfortable or maybe again, that is triggering to them to say the actual anatomical word. And then verbal communication from you as a provider is important. So we're thinking active listening, we're going to ask them about prior health visits, and then you're going to dial in some of your questioning. So from an active listening standpoint, they've probably been dismissed or maybe not heard in previous medical provider settings. So we want to be the ears for them. and asking them specifically about previous physical pelvic assessments, if they've had any, how did it go at the gynecologist or the urologist, or even if they worked with a prior pelvic PT, that can give you an idea for what worked and what didn't or doesn't work for them. And then get curious about some of their personal life events and their symptoms. So, If they've shared any sort of major surgeries or shifts in their personal life, ask with some compassionate curiosity, do you think that your jaw surgery is related to the urinary leakage that you're now having? And then they think back and they're like, oh my gosh, the urinary leakage started happening basically when I had my jaw surgery. So they have sometimes like an aha moment or if a family member died or if they shifted jobs or got fired from their job, that's when they started having intense pelvic pain. So you can, again, be a detective and kind of connect some events together and that can help them feel very heard for sure. And then I went during my actual, if I am going to do a hands-on assessment, before I even palpate someone, I always ask them, hey, is there anywhere that's off limits or that I cannot touch or assess? And I'm going to do the same thing with the person in front of me. If I feel like this is going to be a hands-off assessment, I'm going to ask them, are there any topics or body regions to avoid during our discussion or assessment? And then finally, for the subjective side of things, preconceived notions about the pelvic PT visit. Do they have any? What have they heard? Be sure that you are explaining the pelvic floor assessment thoroughly and that you ask them for their preferred learning type. So if they are a visual learner, is it okay that I show you this pelvic model? Even that, just the visual look of seeing the perineum could be triggering for someone. I had someone who I was showing them the muscles on the pelvic model and they had a visceral, nauseous, triggering response that we worked through. And they kind of actually had a flashback of when they had some childhood molestation. And then moving towards the objective, we want to reframe this appointment like it's a virtual visit. which virtual visits are hands-off. Same, same, but different. Lean heavily on your visual range of motion. Again, if that's okay with them. In terms of asking them to do standing or seated spinal range of motion, hip mobility, we can learn a lot from a seated 90-90 for their hips in general. Abdominal movement with breath. Offer hands-off assessment options that they can select. So is self-palpation of their own pelvic floor okay for them? Or can we do a visual assessment, no hands, but a visual assessment of their pelvic anatomy? And like I said earlier, an external exam, but especially an internal pelvic exam, whether it's vaginal or rectal, is not required to make a pelvic PT session a success. It can though be something that the client and provider work towards if that's something that the client is interested in. A previous client once told me, they said, thank you so much for saying that an internal exam was not a requirement because they had apparently gone to two previous PTs who were basically saying like, hey, if we are gonna figure this out, we're going to have to do an internal exam, which can be very triggering for them. Then in that objective, looking at functional movements like squats, lunges, you get a good idea of range of motion, strength, growth strength, and then the quality. Is it smooth? Is it rigid? Don't forget to collect some pelvic specific outcome measures or even at the very least, a patient-specific functional scale. And then moving on to the treatment section, tuck your manual skills away and focus on the exercise, the education, the ecosystem. Do they have mental health providers or resources on board? From a exercise standpoint, we wanna be thinking movement snacks for these humans, just to keep it short and simple, or rehab EMOMs that focus on mobility, strength, aerobic activity, maybe some self-mobilization or desensitization on a post-op or a C-section or a perineal area. Any sort of scarring, can they do some work themselves? Are they okay with that? Example of a remom for someone, it's got four exercise in it and I gave it to a client who had that traumatic response when I was showing the pelvic model. And they weren't very motivated to exercise. They hadn't been for six months, but they love to exercise. But because they had some onset of urinary symptoms and a recent jaw surgery, I made sure to ask her, what are your favorite exercises? and they said planks and bridges. So I made a EMOM that consisted of a bird dog with a row. So we've got some sneaky strength and motor control of midline, tapping into the pelvic floor based off of the urinary, the, sorry, upper extremity and lower extremity connections. And this is helpful, especially if they are just so disassociated from their pelvic floor. And then I had kettlebell swings. That's gonna tap into our aerobic piece. A deep supported wall squat with diaphragmatic breathing is going to help us kind of calm the sympathetic nervous system and maybe even help them start to connect with their pelvic floor. And then self-mobilization externally of the jaw. One thing to make sure is that these people are comfortable in the positions, the exercises that you suggest. Some of them may be a little triggering, so just make sure like, hey, is prone okay for you? And then for the objective session or treatment session, education is queen here. Okay, so keep it simple and short. A lot of times these folks don't have a lot of room for processing lots of detail. Use their learning style to connect with them. If they're visual learners, send them home with the animated video explaining the anatomy and physiology of the pelvic floor or your whiteboard drawing. And then, definitely tap into their ecosystem, ask them about what's their sleep like, are they getting adequate fuel and hydration, how do they manage their stress, and do they have any mental health providers on board. And then for the after session of this hands-off eval, make sure you follow up with an email or a phone call, check in with them, make sure that they know that you So appreciate them sharing these things with them.

SUMMARY
So when it comes to someone who is apprehensive about a pelvic floor evaluation or who has experienced some trauma, a hands-on assessment may not be in the cards. So be sure that in your pre-session, you've got something in your intake forms that they can check off for trauma or any sort of abuse or things like that. From a subjective standpoint, we want to be emphasizing active listening, looking at their nonverbal and verbal communications, and then dialing in our specific line of questioning. From an objective standpoint, remember that you can remind them they are in charge of the session and there are plenty of hands-off objective measurements that can be taken. From a treatment side of things, make sure that you give them movements that align with their preferences and that you're giving them a ton of education about the pelvic floor and checking in with their ecosystem and mental health providers. And then after the session, give them a roadmap of how the session went. So as a pelvic PT, know that it's okay. In fact, it may be better not to palpate during the first visit in order to establish trust and rapport. We know a lot of outcomes and symptoms can improve purely based on education alone. In our ice pelvic division, we have two live courses that I'll chat about in Hendersonville, Tennessee, January 26th and 27th. Alexis and I will be there. Teaching All Things Pelvic Health. And then the following weekend, Christina, Heather, and I will be in Bellingham, Washington, February 3rd and 4th. And there is still time to sign up for those. Thank you all so much for tuning in and until next time.

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

Jan 18, 2024

Dr. Ellen Csepe // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses this new class of medicines and how they impact your patients and their overall journeys to maximize their fitness and manage their weight.

Take a listen 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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

ELLEN CSEPE
Hey, good morning everybody. And welcome to the PT on ICE daily show brought to you by the coolest continuing education company in all of healthcare. My name is Ellen Csepe. I'm coming to you live from Littleton, Colorado. I normally teach with the older adult division, but today we're going to be talking about GLP one agonist medications and their impact on your patients. Um, You guys have probably heard about GLP-1 medications. They're all over social media right now. They're used to manage obesity and weight issues um and diabetes, so These medications are the medicines like ozempic that you've heard all about or the medication brand of that same Ozempic, but used for obesity, which is called Wegovy. So you've probably heard a lot about these medicines already. And if you didn't see them on your board questions, you might be feeling a little bit out of the loop as to how they could impact your patients. If you're like me, these medications have come out after I've already gotten my licensure as a PT, and these medicines are impacting our patients in ways that I'm not really familiar with. So, this podcast episode today is for you to know a little bit more about how these medicines could be impacting your patients as a rehab professional. This podcast is going to be a lot about introductory level information to talk about these medicines in context of our Patients with obesity this podcast is not going to be a conversation to talk about How these medicines are used by celebrities they're not going to be we're not going to talk about how these compound medications or Illegal versions of these medicines are flooding our healthcare scene and causing a lot of illnesses today, we're gonna be really talking about what they are and how they work, who they're for, what they do other than help people lose weight, and some considerations and practical tips for your patients.

GLP-1 MEDICATION
So let's talk a little bit more about how these medicines work. So in context of treating obesity, these GLP-1 medications are super helpful to kind of overcome the biology behind our body's resistance to losing weight. Let me break that down a little bit. I know it's really easy to look at somebody with weight issues and think, gosh, wouldn't they just feel better if they lost weight? And it's an interesting paradox because our bodies actually fight to regain lost weight. Our bodies might feel better. We might have less pain, less inflammation, less joint problems, but Unfortunately, when we lose a substantial amount of weight, our body's biology fights to regain that. Why? Because usually in the context of our human existence, losing weight has always been a bad thing and it usually means being in starvation. Unfortunately, our biology doesn't know that obesity can be just as much of a threat to our health as starvation. So, when our weight changes, unfortunately our ghrelin or the hormone circulating in our blood blood that's Tells us we're hungry unfortunately that increases when we've lost weight and unfortunately leptin or that satiety hormone is decreases when we lose weight. What does that mean for our patients? It means that losing weight is very difficult to maintain because our body is constantly fighting to get that weight back. So let's talk about these GLP-1 medications. I'd like to first start out by saying GLP-1 medications are the newest medications that are used to treat obesity, but they're not the only ones. They just have a lot fewer side effects than some of the other medications that we've used in the past. For example, oralistat is a medication that works at our gut to decrease the absorption of fat. It comes with a ton of really gnarly side effects. Google what steatorrhea is, and you'll see what I mean. Unfortunately, there are tons of GI side effects for people that use this medication that cause significant fat in their stools and a lot of loose stools with it. Another medication is fentramine or topiramate. Those medications used in combination Basically act as a sympathomimetic to increase our metabolism But those medications are really only effective for a short period of time and they can have a lot of cardiac side effects There are some medications that are used in combination to treat obesity specifically naltrexone was a medication to use to treat opioid addiction and bupropion is which is another antidepressant, in combination that kind of changes our satisfaction behind eating. Those are medications used to treat obesity too. And usually what we can guess is that those medications aren't going to be quite as effective as GLP-1 medicines. Just to kind of review if you're tuning in now, those GLP-1 medications are medications like Wegovy, Sexenda, Ozempic, although of note, Ozempic is only used to treat obesity as an off-label benefit. Ozempic is actually only, excuse me, only approved to treat diabetes by the FDA right now.

MECHANISMS OF GLP-1 MEDICATION
So let's talk a little bit more about what this GLP medication is. GLP-1 is a hormone that we naturally secrete in our bodies. and the GLP-1 medicines are receptor agonists that look pretty similar to that hormone in our bodies and that when used mimic that hormones actions throughout our tissues. For example at the pancreas that GLP-1 receptor increases our body's secretion of insulin and helps to make that insulin last better. So that's why it's also used for people with diabetes. Interestingly enough, we also have GLP-1 receptors in our stomach. So another way this medicine works is to slow gastric emptying and basically make our food last longer throughout our stomachs so that we feel fuller for longer. What I think is the most interesting is that we have these GLP-1 receptors in our brain, in our hypothalamus, and the way these GLP-1 medicines work is to suppress both hunger and cravings. A lot of people with obesity experience something called food noise. And basically because of the obesity, they have these constant and intrusive thoughts about food. They could be eating something and have no hunger, but already be thinking about their next meal. So this GLP-1 agonists, Turn down that food noise to make it less likely for them to experience these constant intrusive thoughts about hunger So we talked a little bit about how they work. Let's talk a little bit more about who they're for so GLP-1 agonists are used for people with obesity. So that means generally their BMI is 30 or more or they could have overweight and a BMI of 27 with comorbidities. Comorbidities specific to their weight significantly causing risks to their health. So these medications aren't just for people who are looking to shed a few pounds. Obesity is a disease and these medicines really help us treat that disease process, which is a long-term, lifelong problem that relapses and recurs, unfortunately, in a lot of patients. It's contraindicated in a few patients. Good news, patients' physicians have to figure that out, not us. But just for context, people that are pregnant, people that have gastroparesis, irritable bowel disease, those patients might not be appropriate for these medicines, as well as those with certain thyroid cancers or familial risks of those cancers. So these medicines are also used to treat diabetes and in patients with obesity and diabetes, this is a great new medication to manage both conditions at once. Interestingly, or Wigovy, which is the ozempic for obesity, is also used to treat those who are 12 and older. So it's not just adults that are using these medicines, it's also those with obesity who are children who are 12 or older and weigh 132 pounds or more and have obesity. So let's talk a little bit about what they do. So pragmatically, they really reduce cravings. We talked about that. They can result in about an 8 to 15 percent weight loss in the first year of use. That's a lot compared to some of the older classes of medication. Liraglutide decreases the risk of diabetes compared to a placebo. So in those with obesity, liraglutide decreases the risk of obesity development and that rate of onset much sooner. So these aren't just to lose a few pounds before summer and celebrities. This medication can be very helpful for people who are struggling with their weight long term. Notably, Long term is how long these medications have to be used. So unfortunately, in most users, if they discontinue this medication, weight is almost always regained, and about 66% of the weight that they've lost over the past year is regained when people stop using this medication. but again, this isn't just a cosmetic thing to lose weight and a lot of us as Providers think about weight in the context of how we look societally and how we feel but this medication in those with obesity and diabetes Decreases the risk of cardiovascular events decreases the risk of stroke atherosclerosis Heart attack. So these medications aren't just here to help you get shed a few pounds These can be really life-saving medications for those with obesity

CLINICAL CONSIDERATIONS
Let's kind of talk through some of the considerations for you as a clinician. So keep in mind these medications are injected by the patient at home one time a week. And the dose is gradually increased to a therapeutic dose over several months. Here's why that matters. Because there are quite a few side effects with these medications. It's not a medicine that comes without side effects. This is not the easy way out to lose medicine. It does not feel good to be on these medicines. And a lot of the most common side effects are going to be nausea, vomiting, GI issues, cramping, bloating, dizziness, headaches and fatigue, hypoglycemia, which is important for us to consider for our patients if we're going to be having them exercising, acute pancreatitis, and gallbladder disease. So how does that impact our patients? Friends, team, we are in the business of helping our patients maintain their muscle mass. That's our job. Our job is to be fitness forward, to advocate for our patients, and to be here for them through every season of life. And on the days that they're taking these medicines and throughout the week, there's a lot of stigma attached to these medicines that we have to be aware of as providers. Where I'm going with that is that they need a hype squad. Patients need somebody to cheer them on and say hey, I know you feel like crap. I know that this medication is hard What I want you to know is that I'm here in your corner You are making a big decision for your health and even if you only lose five to ten percent of your weight Overall, that is a huge huge way to reduce your risk of overall cardiovascular disease.

HYPE UP YOUR PATIENTS
So friends We need to hype up our patients who are on these medicines when it's appropriate and it usually is if it's prescribed by a doctor. This needs to be our goal to hype up our patients and encourage them to maintain their consistency with this medicine. A lot of patients stop because they plateau losing weight after about a year. And they still have the side effects. So they feel like crap. They don't want to take this medicine. They're not seeing the pounds shed off anymore. And they need a health care provider to say, hey, this isn't just a quick fix to lose a few pounds. This is a lifelong endeavor to manage obesity, which has serious risks to your health. So another consideration, our business is to make sure that our patients are sticking through these medicines and Also maintaining their exercise participation and their muscle mass So patients who are taking these medicines feel like crap. They need somebody to still say hey I know you don't feel great. We still need to have a plan to have you doing strength training. We still need to have a plan for you to get enough protein in your, in your, in your mouth throughout the day, because unfortunately these medicines work by saying, Hey, you're not so hungry anymore, which is how those medicines are effective. But unfortunately, if you're not intentional, you will lose not only fat mass, but muscle mass with this endeavor with using these medicines. So, Encouraging your patient. Hey, I know you're losing weight. This is awesome Let's really keep this ball rolling and be super Intentional to make sure that you're still able to get to the gym that you're still able to get enough protein in your diet I'm on your team. I am in your corner to help you and These patients are prime time for behavioral change to say i'm making a change on myself already with this medicine. How can I really? Maximize this and get as much as I can and we are on their team team I recommend patients to talk with their doctor about these medicines. I talk with my patients about their weight all the time in a way that's constructive and empathetic. I listen to my patients and recognize that losing weight is a struggle. These medicines can be super helpful for our patients who have struggled for a long time to manage their weight. And that's not because they're unmotivated or lazy, it's because their biology is fighting to get that weight back. This is not cheating and these medications can be super helpful. I often talk with patients and recommend them to go back to their doctors and ask if it could be helpful in their journey to manage their weight. A quick caveat on that, not all insurances in all states cover these medicines the same, which is very unfair. These medications can be really life-saving for our patients with obesity, and unfortunately, insurance is making it hard for people that need it most to get access to it, specifically those in poverty. Obesity disproportionately affects those from a lower socioeconomic status, and it's really important to recognize that in the treatment of obesity, those people are unfortunately going to be the last to get access to this stuff, and that stinks. So knowing that as a provider is another important thing that I've learned. You can't just shoot from the hip and say, oh, you've got to go talk to your doctor about this. It might not be covered by their insurance, and that's super demoralizing. So make sure that you kind of know that before you make this recommendation that, oh, you can be on this new drug, it'll be super helpful for you, and it's not covered. So friends, to wrap up this summary, so these GLP-1 medications are new but not the only way that obesity can be treated medically. They're very helpful and effective in helping those individuals lose weight but they often come with side effects. Our job as providers is to know what those side effects look like and feel like and how to still emphasize exercise participation to our patients no matter how they feel and come up with a plan to say, hey, we still need to do strength training. We still have protein goals to make sure that you maintain your muscle mass. Thank you guys so much for taking time out of your morning to join me to talk about these medicines. And I hope that it was helpful in the long run for you to know how they can be helpful for your patients. Have a great day.

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

Jan 12, 2024

Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko discusses a recent encounter with low back pain in the gym, offering lessons learned on empathy, the benefits of early intervention, and finishing the drill by returning to regular fitness activities.

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

If you're looking to learn from our Clinical Management of the 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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JOE HANISKO
Awesome. Good morning team. This is your PT on Ice daily show podcast. It is Friday, January 12th. So it is a fitness athlete Friday. My name is Joe Hanisko. I am one of the lead faculty of the clinical management and fitness athlete division here at Ice. Uh, today's topic we're going to get right into it is the benefits of being injured as a physical therapist. And I know upfront saying that a little strange, By no way, shape, or form do I mean that having an injury is a positive experience. We know that injuries can be quite mentally and physically disturbing, but I've recently had an injury and it brought so much back in terms of the value of the experience for me and how I can better shape my practice and reinforce some of my own beliefs about what we do as physical therapists and how we can really bring a good one-two punch to kind of help people who are dealing with injuries as well. So I want to get into the story quickly just to lay the ground. This is like a month ago now, five, six weeks ago. Doing a workout, it was progressively heavy power cleans and intermittently decreasing rep schemes of wall walks. So as you had high volume cleans with a lighter weight, you had high volume Wall walks and you progress down and reps up and weight and down in the wall walks So a lot of just back and forth and I got lazy somewhere in the middle decently heavy bar about 225 Not my max range but an upper level range and I was just trying to get through these reps and I caught it Essentially almost like in a muscle clean position where I didn't do a good job Redipping under the bar and absorbing load and I sort of just got jammed up like it felt like I kind of like Compressed my spine and in the moment as it happened. I was more or less like that didn't feel so hot I dropped the bar. I was doing singles. Anyways picked it up felt. Okay, I Third rep into that, felt a little tight. Only had to do four, I think. On that fourth rep, I was like, oh, something's happening here. My gamer in me, I just kept going, hit the wall walks, but by the time I got back to the barbell, now at 245, man, I was pretty seized up. So, this is sort of like live and learn. I had an opportunity there to maybe back down, but it was just me and my buddy Dakota sending this workout. Couldn't leave him hanging. I continued to go through, and we'll fast forward to the end of the workout, in which I felt like I had a steel rod in my back. Preface this with, I've never experienced a back injury personally myself. Somehow I've been lucky enough to train for 15 years and not have any major back injuries to really talk about. But this was rough. Bending over, taking the plates off. It was one of those within a matter of a minute or two I was in a pretty rough spot and I was like, where is this going? Wasn't too confident about it. So that night though I went home and started working on it myself, doing what we should. pick that the move it or use it option here and we went after moving it i was doing some bat banded cat cows some cat camels but the real story starts with what I feel like came in the next day or two afterwards.

MAKING DECISIONS EARLY IN REHAB
And this is where I feel like us as physical therapists, what we know from our injury rehab experience, and when it happens to us, we're able to make great decisions early on. This is what really started to highlight to me the benefit of having this injury and reminded me all the things that I need to do when I have athletes and clients who come to me with these acute injuries or injuries of any kind. So what I wanted to do basically is lay out the top three we'll call them experiences or lessons learned from this.

LESSON #1 - EMPATHY
The first one being empathy. Had I not known what I know about the human body, about physical therapy, about rehab, about movement and how it is truly medicine, had I not known that this injury would have been debilitating. Not only physically, I was, you know, having a hard time getting around, doing basic things, putting the shoes on, getting dressed. Not only physically was it debilitating, but mentally I would have felt wrecked. I love fitness. Every day I get to show up in the gym and spend time there just like a lot of our clients and members at the gym. and clients here in the clinic, I love it. And I did not feel like I was anywhere close to getting back into the gym. I was wrecked. And having that empathy as a physical therapist now for what clients feel like, especially when they don't necessarily know that there's light at the end of the tunnel, and hopefully sooner than later, that was a terrible experience. Again, my ability to change my psyche on that was helpful, knowing that I wasn't doomed, I was gonna get this taken care of. I wasn't dealing with, neurologic symptoms or things that were overly concerning. No red flags in my history. But again, taking this from the perspective of people who don't have that, the ability of the therapist to empathize with people and say, hey, I understand where you're coming from, man. That back tweak is no joke. It really makes you feel like you're doomed and that you got no bright future ahead of you. But let me tell you that you do. I've had this, I've experienced it, I've walked it on, right side next to you, knowing what this feels like, and we are gonna get this better, and you're in the right spot. That empathy and ability to kind of connect on that emotional level with them after experiencing something like this, I think is super powerful. It puts you right in their shoes, and you've lived it, you've learned it, and you know that it takes a little bit of strategy on our part to kind of convince and educate people that they're gonna be okay when they're feeling like they're hitting the frickin' rock bottom after an injury like that. So empathy or relatability, you can combine those two. But I felt like that was probably one of the most beneficial lessons learned from this whole process is being able to connect with the patient on that level. So it's scary, it sucks, but. we have the ability to control some of that with our education and our ability to empathize and to relate with our patients. So lesson number one, empathy.

LESSON #2 - POSITIVE BENEFITS OF EARLY INTERVENTION
Lesson number two, the positive benefits of early intervention. You cannot sell this enough. Uh, my experience was great. I have a team, uh, onward Grand Rapids. My employees were fantastic. I was able to get in 36 hours after my injury because it was on a weekend. Get in, I got some needles, some cupping, a little bit of manipulation. And man, I was within 36 hours. When I walked in the door, I was in rough shape 36 hours after this injury. When I got off that table, I was 75% better in the moment. 75% better. Early intervention for me was nice because physically I was feeling better and your patients will feel better as well, but this is where it starts to go back to a little bit of empathy and the psychological component of it. The fact that I could bend over, touch my toes with minimal discomfort, 25% of what I was dealing with before, was so, so rewarding to me and reminded me that there is no greater tool than early intervention, especially with these acute injuries. So the early intervention process and It kind of rolls back into patient education, especially if you're incorporating yourself into gyms and fitness. If you get an opportunity, workshops, if you get an opportunity to talk to somebody after an injury, you gotta double down on that because we know that it's so much easier to rehab an injury early on in the process rather than waiting three weeks, six weeks, whatever it might be. But also, psychologically and physiologically, the changes that you can make with these early intervention tactics can be so powerful. It certainly does take a good chunk of education on our part to let people know that, but I think we sometimes struggle as a profession to commit to what we know works because it seems like an inconvenience or it costs money or whatever it might be, but it's our jobs as professionals to relay what we do know and to be confident and to trust our own processes. And in my personal experience, that 36 hour intervention, it was more than worth it. I would have paid whatever it took to feel as good as I felt afterwards. Luckily, I got the free 99 coupon, which is nice, but I'm serious. That was huge So I had intervention at 36 hours and then roughly around 72 hours later and by 72 hours I was probably a 90% to 95% meaning that I could feel some stiffness with flexion. I wouldn't even consider it pain I felt like I could go back and do everything that I wanted to do.

LESSON #3 - FINISH THE DRILL
And I did I got back in the gym and that was really my third lesson then of this after empathy early intervention is make sure we do a good job completing the drill. You know, this is me lacking my ability to walk my own walk and talk my own talk here. I, you know, three days essentially after this back injury was back to training and I chose to avoid intelligently and modify certain things. I wasn't going to go load up my max PR deadlift and just start cranking away. I think the first real workout that I got back to doing was a combination of dumbbell box step-ups, handstand walking, and goblet squats, like a dumbbell goblet squat. So a lot of legs, movement. I was like, man, and going upside down, a challenging position there where it sometimes can cause back pain with that overextension. I was doing really good. So I went from that to a ski erg and did some ski erg intervals, which is a lot of flexion, and I was doing really good. And I swear to God, 40, 50 minutes into my workout when I went to kind of do a little cool down recovery row, some zone two style stuff, it was within the third pull on that rower that everything literally seized up. I'm going to say at like 75% of the worst that it had been, but I just done all that stuff. Uh, I had been doing some rehab stuff for three to five days before that feeling good and I lacked the ability to commit to completing the drill. as a patient and as a therapist. Like I wasn't honest with myself and pushing myself to continue to do the stuff that we know works and building out a plan to really bulletproof and rehab something. I kind of took it as a grain of salt, like, oh, I'm doing so good so quickly. I can probably just go back to doing whatever I want to do. But I learned my lesson. I went right back to essentially square one, had to go back, see Hondo, one of our dogs here, the day after. Luckily, again, early intervention, second time around here. and got back on track. But now I'm four weeks after this process, five weeks after this process, I'm committed to really taking a stand on building some back strength back up. And even if it meant that I wasn't really essentially weak going into it or whatever, I know that I came out weaker from that injury and need to rebuild my foundation. And there's no point in just sweeping this under the rug. I really need to attack it. And so our jobs here as physical therapists with our clients is to reiterate a either empathetic or relatable experience in which we maybe didn't do a great job following through like I did and educate again on the importance of, Hey, even when you're feeling good, especially early on in your recovery process, this is the time to double down. This is when we go after the gas pedal, we floor it and we say, Hey, this window of opportunity that I have right now where I was doing terrible, the window is open, I'm feeling pretty dang good right now, that's the window that we need to double down, get after this, and really start to build back our capacity into whatever injury, region, interlocation that we're talking about there. So, a super, super valuable experience in my opinion. I don't want to understate the fact that obviously injuries are never truly a positive thing, but I tried to spin this as best I could and going after this process and learning about empathy, learning about early intervention and reminding myself about how important it is to complete the drill was so valued to me as a physical therapist because I can now take all these experiences and apply them back into my clinical experience here. Also, the bigger picture here at the end of the day is that it reminded me of why I'm doing what I'm doing from a fitness perspective. Yeah, I like to be competitive. Yeah, I like to throw heavier weights around, but really what we're looking for here is the long journey, the end goal, the healthy longevity lifespan approach. And I will take that back injury 1000 times. over all the other things that could come with not being willing to put your body on the line a little bit, build some resilience and strength and capacity, and suffer from chronic disease or other debilitating comorbidities that are out there just grabbing people left and right right now across the country. So I'm by no means deterred by this.

SUMMARY
We need to remind our patients they should not be deterred by this. We are gonna get them better. You're going to relate with them. You're gonna provide intervention early, and you are going to complete the drill, and they're gonna be in a really good spot there. Hopefully that was helpful. Don't go get injured, but if you do, spin it, be positive, learn from it and help your clients. Or at least take my experience and help your clients and really do a good job selling our profession and what we are capable of because people deserve to feel good and to get back to their sport. Last little sign off here from the CMFA team. We got a couple of courses coming up. It's the New Year's 2024, so live courses are kicking off. Our first couple live courses In order are in January. We got one out in Portland and then we're gonna follow that up with Richmond, Virginia Charlotte, North Carolina, and then I'll be out in April in the Seattle area. I think Renton Washington so look at the PT on ice.com website to look for signups for those and And also early February, first week of February, the CMFA online level two is kicking off with Zach and Mitch and myself as well. That's February 7th, I believe, but definitely that first week of February. So hop on, let's get those Con Ed credits built up. We're looking forward to seeing you guys. Have a great start of your year and have a happy Friday.

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.

Jan 11, 2024

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

In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses key set-up, anatomy, and technique to target the subscapularis muscle.

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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

ELLISON MELROSE
All right, U2 is up. Good morning, PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of Ice. I am here to piggyback off of the Fitness Athlete Fridays for the past two weekend, or two weeks. Two weeks ago, we had Alan going over the evaluation process for determining if the gene is subscapularis muscle. And then last week, Zach Wong went over some treatment techniques, and he hinted at one of the most efficient ways to treat the subscapularis muscle, which is dry needling. So what I wanted to do today was to go over a demonstration of how to needle the subscap muscle safely and efficiently.

NEEDLING THE SUBSCAP
So in order to be able to do this muscle, our patient needs to be able to get 90 degrees of shoulder abduction with some moderate external rotation as well. So patient positioning, they're going to be laying with their arm up in this abducted and externally rotated position. My patient here has some decent mobility, so she doesn't have any issues getting into that position. But for someone that maybe struggled with maintaining that position for the duration of treatment, we can bring their shoulder down slightly. And you can also prop their wrist up so they're not in so much external rotation as well. But again, this patient doesn't have issues getting into that range of motion. The reason we need to have this position is because we need this scapula to be protracted out from underneath the thorax for this to be a safe and effective drain forming technique. So we need to be able to palpate the lateral border of the scapula and appreciate the difference between the lateral border of the scapula and where the lateral border of the thorax is. In this position as well, we can think about the rib cage. It's not parallel, or excuse me, perpendicular with the table in this position. It's kind of diving around. It's oval shaped, right? So it's diving around and posterior and a little bit medial there. So if we get that scapula out from underneath that rib cage, we have some good real estate to needle this muscle. This is a direct technique. So we go for different types of techniques. We have a threading technique and a direct technique. Typically, when we talk about direct techniques, they are direct to a bony contact. So in order to ensure that we're at the depth of the subscapularis muscle, we need to have a bony contact with our needle in that subscap fossa there.

IMPORTANT ANATOMY
So again, patient positioning here. Some other considerations in this area. A, we have the lung field. Appreciating where that rib cage is and how it's diving away and where our scapula is in relationship to that. But we also have some other sensitive structures in the axilla. So we have our brachial plexus that actually runs just anterior to the subscap muscle and exits down the medial humerus here. So we want to orient ourself to where the brachial pulse is as to avoid needling in that region, right? So the best window for subscapularis is going to be just distal in the axilla. If we go too distal, we're likely going to miss that bony contact that we need for ensuring that we're in the subscapularis muscle. Some other considerations here is we have a really strong and powerful motor branch or motor nerve, the thoracodorsal nerve, that runs along that lateral border of the ribcage, which innervates the lats. So if we were to interact with that, we would likely get some fairly strong um, lat muscle activation. So typically it kind of looks like that sprinkler, um, dance move that we all know too well from middle school dance. Um, but so those are our main considerations. So one field and some other sensitive structures, uh, the brachial plexus and brachial artery and vein in that axilla. So again, first we want to bring our patient into this abducted externally rotated position. If you feel like you can't appreciate the, or you don't have a good real estate of that scapula, you can assist by protracting, like grabbing the medial border of the scapula and pulling it laterally. So again, you should be able to appreciate lateral border of the thorax is there, lateral border of there. So we have a good two inches of room to play with. A lot of these athletes that have So we're thinking the athletic population would be one where we want to treat this. Crossfitters, for example, they also have fairly hypertrophy flats. So that's another thing that we have to appreciate is we're going to have to be sinking in to get, again, that bony contact on the scapula. Another common patient population that you may be needling this muscle in is going to be the thawing stages of frozen shoulder, right? So this person was able to They're now in that pain-free, able to access at least 90 degrees of shoulder abduction, or post-op rotator cuff, where they're really struggling with some of that end range shoulder abduction, external rotation, and shoulder flexion even. Sub-scalp is going to be a good muscle target for those patients as well. So before we do anything, we want to prep the tissues. So we're going to clean the skin.

SUBSCAPULARIS TECHNIQUE
I prefer to do most of my needling techniques in standing, especially for this muscle, as sometimes our fingers are not going to, like just our finger pressure is not going to be enough pressure to sink in to approximate that subscap fossa that we want to. We're going to be needing a longer needle than we think. So for Sam, I have a 75 millimeter needle. Some folks may even need longer and that's just based on excess muscular tissue, the lat, the pec muscle that we're kind of orienting ourself around, the skin recoil. So as we compress that tissue, once you release, that skin recoil is going to potentially move that needle. If we don't have a long enough needle and it will choke up on the handle there and it'll pull it off of that bony contact that we've Spent so much time finding. So we want to make sure that we have a long enough needle to maintain that bone depth.

ADDING E-STIM
Another thing to consider is when we're with ice, we are dry needling with e-stim, right? So we're not doing a ton of heavy pistoning. Again, there's a lot of sensitive structures in this area, so it's usually not very comfortable to piston a lot. So we're going to be wanting to layer in the strategy with Easton. When thinking about ECM, you always want to be thinking in pairs. So how can we pair this muscle with another muscle that may be doing something, a similar movement pattern that may be also restricted, or something that's going to reach that motor threshold at the same time? So we want to be thinking about muscle spindle density in our muscle tissue of what's going to reach that motor response around the same time. Typically, I like to pair subscapularis with the clavicular fibers of pec major. So we have another technique for pec major clavicular fibers. Of course. Of course. Why was I logged out? OK, well, I was logged out on Instagram, so we're just going to continue on YouTube here. So we want to maintain the or we want to be able to pair this muscle with another similar muscle that has a similar muscle density. And it's also going to be limiting some of that external rotation in this position as well. So I like to pair those muscles. For today, we're just going to go with the dry needling demonstration of subscapularis.

SUMMARY
So again, we want to orient our patient into abduction external rotation. We want to maintain an appreciation of that lateral border of the thorax. And then we're going to compress the tissue down, down towards the subscap fossa. Usually your palpation here is going to be the most assertive part of the technique. And you might get what we call the Grunner sign, where some people don't tolerate that very well. So orient yourself to that brachial artery. We can find the pulse. So typically I would come around to the other side, palpate the pulse here. Pulse is under my index finger, so I've oriented myself to where that neuromuscular bundle is, and I'm going to be treating just distal to that. So, right in here. All right, so we have an appreciation of that anterior surface of the scapula. Again, using a 75 millimeter needle. So I'm doing a firm palpation, my medial aspect of my hand, so my pinky, ring finger are appreciating that lateral border of the thorax. My needle angle is going to be perpendicular to the scapula here. So really, it's fairly directly anterior to posterior, almost paralleling, or excuse me, yeah, paralleling the ribcage, anterior to posterior. So we're almost, we're very close to that ribcage, but we're going, we're paralleling it, so we're not going to be interacting with in a postural space or lung field here. So again, appreciating lateral border, knowing where that neurovascular structure is, that means safety, lateral border of our scapula, firm compression down. I feel that muscle. You can always do a little internal rotation, good and relaxed, to feel that muscle activation under your fingertips, compressing, giving yourself a little treatment window directly anterior-posterior. and you're on bone right there. So if you look at this, you're like, dang, she's got a lot of needle left over, but let's allow for that tissue recoil. So as we let for that tissue recoil, we have about a centimeter left. So a 60 millimeter needle would not have been long enough to appreciate that depth of the sunscan. As we allow for that tissue recoil, you may start to see like the needle directions a little bit and it may look a little bit suspect, but knowing that we're on that bony contact, that needle tip is not going to be going anywhere once we've reached that depth of the scapula. So we can allow for that tissue recoil and set up our next needle and then set up the stem and feel fairly confident that that needle is not going to go anywhere. Main concern with safety here is if this person were to move their arm, right? That would be something to be concerned. or if we're interacting with that thoracodorsal nerve and we get a very big motor response into that sprinkler dance move. So when we are bringing the stim up and looking for that motor response, typically I would suggest maintaining that appreciation of where that lateral order is and kind of bringing that needle back into its original orientation. Once you feel confident that we're not getting any sort of interaction a less of a motor response than what we want or more of a motor response than what we want, we feel fairly confident that leaving that needle at that bony contact is a safe needling technique. We are rarely or really ever, we shouldn't be leaving our patients stimming with needles in them by themselves. I feel like that is a best practice to be in the area with our patients. And so if this needle were to move slightly or anything like that, you can always maintain contact or redirect as needed. So there we have the dry needling demonstration for subscapularis muscle. Again, my name is Dr. Allison Melrose. I am the faculty with the dry needling division. Some of our upcoming upper quarter courses where you can catch this technique and a bunch of other techniques. We have a three-day course in Longmont, January 26th through 28th. Paul will be out in Wisconsin, February 3rd through the 4th. I will be down in Greenville, South Carolina, February 17th, 18th. Paul will be out in Bozeman, March 2nd through the 3rd. And then I'll be out in Maryland. It's Sparks, Maryland, 22nd through the 24th. So there we have our upcoming courses. And this, hopefully, was a good review or a new driving learning technique that you guys can use in the clinic. Awesome.

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.

Jan 10, 2024

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones covers some good accessories to have on hand (ha) when working with older adults.
Links to these accessories and TONS of other equipment ideas are in our NEW Ultimate #Geri Equipment eBook. Download now by clicking HERE.

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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

DUSTIN JONES
What's up crew? This is Dustin Jones. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'm one of the lead faculty within the older adult division. Today we are going to be talking about accessories for grip in hand issues. We do not want a sore hand, sore grip, sore wrist be the limitation of us being able to achieve higher intensities, right? This is a very common thing that we run into, right? When you are working in that old not weak mindset and philosophy that you are trying to put higher intensity loads on individuals, right? You're gonna run into bears, and we're gonna talk about how we can overcome these with different accessories and different strategies, all right? The first one I wanna speak to is a very important intervention that we will do very often in the realm of geriatrics, and that is weight bearing, floor transfers, think ground mobility, right? The ability to have confidence and independence in a floor transfer just has huge implications for folks in so many areas of life that it really reduces their fear, their fear of falling, and ultimately improves their confidence in what they can do. The walk across the room, if they fall, becomes a little bit less scary. And just think of the implications of that, right? But when we often go to do those transfers, when we go to bear weight on the ground, that can be kind of troublesome for the wrist in particular. but we don't want that to be the reason we don't do this type of intervention or transfer.

WEIGHT BEARING: THE SURFACE
So if we're bearing weight, one thing I want you to think about is the surface. If we're going to and from the ground or maybe a higher level like a bed or a therapy table, think about the The surface in the sense of, you know, you probably want a little bit of cushion, a little bit of softness is great, but if you have too much, that can actually be troublesome for folks. It may feel great on their knees, but it's not gonna feel great on their wrists for most individuals. If it's too soft, what ends up happening is when we go to bare weight, our palms really press down, we end up going into wrist hyperextension, which for a lot of folks is not a comfortable situation. So when we think about surface, when we're going to do floor-based activities, ground mobility, Soft, but firm. Soft, but firm. You don't want a super soft, cushy surface. Soft, but firm is going to be better, provide a little bit of cushion for the knees and a little bit better for the upper extremities and the wrists, for example.

WEIGHT BEARING: CHANGE TE HAND
Next thing you want to think about is maybe if we don't go open hands, maybe we go fists. That'll be a little bit easier. We could also think about using the forearms as well. And so that's the first trouble area, very common trouble area for a lot of folks. We can work around that. We could also use an accessory as well. This is the first one I want to bring out. This is basically going to be show and tell, all right? So for those that are listening, for those that are watching, I'm gonna share where you can get links to all of these things at the end of the episode, but if you're listening, I'll be sure to kind of describe these as well, so you'll get just as much out of it as the folks that are watching. So weight-bearing, floor-based activities, think about the strategies, think about the surface.

WEIGHT BEARING: THE WRIST WRAP
Also think about compression using something like this, a wrist wrap, a wrist wrap. Basically, a little elastic loop that you put your thumb through and then a lovely you know kind of elastic strap that you wrap around your wrist and applies compression and that can often allow people to bear a little bit more weight through their hands also typically allows them to to hold a little bit more weight particularly with something like a overhead press for example makes it a little bit easier on folks so wrist wraps our wrist wraps can be helpful in in the situation of a floor-based transfer all right so that's The first thing I wanted to mention out the bat, now I'm going to be talking about some different accessories that are focused more on working around hand grip issues, alright?

WORKOUT GLOVES
So, the first one, and I cannot believe I'm going to say this, because this is an accessory that I often have maybe made fun of, never thought I would ever recommend, or even wear at some point, and that is workout gloves. I said, I never thought I would say this, but workout gloves, yes. The ones with the fingers cut out and the padding, you know, you see them, right? You see them all over the place. A lot of our folks here at Stronger Life will wear them, and I was very critical of this initially, and then once I checked my bias and just dug in a little bit of why people actually like these, particularly for folks that may have arthritis, that may have a painful grip, With that workout glove, it obviously reduces friction so you don't get blisters and all that stuff. Whatever, right? I don't care about that. But what's really cool about these workout gloves is when you wrap that hand around that barbell, that dumbbell, that kettlebell, that padding basically increases the circumference of the grip and if you've ever worked with anyone that has you know that kind of arthritic pain just grip issues that the wider the circumference of the grip up to a certain point the more comfortable they're going to be. It can be very painful to kind of lock down on a barbell or a dumbbell or a kettlebell, but when you increase that circumference of the grip, even by a little bit with that padding, it makes it a lot more tolerable. And so we found a lot of folks really respond well to using workout gloves for that manner. Never thought I would say that, but I'm going to go ahead and recommend them now. So workout gloves is going to be the first one that can be helpful if we do see a grip kind of limitation or pain.

WEIGHTLIFTING STRAPS
Next one, weight lifting straps. All right, lifting straps. So this is basically a glorified piece of nylon that's stitched so it has a loop and you basically wrap that strap around your wrist and then you wrap it around either the barbell, dumbbell, or kettlebell. Traditionally you see it with the barbell, but I've used it with dumbbells and kettlebells with a lot of folks and they've responded really well. And it basically That strap helps support your grip strength so you can lift a lot more weight and it distributes that load more across the wrist and so you're able to hold more weight and it's usually a little more tolerable if folks do have painful, you know, painful grips while they're loading heavily. The only drawback with this one, particularly with the folks that I work with, we're talking geriatrics, I typically have to assist them in setting this up. It can be kind of clumsy to get a really good grip, a good purchase with that loop on the weight, and so I'm usually helping them out. If you're in home health or you don't have a weightlifting strap, you can kind of rig this up with something like a gait belt. Wrap that gait belt around the wrist, loop it around the weight and hold on on top of that and you've functionally created a lifting strap. So gait belts work. The only downside to that one is the thickness or the width of the gait belt is pretty big which can cut into the wrist a little bit and you're going to have a ton of extra slack or extra gait belt to manage, but it gets the job done. If you're having to help that person in any way, it's not too big of a deal. All right, so we mentioned workout gloves. Can't believe I said that. We mentioned workout or lifting straps.

LIFTING HOOKS
The next thing is going to be a lifting hook, a lifting hook. So what this is, is basically a Velcro strap around your wrist, and that has sewn into it a metal hook. So this is really helpful, particularly for folks that have painful grips, but also very weak grips that you can still load them up in a heavy manner, do a heavy deadlift with someone, even if they can't hold on to the bar. It is convenient for barbells, dumbbells, kettlebells. Also helpful if someone's had a stroke, for example, where they have one side of weakness and their grip is not up to par, but they can still handle some weight using kind of the rest of their body. So a lifting hook. This is really convenient. And all of these things are very affordable as well. Like we're talking, you know, south of $20 that you'll be able to find. And I'll show those links at the end. So lifting hooks. All right.

WRIST WRAPS REVISITED
And I also want to mention here, the wrist wraps again, because I find them helpful with weight bearing activities, but then also with anything where you're holding the weight particularly in like a front rack position or overhead where you're going to press particularly for folks when they are new to handling heavier loads and they're really pushing those higher intensities there's that adaptation period and all y'all probably felt this too right when you started to press heavy overhead or work on that clean or a lot of folks will feel when they start to work on handstand or inverted gymnastic movements, the compression can help. We don't want to use it as a crutch, we want to build tolerance in that joint, but it can help early on. All right, so those are some accessories that I've found very, very helpful in working with older adults. Now let's talk about what we can think about if we just need to take the whole upper extremity off the table in the sense of we don't even want to load the upper extremity at all, right? Because let's say I have someone with a right-sided stroke and they have a weak grip and so I'm going to use this lifting hook. Well, what if they don't have great right shoulder stability, right? That's not going to be great if I'm going to do something like a loaded carry for example, and they're not able to maintain that shoulder stability and could potentially, you know, sublux for example. So how can we distribute the weight just taking the upper extremity off the table?

THE ALDRIDGE ARM
So the first one I want to mention, it's a really cool piece of equipment, is the Adaptive Single Arm Lifting Attachment. And so what this is, it is a popularizer created by Logan Aldridge who is He has upper extremity amputation. He's now a Peloton coach, but he's really well known in the CrossFit space, definitely in the adaptive athlete space. And he's thrown around some super heavy weight, particularly barbell deadlift with the single arm lifting attachment. It basically hooks on one side of the barbell, goes up over your shoulder, and then hooks up on the other side of the barbell. And so the upper extremity is taken out of the equation. You're still able to load very, very heavy. Next up, kind of a similar philosophy, and that is a purse carry. So this is something that I learned from Alex Germano, faculty within the Older Adult Division, and that's basically taking, kettlebells are great for this, where you basically take that kettlebell, gait belts are useful, you loop that gait belt through the kettlebell handle, and then you just put that weight on like a purse, one side or cross body, and you're basically getting load through the trunk and you can do lots of movements, carries are great for this, but you're not asking hardly anything of the upper extremity. Gate belt, I typically use gate belts for this one. So that's the purse carry. We talked about the adaptive single arm lifting attachment, the purse carry.

WEIGHTED VESTS
Next, think weighted vest. How can we wear the weight not using the upper extremity? Weighted vests are a great option. Backpacks, loading them up with cans of beans if you're in home health, great option to wear the weight to remove the upper extremity. Belt squats is another great example where we have a belt Around our waist and that is that belt is attached to some form of resistance You can get some real fancy pieces of equipment You could use the gait belt again wrap the gait belt around the waist and then loop That the gait belt through the handle of like a kettlebell for example and get a similar stimulus but you're basically loading up the pelvis and the legs and and able to achieve a higher intensity, particularly for the lower extremities, without bothering the upper extremity at all. And then think about some different pieces of equipment outside the barbell, dumbbell, kettlebell, but think about like the rower, for example. Cardio piece of equipment that we still want to maintain that cardio fitness, you can get a single arm rowing attachment. So you are not having to use that upper extremity that's limited and you can use the other one. So there's lots of options. I think the big thing from this is that we don't want to let that sore grip, hand, wrist be the limiting factor in being able to apply heavy loads to folks. We can work around these issues so folks can achieve those higher intensities and get the results that we know they deserve.

THE ULTIMATE GERI EQUIPMENT E-BOOK
All right, so I've mentioned a bunch of stuff. I showed a bunch of stuff. You can get links to all of these things in one place. Last week, the MMOA division, we released our new e-book, the Ultimate Geri Equipment e-book. In that e-book, you will see links for all of these accessories, but also all kinds of ideas for other pieces of equipment that you would want in your clinic or gym if you're going to be working with older adults. This is basically, if we had a blank slate, what would we want in our spot? And the whole team contributed. We organized that list by what's fundamental and what's optional, but then also by benefit, strength, endurance, balance, and mobility. All right, so you can get that ebook for free. It's a free download. It's in the Humpday Hustle email that just went out. So it's the first link on there or you can go to ptonice.com and then click on free resources And you will find that at the bottom of that page Tons of good stuff on there. So check out that resource lots of good stuff Just to mention those links are not affiliate links or anything. We don't get any kickbacks for any of that stuff We just want to share helpful information and basically our wish list right of what we think is cool And hopefully you'll find some good ideas in there as well. All right, so check out that ebook. Don't let those grip or hand issues be a limiting factor in the progress of your patients.

SUMMARY
And before we go, just real quick, want to mention our CERT MMOA courses, our level one online, level two, and then our live courses. All three of those culminate into the CERT. Level one just sold out. Our next cohort is going to be March 13th. Level two starts tomorrow. There's some seats left there. Our next cohort will be around May or June. and then three live courses I wanna bring your attention to. We're gonna be across the country all year, so we're gonna be close to you at some point, but three in particular that are coming up pretty quick. January 20th and 21st will be in Greenville, South Carolina, and then Clearwater, Florida, and then on January 27th and 28th, we will be in Kearney, Missouri. We'd love to see y'all in the row. We'd love to see y'all in the online cohorts and pursue that CERT-MMOA. All right, appreciate y'all. Have a lovely Wednesday. Grab that e-book. I'll see y'all soon.

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

Jan 9, 2024

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren discusses key research supporting using dry needling with electrical stimulation to target peripheral nerves to reduce pain and improve muscular function.

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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

PAUL KILLOREN
Good morning team. We've got YouTube up. We've got Instagram live. Happy to kick off the PT on ICEDaily Show this morning. If we've never met, my name is Paul Killoren. I'm the current division lead for the dry needling division with ice. And this week you actually have a dry needling double header coming at you. On Thursday, our lead faculty, Ellie Melrose, is going to dive into technique Thursday. with some subscap tips. Zach Long, barbell physio, hit subscap pretty hard last week. So we want to bring you the dry needling tips for subscap on Thursday. That's with Ellie. Catch it live in the morning or catch the recording. Today is clinical Tuesday, and we're actually going to kick off a topic that really celebrates our advanced dry needling course. As a division, we have two courses going down this weekend. One of them is myself hitting the advanced dry needling course in Bellingham, which is really cool for all of the reasons. It's an advanced course, it's kind of the last part of our dry needling trilogy, our three course series, which will build out our dry needling cert with ice. It's really cool in Washington that that third course is what gives our kind of our inaugural group the 75 hours, which as of last week, the word is that in Washington, PTs will be able to dry needle patients as early as July. So really cool stuff happening this weekend. And the advanced course is really my direct segue into the topic this morning.

PERIPHERAL NERVE STIMULATION
If you saw the teaser yesterday, we're going to talk peripheral nerve stim. And I guess first to qualify our advanced course, the first half of the course is treating more technical or slightly higher risk targets. Muscles around the scapula, around the thorax, we treat the suboccipitals, we treat some more technical muscular targets. That's the first half of the advanced course. But the second half of the advanced course, we stop having intramuscular interactions with our needles and e-stim. And what I mean by that is we do tendon needling, we do scar needling, but we do peripheral nerve stim techniques. So I figured it'd be worth at least having a little teaser topic on the podcast to discuss What are we doing with all that? And really, this is a short format this morning. So what I'm not going to do is dive deep into all of the things and all of the reasons and all of the research as to why we might intentionally, directly interact with a peripheral nerve with our needling and e-stem. But I wanted to give you some research teasers, kind of a little sampler platter, a little charcuterie board of research when it comes to peripheral nerve stem. And again, without getting into all of the reasons we might do it, it might be obvious for me to say that there's actually some pretty sound research that says if we have a true nerve injury, it was injured in surgery or there's a degeneration or a palsy or a tractioning, but if there's a direct trauma to a nerve and we're trying to regenerate or we're trying to improve the nerve health, It might sound kind of obvious that there's quite a bit of research that says if we can directly stimulate that nerve with our needle and e-stim, that there's great benefit there. I mean, that's obvious, that's a home run. Treat the tissue that was injured, all of that stuff. What you might not necessarily immediately assume is that there's actually pretty solid research when it comes to direct nerve stim being the sciatic nerve for low back pain or for improving muscular performance. even some neuropopulation stuff. That might not be the immediate thought when we talk about influencing a nerve with e-stim. And again, what I'm not going to get into today is all of the stratifying, the decision-making process of when we might stim a nerve versus when we do our intramuscular stuff. I really just want to tease you with some research because these techniques are out there. These percutaneous neuromodulation therapies are actually becoming much more popular. whether it's for pain relief as an alternative to pharmaceuticals, whether it's post-surgical pain modulation or improving muscular performance. These techniques are growing in the rehab realm, in the sports medicine realm. So I want to tease you with some research.

THE RESEARCH BEHIND PERIPHERAL NERVE STIMULATION
The first one, it's kind of a pilot research study from 2019. The author is Alvarez-Pretz. That's a hyphenated last name. And what they did was basically did one bout, it was 10 trains of 10 hertz frequency, but one session of femoral nerve stim. And what they looked at, these are patients with unilateral knee pain, they looked at immediately before and immediately after strength output. So max isometric strength for the quads before and after femoral nerve stim. And it improved. Not only did it improve statistically significantly from pre to post, but it outperformed a healthy control. So pretty cool stuff. Again, I'm just giving you these little nuggets today. But here's the first citation that says femoral nerve stem improved quad performance. And these are knee pain patients. So again, you can get deeper into the inhibition mechanisms and why that might be, but immediate change in max strength output of the quads with femoral nerve stem. Since I brought up the femoral nerve stem, let me tease you with one more. It's a 2020 publication by Paola Garcia Barmejo. Again, she's looking at anterior knee pain. One bout of ultrasound guided femoral nerve stem improved knee pain, but also range of motion, functionality, and there was a crossover. So they did it on one side, and they saw changes on both. So again, femoral nerve stim, we have changes in not just quad strength, but knee pain, functionality, range of motion, all the things. But let's talk back pain. Or let's frame it this way. Let's talk sciatic nerve stim for a moment. Because the first research publication, 2008, it's by an O, Fascinating stuff. Because again, it might be kind of obvious for me to say if we wanted to improve blood flow to the sciatic nerve, if we wanted to send blood into the vasonevorum, like engorge the vessels to the nerve, improve blood flow to that nerve tissue, it might be pretty obvious for me to say that doing direct sciatic stim does that. And it does. But here's a research article that's fascinating and gives context as to other interactions. Because for this research, they're looking at blood flow to the sciatic nerve, and they had three groups. Group one, they actually did lumbar muscle pumping e-stim. So they didn't necessarily say multifidus, but they did that muscular motor response e-stim to the lumbar paraspinals, and then they looked at blood flow to the sciatic nerve. Group two, they did the sciatic nerve stim. They put a peripheral nerve stem directly on the sciatic nerve and they looked at blood flow. Group three, they actually did e-stem to the pudendal nerve. So a separate nerve, but again, they're looking at blood flow to the sciatic nerve. Here are the fascinating findings. 57% of the folks in that lumbar paraspinal group saw improved blood flow to the nerve. So whether you want to say that that pushes us kind of towards the the changan, the radiculopathic influence, or like the segmental influence of nerves, the myotomal influence you could say, 57% of the folks that got lumbar paraspinal e-stim saw improved blood flow to the sciatic nerve. But here's the rest of the fascinating findings. 100% of the folks that received sciatic nerve stim saw improved blood flow to the sciatic nerve. That was almost their control and it worked. But the last piece here is that 100% of the folks that received e-stim to the pudendal nerve, also 100% of them saw increased blood flow to the sciatic nerve. Fascinating. So we do have an influence approximately from that muscle pump of the lumbar paraspinals, but it's almost like we don't have to be nerve specific because we can put some e-stim on the pudendal nerve and we saw improved blood flow in the sciatic nerve. Again, I'm just going to tease you with more research. The next publication by San Mitro Iglesia in 2021. Love these names. I mean, I will say most of the research being done right now is overseas, international. For this research, they had folks with low back pain and they had three groups. Those three groups all received sciatic nerve e-stem. but they were in three separate anatomical locations. So group A, they put e-stim on the sciatic nerve proximally, so near the issue of tuberosity. Group B, they put e-stim mid-hamstring, so mid-thigh, just a different anatomical location for a sciatic nerve. And then the last one was actually the popliteal fossa, so you wanna call that tibial nerve, whatever. But they're stimming the sciatic nerve or sciatic components in three separate anatomical locations. Fascinating outcomes, these are folks with low back pain. Every single group that received eSTIM to a nerve improved in low back pain, in range of motion, actually in their balance tests, and in their functional scales. And there was no difference between these three groups. So with those last two kind of research nuggets, I'm calling them, it almost seems like we can have a profound impact with nerve stem, peripheral nerve stem, and maybe we don't need to be nerve specific and we certainly don't need to be location specific, meaning we're having a global impact here. And if you've, and if you're out there and you've taken one of our upper or lower courses already, hopefully you gathered that the nervous system influence is really the driver of our contemporary understanding for the therapeutic benefit, the therapeutic mechanisms of dry needling. Now that we're interacting with a nerve, a peripheral nerve, early indications are that we're having a very similar, but maybe a more profound, more substantial nervous system interaction. Maybe it's everything we talk about, muscle spindle and motor unit loop interactions up to the dorsal horn and then, you know, supraspinal centers going to the cortex and somatosensory, all of that stuff. We're now interacting with a much more sensitive much more nervous peripheral nerve structure, and that nervous system influence has to be times 10. So again, today I really just wanted to tease you with that. We do cover peripheral nerve stim techniques on our advanced course. Again, the first half of the course, we keep doing muscular interactions. We do the rest of the muscles that you didn't get in upper and lower, the more advanced, the higher technical muscles. But then the second half of our advanced course, we do peripheral nerve stem, tendon needling, and scar needling. And maybe we can grab a few more of these podcast spots throughout the rest of this year to say, why would we interact with a peripheral nerve? Today, I just set for you a little charcuterie board of research that says we can change, not just nerve health, not just nerve blood flow or neuro regeneration, but we can improve muscle function. We can change strength. We can change pain. And maybe there are patients like low back pain where the initial strategies of conservative therapy, maybe even our, our typical paraspinal or multifidus estim isn't working. We now have one more strategy, one more tissue interaction to consider. But again, that's all I wanted to jump on today was to give you a quick snapshot of nerve stim research. Not gonna give away all of our secrets on how we stim nerves. It's probably fair to say or fair to acknowledge that all of the research I just went through, almost all of the percutaneous neuromodulation, so peripheral nerve stim with needles, fair to say that almost all of that research is done under ultrasound. And that's to ensure safety kind of, but also ensure that it is a direct peripheral nerve interaction. We're not going to use ultrasound on the course. So really the beauty of the technique is how do we interact with it safely again, for sure, but consistently and effectively. So peripheral nerve stim is a big topic on our advanced course. We have a couple that will be popping up. Again, the first one is this weekend in Bellingham. If we're not sold out, we're nearly sold out. We have one in December in Colorado, and there'll probably be one or two more that pop up Q2 and Q3. Hopefully we're targeting the Midwest. We are probably going to be back here in Washington, because again, we need that for our 75 hours to treat patients. But peripheral nerve stim, if anything, I wanted to put that in your mind today. And I mean, big picture before we continue this podcast series about why and how and when for peripheral nerve stim. At the very least, I want to keep throwing out this topic because on the ground floor, if nothing else changes in your mind, I'd like to kind of decrease the paranoia or the concern of needling near a peripheral nerve. Or if you use eSTIM, I'm sure you've had that interaction where the needle goes in, all of the words from the patient are normal, achy, crampy, sore, no nerve words. But then you add yeast into the equation and clearly you're near a peripheral nerve and you generate a different response. At the very least, I'd like to turn off some of the alarm bells that we're so paranoid of interacting with a peripheral nerve that we don't acknowledge there's benefit there. Again, upper and lower, our goal is just to treat muscular targets. We're not intentionally trying to interact with a nerve, but advanced we will. So on the ground floor, I'd love for just The, we always respect nerves for sure, but we don't want to respect them so much that we don't see that there's benefit there. Again, you should be trained in a technique. We're not trying to intentionally or accidentally interact with the nerve. We need to know where they live. If you took a level one or a level two course from somewhere else, I'm sure they mapped the large vessels, the large nerves, and we want to avoid them at all costs. And you should do that to start with. I mean, there's, There's something very precise and very safe about knowing how to not interact with it directly with the needle. But then there is another layer on top of that, that eventually, especially when we use e-stim, so we're going to piston much less, we're going to use e-stim, there's value to knowing where these tissues live and interacting with them directly. So for now, I just want to put that thought in your mind. I want to decrease some of the paranoia, some of the nervousness of being around a nerve, and hopefully I can keep teasing you with certain research. We'll throw some stuff up on Instagram. If you've taken upper or lower through us, you can look for the advanced courses popping up. To complete the CERT for ice, it is upper, lower, and advanced, but you only need to take one of them to show up on the advanced course. So let me know what you think. I mean, do you have questions on peripheral nerve stem? Throw them on Instagram. Hit me up directly on Instagram if you'd like, at dptwithneedles. Otherwise, stay tuned for Thursday. Ellie is going to jump on and show you some subscap tips. Such a key muscle for your shoulder, folks. Again, go back and listen to Zach Long's episode from last week. and how he assesses it and how important it is to treat and how he loads it because Thursday Ellie's just going to bring the dry needling smoke. She's going to teach you how to get in there safely, consistently and effectively. It's a key target. So that's what we got coming at you. Thanks for joining.

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.

Jan 8, 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 her journey to becoming a pelvic floor PT.

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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

CHRISTINA PREVETT
Everyone and welcome to the PT on ICE daily show My name is Christina Prevett and I am one of the lead faculty within our pelvic health division Today I want to talk a little bit about kind of my journey in to pelvic PT and the reason why I want to do that is because when I first started in pelvic I was actually really adamant that I was never going to be a pelvic PT. It was not something that I wanted. It was not something that I wanted to do. And I want to talk to you a little bit about why I think that's important and where we have seen a shift in pelvic PT that I think is super beneficial. So you all haven't seen me on the podcast now for a while. You know that my start and my love is working in geriatrics, right? My PhD was in geriatrics. My business model was very focused on, with Stavoff, on healthy aging. I did a lot of bridge programming between one-on-one rehab and group fitness wellness for individuals with complexities with the idea of removing barriers to exercise, and optimizing as many facilitators as possible in kind of a medically supervised but not medically necessary type of way. And part of my PhD was really trying to get into this health and wellness space. And you know that fits the bias at ICE really beautifully because we truly believe in preventative healthcare versus our sick care system that we currently have. And part of that was to do a scoping review around where physical therapists could be involved in health and wellness. And I meant that as a primary and secondary prevention aim. So not once disease has already been established, but what to think about this bridge, identifying risk factors to potential issues, or to really think about population level health. And of course, there was a lot of things in the literature that lit up around, you know, chronic Z self-management and working and isolating at risk factors like blood pressure. But one of the other things that came up and came up really strongly in the evidence base was around perinatal care. And so a lot of people go into pelvic PT around their own experiences, and that was actually not the case for me. And so I had applied for a city grant. I was like, well, if this is where we are going and we want to take a lifespan approach, then let's try and get involved in exercise in the perinatal space. And so we applied for a grant, we were able to get grant funding, and we started a program called Strong Like Mom. it was a new area for me you know i did my research on like exercise this is a lot of postpartum exercise in canada we have a year of maternity leave so a lot of moms in the first year would bring their babies in it was really great i was kind of in a period of my life where my husband and i were talking about having kids so i got exposure to other moms and their experiences i got to talk through different pelvic health complaints. And from an external perspective, I was able to help manage a lot of those conditions. But I was not internally trained. And this was back 2018, 2019. And I was still adamant that I was not going to be internally trained. And here's why. I had this belief that I had to be a Volvo Cupcake type of person. And this is absolutely no, no negativity at those who go into pelvic and love it so much that they buy a costume where their head is the clitoris. Like we need those people because they reach individuals in such a unique way. But that was the way that I had interpreted going into pelvic. So I had my exercise class. I was talking about pelvic health issues. But I really truly thought that as soon as I became a pelvic PT, all I did was internal assessments. I stayed in the room with people in supine and I stopped getting an orthopedic caseload because everybody that I talked to, their entire caseload turned into pelvic. And I loved working with older adults. I loved working orthopedically. I saw a lot of people with complexities and multimorbidity. I loved that part of my job. And I did not want that to go away from me. And so in 2018, so I must've started this program in 2017. So we're talking some years now. In 2018, I was a national level weightlifter and I got pregnant with my daughter. And we got pregnant faster than we thought we were going to, which is such a blessing. But I was prepping for a weightlifting meet, trying to qualify for nationals again for 2019. And I already had the meat. I was like well into my prep. And so I was like, you know, I'm not worried about weight. I'm well off my weight category. I'm still gonna compete. And I remember the first time I went to snatch heavy and I made contact at my hip, I started to cry. And I knew that exercise was not bad. I had well gone into the literature with me being a PhD student around exercise and pregnancy, but the visceral, fear response and the thought that everything in my brain had said, I need to protect was real. And I was lucky. We had a referral network with individuals. We were working in a research program with a high-risk fetal medicine physician and obstetrician. And we were doing referrals back and forth for individuals with cardiovascular risk. That's a whole other conversation for another day. But in that moment, I reached out to him and I said, Hey, like I'm a weightlifter. And I sent him a video of a snatch. I was like, I'm prepping for a meet. What are your thoughts?" And his messaging was so clear. He said, that baby's so small, it is back in your pelvis, and your body is used to this. It's okay, you are going to be fine. And my fear melted. It melted. And I will never, never not be grateful for that interaction. And in that moment, I recognized one, how much fear we can have around pregnancy because it's so protected. But number two, how much that fear can be melted away by somebody in the obstetrical space that you trust, that allows that fear to extinguish. And so, This was all kind of happening. Again, I wasn't doing internal PT, but I started to feel this like gut pull to this space. But I still had this like interaction where I just did not want to do only internal assessments. This is kind of the origin story of pelvic. And so I was still not coming to terms with this, but I really wanted to start bridging towards this fitness. I had been doing Strong Like Mom for a couple of years. I was a national-level weightlifter on Instagram and social media. I was getting comments about my body prolapsing and all these things that were so fear-focused, and it started to just gut me that it was so fear-invoking. and I was going and I was interacting with other pelvic BTs, they were the ones who were making me afraid because they were the ones telling me that I was going to prolapse. They were the ones who were saying, and this is not against them because that is truly what we believed and what we were taught in our training. We have come so far to move away from that narrative, but that was where the narrative was in 2018. My staff member who was an internal trained PT and I went to fitness athlete and being in this space, we kind of took over a little bit, sorry guys. In this live course, talking about things like diastasis recti and talking about how to load the core and it very naturally for me became this teaching moment. And this was in 2018, 2019. And in that moment, because Alan was there, he was like, this needs to happen. This needs to happen. And even then. When I started teaching, I was like, I do so much externally. I've seen such great results. I know there's a referral network if I need it for looking at these interactions, but I'm not, I'm still resisting against it. So I was there and we have so much evidence around telemedicine. And it was just, it was still, I was still doing everything externally. And I was like, I'm not going to bridge that gap. And so you're probably wondering where it switched. It switched when I realized that I could do pelvic PT my way. I did not have to be a person who loved looking at vulvas on cupcakes in order to be unbelievably passionate about removing barriers to exercise. You have heard me say that very quickly, when people start interacting with the healthcare system, they start to be afraid. in females or peoples with uteruses where their fear often can start is in pregnancy because they want to protect and our medical system is designed to look for what is wrong and try and mitigate those risks. And I recognize that in order to be a frontline person, to be able to mitigate that messaging, the internal PT part was necessary. And so in 2019, I went back and started doing some internal training and the training was fantastic. I loved it, but it taught me the assessment. I spent a lot of time on the assessment and I was so thankful that my external training and just figuring out my own caseload over several years had allowed me to know the intervention side of things. And they had to marry. And so our online course is very focused on external techniques. That was where my expertise was. I started blending that with my internal techniques. And I realized that the internal assessment is a tool in our toolbox. It is not our profession. It is not our profession. And as I have started to interact and build more experience and all these types of things in this space, in tandem with some of the research side of things, I so sparingly use the internal assessment outside of often times if we're working with individuals with pain. But it is not who pelvic PT is. And when I removed that expectation, yeah, 100% this, when I removed that expectation that that is what my job was, that is what defined me as a pelvic PT, I became very free to explore this beautiful area of our profession. And I blend my orthopedic knowledge all the time. I use the information from the internal assessment to provide education. And as we were doing this, and as Alexis was coming into our division and all these things were happening, I realized that our online course would not be enough. It would not be enough because we had to be able to bridge from lying in supine to fitness. We were having this disconnect where we had exercise professionals who felt very good about being able to have all of these movements and interact with these different conditions. And then we have these pelvic PTs who are very good at the assessment aspect. But going from that assessment and early foundational graded exposure to getting individuals running and playing and expressing joy with different planes of movement and different unexpected changes in their body's positions, we had a disconnect there. And so our life course started to really take form in 2020. And I know that people may think that while we do it really differently in our pelvic course, than others and the reason why it's so different is that yes we teach the foundations of the internal but we teach it in the morning of the first day because it is a tool in our toolbox. It is not an entire entry-level course in our perspective. And so we teach it in Supine, and then we bridge that to standing because how are we going to figure out where people are leaking? Yes, Supine gives us tons of information, It allows us to get some orientation, and then we go into the standing assessment, and from there we bridge. And we spend the rest of the weekend bridging, because that is where our profession needs to go. Just like you were saying, we need to use the internal. It is an absolutely pivotal skill, but we need to do that and bridge to fitness, and we are not just pelvic PTs. We are pelvic orthopedic PTs that blend everything that we know within our medical training in order to drive a fitness forward message. And so now I am loud and proud that I am an internally trained pelvic PT and I leverage it in my practice every single week. I'm a part-time practicing clinician right now because of my research. and it gives me so much insight. My patients do amazing, but it's not because of my fingers and their vulva. It is because it is the basis of which we build our foundations, just like I'm not going to just do Kegels, right? I'm going to teach the coordination of the pelvic floor to bridge to function. That is the same thing that we are doing in this fitness forward pelvic PT approach. It is why I hope that when I share my story, that somebody resonates with it. Somebody who has hesitated and said, I do not want this to be who I become. And I hope it gives you freedom, that it gives you this unbelievable understanding of the bottom of the core canister. So if you are interacting with someone who has hip pain or back pain or abdominal pain, you are interacting with it. You are interacting with the pelvic floor. And it will give you this idea that the training is not going to put you into this pigeonhole that you cannot get out of. All right, that is end for me. If you are interested in figuring out our internal assessment, we have so many live courses coming up over the beginning of 2024. I'm gonna be in Raleigh, North Carolina. We only have three spots left for that course. This weekend, end of the month, Alexis is doing a course in Hendersonville. And then beginning of February, I am going to be in Bellingham, Washington. doing all things pelvic PT. So if you are interested, let us know. Otherwise, have a really wonderful start to your week and we will talk to you all soon.

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

Jan 5, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty discusses treating the subscapularis muscle for the fitness athlete. Zach discusses modifications for pressing, pulling, and Olympic weightlifting. In addition, Zach discusses go-to exercises to use for HEP with these individuals.

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

If you're looking to learn from our Clinical Management of the 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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

ZACH LONG
Good morning, everybody. Welcome to the PT on Ice Daily Show, where it is not only the PT on Ice Daily Show, but it is the best day of the week here on the PT on Ice Daily Show, and that is Fitness Athlete Friday. I'm excited to be with you all this week. My name is Dr. Zach Long. I'm a faculty member inside of the Fitness Athlete Division, teaching both our live and advanced concepts course with the rest of the team there. Today, we are going to talk about subscapularis treatment with the fitness athlete. So the subscapularis muscle, I think, gets commonly overlooked in the fitness athlete's shoulder. Alan talked about it last week, so I'm going to follow up his discussion last week with a few other things. But like Alan said last week, this is the largest and strongest of the rotator cuff muscles, and I think it commonly gets overlooked when people are dealing with shoulder pain. And so we're gonna jump into kind of some of the different modifications and treatment strategies that I use when patients have subscapularis pain. Make sure you listen to last week's episode as well. A little quick recap of last week's for you just to set the stage here.

SUBJECTIVE EXAM FOR THE SUBSCAPULARIS
Subjectively, what I hear most frequently when people are dealing with subscapularis strains are that they have pain with dips, pushups, and the bench press, so with shoulder extension-based pushing motions. And then things like snatches, overhead squats, and kipping pull-ups, where their arms being really stretched overhead in that position.

OBJECTIVE EXAM FOR THE SUBSCAPULARIS
Alan talked quite a bit last week about testing positions for the subscapularis, and those were absolute gold for ruling in and out the subscapularis. I'm going to throw one more test at you before I move on to more of the treatment stuff. And I like this test because As Alan talked about last week, when you do like IR at neutral, the pecs are such a big muscle working right there that it's not going to be sensitive enough on your subscap. So that's why he talked about like the liftoff test in your arm. The one kind of issue that I have with the liftoff test, I use it with all my subscap people, is for those that are highly sensitive and you know that they're already really irritable, I find at times that just getting into that position really lights them up. So the test that I prefer to start with is that internal rotation at neutral, but we get rid of the pec involvement a little bit. So imagine somebody standing with their elbow right at their side, elbow bent to 90 degrees. You then put one of your hands outside of their lateral elbow and you have them push out like they're doing a lateral raise. You don't let them actually push away from their body, but they're trying to. And then you test internal rotation resistance with the other hand. And you'll find that that little lateral raise push gets rid of a lot of the peck involvement in there and will let you get a positive test for a lot of people that have a subscap strain that your standard IR at neutral would not.

SUBSCAPULARIS TREATMENT
So let's jump into treatment a little bit and modification. I'm going to say number one, from a manual perspective, like if you made me choose only one area of the body to needle for the rest of my life, and you said you can only needle one thing for forever, choose what muscle. Now this might just be because I treat primarily shoulders, hips, and knees in the clinic, but I would choose subscapularis dry needling over every other area of the body. It has just been the area that I find most frequently gets huge improvements in their symptoms after a quick dry needling session. So if you're not familiar with that, look up Paul iDryNeedle. Paul runs our dry needling division along with Ellie. and the great faculty that we're building over there, but check out their coursework. That is just a money technique to have. From a treatment perspective, so much of my treatment with this comes down to the combination of wanting to build the subscap up, but also wanting to make sure we're not continually overloading the subscap. So I have a lot of conversation with my patients on what sort of modifications they need to be making to their training to not further aggravate the subscapularis. And so, All of these are obviously based on somebody's irritability. So when they strain their subscap, if it's very, very minor, I'm not pulling all of these levers, but if it's very major, I might be. And as y'all know, our goal with the fitness athletes and all of our people in general is to keep them active. We don't want to tell them, stop benching, stop doing pushups, stop doing dips. We want to find ways for them to do those movements or similar movement patterns with less pain. So that's breakout kind of where I kind of go with modifications.

MODIFYING HORIZONTAL PRESSING
So if we start with like our horizontal pressing motions, which I think are the most common things that I hear people with subscap strains discuss subjectively, that's the dips, pushups, and bench press. I think the reason why those hurt so much is as we take the shoulder into extension, I think you can appreciate as your shoulder goes into extension that you're gonna create a little bit of compression on that anterior shoulder. And as we know, tendons don't like compression. So I think that's why extension is so irritable for these individuals. So one thing that I find myself doing more than anything else in people with subscapularis strains is I actually have them stop doing dips. And we end up replacing dips with, with push-ups or banded push-ups or some variation that doesn't take the shoulder into quite as much extension. When push-ups are pain-free, then we start moving back to dips. But generally, I find that dips are going to be really painful if the push-ups still hurt at all. So that's kind of a general rule of thumb for progression there on the dips. In terms of the pushup and bench press, I find that the most valuable thing we can do for people in terms of modifying is to just adjust the range of motion a little bit. So for the pushup, kind of the two modification, three modifications I make there are a lot of times I have individuals do a pushup down to an ab mat. So that ab mat's just gonna, they touch their chest to the ab mat instead of the floor. We reduce that range of motion, maybe an inch and a half or so with the ab mat there. And so frequently that is enough that we can now still do the prescribed workout with just that slight modification to the range of motion. Other times I find that having them really torque their hands into the ground or keep those elbows close to their side and making it a little bit more like a close grip pushup can help them out quite a bit. From a bench press perspective, very similar. So maybe instead of bench pressing, we do a floor press or a board press. So a floor press is simply a bench press where we're laying on the ground. So when the elbows get to our side, they hit the ground and you can't actually take the arm into extension. That can usually be enough that people can still press really heavy. The floor press is one of the best exercises you can do by far to improve your bench press strength, so it's a great modification in this time period. We can also do a board press where they're on a bench, but they go down and they touch one, two, or three 2x4 boards that are placed on their chest to reduce the range of motion. And then very frequently I also have, especially with more like my power lifters or people that care about bench pressing a lot, I'll use accommodating resistance. So maybe with a lightweight, they can touch their chest and not have that much pain, but if it's really heavy and they touch your chest, they get pain. So that's resist the bench press with bands so that at the bottom, those bands are unloaded a little bit, and then that weight increases as they go towards lockout. So that's a great way to really challenge the lockout, still train full range of motion, but not irritate that already irritated subscapularis. So the big key there is to probably reduce the range of motion a little bit and play with some of those variations to see if you can get people to not continually aggravate the subscapularis but still get in that horizontal pressing stimulus.

MODIFYING KIPPING
When it comes to kipping-based movements, so toes-to-bars are one that really tend to aggravate the subscapularis, I see quite a bit. I will Usually prefer to just get people to do a really tight kip where they maintain a lot of tension and they don't go into as aggressive an arch position. That is actually a performance advantage in the toes to bar. People will cycle their toes to bar reps a lot faster. So this is a great time to make people do smaller sets because a lot of times they'll fatigue more rapidly with this. but to actually work on a technique improvement that will help them out long-term. So those quick cycled reps with a little bit more tension. If it's more irritated, then we might just do an active hang, knee raise of some sort so that we're still getting the hanging stimulus. We're still getting the ab stimulus, but we're just reducing a little bit of the shoulder demands. And then when it comes to things like kipping pull-ups, if it's highly irritable and I don't feel like kipping is in their best benefit right now, we just turn that into strict band-assisted pull-ups that we maintain that high volume of the vertical pulling stimulus. We maintain those fast reps that keep our cardiovascular system up if we're talking about prescribing kipping pull-ups in a Metcon, but it will unload the shoulder just a little bit to do a strict band-assisted pull-ups versus kipping when somebody has a subscapularis strain.

MODIFYING OLYMPIC LIFTING
And then the final thing that I often modify is their snatches. So frequently, it's the turnover and the catch of the snatch that really irritate these individual symptoms. So at times, that just means we move to variations where we're not doing the turnover or the catch. So we're doing snatch grip deadlifts, snatch grip high pulls, snatch grip pulls, exercises like that. So we're still building their technique. and working on things that will help their snatch overall. But again, we're just not adding more fuel to the fire there. So that's the main modifications that I make when somebody has subscapularis pain.

TREATING THE SUBSCAPULARIS: LESS IS MORE
Let's jump now into treatment. And I think from a home exercise perspective, one thing that I'm really big on is that less for your HEP is more. We don't want to overload our patients. So a huge percentage of my patient population at this time are people that are seeing me for a second opinion. And I kind of see three things most commonly pop up when people see me as a second opinion. Number one, they were just underloaded. They didn't get a sufficient enough stimulus, their therapist was on the right diagnosis, but they didn't challenge them enough to actually build tissue strength up. Number two is they're on the wrong diagnosis, which we all see all the time. Somebody thought, you know, that because this person's pain was on the back of their shoulder radiating down to the tricep, they assumed that it was a posterior rotator cuff pain and they didn't do a great job screening out the subscapularis with the tests that Alan talked about last week and I talked about earlier. And so they're treating posterior rotator cuff when it's really the subscapularis instead. And then the third thing is people come in and they have an HEP list of eight exercises that they're doing for three sets. And I look at that and I'm like, man, that's going to take 40 minutes to get done. Less is more here, folks. So the rule of thumb I have here is that my goal, sort of like your post-op ACL that needs a full strength program, My goal with most of my individuals is to try to limit their HEP to 10 or 15 minutes or less, four-ish days a week. I think that that's pretty manageable for most of our people. It gets really crazy when you're asking people to do 30 minutes of work every single day. So to get this done in 10 minutes or less, that usually means that I'm trying to stick to three exercises, maybe four. So in the subscapularis, maybe they do some soft tissue work on their subscapularis. That's one minute. And then we do a nine minute EMOP. So that's 10 total minutes of work. We add in grabbing equipment. They get this done in less than 15 minutes. Less is more with these individuals. Try to really stick to that. And I think you'll see your HEP compliance go up quite a bit. So three exercises, less than 15 minutes, preferably less than 10 minutes is my goal. When I'm looking for exercises, I kind of have four different exercises that we might have in those three of their HEP. Number one is going to be obvious. Like if they have a subscapular strain, we're doing something to try to build that muscle and tendon backup. It would be way too hard for me to really describe these exercises here on the podcast, but if you go to my YouTube channel, Barbell Physio, you can search for all of these exercises. But kind of my general progression here, highly irritable. I'm doing internal rotation at neutral, but I'm going to do it similar to how I did the testing. So I take one band and I'll put it around their arms. So one big resistance band going around both arms. So they have to do that little lateral raise before they do the internal rotation. I'll find that that again isolates the subscap a little bit more than the pecs. Progress that to an IR punch. Progress that to an IR diagonal. Progress that to IR at 90 degrees. That's my general philosophies there. So number one, load the subscap. Number two thing to have in that HEP is to look at any mobility limitations that they might have. Like is their overhead positioning stiff? Is their Tyler test for that posterior shoulder capsule stiff? Do they lack shoulder extension? Does their thoracic spine suck? Does something as far away as their ankle mobility suck? And that's putting them in suboptimal positions for things like overhead squats or snatches. So the second component there is to dial in their mobility, The third component is lat strength. So the subscap and lats have a lot of similarities in terms of their function, but I'd say overall for the athlete doing rig-based gymnastic skills, when they have lat weakness on board, the rotator cuff ends up taking on more of the stress of those movements. I call the lats the glutes of the upper extremity. What happens when somebody has weak glutes in athletic performance? They strain their hamstrings more. They tweak their back a little bit more. Their performance overall goes down. Strong lats are so important to the fitness athlete population. So make sure you're thinking of that with individuals. That's number three on people with subscap strains is to load their lats up. 4. Something to pump a ton of blood into the shoulder tendinopathy, whatever you want to call it. And lateral raises don't bother their shoulders. So we do something like an internal rotation diagonal to directly load the subscapularis. Now lateral raises don't hurt, but we know lateral raises are going to challenge the deltoid quite a bit. They're going to challenge the supraspinatus. Those muscles are all around the subscapularis. So if I then have them do a set of 15 to 20 lateral raises, I'm going to pump a bunch of blood to the shoulder. What happens when we pump blood to an area that's currently injured? We help with inflammatory chemicals that are sitting out in that area. We help with, you know, an overall endorphin release. We just make everything feel better when we add a little bit of blood pump to an irritated area. So that's make that be our final exercise in that little EMOM for them. So I hope those modifications and HEP discussion help you out a little bit more when you see subscaps. Again, make sure you go back and check out Alan's episode. He did a great job discussing internal rotation and shoulder extension and why that's so important in this population as well. Hope y'all have a great Friday and a great weekend, and we'll see you here next time.

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

Jan 4, 2024

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the most recent round of cuts to Medicare reimbursements, why reimbursement is cut every year, and potential fixes to Medicare and the American healthcare system as a whole.

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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

ALAN FREDENDALL
Good morning, PT on ICE Daily Show. Happy Thursday morning. Hope your day is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at ICE and the Division Leader in our Fitness Athlete Division. I hope your Thursday is going better than mine. Very, very sick as you can tell. I'll try to get through this. If it's too hard for you to hear me live here on Instagram or YouTube, when I mix this podcast here in about 30 minutes, I will boost the audio and try to clear up some of my raspiness. So hopefully you can hear me better on the podcast episode. So it's Thursday, it's Leadership Thursday. We talk all things business ownership, practice management, that sort of thing. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday is a true gutcheck-style workout. The harder you want to work, the sooner you will be done. So what is the workout? Every three minutes on the three minutes, including the start of the workout, so at zero, you're going to perform 40 double unders. you're going to perform 20 ab mat sit-ups, and then any remaining time you're going to do burpees. And you are done with this workout when you hit 120 burpees. So this workout rewards those of you who have unbroken double unders or who are willing to scale, maybe practice for 30 to 60 seconds, or just do single unders and move on. It also rewards folks who want to drop the hammer, especially early on in the burpees and get a big chunk of that work done out of the way. We recommend today that you read the Instagram post for this workout that was released last night to learn how to scale and modify this. What we don't want to see is people just doing double-unders or failing double-unders for three minutes and not getting their heart rate up, really not getting any double-unders or sit-ups or burpees in, and just kind of spending 18 minutes tripping over a jump rope. That's not the goal. So make sure you read that post and scale appropriately.

THE FUTURE OF MEDICARE
Today, what are we talking about? We are talking about the future of Medicare. So if you are unfamiliar with Medicare, maybe you see patients who utilize Medicare insurance in your clinic, but maybe that's the extent of your knowledge. I recommend you go back to 2023. Look on our YouTube channel. and look up the four-part series, Mysteries of Medicare. And if you're a Virtual Ice subscriber, we're going to be condensing those four episodes into one brand new session for you that's going to actually premiere this coming Tuesday at 8.30 on Virtual Ice. So that's going to be a great resource to prime you for today's discussion. Today we're talking about Medicare cuts. It is something we hear all the time. Those of you who maybe work in cash therapy, I would urge you to continue to listen. I think we have a lot of room in the cash-based therapy space to work with these patients. We can see these patients, take cash from these patients, and have these patients get reimbursed for their visits from Medicare. if we're willing to do a little bit of extra paperwork. So I think this is an issue that affects the entire profession, affects the healthcare system in general, but it's not just something that insurance-based therapists need to deal with. It is ultimately going to affect our healthcare system as a whole. So today we're going to talk about the upcoming Medicare cuts. We're going to talk about the way that Medicare is divided and how that might look for the future of Medicare. And we're going to talk about maybe some potential ways that Medicare could be fixed.

MEDICARE CUTS
So first, let's start with the cuts. If you haven't seen, we have a 3.4% cut coming in 2024. Those of you who have been practicing for a while, this is nothing new to you. Medicare has been cutting reimbursement for Most healthcare services, but specifically physical therapy, for most of physical therapy's existence. There really has only been one year that we didn't get a cut, and that's because we agreed to a 20% cut for physical therapy and occupational therapy assistance. So, PTs ourselves, OTs ourselves, we avoided that cut. And we passed the burden on to our assistants, which now is creating an employment issue with those folks because they don't get paid as much to do sometimes the same amount of work. So we have a 3.4% cut coming in 2024. And some of you are maybe upset about that. Some of you are maybe proactive and you wrote your state senator or whatever and that's great. But the question we hope to answer today is why should you care? We talked about this in the Mysteries of Medicare series. 10,000 people a day right now are becoming Medicare eligible every day until 2030. This is the height of the baby boomer era, the generation of those folks. hitting age 65 or older and becoming eligible for Medicare or otherwise enrolling into Medicare for the first time. So what we're going to see, and it's now 2024 if you haven't been keeping up the past couple days, what we're going to see over the next six years is that our population is going to go into an inverted pyramid where the vast majority of our population is going to be at the top of the pyramid. What does that mean? What are the implications of that? That means that over time, most of our population is going to become older adults. What are the implications of that? That means the majority of those folks are probably going to be using Medicare insurance for their healthcare needs. That means there's, if we look at it as inverted pyramid, where, let me do a pyramid with my hands. There we go. Kind of, whatever. That means those of us still working, there are less of us still working than there are those who are now drawing from those Medicare funds. And we could potentially be in a situation where both the Part A or the hospital insurance fund and the Part B or the supplemental medical insurance fund that we use in outpatient physical therapy could become insolvent, which doesn't mean bankrupt and we'll talk about that here in a second. So our second point today is what are those two funds and why do we keep seeing these cuts? We keep seeing these cuts because we are trying to stretch what is going to become a decreasing amount of money if absolutely nothing changes in our medical system, a decreasing amount of money over time to the point where maybe Medicare no longer pays for all services, some services, or part of some services.

FOLLOW THE MATH: HOW MEDICARE IS FUNDED
So understanding how the money works is really important and that's what we're going to talk about right now. Medicare is split into two different trust funds. The first is Medicare Part A, or called HI, the Hospital Insurance Fund. This fund is separate from the Part B, or the Outpatient Supplemental Fund. This fund has enough money right now to be completely solvent, pay for 100% of hospital-based care until 2028, even if every single person working right now stopped paying Medicare tax. Now, that doesn't mean it's going to be solvent forever. It is forecasted that this fund will slowly become insolvent beginning in 2031, unless somehow the money that those of us still in the workforce paying into the system exceeds what those who are drawing out of it for healthcare services slows down, right? If we can get to a place where revenue begins to exceed expenses again. I don't think that's possible. Let's talk about why. We need to understand that those of you and those of us who are in the workforce still and seeing those payroll taxes come out of our paycheck, only 3% of that goes towards Medicare. That means that we only need to pay 40 quarters or about 10 years of that tax into Medicare in order to have 100% premium free hospital insurance also called Medicare Part A from Medicare. What we should know is that also covers your spouse even if your spouse never worked a day in their life. You and your spouse both get access to that. for just paying into that fund 3% of your paycheck every paycheck for 10 years. So let's do some hypothetical math. Let's keep it simple. Let's look at nice even numbers. Let's say that you're a physical therapist and you make $75,000 a year and your spouse has never worked and will never work in their entire life. That means you're gonna get about $2,884 per paycheck, and that means about every paycheck, you're gonna pay $87 towards Medicare for you and your spouse. Across the 10 years, or 120 months, or 40 quarters, or however your brain makes sense of that, that means that you're gonna pay about $10,000 and a half into Medicare. Now already some of you are saying, wait a second, that doesn't seem like a lot of money, especially for potentially two people. And you're exactly correct. Is $10,500 enough to justify the government paying for 100% of your hospital costs from the time you turn age 65? until whenever you die. 70, 80, 90, 100, 108, 115. And even if you're really bad at math, you should know that across 10 or 20 or 30 or maybe even 40 years of living, you're definitely going to exceed $10,000 in healthcare costs. And already we're kind of understanding the problem that Medicare has. So it's expected over time that this hospital-based fund will drop and become insolvent. What does that mean? It doesn't mean it's out of money, it's not bankrupt, it just means that what we're going to continue to see happening is going to continue happening. We're going to see reimbursement be cut, we're going to see more restrictions on folks getting access to care, and ultimately we'll get to a point where the fund is insolvent, which means now 100% is no longer possible. Maybe you go into the hospital and you had a heart attack, and you need a bypass and it costs you $50,000, maybe now Medicare only pays 80% of that, right? And now you owe 10 grand to the hospital, which if you're 80 years old, you probably don't have 10K in cash just hanging out to pay, right? So already, again, you begin to see the compounding of the finances in a way that is not sustainable. The other fund that money goes into is the Supplemental Medical Insurance Fund, SMI. This is also known as Medicare Part B. Those of you working in outpatient, this is what you interact with. This does not get money primarily from our taxes. This is primarily paid for by premiums that you pay to the government when you turn 65. As of right now in 2024, that's about $175 a month or about $2,100 a year. And that works on an 80-20 system. We explained this a bit back in the Mysteries of Medicare series, that if you go to physical therapy and it's $100, Medicare pays $80, the patient owes $20. Now the question again is, is $2,100 a year enough to offset how much a patient may use of outpatient costs? And again, those of you who maybe are even really bad at math and you get nervous around math, you don't have to be a math genius to understand that's not gonna cut it, right? The average Medicare patient consumes $16,000 a year of healthcare money. So is $16,000 more than $2,100? Yes, it's eight times more money, right? That means that the average person is consuming eight times more money from Medicare than they pay into it. Again, we begin to see the compounding financial problem that the math does not check out and has not checked out for a long period of time, which begins to explain why we are continually trying to stretch these funds. as long as possible. What we are doing with these cuts is essentially kicking the can down the road and hoping that something happens in the future where our population increases and we suddenly have more young people than old people that are paying into the system and these funds can potentially become solvent again.

CAN MEDICARE BE FIXED?
So, our third point, summarizing here, bringing all these points together, can this be fixed? Currently, this is a very broken system for all the reasons that we just explained. The average person consumes more money than they paid into initially or currently pay into with their premiums. We are definitely on track to become insolvent, which means payments are going to continue to decrease and that Medicare is no longer going to be able to cover all or part of some services, which means patients are going to have to pay for more and more out of pocket. What do we know that translates into? Well, when people don't have access to health care, they tend to not use health care. until they absolutely need it, right? They stop going to primary care appointments, they stop going to physical therapy, they only enter the healthcare system when their symptoms are now impacting their daily function. They're now ready to go into urgent care or the hospital, right? So what do we need to happen? We need to have a drastic reduction occur in the costs that we consume from this system in such a way that the revenue begins to exceed the costs again. What does that look like? At the end of the day, that looks like we need to have a significant decrease in how much health care the average American consumes. This is where we make our case for rehab, right? Somebody seeing you one or two times a week for maintenance therapy on Medicare that does not require any medications, any surgeries, any hospitalizations, that person is going to consume way less money than they would on average if they were not staying in shape and working with a physical therapist, right? This is how we justify our utility to the healthcare system. We need to make a significant dent in the chronic disease epidemic if we're ever going to have a hope of fixing this system. Now, I'm not a pessimist. I'm also not an optimist. If you know me very well, I would consider myself a realist. I'm not the person that's going to clap it up for you and tell you you're doing a good job, but I'm also not the person that has a bunker full of, you know, 15 years of canned goods and batteries and solar panels and that sort of thing. I'm kind of right in the middle. The realist in me says that we're not going to be able to turn this ship around in time to fix this. and that if you're listening right now and you're of working age, that you should do everything possible to ensure that you do not need to rely on Medicare yourself for your health insurance. when you will be Medicare age. You should also expect that the age to become eligible continues to get pushed back. It's not unrealistic to think that those of us who maybe are in our 30s or 40s now that in 20 to 30 plus years you may have to be 70 or 72 or maybe even 75 to begin to collect those Medicare benefits. That means you need to be able to provide your own insurance or otherwise pay for your own health care or Humor me, exercise enough so that you don't need to use a lot of health care because it's not going to be available for you anyways, right? And this is the message we need to imprint on our patients, especially if we can get them younger, right? Especially if we can get that 19 year old World of Warcraft player who doesn't like to exercise shake that person Spencer damn it will you please go and pick up some heavy stuff a couple times a week and get your heart rate up because you're looking at a really long life of decreasing quality and quantity of life and oh by the way in your future because you're so young nobody is going to be around probably to help you pay for that so we need to be realistic about that as well we need to understand why these cuts happen and There is absolutely, I believe, nothing we can do to stop or reverse these cuts. They happen across the board. They're beginning to happen to physicians as well. Everybody is being affected because we're getting closer and closer to that time point where these funds are going to slowly become insolvent.

SUMMARY
So that's Medicare, that's why we have cuts, why we have cuts every year. Why do we have cuts? We are stretching a limited amount of money and hoping for a brighter future to magically stumble along where somehow we start having more children so that our population shifts to have more young than old again, and also maybe a future where enough people take care of themselves to the point where they don't need to consume $16,000 a year on average from the healthcare system. Is it possible? I don't know. Call me in 10 years and check in with me. But I think it's important that we understand this baseline and have a knowledge of this both for ourselves to understand why sometimes in the clinic things happen the way they do and also to better educate our patients Hey, in the future, especially those folks who are younger or middle-aged, there's no one coming to save you. We need to find you something that you like to do every day so that you can save your future self, right? I love what the older adult division says. We're all older adults in training and we need to start acting like it. There may potentially be a future where there are no safety nets for us. It's you against the world. At the end of the day, if you have some sort of issue that causes you to enter the healthcare system, then we need to begin to prepare our bodies for that potential future. So if you're a Virtual Ice member, join us on Tuesday. We're going to talk a really deep dive into Medicare. We're going to talk about why it's relevant, yes, to insurance-based clinicians, but also how cash-based therapists can interact with Medicare patients as well in a legally compliant way that still sees them get paid for working with Medicare patients. So I hope you have a wonderful Thursday. Have a great weekend. We'll see you next 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.

 

Jan 3, 2024

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses the top 4 "ins" and "outs" to geriatric practice in 2024.

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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

CHRISTINA PREVETT
Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of the lead faculty within our geriatric and pelvic health divisions and happy 2024. So I'm really excited because I have been seeing these like ins and outs of 2024 all over social media and I thought they were so fun. And therefore, I wanted to try and do the same thing for geriatric practice. I think it'd be so fun. So in today's episode, I am gonna be doing four ins and four outs for 2024 for geriatric practice.

IN #1: HIGH-INTENSITY
So the first, we're gonna start with the ins. And the first one that you know if you've been following MMA for any amount of time is we are going to put high intensity everywhere. And we recognize that high intensity is relative, but we have actually updated our content in the last year to just reflect that we cannot ignore intensity anymore. And that doesn't say that we're gonna ignore the accumulated effects of low to moderate intensity exercise. That's absolutely not it. It's that we cannot be afraid of high intensity exercise anymore when we have overwhelming evidence across all life stages and across a variety of different chronic conditions. So when we have octogenarians and individuals with lung cancer and individuals who have had a stroke who are successfully able to participate in high intensity endurance training or aerobic training, We can't ignore it anymore. It's just the evidence is just too strong. And so that is going to be our in is to push every single day to do something a little bit higher intensity than we previously would and play around with intensity as a variable. That's number one, high intensity everything.

IN #2: USE OBJECTIVE MEASURES THAT MATTER
Number two is that we need to get objective measures that matter. When we teach at MMOA Live, we always look around the room before we start our outcome measures lab, and we try and make outcome measures fun, I promise. I think it's fun anyway. We ask individuals, how many people are having a goal for their geriatric patients that are they need to get objectively stronger? everybody puts up their hands right if you're older adult can't get out of a chair without using their hands like their leg strength is less than their body weight which is a dangerous place for them to be because what happens if they they break their wrist and so that is almost everybody says yes this is what I want them to do when we ask how do you how many people take an objective measure of strengths that they know is that they're prescribing in the right intensity zones, that is usually a lot less. That's a lot less people putting up their hands. And I get it, we think that we have to wonder at max deadlift with somebody and that seems absolutely ridiculous for some of our patients who are maybe seated a lot of the time or have a lot of frailty on board, but that's not the case. That's not the way that we need to do or we need to always think about objective intensity. We have different ways. And so our in for 2024, number two, is that objective measures for function matter. And we are not going to know if we're hitting the right spot. There's always this Goldilocks equation, right? Like I've had people mad at me because I've been a little bit too hot on the intensity, but I've also left a lot on the table from being a little bit too cold. So we have to be able to objectively measure where we need to be and we need to know what we can do in order to hit those targets. So that's number two.

IN #3: PRIORITIZING A FITNESS-FORWARD APPROACH TO GERIATRIC CARE
Number three is that we need to start prioritizing a fitness-forward approach to geriatric care. And I know, you know, I would probably say that the geriatric space, with so much being involved in balance, false prevention, we're not as manual therapy focused. We always joke at ICE that, you know, which ones are our gericrew, because our hands are just not nearly as good as some of our orthopedic outpatient therapists. But There's this idea when we start talking about kettlebells and heavy bands and barbells that fitness forward approach and geriatric care is expensive. And our MMA crew, we have to just laugh. Like we laugh and laugh and laugh because if you look at the cost of a new step, our clinics are not hesitating to buy a $10,000 piece of cardio equipment but do not want to put in $1,000 in order for them to be able to get some true measurable objective strength training equipment. And Alan tells me, because he's a guru in this stuff, that you can get a lot of that reimbursed through a tax credit. So it is not as expensive as you think, and it doesn't have to be as in-depth as we are thinking when it comes to buying fitness forward equipment. And for our home healthers or those that are traveling, you know, having a heavy road ban and having one or two kettlebells in your car is not a huge investment. And it's absolutely something that we can do in order for us to take a fitness forward approach to rehab. So we have one high-intensity everything, two objective measures that matter, that give us information, and three is just prioritizing that fitness forward approach.

IN #4: POST-MENOPAUSAL ACCESS TO HORMONE REPLACEMENT THERAPY
And then number four, I have to put my Jerry UI, Jerry pelvic hat on, is that we're going to start removing some of these barriers for women who are post-menopausal to access HRT. There is a big push right now because we see, for example, that topical estrogens can significantly reduce rates of urinary tract infections. Urinary tract infections are absolutely devastating for some of our older adults. And there is a lot of fear. I'm pushing against it every single day in the clinic when I'm working with someone post-menopausal and I bring up estrogen and they say, I talked to my doctor and they said it's dangerous. It's going to give me cancer. they're not prescribing it and that is just so behind the times and that is not where we want to be so in 2023 going into we're going to get rid of it 2024 we're going to be advocates for it and we're going to have our own knowledge to be able to be able to give our clients up-to-date information about something that can significantly impact their health. I was just reading a cross-sectional survey on menopausal women who were active, and it showed that 68% of them, as they went through the menopausal transition, had an increase in joints, aches, and pains, which means that we're missing something oftentimes in our assessments if we're not trying to take into account estrogen status with how they're presenting in the clinic. So there are our four M's, high-intensity everything, objective measures that matter, a fitness-forward approach, and it isn't that expensive, and using HRT for menopausal women who may be eligible for it.

OUT #1: DISMISSAL OF COMPLAINTS DUE TO AGE
So let's talk about our outs. What are we going to kick out in 2024? Number one is we are going to kick out these dismissal of complaints based on age. We are going to kick them to the curb. Almost every condition in our medical system has age as a risk factor. The longer we are on this earth, the more wrinkles we have on our insides, we have on our vessels, we have in our organs. Yes, it is an increased risk for orthopedic musculoskeletal pain, for different signs and symptoms of functions at different organ systems, yes. but saying that it's because you are such age or that you should not have the expectations to feel healthy and vibrant at 70 because you're 70, that is not okay. We are going to stop dismissing complaints, stop saying things as physios like, of course you have bone and bone arthritis, you're gonna have pain in your knee or you're over the age of 60, pain is never going to be completely gone. You're never gonna be pain free again. Things that I've heard from a rehab clinicians in my area We need to stop dismissing complaints.

OUT #2: ELDER SPEAK
The second thing is elder speak. We're going to kick elder speak to the curb. Oh, I have a 99 year old. She's so cute. She was a surgeon. She has raised 10 children and has 25 grandchildren and is still a really active part of her family. I hear this on our courses all the time. Oh, I have the cutest 75 year old. It is meant well, but it is dismissing or infantilizing our older adults that deserve our respect and reverence. And so we are going to adamantly hold that line. And kind of our to be to this is we're gonna really focus on using patient first language. So many times when we ask like, tell me who you're going to work with to implement some of these things from MMOA on Monday, we say, I have a stroke that is 75. instead of saying, I have a person who had a stroke, who is 75. And it can completely dehumanize them. And we do it for quickness of communication often, but it is definitely something that we need to be better at in order to allow individuals to not have their disease central to their wellbeing and their identifiers as a person, right? We see this all the time, that individuals start to become their diseases. And if we speak like that, then it becomes so much easier for that to happen, right? We do not want to say you are your stroke. You are a person who is hopefully going to live a very high quality multidimensional life with impairments that you did not have before, but you are not your stroke. So I kind of put that as an elder speak bee, okay? So the first thing we're going to make sure we kick out is dismissing complaints based on age. The second thing is we're going to watch our own communication. We're going to kick out elder speak. We're going to kick out this patient first language, or we're going to use this patient first language. We're going to kick out identifying individuals as a shoulder or a knee, or I have a total joint replacement. Got three knees and a hip on my schedule. We're going to kick all that language out because it starts with the way that we communicate in our minds and with our colleagues, and then it trickles into the way that we communicate with our patients.

OUT #3: BLANKET CONTRAINDICATIONS
The third thing, this might be a little bit of a lofty goal, but I'm gonna say it anyway. We're gonna start removing blanket contraindications, right? If you've kind of been around our crew, you know that the bed lift twist restrictions after things like lumbar surgery, people go to the bathroom the first day, they're bending right away. They just have to be taught how to bend or something. We know that our hip precautions don't really do anything. And we have all seen that patient that comes in 10 years later after getting a stent done and says, well, I can't lift more than 20 pounds. I had heart surgery in 2014. And we're like, whoa, whoa, whoa, whoa, whoa. What are we talking about here? We need to DC those recommendations. So what we're starting to see over and over again is that blanket recommendations are kind of done based on theory of tissue healing. But we know as rehab clinicians that they all respond to stress. Right, our body needs to gradually reintroduce stress across a graft, across a surgical stalcar, across an injury, and that needs to be done in a nuanced, individualized approach, and these blanket recommendations oftentimes do not really help, and what they do do is create a lot of kinesiophobia. And oftentimes, because of the way that our medical systems are set up, where we don't have appropriate or adequate follow-up, because we're just so overrun with a lot of different medical professions, they don't get discharged. And so we wanna try and be really mindful of that. All right, elder speak, A and B, dismissing complaints, blanket contraindications, and then the last one, and I'm gonna end here, is that we are going to avoid taking a siloed approach to our rehab.

OUT #4: SILO APPROACHES TO HEALTHCARE
So often, PTs are not tapping the shoulders of our OTs, our speech-language pathologists, our social workers, our nurse practitioners, our pharmacists, and we think that we need to know all the answers. It is funny, the more education that I get, the more I realize how much I do not know. Every time we are doing a course, I get somebody teach me something new and We don't need to. We don't need to know everything because we have our colleagues. We have our friends. Our healthcare system is meant to be a multidisciplinary collaborative. process. And I know you all are looking at me being like, well, you know, it's got to go both ways. And I totally agree, especially with our physician spaces. And that is something that I'm really passionate about advocating for as well, is letting our physicians as well kind of pass the baton and say, I don't have the space, I don't have the knowledge, but this person does. And so what I want to see get kicked out in 2024 is this idea that we are our own island. because it just makes our patients feel so alone or so unheard. because the communication doesn't go back and forth. In our medical professions, we're starting to become so hyper-specialized that sometimes we only look at the tree and we don't see the forest. This is where our PTs, OTs, rehab clinicians, we do a good job of zooming out, but sometimes we put ourselves in these silos too. I'm not a pelvic floor PT, so I'm not gonna talk about your pelvic floor despite the fact that the reason why you're not exercising with me is because you're peeing every single time. I'm not a vestibular specialist, so you're gonna tell me that you're dizzy, but that's not in my wheelhouse, so I'm not going to talk about it, even though it's the biggest barrier to you exercising, right? These are all things that we silo ourselves within our profession, and then we don't often tap on or even look for other clinicians in our area that could be helping our patients. And so we wanna take this siloed approach, kick it out, and kind of an in is that we're gonna really try and lean on relationships with our colleagues. And it's hard in a really busy clinic, I get it, but we absolutely have a role to play and we want to lean on them so that we know what they are capable of. And so we wanna even know their scope of practice. So we have so much, so much work to do.

SUMMARY
So looping this around, what are our ins? High-intensity everything, objective measures that matter, a fitness-forward approach, and using HRT for menopausal females. What are our outs? We're not going to dismiss complaints because of age and just say, well, you're 80 years old. Nope. We are not going to communicate with elder speak or avoid patient first language. We are going to maybe hopefully get rid of some of these blanket contraindications, take a very gradual approach. And then we are going to kick out the siloed approach to rehab. Alright, if you are looking to catch MMA, our Level 1 and Level 2 courses. Level 1 starts January 10th, formerly known as Essential Foundations. Our Level 2 starts January 11th. If you are trying to see us on the road, our first courses back start the 13th, 14th. So we are in Maryville, Ohio, and we are in Santa Rosa, California, the 13th, 14th, and then the 20th to the 21st, we are in Clearwater, Florida, or you can catch me in Greenville, South Carolina. So hopefully we will see you on the road sometime this year, or we'll see you in our courses. We have some big, exciting changes that are coming around the ICE pipeline. So stay tuned, have a great day, everyone, and happy 2024.

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.

Jan 2, 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 dealing with doubts in the clinic, how adopting a fitness forward approach can help solve a lot of "What if?" problems that arise when trying to pick "the best" intervention, the concept that doubt is bilateral, and how a fitness forward practice style can help build confidence with both patients & providers.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.

ZAC MORGAN
Alright, good morning PT on Ice Daily Show. For those of you who don't know me, I'm Dr. Zac Morgan. I lead in the Spine Division with both Cervical and Lumbar Spine Management. Great 2023 with all of you all on the road. Exciting 2024 ahead of us. So we've got a lot of changes coming with ice, so keep your eyes peeled. You've seen some of the certifications roll out. You're seeing courses pop up there on the website regularly. We will have more to offer there as well. So we're not fully booked with Spine, but we're getting close. So eyeball some of those dates. We'll cover those in a little bit. Let me start off by kind of debuting today's episode.

DEALING WITH DOUBT
So I kind of want to set the stage with a little bit of an overview of what I'm talking about when it comes to dealing with doubt. And why I think using a fitness-forward approach in the management of your patients with really any musculoskeletal issues or whatever issues they're coming to you with, I think using that fitness-forward approach adds so much certainty in those doubts. So what is fitness-forward PT and how is it different is a good place to probably start. Thinking about the concepts of fitness-forward PT and how that might differ from other approaches, I think this for me is obvious when you see it. Fitness-forward PTs are trying to at any corner to bleed fitness into their plan of care. They're trying to bleed health concepts into their plan of care. So rather than your first choice always being mobilization, or manipulation, or dry needling, or any of those things that we also love, you might see fitness-forward PTs just as equally choose something like isometric loading to reduce pain symptoms, use cardiovascular exercise to reduce pain symptoms. More on those types of things later, but I just think it's important to understand that those things could be utilized for the management, for the modulation of symptoms just as much as manual therapy and in fitness forward care you will see that. So we love highlighting these things. Let me tell you a little bit personally about why this episode is important to me. Early in my career the biggest thing that plagued me, the biggest thing that got in my way of helping patients when I think back to those times It was my own personal doubt. So I had a lot of personal doubt in the approach of care that I was delivering to people. That approach, for me, when I first started in this profession, centered a lot more around manual therapy. That was basically where my head was at, was trying to figure out the right mobilization for that person, doing it in the right direction, the right level of vigor. These types of concepts were always running through my mind in the middle of that evaluation. I wonder if this person would respond to thrust manipulation. I wonder if I should try grade 3 moving immediately. All of these concepts were bouncing around and I'll be honest with you all, what it led to for me was a lot of confusion and a lot of concern that I might be selecting the wrong technique for the person.

"DOUBT IS BILATERAL"
And what that ended up leading to clinically was doubt that was bilateral. So what I mean by that is that my client, they could start to tell that really what I was doing was somewhat bouncing around interventions trying to solve their problem. The problem was it wasn't solving their problem. So as we switched from intervention to intervention, that client often started to develop some doubt in my point of care. Perhaps just as importantly, if not more, I started to develop doubt in my plan of care at this time in my career. So I wasn't sure what was going on. I knew I was recognizing some patterns in front of me, but whenever I would see them, I wasn't sure exactly what the best solution might be for that person. And so I had a lot of doubt. And I think that then allowed space for that patient to also create a lot of doubt.

OVERCOMING DOUBT
So let's talk a little bit about dealing with this and what I think this kind of manifests as for most of us clinically. And I think this happens the most at the front end of your career versus the back end, but it happens really regardless. It's imposter syndrome. So if you're not familiar with imposter syndrome, this is that feeling you have where you're not quite sure you're good enough. where you think you might not be the right person for that client in front of you. If they had gotten the therapist next door, they would have been way better off, might be a thought that's going through your mind if you have a lot of imposter syndrome that you're dealing with. And I know I dealt with this tremendously, and all of the newer graduates that I talked to on the road, the ones that we mentor here at the clinic, all of these things, they often lead to imposter syndrome, and we get to the point that we're not quite sure what's going on with the patient, And that leads us to the spot of, I'm not quite sure I can help, and they would probably be better off with someone else. Well, team, we have to pull through that because we all have so much value we can bring to clients. And as you get further in your career, you start to believe that more, and it becomes a little bit easier to somewhat sell that plan of care to the client in front of you, to build them the bike, to get them moving forward. This happens to all of us at some stage. And so I think it's important to understand if you're there, what are the moves that I can make to get out of imposter syndrome? And if you're not dealing with imposter syndrome, it could always come back up. It's something that even to this day, there will be times where I'll have that moment where I'm like, man, I'm not quite sure. So it is something you will deal with clinically and it's something you want to be well prepared for because it has some clinical impact. The clinical impact that I was talking about before of lack of confidence, both for you delivering things to the patient, but also for the patient receiving those things from you. there is no doubt that there's clinical impact to imposter syndrome and we want to get rid of that. That way that clinical impact is all positive. The way I believe that we're going to do this is by shifting the manner in which we manage our patients.

MOVING TOWARDS A FITNESS FORWARD MINDSET
What I mean by that is if you're not already, you have to move towards a fitness forward mindset. You have to kind of underline your care with fitness forward. The issue with the way I did it early in my clinical career of being more like manual therapy focused. is that you're constantly using all of your brain power to try to figure out which mobilization the person would respond to. To try to figure out what direction, what level of vigor, how long should you do the mobilization. All of these factors are running through your mind clinically. And a lot of times, the answer doesn't live with manual therapy. The answer lives with what that person does for the remainder of the hours of their life when they're not on your table. That's a huge portion of what's driving people's pain scenarios. And the beautiful thing about that is the things that work for all pain scenarios are lifestyle changes. They're these fitness forward approaches. So you take something like cardiovascular training. So getting the heart rate up, whether it's for a short time at a higher heart rate or a long time at a bit lower of a heart rate, that no doubt will reduce symptoms. So in those patients that I'm confused on, I'm not quite sure what's going on, I feel a little doubtful, early in my career I would be trying 10 different mobilizations on them and by the end of that hour They would have got up probably sore, mostly maybe even just from laying in all those different positions while I was troubleshooting different techniques. But overall, they would often get up off the table, they'd be sore, and I'd be confused. They'd be like, ooh, it doesn't seem like Zac knows what's going on. In the back of my head, I'd be going, ooh, I really don't know what's going on. This person seems worse, not better. The way I would approach that person now is completely different, and that's because I've shifted in the direction of fitness forward. Now, when I'm unclear as to what's going on, if it's early, think like really acute neck pain, really acute back pain, those people that move through the door and you can just tell by looking at them, this person's not going to tolerate a whole lot of movement today. In the past, I would have badgered that person with a lot of manual therapy. Now, I'm going to get that person really comfortable and give them a cardiovascular stimulus. Maybe that's standing on the bike where they can use arms and legs. Maybe it's on the rower. Maybe it's on the skier. Could be the arm bike. It could be really anything. Could be the new step. The beautiful thing about cardiovascular exercise, it doesn't really matter how you leverage it. The pump gets going regardless. So as long as that heart rate gets up, you're gonna see some pain drop. I might would choose some isometric loading for this person now. I might would choose some breath work, right? Just having them in a comfortable position, just simply sitting down, thinking about nothing other than their breath, doing some physiological size or box breathing or 478 something to stimulate that parasympathetic output. When you think about this, this is a lot more global on the human than that local joint and how it moves. Do we want to address that local region with even with manual therapy? Absolutely. Does it always have to happen on day one? Absolutely not. And I think that's where it has shifted for me. So rather than being focused on kind of underlying my whole plan of care on did I select the right treatment plan, the right mobilization, the right progression of forces for this person who has a pattern of pain I recognize in front of me. Rather than doing that, now it's how can I get this person fitter? What in the world can I do to get this person to adopt a more healthy lifestyle? And in the short term, I still want to recognize those patterns. I still want to provide those positive stimuli, but at the end of the day, I'm trying to get after the big rocks, the big levers in their lives.

FITNESS FORWARD BUILDS CONFIDENCE
The reason I think this is so advantageous when you compare it to that manual therapy based approach, or just maybe more focus in the manual therapy based approach that I kind of grew up in in this profession, is it builds confidence. It builds confidence for a few reasons. One, you know that you've provided this person with something that's positive in their life. They may not get any exercise without you encouraging them to do this. you know what you've done for them is helpful and potentially life-changing. Like if you can convince that person to sleep a little better, you can convince them to do a little bit more on their day-to-day with exercise, that may dramatically alter the course of their life. The beautiful thing is, odds are pretty good it will also reduce their symptoms, which is why they walk through the door. Now if you did it the old way, you might be trying to select the right mobilization, the right direction, the right force. All of these factors would be at the foremost of your mind versus how do I get this person fitter. And while I'm okay with you thinking about these things, and I hope you're not hearing down manual therapy, I just don't think it's where your brain should be. Because when you think about it, if that doesn't work, and you get through the session the way I used to, at the end of that hour, the person's often sore. They're often a little achy, and they've lost a little bit of faith in what we're doing here, and so have you. And so that prognosis at the end of the session doesn't sound as strong. But when you know what you're giving the person is something that will be beneficial and positive to them, you can feel really confident when you deliver that plan of care. And team, in watching a lot of young therapists and doing this for a while now myself, I think the delivery of the confident plan of care, reassuring that patient, we see folks like you a lot, what we'd like to do now is X, that moment for patients is more important than what mobilization you selected. It's more important than what manipulation you did. It's more important than the direction you went. We want to create that moment where the patient goes, oh wow, I think they've got me. I think you will feel more confident delivering that moment when you underline your plan of care with fitness forward care versus when you're trying to select the perfect treatment. We have to absolve ourselves and understand no one knows what's going on with our patients. We're never going to have our exact finger on the pulse of precisely what's wrong with that person from a tissue diagnosis standpoint and it wouldn't matter if we did. What we do know is when we get people more towards a healthy lifestyle, when we give them some psychologically friendly understanding of what's going on, when we give them some skilled manual therapy, and when we do that in a fitness forward package, we move that person forward. And that has just given me so much more confidence in my plan of care delivery, as well as just prognosis delivery with those patients. And I see it happen a ton with new grads and folks that I mentor all the time. So I think the last thing I want to say here is if you still feel a little bit of that imposter syndrome and you still feel like, oh man, I'm not quite sure if I'm the right person for this patient to see who's dealing with acute back pain, I want you to think of where else they could go. So, yeah, not only could they not receive a fitness-forward approach, which is a bummer, but on top of that, if they didn't go to you, who may not know what is going on and may be a little nervous about treating this patient, if they didn't see you, they might go to Urgent Care. They might go to the emergency department. Those places are no place for you if you have acute back pain, if you have acute neck pain. You need to be in a conservative provider's office. Now if that conservative provider decides that you need to be elevated into the healthcare system, so be it. But we need to be at the forefront of that. Because think about it. Not only do costs go up, think about the psychological sequela of going to the emergency department first. having that scan done, being told here's what's wrong. Think about the patients you interact with who have chosen this route that right now are probably the most frustrating ones on your schedule. We have to get them out of that muck and if we sit here thinking what we do isn't effective, we'll never be able to get patients out of that muck. We have to be completely confident that what we deliver is the most effective thing that they could get and And that is fitness forward care. And when we deliver that, we can be confident in it. And when we're confident in it, we can pull people out of that muck of the healthcare system. This is the point of today's episode. And so team, I think that's why we, that's the way in which we can deal with doubts and shift away from imposter syndrome. So just quick summary. All of us deal with imposter syndrome. We all deal with doubts. There are times where a patient is in front of you and you go, man, it could be one of these three patterns and I'm just not quite sure. Rather than trying to be perfect and select the perfect treatment every single time, why don't we select the actual best treatment for that person, which is probably to move them more towards health. That may come in the form of fitness, it may come in the form of sleep improvements, perhaps changing some of their dietary factors, dealing with their stress differently. TINA could be any of these factors, but we have to be ready alongside of this person to move them dramatically in that direction quickly, so that when their symptoms start to drop, they associate that with those health behaviors. Once we get that association going in their brain, You just changed the person's life. You didn't just stop at back pain. Sounds dramatic, but it's true, and that's what we're after. So team, the way we deal with doubt is to use fitness forward care. The beautiful thing about fitness forward care is even if you were wrong, you helped the person. You helped them dramatically. So even if you thought it was a derangement, it turned out to be a dysfunction, doesn't matter. That person still left 1% fitter. That person's moving forward, dramatically in their life, you're going to figure that out session over session. So the next time you see the person, it may be a different pattern. That's the point of the symptom behavior model. That's why we gather data. That's why we look at asterisks, so that we know we're helping. So maybe the pattern wasn't perfect on day one, but when you choose fitness forward, the treatment will be.

SUMMARY
Team, that's all I've got for you all this morning. I just want to kind of last wrap things up with a few quick point outs of where we're going to be on the road this year. So starting in Q1, if you're looking for a little bit more in the clinical reasoning realm, if these words like asterisks and rechecking asterisks and kind of forming that plan of care or things that you're looking to improve on in the new year, I would definitely suggest jumping into cervical or lumbar. That's where we really focus on those clinical reasoning measures. And in February, on February 3rd and 4th, we've got two courses for you. So there's Hazlet, Texas and Wichita, Kansas. be aware Wichita, Kansas only has a couple seats left, so if you are near there and you want to jump into that course, do it soon, because that course is about to sell out. And then at the end of that month, February 24th and 25th, West Coast, Simi Valley, California, so right outside of LA, that one's selling really well too, so there won't be a whole lot of seats available by the end of that. So if you're looking for any of those, jump in. If you're looking for lumbar management, January 27th and 28th, Rome, Georgia, Cincinnati is close to sold out. That one is actually the March 9th and 10th, and then March 23rd and 24th, Milwaukee still has some seats left. So if you're looking for either cervical or lumbar, those will be your Q1 dates to look for. That's all I've got for you all this morning. If you want to continue the conversation here in the chat, I will be on it all day, but thank you for your attention this morning, and I will see you on the road in 2024.

SPEAKER_00: 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.

 

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.

Jan 1, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan defines interrectus distance and how to measure it, how to functionally measure core strength, and the limitations of focusing on interrectus distance with patients.

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

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

ALEXIS MORGAN
Good morning, PT on Ice. Getting both our cameras going here. Good morning, PT on Ice Daily Show. My name is Dr. Alexis Morgan, and I am excited to be with you on this morning, this new year. Happy New Year, everyone. And let's talk about measuring IRD or inter rectus distance versus measuring strength. Which one matters more? So to jump right into the topic here, Interrectus distance is a common measurement that individuals are going to be taking in pelvic health.

WHAT IS INTERRECTUS DISTANCE (IRD)?
So interrectus distance is the distance or the measurement of the linea alba width. It's that linea alba between the rectus abdominis on the left compared to on the right. What is that distance between? That's our interrectus distance. Many people advocate for measuring interrectus distance. Number one, it's measured in a lot of our scientific studies that is looking at diastasis recti. There's a lot of studies that are looking at it. And so if they're looking at it in the studies, well, maybe we should be looking at it in clinic as well. It's also repeatable. We can measure it the exact same way and we can see if there is change. And we like data that we can measure and we can see if there is change. So people are definitely advocating for its use. There are some benefits from measuring change. Obviously, you're here at ICE, you know that we are recommending to be able to test and retest to see those differences in all aspects of care. So, of course, we should be recommending that here, right? Well, we do recommend testing and retesting in this space.

MEASURING STRENGTH
However, we recommend measuring strength. So, measuring strength entails getting functional with your clients. One of our favorite tests is the sit-up test. We talk about it in our online course, and it is a way in which you can measure how strong an individual's rectus abdominis is. So they're sitting up. How much support do they need from their legs? How much support do they need from their arms? Do they need to whip themselves up or can they control themselves up? Do you need to hold onto their feet or not? This gives you a score. And with that score, we can then track change over time. It's extremely functional. This is what individuals are doing when they're getting out of bed or when they're getting up out of the floor with their little ones. This is also very functional for all populations. So not just the postpartum individual, but this is also helpful for individuals who are post hernia surgery or pre-hernia surgery. This is great for individuals with varying levels of adiposity. You don't have to measure, you don't have to assess something and be distracted or be, oh, I don't really know what I'm looking at because there's adiposity. We're just measuring strength. We're just testing the functionality.

LIMITATIONS OF IRD
When we think about the limitations of measuring the interrectus distance, Really, I could go on for a long time here. There's actually no known pathological number or centimeter or measurement. There's no known measurement that we all are in agreeance of like, yes, that number is pathological. We don't have that. In 2021, a recent paper came out and actually I believe Rachel did a podcast on this exact paper. So I'm not going to go into all of the details. You can search back to listen to this, but in 2021, a paper came out looking at individuals ages 20 to 90 males and females of all BMI sizes, looking at their CT scans and they measured the interrectus distance. With all of these people, 57% had greater than two centimeters in that interrectus distance. Now for reference, over the last 70 years, much of the data, much of the science that is looking at diastasis is using measurements, oftentimes in centimeters, and they vary. There's no agreeance in these studies. So sometimes there are two, sometimes it's 2.2, sometimes it's 2.5, that that one particular study calls pathological because there's no known pathological. But around that two centimeter mark, Well, now we have this study just in 2021, looking at what is normal. And we see that 57, so over half of the individuals actually had greater than two centimeters. So there's a problem here. We can't call this pathological of more than half of the individuals of all ages, of all BMIs, parity being one risk factor, but BMI and age also being risk factors. We can't use that. Not to mention in all these studies there's a variety of tools that are being used. So measuring with just fingers, measuring with calipers, measuring using a ultrasound machine. There's a lot of different ways to measure and of course those are going to be different between different tools. We don't have any standards. We don't know where exactly should we measure. In all of these studies, sometimes it's a couple centimeters above the belly button, sometimes it's more, sometimes it's less, sometimes it's right at, sometimes they avoid. There is no absolute on where we should measure, nor the type. It's all over the place. And one of the aspects that I think is the most concerning here is that, well, I've just laid out one, the fact that we don't have any agreement on any of this. Why are we doing, why are we measuring?

FOCUS ON FUNCTION AND NOT APPEARANCE
But number two, when we're measuring, we are perpetuating this focus on the looks. We're focused on what they look like and what that measurement is has nothing to do with their function. We talk a lot in our level one course on diastasis and a big aspect that I'll have to leave for another podcast on another day, or you can join us in our course, but another aspect of this is body image. And many individuals are very concerned and have body image dissatisfaction. If we can help them by shifting the focus to function in our little space, absolutely we recommend referring out to mental health professionals to help with that. But in our little space that is the physical world, If we can help by shifting the focus to physical and to function, then why would we not do that? Especially when there's a lack of evidence for clarity on measuring that inter-rectus distance. Our newest research in this space in the last handful of years, our newest research has shifted in this direction. it shifted in measuring abdominal torque. the rotational torque that is that one can generate power. Why? Because that's functional. Or that sit-up test, like I mentioned, it's functional. Our newest evidence is heading in this direction. Let's not wait 20 years. Let's go ahead and jump on this train and let's start measuring function today, this year, for 2024. Let's measure function and let's focus on what matters. for our clients, and let's follow this research. And when we do that, we know we can absolutely help them increase in their function. We've got no doubt about it. I know for sure if you can't do a full setup, I'm gonna give you the modifications and I'm gonna give you that home exercise program that will allow you to do a full setup in due time. I have no doubt about it. I can sell that so easily and I would hope that you can too. So let's stop focusing on interrectus distance. Let's start focusing on function. Our recommendation is that if somebody comes in and asks for an interrectus distance measurement, if they're asking you to measure, and they fully believe in its importance in their rehab, that would be the only time in which you would use measurement. Other than that, other than they're asking for it and there is a significant belief in its importance, If those two things are not both on the table, then we need to set the measuring IRD aside and focus in on strength. Thank you so much for joining me this morning. I hope it made you think. It's something we've been thinking a lot about, both in reading the evidence and in practicing clinically. And I hope it helps you focus in on what matters this year for your patients. This material and a whole lot more is in our online level one course. Our course starts next week. It's absolutely sold out. We are closing, we will be selling out for the March cohort well before March as well. So if you are wanting to get into this level one course, it's been revamped, all brand new. If you want in, you should go ahead and register for that March cohort. If you've taken our online courses before, online level one before, then you will be interested in our online level two course. And that is a brand new course, which starts April 30th. If you want to catch us live, we're going to be on the road a lot in 2024. All of that's on the website. You can see it. I'll just mention the few that are coming up in January and February. We are going to be in Raleigh, North Carolina, January 13th and 14th, Hendersonville, Tennessee, January 28th and 29th, and Bellingham, Washington, February 3rd and 4th. We are so excited to see you all out on the road in 2024 and can't wait to see you all online as well. Have a great day. Happy New Year. And we'll catch you next time.

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

Dec 29, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses assessing & treating for issues related to shoulder internal rotation & extension limitation with overhead movement in the fitness athlete.

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

If you're looking to learn from our Clinical Management of the 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, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

ALAN FREDENDALL
All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning's off to a great start. We're here at Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently, I have the pleasure of serving as the Chief Operating Officer here at ICE and the Division Leader in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things fitness athlete, CrossFit, Olympic weightlifting, powerlifting, endurance athletes, and any recreationally active person. we talk about how to address those concerns. I have Dr. Haley with me here today. She's going to be my demo for some hands-on stuff. If you are listening to the podcast right now, I don't know why I pointed to my ear. If you're listening, you can't see me anyway. If you're listening, please switch over to our YouTube channel and watch the video because about halfway through, I'm going to show a lot of hands-on assessments and techniques, and you're not going to be able to see that if you are just listening on the podcast.

SHOULDER INTERNAL ROTATION & EXTENSION: ANATOMY
Today, what are we talking about? We're talking about the combined motions of shoulder internal rotation and extension in the shoulder, especially its relevance to the fitness athlete. So when we talk about these motions, we're primarily talking about the subscapularis muscle of the rotator cuff and the shoulder blade. So this muscle gets neglected a lot, mainly because most human beings no longer exercise, which means they are no longer vertically pulling and pushing above their head. So they're often not needing to use a lot of internal rotation and extension of the shoulder because they live their life with their arms relatively neutral. But if we look at the actual anatomy specifically of the subscap muscle, we know it is actually the largest and strongest rotator cuff muscle. It takes up the whole anterior portion of the shoulder blade on the anterior side of the scapula and is primarily responsible, yes, for internal rotation, but when the arm is elevated or out in front of the body, It also performs some combined motions of adduction and extension. It functions very similar to our lat muscle. So we have our subscapularis and our lat muscle counteracting all the other muscles of the shoulder and the rotator cuff that elevate our arm above and overhead. Most importantly, from the anatomy is knowing the attachment points. It attaches right on the anterior capsule of the shoulder. And when we see referral pattern, we can see anterior shoulder pain, folks point directly to a spot right on their anterior shoulder. But it also has referral into the posterior rotator cuff and into the medial scapular border. So a lot of times we can chase treating the posterior rotator cuff, especially in the fitness athlete when we actually need to be treating subscapularis.

SHOULDER INTERNAL ROTATION & EXTENSION: ASSESSMENT
Now how do we know this is a target for treatment? Well that's going to be revealed in our subjective and objective exam. So when someone comes in and I'm gauging their symptom behavior and I'm getting a list of their eggs and eases, especially with a fitness athlete, I'm looking to hear things like pain with dips, pain with bench, especially in the bottom position of a bench press, things like pain in the turnover, or what we call the catch of a bar or a ring muscle up, handstand push ups, again, especially the lowering the eccentric phase, where we're now going from an overhead, flexion, abduction, external rotation. And now we're lowering eccentrically into extension and internal rotation, very similar to the bottom position of a bench press. And then in that pull, that high pull motion that we have in our cleans and snatches with Olympic weightlifting. So when I hear aggs like that, my hypothesis list subscapularis jumps up. I'm looking to assess internal rotation and extension in that athlete, much more so than that sedentary person who comes in and complains of shoulder pain. I'm really not thinking this person is probably having a lot of issues with loaded internal rotation extension in the gym. because they don't go to the gym, right? That is a person where I'm probably going to look to the posterior rotator cuff and maybe the lats for strengthening and the delts for strengthening and just basically get that person's shoulders stronger versus specifically addressing a specific muscle like the subscapularis, which I would with a fitness athlete. So let's talk about how to actually assess the shoulder. So I have Haley here. We're going to demonstrate on her shoulder. You're all probably very familiar with this seated screen. It's something you learned in school. We're going to go through it really quickly. So having Haley lift her arm up and overhead and sitting to look at flexion, coming out to 90 degrees to look at abduction. We can meet in the middle and look at scaption at that 45 degree angle like that. We can put our arm at our side and now we can look at extension. And then we can hold our arm at a side and we can go across the stomach, internal rotation, and then out away to look at external rotation. Now what do we like about that screen? It's a screen, that's it. I hate almost all of that for the fitness athlete. Why? It's really not challenging a lot of true end range positions, especially of extension and internal rotation. The main thing to remember about internal rotation is if Haley's arm is at her side and she's internally rotating, she can palpate on herself. When the arm is at the side, the pec is the main mover there. It's not actually subscap or the deltoid at all. So when the arm is at the side, we're not even challenging actual internal rotation. We're using nothing about the subscap at all. Likewise, if we're seated and we're going through extension, I need to know how can I challenge sheer force to the shoulder like it might encounter in a bench press, a muscle up, a handstand pushup. I can't do that in sitting.

SHOULDER INTERNAL ROTATION & EXTENSION: DITCH THE SEATED EXAM
So for fitness athletes, we need to ditch the sitting exam and we need to go prone for the shoulder. So I'm gonna have Haley lay on her stomach here. We're gonna look at her left shoulder. We're going to look at internal rotation first. So I want her arm out at 90 degrees, about parallel with her shoulder, and I'm going to instruct her to bring her palm up towards the ceiling. And I want to look at that internal rotation. So we're cheating a little bit here, a little bit of abduction, but we have a really good assessment of internal rotation here. I can overpressure this as well. Haley, don't let me put your hand down. And I can look to see if that's symptom-provoking. So that is how I will assess internal rotation. Is the motion full? Is it provocative with an overpressure test? We can also look at extensions. I'm going to have her scooch a little bit to her right. She's going to bring her arm up at the table next to her side, and then she's going to lift her arm up in the air. And I'm looking to see, again, does she actually have full straight plane extension, or does she drift out into a lot of abduction? Good motion here. Same thing. I'm going to overpressure this. Don't let me push you down. And I'm going to see, is that symptom-provoking? So I'm going to challenge extension in a manner where gravity is providing sheer force through the labrum for me to see if that's provocative. And then I'm also going to overpressure the arm to see if I can overpressure and get any symptom provocation out of the shoulder. The last test that I will do is I'll have Haley stand up and then she's going to turn her back to the camera. We call this the liftoff test. It's also called Gerber's test. Very old test, almost 30 years old now. Tons of great research on it. So I'm going to ask her to pick a hand and I'm going to have her put it in the small of her back. And really I'm going to see how far up her back she can go with that hand. So can she go any higher? Good. Some of you might measure range of motion this way. That's great. I usually see what level of the spine can the thumb get to. Very functional for women, right? Somebody that can't even put their hand in the small of their back is probably going to have a lot of trouble with something like taking a bra on and off. But we get a good measure of range of motion. We know that if she can reach the small of her back, we're primarily now looking at subscap. A really good study by Greece and colleagues way back in 1996 found that if someone can get their hand in the small of their back versus down at their glutes, that just by getting it higher to the low back, we can get 33% more subscap activation. So I know if a person can achieve this position, they have really good range of motion out of that subscap muscle and that we're primarily now looking at subscap in isolation. What do we do now? We do the actual lift off. So I'm going to have Haley lift her hand away. She can lift her hand away and keep it approximately in the small of her back. And then if that's not pain provoking, at this point I am confident in ruling out subscap. Why? This test has 99% sensitivity. If that is negative, I can cross subscap off my hypothesis list and now I can look a little bit deeper into the shoulder. All of that has only taken us eight and a half minutes with a lot of talking. This is something you could probably do in a minute or less in the clinic and immediately rule out the subscap and be really confident that it's not the subscap. So, Haley, go ahead and have a seat.

SHOULDER INTERNAL ROTATION & EXTENSION: TREATMENT
So, what if it is a subscap, right? What if somebody like me walks in, my left shoulder looks okay, my right does not, Immediately I'm thinking I know which side I'm going to treat. I know which muscle I'm going to treat. We're going to talk about treatment next week. Zach Long is going to get on here. But the main thing is we need to restore that internal rotation range of motion, especially under load. Why? These folks are using this range of motion in the gym or they're trying to use it, which is maybe why they're bumping into symptoms with things like handstand pushups and Olympic lifting and muscle ups and that sort of thing. So we need to restore that full internal rotation range of motion. we need to increase its load tolerance, and we need to, in general, get the shoulders stronger, both delts and lats. But specifically, working on the subscap is going to give a lot of benefit to that athlete. So someone like me, I would needle my own right subscap, try to improve some of that range of motion, and then try to load that internal rotation. We'll talk more about treatment next week with Zach. He's gonna do a follow-up episode specifically on how to treat the subscap for the fitness athlete. So make sure you tune in next Friday. That's all we have for you today. I hope you have a fantastic weekend. Courses coming your way. Head on over to ptinex.com. Remember, all of our courses priced at $6.50 will become $6.95 on Monday. So if you have a course on your list, make sure you buy it over the next couple days and avoid that price increase. All of our courses from the fitness athlete division are on PTONICE.com. Hope you have a fantastic weekend. Have a wonderful new year. See you next week. Bye everybody.

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

Dec 28, 2023

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

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses balancing consumption with creation, the illusion of consumption as productivity, and the need to be authentic to stand out.

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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JEFF MOORE
Okay, team, what is up? Welcome back to the PT on ICE Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of ICE, and always thrilled to be here on Leadership Thursday, especially as we go into a new year, and always happy to be here on Gut Check Thursday. And this one's gonna be a little bit different. I present to you our Gut Check Thursday for this week is a 36-hour water fast. So maybe it's a little bit of a pushback against some of the excess of the holidays, kind of pulling that back in, especially around New Year's Eve time. We are going to run our official Ice Physio Water Fast from Friday at 5pm until Sunday at 5am. So it's going to be 36 hours. We're going to break that Sunday morning. Um, for those of you that don't know, um, over at ice physio, we have a relatively large group of us that does a 36 hour water fast every month. And then a prolonged three day fast every six months, which we're actually moving to a four day fast. Um, in the middle of next year. Um, again, that'll be our first four day water fast. Um, that'll be done annually, but, um, lots of thoughts behind this. Um, a lot of things about, kind of the qualities of restraint and enjoying maybe the exact opposite of excessive consumption that we're oftentimes so drawn into, which is the topic of today's episode, but a really good time of year to maybe pull in those reins. So over the next week. See if you can find a 36 hour period where you can just consume water. And feel free to consume it liberally, but I think you'll find it, if you have not engaged in this, to be both a unique experience and a very, very productive one. Not to mention maybe some benefits in longevity and you think about apoptosis and the ability of your body to clear some of that stuff out. Join us. It's both a mental and a physical feat that we think has some great rewards. So that is the Gut Check Thursday. It is not adding on to high-intensity stimulus. Over the busy week, it is in fact going the other direction and see if we can't exercise our restraint for a 36 hour period. So if you have any questions, hit me up, let me know. It's something we do every month and we love it. We'd love to have you join us. We will be going in Friday, 5 p.m.

AUTHENTICITY
Sequels suck. I think we can all agree with that. So let's dive in and talk about why. And I want to give you an action item as we are about to turn the calendar page to 2024. I want to leave you with a thought to maybe move in the opposite direction of what is too commonly done, not unlike the gut check Thursday this week. So we all agree that sequels suck. The question is why do sequels consistently suck? And of course, there's some exceptions and we don't need to play that game. Generally speaking, they leave a bit to be desired. Why? The answer is that it's impossible to be authentic when you're copying from a template and people connect with authenticity. One of my deepest beliefs is that real makes you feel. If you're wondering why in a certain relationship or when you were listening to a certain speech, you felt particularly captivated, it's because the person was being real. Whether you're delivering or receiving, real makes you feel. is a tried and true reality. There is something unique that each of you bring to any situation to bear that nobody else possibly could because it is uniquely you. When you present or deliver or connect from that space, it is absolutely captivating. Sequels, by design, make that impossible, right? It can't be truly unique because you are intentionally building off a template. And so there is already the impossibility of that uniqueness to fully manifest in that piece of work, which is why we tend to really struggle to connect with sequels. Now, many people have become sequels. This is why a lot of times content is boring. Sometimes I hate to say this, but it's why sometimes relationships or engaging or people themselves seem to lack a bit of sparkle because so many people have become sequels and they're not trying to do this, right? There is just too much information coming at us. If we don't want to become sequels, if we don't want to constantly be consuming all this information and then essentially just building off it in the same way a sequel would, you have to schedule breaks from it.

REBALANCE CONSUMPTION AND CREATION
What I'm saying is you need to rebalance intentionally consumption and creation. The problem is consumption feels like you're moving forward. This is where most people run into trouble, right? There's so many good things, so many great books, so many amazing podcasts. There's so much out there that you want to consume. And while you're constantly consuming it, you feel like you're moving forward. But there is undeniably a ceiling or an upper limit on where that is no longer a reality. The best analogy I have for you is it's like taking notes on your notes, right? That always used to bewilder me. I would watch people take notes in class or whatever. Then they would go to the library and take notes on their notes. And it's this never ending, right, reading and reading and reading and feeling like you're learning, but you're not. If you really wanna learn, stop. Stop and think about your notes. Stop and actually listen to that person talking and think, man, what do I and don't I believe? What naturally jives with me and where do I feel some dissonance? Now, where that dissonance is, why do I feel that? Get in to the thought and the why and the wonder. Because that's when things really start becoming a part of you. That's when things truly assimilate and become usable. It's not just constantly reading and copying and reading and copying. It's when you stop and say, what do I think about that? How does that jive with what I've known up until now? It's when you pause that the actual learning happens. Even though the constant consumption feels like learning, it's when you pause that you allow the knowledge to change you. And so when you're constantly consuming, that second part never happens.

STOP READING & START LEADING
Which is why my action item for everybody in 2024 is to stop reading and start leading. Stop reading and start leading. Create between every knowledge acquisition. This is my challenge. And I don't mean stop reading entirely. I mean begin to develop a more balanced schedule between creation and consumption by committing to creating in between every knowledge acquisition. As opposed to finishing the end credits on one Audible book and starting the next one immediately. Give yourself a break. to create, to think about how that, what you just engaged in, altered you, changed you, challenged you, and do something with it. Now I wanna give you an actionable how, because I think sometimes we get into this philosophical space and don't deliver that. My how for you in 2024, if you're trying to rebalance consumption and creation, is to have a forced content schedule. Meaning something that you commit to putting out for somebody Okay, this could be for your business your community your family your gym your church, right? Whatever you're involved in commit to a content schedule being forced to create At a regular rhythm is the greatest way that I know to successively approximate your true self, meaning your unique self, meaning the thing that people are drawn to and captivated by because nobody else could be that thing. Being forced to create at a regular rhythm is the greatest way that I personally know to successfully or to successively approximate your true self. Commit to a schedule. As I kind of look at my world, there's nothing I'm more thankful for than this podcast is a great example, which every week we're having to think about how do we think about things and how could we share that with our community. And I think about things that we do at ICE like hump day hustling or even gut check Thursday, like coming up with that fast this morning, but we are committed to you all. that we're going to put things out for you. And that forces us, if we don't just want to be replicas, to be original and think about what we want to share, what means something to us. And that allows us then to come to these platforms and try to successively approximate our true selves. And that process is really in many ways, in my opinion, anyhow, what life is all about. And certainly one of the things we enjoy most about sharing and receiving is when we do successfully approximate our true selves. So commit to a rhythm. In new years, in this new year coming up in 2024, don't create an endless consumption list. Instead, share your unique creations on a committed schedule. It will force your hand. It will make you say, well, I can't go consume nugget number 7,206 this week. I need to pause because I said I was going to put something out. I need to stop taking notes on my notes and start doing some real thinking because I need to bring something to bear. Commit to creating regular organic content to somebody, to your family, gym, church, business, community, whatever, and decide that in 2024, you're never going to miss one of those marks. You are going to find by the end of the year, that you have learned so much about the way that you think about the constant stream of information coming at you. And it will be that that will carry more value than I promise you any single part of that endless, incessant communication or information stream, because it is your uniqueness you're trying to find and share with the world. And it is that which they will receive most voraciously, I promise you. In 2024, let's rebalance consumption and creation. Team, big alert on the courses. The prices go up Monday. So if you want to grab an ice physio course, all the 650 courses go to 695 on Monday overnight. So you need to grab those courses by Sunday. If you want to save whatever it is, 45, 50 bucks a course, it's not a huge amount of money, but if you're going to grab a couple of courses in 2024, grab those ASAP so you're not paying extra. over at PTOnIce.com is where everything lives. Team, have a wonderful new year. Enjoy the weekend. For those of you joining us on the Water Fast, Friday at 5 p.m., we'll cut off the nutrients, all water, till Sunday morning at 5 a.m. I promise, it's a unique stimulus that is highly productive. Cheers, team. Have a wonderful weekend. Happy New Year.

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.

 

1 « Previous 1 2 3 4 5 6 7 Next » 78