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Jul 13, 2023

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses that the decision to innovate or imitate is a career-defining choice with long-term implications. The host emphasizes that while collaboration and sharing of ideas are common in any field, blatant imitation is detrimental to one's career. The host distinguishes between collaboration and imitation, stating that imitation involves repeatedly hijacking other people's logos, sayings, or content.

The episode provides three reasons why being an imitator ensures a mediocre and short-lived career. Firstly, the process of creation, coming up with something new and contributing in a unique way, is described as the most invigorating aspect of any career. The host emphasizes the satisfaction and impact that comes from thinking differently and having others benefit from one's novel ideas or techniques.

Secondly, the episode highlights the importance of authenticity in career success. The host suggests that imitators may experience imposter syndrome because their success levels do not match their actual contribution. They are described as grabbing ideas from others, recognizing what will resonate with their audience, and building their business without truly creating or going through the challenges that lead to breakthroughs. The more their success grows without a true contribution, the greater the asymmetry and imposter syndrome.

Lastly, the episode emphasizes the value of continuous creation and innovation for a long-lived and energetic career. The host encourages listeners to keep creating and strive for novelty and harmony in their careers. It is emphasized that the decision to innovate or imitate is a defining one, and individuals should aim to put forth their authentic selves rather than copying someone else's.

Overall, the episode argues that choosing to imitate instead of innovate can lead to a mediocre and short-lived career. On the other hand, embracing innovation and creating something new is described as invigorating, authentic, and essential for long-term success and fulfillment.

Take a listen to today's episode.

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

00:00 JEFF MOORE
Alright team, what's up? Happy Thursday, welcome to the PT on ICE Daily Show. I am Dr. Jeff Moore, thrilled to be your host, currently serving in the role of CEO here at ICE. It is Thursday, which means it's Leadership Thursday, but it also means it's Gut Check Thursday. Let's talk about the workout. This is going to be familiar to a bunch of you. So this is the workout from the CMFA Essential Foundations Course 21-15-9 Deadlifts Bar Facing Burpees. Quick, painful. Go get some of that. Post your time, post ICE Physio, hashtag ICE Train, hashtag Gut Check Thursday. It's a classic workout, we've done it a lot. It's a really nice benchmark one to challenge yourself in that kind of middle distance, high intensity space to keep coming back to every year and see how your fitness is evolving. So give that a shot. 21-15-9 Deadlifts and Bar Facing Burpees. Upcoming courses, I want to highlight Modern Management of the Older Adult Live because we've got a ton of options. So if you're trying to become the fitness for provider for your older adults in your community, you've got to hit the MMOA Live course. This weekend, they are in Watertown, Connecticut. Next weekend, July 29th, 30th, they are in both, Waukonson's, Georgia and Meridian, Idaho. That'll be the first, that's in Boise. That'll be the first course, I believe, at Onward Boise. So go get some of that. And then August 5th, 6th, they are at Onward Physio in Frederick, Maryland. Important to note, August 12th, 13th, they are in Lexington, Kentucky, and that is at Stronger Life, and that is the MMOA Summit. So if you want to meet all the MMOA faculty, they're going to be at that one course, August 12th, 13th, and that's at Stronger Life. So if you want to see the Stronger Life operation that Dustin and Jeff and the crew have been building out in Lexington, that is a really, really cool opportunity to kind of see behind the curtain and meet a ton of faculty. So go check out those courses. That's Older Adult Live on the road everywhere. So go get some of that action. Innovation or imitation, the career-defining decision. That's what I'm calling this episode. And I am not saying that lightly. I think if you really zoom out, and if we're talking leadership here on Thursday and thinking about looking long, long term at your career, if you decide to innovate or if you decide to imitate is probably the great decider. I mean, let me tell you the three biggest reasons why. But let me first note that we're not talking about sharing ideas, building off of each other, sharing techniques. There is a very reasonable amount of collaboration that is not copying an imitation. We're talking about blatant imitation, right? Where you know who you are, that you're hijacking other people's logos or sayings or content on the regular, right? Over and over again. I mean, if you scroll your feed, it's like you're obviously doing this. You've probably been reached out to. And then on the other hand, many of you probably have your own imitators, right? Where you look and you're like, gosh, that person's always taking my stuff and trying to put a very lame or benign twist on it. But it's pretty obvious what's going on. That's what we're talking about. Being that person, being in a position where you've got that person tailing you, we're going to unpack both sides of it. There's only one line on being imitated, many lines on being the imitator. So three reasons why being an imitator ensures a mediocre and short lived career. Number one, creation. Coming up with something new. Feeling like you really contributed because you saw something a different way or said something a different way and other people legitimately benefited that would not have if you didn't create that process is the single most invigorating thing in any career. That process of thinking differently, of contributing something novel, of having somebody come up to you and say, Hey, because you said it that way, things have really gotten better for me. I hadn't heard it like that. I hadn't thought about it like that. I have not used that technique. And now because you did that, things are better off in my sphere. That process of creation is the single most rejuvenating thing in any area of business. When you look at entrepreneurs, you look at people who are constantly high energy, are constantly seem to be thriving. It is largely because they're tapping into that creation energy on the regular and it gives back three times what you give it. That process of doing things novel and useful is what extends careers. It's what makes careers exciting. It would make it so it makes you get up in the morning and be absolutely beside yourself to dive into that next project. It's what builds anticipation for the next year of business. It is all of the things that constantly give you energy back that make burnout sound like a ridiculous idea because you couldn't imagine ever wanting to stop riding that train of creation. Creation is invigorating. And if you're copying, you're not creating. So you're never getting that energy back. And there is simply a timeline for how long you can go without it. Number two, this is the one that people don't see when they feel like taking other people's ideas is a viable way to continue their business. It's not. And this is why you can't build on a foundation you didn't pour. I'm not saying you can't go take the idea and put it on your platform and get a few likes. You can do that. You can get a short term bump in your business. There'll be plenty of people who didn't know you did it. Like you can do that, but you can't build on it. One breakthrough and by breakthrough, I mean the process of the breakthrough. When you were thinking about a certain idea and you realize in the moment, hold on, there's a better way to do this. There's a better way to say this. There's a better way to build this. That process, that breakthrough, having that moment changes you. Like it really changes you because not only will everybody that you told think a little bit differently or be able to use it novelty, but you changed because your mind saw a different pathway. That change is what's required to make you different, to see the next thing. When you're going through the hard work of trying to make something better and having that breakthrough, that process of when it happens is what allows you to see the next one because you're now different for having had that breakthrough. If you're just hijacking ideas all the time that sound good or look good or think might get you some business, you're not actually changing. You're not developing. You're not going through those breakthroughs. So you're not going to have the next one or the next one. So pretty soon your only option is imitation because you're not doing the work of creation. You can't build on a foundation you didn't pour. Other people's ideas being on your platform does not make them yours from the sense of you are not different for having come to them. So there is no way now that you're going to be able to go from there because you didn't even really get there. So think about how hijacking that process prevents your ability to look even further. The final one, and I don't speak all that much on this topic because it kind of annoys me, but it's important to acknowledge this is where imposter syndrome I think actually comes from. The worst cases of what you would call imposter syndrome, a complete lack of authenticity in an individual in a certain position that maybe didn't earn it, you can kind of feel that, that case of imposter syndrome, the worst cases are when somebody's, and I'm those listening on the podcast, when somebody's success levels don't match their actual contribution, and this is the case of the imitator, right? So somebody who's grabbing ideas from other people and they're catchy ideas, right? They're good at recognizing what's going to resonate with their audience, grabbing ideas from other people, putting them out on their platform, never really creating, never really never going through kind of the trough of challenge that leads up to a breakthrough, never experiencing that, just hijacking ideas and quote unquote building their business. The more their success grows in the absence of a true contribution, the greater that asymmetry, the greater the imposter syndrome. And the problem is the momentum only goes in one direction because like I said, once you start imitating, you're no longer changing, so you can't make the next step forward, so you're never going to. So all you're going to wind up doing is put yourself in a position where people think that you know a lot of stuff or have done a lot of the work when you know you haven't. And the more quote unquote successful you get, a lot of people knowing of your work and maybe even financially benefiting from it, but the more deep down you know you haven't really done any of it, the greater that asymmetry, the more fragile your steadiness in that space because of the absence of authenticity. You know deep down you haven't earned that success and the more that asymmetry grows, the more other people can feel it. The phonier it feels, the more it lacks authenticity. And team, as we talked about over and over again on Leadership Thursday, authenticity realness is at the end of the day, what people really resonate with long term. And you will have less and less and less of that every year, the asymmetry of what it looks like, you know, and what you've actually contributed grows. That is an exhausting place to be. Nobody likes that feeling of I'm going to be exposed. Nobody likes that feeling when it's getting worse and worse and worse and worse every year. It will eventually overwhelm that person. And that's what brings me to the last point of this podcast. For those of you out there who are doing the hard work of creation, who feel like you're often being imitated by that person in town, by that person online, whatever, right? You feel like gosh, I really thought that, you know, I put a lot of effort into that and it kind of got hijacked, right? And you're feeling that chronically. You're not. Because those individuals always succumb to the above. They can't have longevity because creation isn't filling their cup. They can't jump from a foundation they haven't built. And every time they do that to you, their imposter syndrome grows. They know it was your work. They know they didn't and couldn't have thought of it. But they also know other people think they did. And the more that asymmetry grows, it has a breaking point. They never have longevity in the space. So stay in your lane and drive fast. We know how frustrating it can be, right? We know how exhausting it can seem at times. But understand that because of the above, every single one of those people's careers will be short lived and fizzled because all of the above are fixed equations. There's no getting out of that stuff. It's the wellspring of what a long lived energetic career can be. In the absence of those things, it simply can't be. So for those of you who feel like your work is being ripped off, let that be kind of a statement of confidence that I promise you because of all of the statements above, that will be a temporary discomfort for you. Keep creating. Team, innovation or imitation, it is the career defining decision. Do the work to try to come up with novel things that excite you, that excite others, that bring harmony into your career because you're actually putting forth your authentic self, not somebody else's authentic self. Do it right. You only get one shot at it. Cheers, team. I hope that helps on Leadership Thursday. I will see you over here next week. PT on ICE.com. It's where all the goods live. Have an awesome Thursday.

13:18 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 PT on ICE.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 PT on ICE.com and scroll to the bottom of the page to sign up.

Jul 13, 2023

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

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Christina Prevett discusses the significance of research in the field of physical therapy is along with the importance of translating that research into evidence-informed practice. She acknowledges the substantial nature of their research and highlights the necessity for clinicians on the front line to have access to this valuable information. Staying up to date with available evidence and combining it with clinical expertise and patients’ experiences and desires is emphasized as crucial for clinicians. The episode also addresses several gaps in research that need attention, including the need for rehab research for individuals in sitting positions, outcome measures for wheelchair users, and managing conditions in neurological populations. The host expresses frustration at the lack of clinically relevant outcome measures for wheelchair users and emphasizes the need for research to support the role of rehab in enhancing quality of life and managing various conditions. Overall, the episode underscores the importance of research in informing and improving physical therapy practice.

Take a listen to learn how to better serve this population of patients & athletes.

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

00:00 INTRO
What’s up everybody, welcome back to the PT omn ICE Daily Show. Before we jump into today’s episode, let’s chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they’ve made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can’t miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you’re sure to use the code ICEPT1MO when you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody.Enjoy today’s show.

01:33 CHRISTINA PREVETT
Hello everyone and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty in our geriatrics curriculum. So in our geriatrics curriculum, we have three courses in CertMMOA. We have our online eight-week essential foundations course, our online eight-week advanced concepts course and then we have our live course. We are on the road in the summer and into the end of 2023. So our books are closed for 2023. So we have all of the courses that are going to be on the 2023 calendar on the calendar. And so if you are looking to get into one of our courses, know that there isn’t going to be an option for something closer until we’re kind of booking for 2024. So this weekend, Julie is going to be in Watertown, Connecticut. And then the next weekend, 29th, I guess it will be two weekends, 29th, 30th, I’m in Watkinsville, Georgia. There’s still some room in those courses. And so if you guys are interested, just let us know and come hang out with us for all of our geriatric research and all of our geriatric course material. Okay. In today’s content, on Monday, I talked about gaps in pelvic health research. So I’m on our pelvic faculty as well. And so today I’m going to take the exact same approach and talk about gaps we see in the geriatric research. I am obviously in full blown research prep mode. I am defending my PhD on resistance training in older adults, at risk older adults at the end of July. So you’re going to see me full blown in the research space. And so hence the topic of these podcast episodes. When we are comparing different areas of literature, and we’re talking about geriatric rehab in particular, one of the things that I want to start out with is that the state of our research in geriatrics is actually pretty good. You know, we are pretty far ahead when it comes to comparing to other areas. Like when I compare to pelvic health research, there is no comparison. I can off the top of my head bring out 10 studies that have never actually even been done before in our pelvic health research, but I cannot say the same thing in geriatrics. I had to really, pardon me, I had to really think about where I thought our gaps were. And obviously I’m thinking about this around my contribution to the literature with respect to my PhD. So the first thing that I wanted to talk about is the fact that our research is pretty good. You know, we have a lot more in this space and now we’re kind of going into the nuance of our rehab and how to translate the research that we do have so that clinicians who are on the front line have access to that research and can really truly embrace evidence informed practice where they are up to date with the evidence that is available. They’re taking their clinical expertise, they’re taking their patients experience and desires and kind of combining them together. So that’s the first thing. So I’m going to be talking about four, three or four different gaps in the research that we have so far and what this means when we are making recommendations or we are thinking about them with respect to our plan of care for our older adults. So the first thing, and I’m on, this is my bias because this is where my PhD was, was we have very few studies that have looked at high load, low repetition weight schemas for resistance training with older adults. We have one that I can think of maybe two studies and the second study is kind of an ish because it had a descending rep scheme where they use less than five repetitions and higher loads. My PhD tried to change that. I did two pilot studies that looked at the safety and feasibility of a three sets of three to five repetition schema at an intensity of seven to eight out of 10. So that high vigorous intensity, high load, low repetition resistance training. And so it’s important for us to know this, right? We don’t have this research. And when it comes to the way that we work in geriatric literature is that we see what works in our younger or middle aged individuals. Then we push into our healthy older adults and then we push into pathology. Right. This is the story that we saw with high intensity interval training, for example. Right. We saw that it worked in athletic populations. We started pushing the intensity into HIIT training in middle age, healthy older adults. And now the state of the literature, we cannot even deny it because we have evidence for HIIT training in a variety of different pathologies, multimorbidity, obesity, different age groups, et cetera, which is great. We don’t have that yet when it comes to geriatric literature in this high load schema. What we see from a muscle physiology perspective is that the magnitude of strength increase tends to bias heavily towards heavier weights. See the one that I did there versus lower weights, higher repetitions. When it comes to individuals who are doing nothing and they start doing something, of course, we’re going to see improvements in strength at any set reps. But the magnitude of those differences tends to bias when our loads are heavier. Because we don’t have anything in the under five repetition schema, we see this reflected in our exercise guidelines. Right. Why are our exercise guidelines the way they are? Right. Two to three sets, eight to twelve repetitions, 60. Now we’re kind of pushing into that 70 to 79 percent of a person’s one repetition maximum is the standard exercise prescription that we’re seeing out of the American College of Sports Medicine. We saw it in the International Conference for Frality and Sarcopenia Research consensus statement. And this is because that is where the vast majority of the literature goes. And this is where this momentum can build around two to three sets of 10. Right. Because we’ve always done it this way. There’s a good chunk of literature that’s there and we don’t have anything on the flanks. Right. We don’t have anything in under five. We don’t have a ton in the 20 plus. And when we get into the higher repetition ranges, now we have this interference that can happen between cardiovascular fitness and neuromuscular fatigue. And which one is the one that’s breaking down first or is the limiting factor? All of this to say. When we don’t have those discrepancies, we have to be mindful, one, about the strength of our recommendations, but number two, we have to be pushing towards trying to get studies that evaluate this type of loading schema so that we can take a big picture view and then really start to look at dose response data. So that’s number one is that we don’t really have a ton of studies that look at repetitions less than five and kind of my one B is that this influences things like our exercise guidelines and not in a good or bad way, just a we have to use what’s available. And that’s why things are the way that they are. The second one is going to kind of be a blend of pelvic health because we in advanced concepts, we go through in week five urinary incontinence and pelvic health issues and geriatrics. And I’ve talked about this a bunch on the podcast before. But we have very little evidence that’s looking at conservative management of pelvic floor dysfunction for individuals over the age of 65. And we have almost nothing when we look at individuals over 75 or 80. Urinary incontinence is one of the leading causes of institutionalization. So where individuals need a higher level of care, end up in assisted living, end up in institutionalized setting is because of issues with urinary incontinence. That should be justification enough that that we need studies in this area and kind of this one B or two B to C type of step down is we don’t really have a ton on pelvic floor muscle training in older adults. We have some. It’s not a ton. Oftentimes, our older adults are giving are given medications that influence their urine flow rate, whether that’s directly with medications being given to work towards helping with kidney function or things that are given as a consequence of having urinary incontinence that change urinary flow and urinary output. A big example that has nothing to do with either of those things, but is actually a side effect because this is the second classification is individuals are given a medication for one issue and side effects relate to urinary incontinence or other pelvic floor dysfunctions is Lasix or diuretics. Individuals who are on diuretics can have horrible, horrible problems with urinary urgency and urinary incontinence or both. And it has a huge impact on their quality of life. And right now, the only research we have is that it negatively impacts their quality of life. And the next step is to try and figure out what to do about it or what can we do about it conservatively? Can we change medication timing? Can we work on different things? Can we work on urge suppression techniques? Is that going to be relevant because urine outflow is higher because of the water pill? There are so many questions, but we have nothing like we have zero studies that have looked at how to help our clients with urinary urgency or urinary incontinence as a consequence of their medication regimens. This is important because the thing that happens is that people stop taking their meds because they literally cannot go out of their house or cannot be too far from a bathroom without not taking their pill. Because if they’re on their pill, they’re going to the bathroom all of the time for the five to six hours post taking their medication. And so this can essentially make a person homebound. That is important, right? In PT, that’s a super big thing. In OT, it’s a super big thing. In rehab in general, we are trying to discharge homebound status. And this is a big influence of that. Kind of in this urinary incontinence vein for the elderly, for our older adults, you know, we have conservative management in general. We have men management in combination with conservative management when there is a medical side effect because of the medication a person is on. And then the third one is some of the issues that we see post catheterization. So individuals who are placed with an indwelling catheter and then are removed from that get into this situation where they are in bed, they go to the bathroom whenever they need to because the catheter is there. And then once the catheter has been removed, sometimes there can be a disruption of pelvic floor musculature. There can potentially be damage to the urethral structures. And then you also have to try and work on those urge suppression techniques so that now you’re not just going to the bathroom whenever you get the slightest urge to go to the bathroom, but you’re holding it in order to go to the bathroom when it’s convenient for your schedule or when you have the block of time within your day that you can go to the bathroom. We are now also seeing different types of catheters like periwicks, which are external catheters. And what do those do? All of these things that we’re seeing hugely in acute care, we’re seeing it in, you know, individuals going into home health. This kind of goes into neurological populations who may be doing self catheterization. All of these things and the role of rehab in managing these conditions to improve a person’s function and quality of life really has been understudied and a big low hanging fruit that we could potentially be having huge impacts and potentially preventing transitions to institutionalized care is by being able to tackle some of these problems. But we need the research to back us up first. So that’s number two and two A and two B. And then the third one that we’re going to talk about, and I think this one is a frustration point for a lot of our clinicians, is clinically relevant outcome measures for our wheelchair users. So we have a ton of outcome measures in the geriatric space. One of the things that I think is actually really cool is that in our rehab space, our geriatric outcome measures are very strong. We have we have several options. We have good cutoff scores. We have reliability and validity data. We have minimally clinically important differences. All of these things. We have standardized protocols. We have different MCIDs, different reliability and validity data across different settings, which makes sense because our older adult population is extremely heterogeneous. All of that is good. You know, that is great. We touch on that a lot in MMOA about how we want to be leveraging our outcome measures and not just for the sake of doing outcome measures, but in order to guide our clinical reasoning and create risk stratification, which is what they’re intended for. The problem becomes when we have a client who spends a good portion of their day in sitting. When it comes to our outcome measures, we have this Goldilocks type of scenario that we need to be mindful of. We are going to have a cohort of individuals who are going to experience a floor effect and a person who is a wheelchair user on a 30 second sit to stand test is a very good example of that. They are going to get zero and they are probably always going to get zero. And therefore using a 30 second sit to stand test for a person who spends the majority of their day in a wheelchair is not helpful. We also see that we’re going to have some older adults who are going to have this ceiling effect where they are going to knock it out of the park and we’re not getting any information. When I was working predominantly in outpatient, one of the first things that I would ask my older adults who walked in independently into my clinic was can you stand on one leg? I was not going to be wasting 15 minutes of my time doing a Berg on those individuals because it’s a waste of their time. It’s a waste of my time and it doesn’t tell me anything. And so we have to kind of figure out we want this composite, we want these tools in our toolbox that we can pull and leverage based on our clinical impression after a person’s subjective. But when we have individuals who are sitting, we have very, very few outcome measures. We have the function in sitting test, we have stuff like the FIM. We can maybe start using the Berg and look at some of their transfers, but our pool to try and fit this Goldilocks scenario is quite limited. And so we really do need to think about clinically relevant outcome measures for things like transfers or bed mobility or things that are relevant for them. And these things are starting to come out. We have some pilot research on different outcome measures. But what we try and leverage now with an MMOA is trying to get objective data for things like transfers. And what that can look like is instead of giving MinMondax assist, which is important, we’re going to do that based on our clinical judgment, but also put a timer on it. And so if we can put a timer on it, then we can see the first time we did this sitting at the edge of the bed transfer, it took us five minutes from start to finish. And now it’s taking you 30 seconds. Like that’s a huge improvement or it’s taking three minutes. That changes the flow of a person’s day. It helps the caregiver a ton. It makes individuals feel more capable who are trying to help their caregivers with their care. And so we also need the research to back us up with that. And we need help to try and figure out how we can justify our rehab for individuals in sitting. If we can’t use the outcome measures that are so commonly prescribed in different settings to try and see improvements over time. And we can make huge improvements in a person’s function and a person’s capacity who may not have the potential to get into standing and do more standing tasks, but still has an infinite amount of potential to improve their quality of life and the things that they’re doing throughout their day. So those are kind of my big three areas in geriatric practice that I think we need to be focusing on that rep dose response data in resistance training, where we’re looking at load under five repetitions and seeing, does that have any improvements or the magnitude of that improvement in strength with, with a direct influence on a person’s physical function? When it comes to pelvic floor in the older adult space, we have a lot of work to do when it comes to just conservative management in general in our individuals over 75, anything with response to medication management, symptoms, side effect profiles of medications and their influence on the pelvic floor. And then post catheterization work, whether that’s indwelling or external catheterization and what that does to things like urgent continents. And then our third is helping our individuals who are spending most of their day in sitting. How do we help our wheelchair users so that we can justify our care, have normative data and reliability and validity data of outcome measures to be able to speak to our insurance providers who are, you know, a lot of times we’re trying to justify our treatment interventions and then make sure that we know when we’re making clinically relevant changes in their quality of life, when the goal of getting them in standing is not the one that we’re looking at. All right. I hope you found that helpful. If you have any other questions, just let me know. I’m going to be in the research space a lot in the next couple of weeks. I might be sick of it by the time I get to the end of the month with my defense. But let me know what your thoughts are. If you have any other questions, if you are not signed up for MMOA digest, that is our every two week newsletter where we bring all of that research to your inbox. So if we see any studies that are coming out that are filling in some of the gaps that we were talking about, you’re going to know about it first. If you’re signed up for MMOA digest, just head to ptnice.com slash resources. If you’re looking for research in general, make sure you are following hump day hustling. All right. Have a great day everyone. And we’ll talk soon.

20:07 OUTRO
Hey, thanks for tuning into 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 pt on ice.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 pt on ice.com and scroll to the bottom of the page to sign up.



Jul 11, 2023

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

In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the importance of including lumbar flexion in a robust rehabilitation program. Take a listen or check out the episode transcription below.

If you're looking to learn more about our Lumbar 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

00:00 ZAC MORGAN, PT
Good morning PT on Ice. I am Dr. Zac Morgan. I am with our spine faculty, so I lead the spine division teaching lumbar and cervical spine courses. And this morning's episode is going to be a little bit on that topic of spine pain and specifically why low backs must flex. So we'll get to that, but before we do, let me just point you in the direction of a few courses that we have coming across the country over the next few months for both lumbar and cervical. So over in Richmond area, lumbar, the next offering will be September 23rd. We actually have several courses going, lumbar that weekend. So if you're anywhere in the country and you want to catch lumbar spine, September 23rd is a good one to have marked down. So it will be outside of Richmond, in Baton Rouge, and over in Parker, Colorado, right outside of Denver. So several good offerings spread all around the country. If you're looking for cervical management, we've got a few coming up as well. We've got Brookfield, Wisconsin, that's July 22nd, that weekend. And then August 26th and 27th will be over in Charlotte, North Carolina, and then September 9th over near Atlanta in Roswell, Georgia. So several good open offerings. If you're looking for one of those spine management courses, we'd love to see you out on the road. We'll have a bunch more throughout the year. So watch the website, watch the podcast, and you will know when we're going to be in your area. This idea for this episode came into my head this morning about, or not this morning, this idea came into my head over the last few weeks as I've seen more and more posts from, we'll just say Instagram influencers, people that are in this space of Instagram and perhaps are physical therapists and treating a lot. And I see a lot of vilifying of lumbar flexion, specifically a lot of pointing towards anatomy and the reasons why people shouldn't flex based on their anatomy. And the most common reason that you're going to see people vilify flexion in the low back is due to concerns of disc herniation. And we all know that there's some older studies that have pointed towards lumbar flexion, putting an increased pressure on the posterior annulus of the disc, and thereby making a lot of therapists for a long time very concerned about having their patients move into flexion because of the fear of every flexion weakens the posterior annulus of the disc. And with each flexion, you're actually weakening that tissue, eventually causing a problem. But I want to push back on that narrative a little bit. Now understand that at ICE, we think of back and neck pain in patterns. So there are some patterns of back pain where I will withhold flexion on my clients. I'll tell my client, hey, please, I need you to stop flexing. Sometimes I'll even utilize tape so that that way they're able to feel when their low back is moving into flexion. But that pattern is fairly obvious. And that one is what you classically think of as more of your lumbar radiculopathy or derangement presentation. And typically in that client's objective exam, when you ask that person to move into flexion, they're going to worsen. So each time you have them flex, they'll either lose range of motion in deflection, meaning their fingertips won't slide as far down their thighs as they did prior, and or they'll peripheralize. Their symptoms will exit the low back or maybe intensify in the low back and start to spread down the limb if they have some sort of sciatic related complaints as well. So if you're seeing a loss of forward flexion and or peripheralization of symptoms, that is the client where I would withhold flexion and not forever. I would tell that client on day one, Bill, right now, when you've been forward, your symptoms are getting worse. For the next couple of weeks, I need us to be really judicious and careful with forward bending. But understand that is a normal, healthy movement for your low back to make. And one day we're going to get back to it. So make sure you always prep them with that because we want that client to know we're coming back to flexion no matter what. Flexion is a normal part of the range of motion of the lumbar spine. It's really challenging to move through the world without flexing your low back. If you don't believe me, go ahead and throw some tape or have one of your coworkers throw some tape on your back and see how often you're pulling that tape top. Every time you put your shoes and socks on, when you sit on the toilet, putting your pants on, loads of things make your back into reflection. People recognize this when they hurt their back and they're flexion sensitive. All of a sudden they're like, wow, I didn't realize how much I use my back. What they're usually complaining about is that flexion. I didn't realize how often I flex my back. So let's get into it. There's a time and a place to withhold flexion, but it's certainly not everybody because for most people they need to be able to move. So one pattern in particular that pops into my head of people that really need to flex is the dysfunction patient. And if you're McKinsey trained, you've probably thought of this in terms of like, if a derangement doesn't clear up their end range flexion, they will become a dysfunction. But I like to think of that pattern as more all encompassing. Essentially a dysfunction patient is someone with soft tissue extensibility dysfunction across the posterior side of their spine. Meaning they don't have the elasticity in their muscles, in their paraspinals, and all the structures on the posterior side of their spine. They don't have the elasticity to move into flexion. And you'll hear this person say things in the subjective exam like, Zach, it's so tight. It feels very tight. It feels like I need to stretch. My back is always tight. When I wake up in the morning, my back is tight. If I've been standing for a long time, my back will get tight. If I have to sit for a while, my back will get tight. You'll hear them complain of things like tightness. And one thing that always stands out in this person's objective exam is you'll ask them to forward bend and they'll turn to the side and go to forward bend. And you'll see that they only access hip flexion. They actually don't reverse their lumbar curve at all. So you'll see that low back just stay flat as they move their fingertips down their thighs and their hip flexion will eat up all that motion. Often this person will have adapted pretty decent hip flexion. And sometimes I'll even see them put their palms on the floor. But if you look at their lumbar spine, there's no motion coming from them. So when we see that pattern, often flexion is part of the solution. Getting that person's low back to accept load and deflection can be part of what helps them solve this problem. So I always want to be really careful when it comes to vilifying any motion, because for some people that motion's the solution. While for other people that motion may really bother their symptoms. And this is the big overarching point is one solution is never going to work for all of back pain. If there was one solution, if the solution was to not flex, or if the solution was to only extend or spinal manipulation or dry needling or anything, we wouldn't see back and neck pain be this multi tens of billions of dollar problem year over year. If we had it figured out that well, this problem would be much easier to solve. So it seems clear that some people need it and other people's don't. And that's how back pain works. That's why you listening to this episode as the provider need to be confident in this space and understand that not one prescription works for all of back pain. So let's talk about why flection works a bit. And some of the things to think about moving forward, just to help push back again on that narrative of vilifying flection. First things first, with a lot of these people, they feel very tight and they feel very compressed. I don't have perfect proof for this, but if you think about the attachment site of the pair of spinals, I mean, from the base of the skull all the way down to sacrum, those big ropey muscles run parallel to one another on either side of the spine. If that person's tense, if they truly are tight, if their nervous system is just really heightened in the region, often that tone in those pair of spinals goes up. And what you see is a compressive type feel when they have it in the neck, they'll feel like somebody's got their hands on their head, just pushing down in the low back. They just hate sitting or hate compressive load. And one person that tends to do really well with flection based exercise is this one. So often, if you have that person start to put some length into that system by repetitively challenging flection, those muscles will relax a bit and the tone will drop some. And as that tone drops, the person will report a better feeling in their back. Hey, it feels like it's stretched out. That really feels like a good stretch, Zach. I love moving in that direction. Yeah. Now that I've done that, I feel better. Reminder the derangement patient who doesn't need to flex. They're going to feel worse each time that they do this. The dysfunction patient may feel bad while they're flexing, but they feel better after. So that's one of the key differences. And part of that is cause I think we're reducing some of the compressive load. That's just sort of statically sitting on this person's spine by getting them to move those muscles. So one thing that's nice is we get a reduction in that compressive load. This kind of goes hand in hand, but that subjective report that your patients give you of, man, my, my back feels so tight. It's so tight. I need a stretch. This addresses that feeling for whatever reason, their nervous system feels as if they're tight in that region. Sometimes people are, they truly have muscle extensibility dysfunction. Other times people are just tense and they have a hard time relaxing those muscles. Either way, repetitive flexion in my practice has been a really good way to sort of give those muscles some input or give them some actual stretch that allows them to lengthen out and allows that person to move with more, uh, fearless, thoughtless movement that allows them to kind of move about their day without feeling like a robot quite so much. So often getting rid of some of that tightness feel involves doing some stretching. And I realize I'm kind of going counterculture here because I feel like the pendulum is swung very far away from sweat stretching. But the most common question I get asked in the clinic is, can you show me a stretch for this? And I know a few of you are laughing and thinking, gosh, yes, people always think that's all we do is show stretches, but people see value in stretching. And if we believe in, in, um, patient expectations, then we should match those expectations to some degree. I'm not saying we're not going to load as well. We're off. We're going to do that. If the patient's impartial, my preference is certainly eccentric exercise because you get the added benefit of tissue durability alongside lengthening. But if we're just trying to get the person to buy in, I'm all for stretching and often stretching those pair of spinal makes this person's back feel way, way better. The next piece is just motion is lotion, right? Like our, our body is built to move. It is not built to be static. It has been adapted over years and years for movement, not for desk sitting, not for being really still. And so part of this is just motion is lotion, right? Like when we get a fluid exchange through those structures of the spine, through those muscles, the person's back feels significantly better. And there's no reason to run from that. We want that fluid exchange. We want that person moving around. And then the last piece team that I want to emphasize is why we should flex is that function is huge here. So if we were unable to flex our back, things like putting on our socks are completely a disaster. If you don't, if you've never experienced a derangement, I hope you never do, but spoken from someone who has that morning, you wake up and you can't flex. Everything's harder. You're considering asking your wife to help you get your pants on because it's so hard for you to move forward. We have to be able to flex. If we can't flex, all of those activities get way harder. And if we put forward the message that you need to be fearful of flexion because of your disc health, people are going to stop doing it. They're going to see those videos and they're going to say, you know what, that person's an expert. Let's be really careful with flexion. We don't want people being careful with flexion. Now I would never coach someone to lift a heavy load, a maximal deadlift with their back flexed. And that's partially due to, I do think end ranges are probably not the best for lifting, but a lot of it's performance, like straight lines or strong lines. I love when Mitch Babcock says that when we get the back flat, you can utilize your hips so much better and you can move more load. So from a performance standpoint, it makes sense to me to keep the back flat at heavy loads. When we're talking about putting our shoes and socks on, when we're talking about grabbing something off the floor, when we're talking about even doing things like ski, Yerg, GHD sit-ups, rowing, our backs are going to enter flexion. And if they don't, that will start to feel like movement dysfunction for the person. And if they try to stay perfectly flat through all of those things, it often drives this dysfunction pattern. So team, I really just kind of wanted to hit the high levels here of why our backs have to flex. And like I said, I see it over and over where there are different influencers who are vilifying lumbar flexion. And I think it's something that we as a PT community need to stand against. And it's not that we need to vilify those influencers. They are putting forth great information as well, but I do think it's a bit of an outdated narrative, outdated narrative for us to stop flexing the low back. Are there people who need to transiently limit their lumbar flexion? Absolutely. I see them all the time in the clinic. It is not rare for me to say, Hey, I need you to hold back on that motion for the short term. That said, do we need to drive a bunch of content towards making people fearful of that motion? No, much like knee flexion. We don't want people afraid of knee flexion. Same deal with the low back. It's just like everything else. It's a bunch of joints with a bunch of muscles surrounding it and a bunch of nerves giving it input and output from that region. That area needs to move. So let's not vilify it. The next time I'm on here, what I'm going to do is show you on a technique Tuesday. So we'll bring back technique Tuesday and I want to show you some mobilizations that I love to improve lumbar flexion in this person that we've been talking about. So that's all I've got for you today. Hope you have an awesome Tuesday and we will be back tomorrow morning. Same time. Thanks team.

14:56 OUTRO
Hey, thanks for tuning into 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 CU's 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.

Jul 10, 2023

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Christina Prevett discusses current gaps in pelvic floor physical therapy research. Take a listen to learn how to better serve this population of patients & athletes.

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.

EPISODE TRANSCRIPTION

00:00 INTRO
What's up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today's PT on ICE Daily Show.

01:27 CHRISTINA PREVETT, PT
 Hello, everyone, and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. I'm so excited to be on the podcast. I feel like it's been a hot minute since I have been on here because our other faculty have been doing such an amazing job sharing content with you. If you're looking to get started and join us within the pelvic health division, we have our eight week online course starting today. So eight weeks going from preconception all the way to postpartum return to sport. We're going to spend a ton of time going through different concepts, research, all that fun stuff and then you get to hang out with us for the next eight weeks. So if you're interested, make sure you go to PT on ICE.com and you should sign up while you're there for our pelvic newsletter. So we're going to be talking about research today. That is where we send out new research articles that the faculty sees and we have a pretty big announcement coming into the newsletter. So if you are not on the pelvic newsletter, you should go to the resources page on PT on ICE.com and join because there's fun stuff happening over there. All right. So today we're going to be talking about gaps in pelvic health research. We have done an incredible job over the last several years of starting to fill in gaps in our knowledge. And part of the reason why we do not have as much research in some of these areas is because the rise in popularity of some of these movements or these exercise trends has really changed over the last five to 10 years. And research takes time. It's important for us to know where the state of the research is so that we know how much confidence we can give to our recommendations and assessments. When it comes to evidence informed care, it is three pronged, right? We have our evidence base, what research says. We have our clinical expertise and we have our patients or clients lived experiences and their hopes and desires. And when we don't have the evidence base, we rely on the other two. However, there is bias that gets introduced there. There's bias that gets introduced in research as well. But I think it's important for us to know what we can confidently say from a research perspective and what we can't. So today I'm going to go through five big gaps that I have seen in the pelvic health research. If you are interested in doing a PhD from somebody who is about to defend their PhD at the end of the month, here's great topic areas because our research base is really small or completely non-existent. And the completely non-existent one that I'm going to start at the very beginning because it actually blows my mind is on C-section scar massage. Scar massage after a C-section is the gold standard for helping with the rehab process. It creates more movement and motility. It allows us to get into more stretched positions. Some individuals have seen potentially some association between adherence and scar tissue and low back pain. Alexis did a podcast episode on a case study with that. But we have no research in any type that has looked at C-section scar massage. And that blows my mind because we are so confidently talk about using C-section scar massage. And it's because clinically and with our patients right there lived experience, we see such a huge benefit. Because we don't have any research, why? We can't even say is this effective or not. But the second thing is that we have no idea around dosage. Do you need to start at six weeks? Can you start at six months? Is it the same effectiveness? Should you be doing two minutes or five minutes? We don't have any research that is looking at what is the most effective dosage or does this work at all or is it a placebo because we're starting to desensitize our body to that surgical site. We don't really know. And so it's really neat to see and really important for us to recognize that there is a huge gap there that should be getting filled. All right. The second one that we see a complete lack of research in and this became really relevant with some of our athletes is around coning during pregnancy and its impact postpartum. Really confidently people say online that you should avoid doming and coning during pregnancy within our pelvic health division. We do not create fear around doming or coning. We try to minimize it as much as possible by getting recruitment from other core muscles because we think that is going to keep the pregnant core stronger, not because we are trying to mitigate damage, not because we are trying not to ruin anything, not because we are trying to prevent diastasis recti postpartum. But we know, pardon me, that when we reduce that coning that usually that also means that individuals are stronger. Unfortunately the prevailing messaging online is that if you cone during your pregnancy, you're going to have diastasis recti postpartum. And we don't have research either way about that narrative despite how confident people are saying that. What we do have research for is that individuals with postpartum diastasis recti are weaker than those that aren't. And so by scaring individuals around avoiding coning during pregnancy, we may be unknowingly or unintentionally deconditioning that pregnant person and their core. And so we need to be doing research on this about, you know, what if we don't do any modifications to their core training? What is that going to do for them postpartum? You know, when I think about a late term pregnancy, that stretching of the linea alba, when a rectus contracts, it comes together and there's going to be almost like an air pocket that occurs because of that lengthening of that tissue. In my mind, like that, especially a little bit of that is not something that I see as quote unquote bad. But I know that I am not not everybody agrees with that narrative. So we just need to be sure that we're doing more research on this. So that's number two. Number one, C-section scar massage. Number two, avoiding coning during pregnancy and its influence on postpartum outcomes. Number three is any postpartum protocols for return to activity. We have maybe the beginning of research in the running space. And largely in the running space, it's helpful because a lot of people enjoy the sport of running. It's an easy barrier. There's no barrier to entry in terms of just putting on running shoes and going on to the pavement or onto the trail. And so we're starting to see more and more research. But when we're trying to look at things like risk factors for issues with postpartum return to running, we're seeing a huge amount of variability. And that is where us and the pelvic PT space and us in the PT space in general are like well done because everyone is going to have different experiences, different support systems. All of those other factors are going to influence. And so we see some people are waiting a full 12 weeks before they go back to running. We have other individuals like our elite level athletes who are starting with four to six weeks and are back to 80 percent of their running volume by 14 weeks plus or minus 11 weeks at standard deviation. So a huge swing in terms of how long they are going back or how long they are waiting before going back. And so we need to try and look at some of this early return to activity and try to figure out different protocols to try and minimize risk for not only pelvic health concerns, but we're seeing also a larger risk for musculoskeletal injuries. And so we're seeing individuals returning to postpartum impact, which is running and are having lower extremity issues. So we have so much work to do. And then when it comes to the resistance training space, oh my goodness, we have literally nothing. In the cross-sectional study that I designed with our collaborators, we tried to give some descriptive data of when individuals are returning. But again, that is just scratching the surface of what is possible or what we may be seeing in this space. So number three is any postpartum protocols for return to activity. Anything that people are utilizing now is based on physiology theory and clinical experience. We don't really have anything in the research right now to identify those things. All right. Number four is information on pelvic outcomes with interpregnancy windows. And this may seem a little bit off to right field from me, but hear me out. So when we think about family planning, individuals kind of have often an idea of how close together they want their pregnancies to be, what sometimes these pregnancies are a surprise. Sometimes there are things outside of our control that leads to when individuals are having pregnancies. What we do tend to see in the literature where we do have research is on fetal outcomes. And we always kind of start on fetal outcomes where risks to baby increase when a person has a subsequent pregnancy less than six months after delivery versus those that wait 18 months. What we see clinically is that sometimes rates of pelvic floor issues and diastasis recti can follow that same trend where when individuals get pregnant really close together, they didn't have that window of time where they were able to recover their pelvic floor and their core strength back. And therefore they have potentially a harder time recovering after a subsequent pregnancy. Some of these fetal outcomes like increased risk for miscarriage and stillborn birth that can happen in those close interpregnancy windows may be a result of things like pelvic floor insufficiency or just not getting the strength back in those structures in the pelvis between pregnancies. And so we don't have any research on this, but as a faculty, we are super interested to see is it the interpregnancy window or is it the amount of time it takes individuals to get back at least close to baseline with respect to core strength and pelvic floor strength after baby. And so information around interpregnancy windows with respect to mom's outcomes, I think are super important. So number one, C-section scar massage. Number two, postpartum or coding during pregnancy. Three postpartum return activity and four information on interpregnancy windows. My last one and I left it for last because this is like where my research brain is right now is on lifting during pregnancy and appropriately dose resistance training. So if you guys have been following the podcast or you follow me online, you know that I was projects that looked at cross-sectional data on individuals who lifted heavy during pregnancy, over 80% of their one rep max at least at some point. And we tried to describe individuals experiences, what their labor and delivery looked like and what some postpartum issues or complications may have been. Now right now I am working on a project that is a systematic review on what we know from resistance training and pregnancy literature. So I am doing a complete scour on the research that is looking at what the dosage, what outcomes individuals are looking at and trying to make some, see some gaps in the research and make some informed decisions. Y'all, what we have so far is all exercises in sitting one to two kilos max weights. So five pounds max, we have fair band exercises and these are what we are using to make decisions. Overwhelmingly the outcomes are related to the fetus, right? So we are looking at and that is super important. Do not get me wrong. That is super important. But I think at this point we can say especially under dose resistance training is not going to be bad for baby. That is where the gross majority of our research exists. We have nothing that is heavier really than a person's purse that they use to walk in here and it gave me an unbelievable understanding of where our conservative under dose recommendations come from because all of our research was on therapy and exercises, stuff done in sitting, pelvic tilt and abdominal breathing was a protocol for resistance training. When is breathing resistance training? But that's the state of our research right now. And so we get upset about the fact that these are recommendations and yet there's this huge gap that we are seeing in the literature that does not have anything. And so because pregnancy is such a protected time, we don't want to make recommendations that we don't really have anything to base off of. And so we have so much work to do. And so here are my five, right? We have C-section scar massage, coning during pregnancy and postpartum diastasis outcomes, any type of postpartum protocol for return to activity, especially in the lifting high intensity space, information on pelvic floor outcomes and core outcomes for interpregnancy windows and the influence on pelvic floor dysfunction. And then my personal, like one that I am spending a lot of time on is around lifting and appropriately dosed RT during pregnancy. Like you all know that I am in the geriatric faculty as well and it's like just as bad, if not a little bit worse with respect to some of the RT dosage that I'm seeing in this space based on, or as compared to systematic reviews that I've done in community dwelling older adults that are struggling with mobility. And so that is saying something. And it just shows that we have so much work to do. And so I want to kind of finish off this podcast. I'm going a little bit long winded and I knew that I would talk to you about research is that we have work to do, right? We need to one show that these are things that individuals are interested in. We need to try and help inform practice. And then we need to be patient. You know, there are researchers that are working on this. I was at female athlete conference in Boston and I saw and got to connect with so many PT PhDs and other medical providers who were doing research that were trying to bridge some of these gaps for individuals who love exercise at any capacity, at any stage, at any level. It just it takes time. You know, where I'm getting ready to hopefully ramp up for perspective data, which means that I'm going to follow people through their pregnancy. But a pregnancy is 10 months and it takes time to recruit people and it takes time to go through ethics. And then we got to do all the analysis and then we have to write the research paper up and then it has to go through peer review. And that takes time as well. And so we are getting there. This is my I am so excited. If you want to do a PhD and jump into this army of trying to create research, I am here for it. And hopefully we are going to continue to see individuals pushing into this space and we're going to be able to close some of these gaps. All right. That's all I got for you today. If you are interested in learning more or you want to talk about PhDs and all those types of things and doing research, make sure you reach out. I did an entire thread in our ICE students group. So if you have taken an ICE course and you were in that Facebook group, I talked about doing research and I hope you all have a wonderful Monday and I will actually see you on Wednesday for the geriatric podcast. All right. I will talk to you all soon. Have a great day.

19:00 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.






Jul 5, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discussed several strategies that can be employed to achieve intensity, which is crucial for cognitive changes. These strategies, including increasing load, decreasing rest, and increasing work time or volume, are part of physical training and can drive metabolic adaptation and enhance cognitive benefits. By challenging the muscles and cardiovascular system through increased load, individuals can experience improved cognitive function. Similarly, reducing rest periods allows for a more continuous and demanding workout, while increasing work time or volume extends the overall duration or amount of exercise performed. All of these strategies contribute to increasing the intensity of the workout, which is essential for promoting cognitive changes.

Incorporating a dual motor task and cognitive layer during exercise can further enhance cognition. This can be achieved by integrating activities that require both physical movement and cognitive engagement. For instance, one way to introduce a dual motor task is by having individuals hold two cups and transfer water from one cup to the other while walking. This adds complexity to the exercise and challenges both the motor and cognitive systems. Additionally, engaging in mental tasks like answering questions or performing mental math while exercising can also enhance cognition. Starting with simple preference questions and gradually progressing to more challenging cognitive tasks can create a cognitive load while individuals focus on the physical activity, leading to cognitive changes. It is crucial to control the intensity of physical training by adjusting factors such as load, rest, work time, or volume to ensure the desired cognitive benefits are achieved.

Shifting exercise sessions to a busy environment can introduce cognitive load and improve cognition. Instead of conducting sessions in a quiet one-on-one room, it can be beneficial to move to a busy clinic space, a bustling hospital hallway, or even an outdoor setting with unpredictable elements. Exposing individuals to a busier environment adds a cognitive challenge to their physical activities, such as skating or walking. This cognitive load stimulates cognitive changes and enhances the cognitive benefits of training. It effectively adds a cognitive layer to the exercise session and promotes neuroplasticity. Furthermore, incorporating a dual motor task, such as moving water back and forth, and asking cognitive questions like preference inquiries or mental math can further amplify the cognitive benefits of the exercise session. Overall, integrating a busy environment and cognitive tasks into exercise sessions can be a valuable strategy for improving cognition.

Take a listen to learn how to better serve this population of patients & athletes.

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

00:00 INTRO
What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're sure to use the code ICEPT1MO when you sign up, that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 

01:33 DR. JEFF MUSGRAVE, PT, DPT
All right. PT on the ICE Daily Show. Welcome. This is Wednesday. This means it is Geri on ICE talking about all things, topics to help make your care for your older adults as good as possible to really set yourself apart as an expert with older adults. What we're going to be talking about today is exercise that improves cognition. There are a couple different types of exercise training that is really superior for improving cognition for older adults and we're going to talk about what those are and then how to incorporate them into your care. Before we get to that, just a quick rundown of what we've got going on in the older adult division. If you were hoping to catch the next cohort of Essential Foundations, that'll be starting in August, August 9th. If you're looking to get your advanced concepts, if you've already taken Essential Foundations looking for that next step, that'll be October 12th. Next opportunity to see us live, you've got three opportunities in July. We're going to be in Connecticut, Georgia, and Idaho this month. If you have been itching to see us on the road, get to do some of these fun labs and things that you've probably seen on social media, book your seat, come see us. We're going to be all over the place as we do 2023. Many of our older adults are worried about their cognition. They may already be experiencing cognitive changes. Maybe they've got just mild cognitive impairment. They don't have an official diagnosis. Maybe they've got early stages of cognitive change all the way to advanced dementia. It's not uncommon for us to be treating community dwelling older adults or older adults in an institutional setting that have experienced some cognitive changes. When we're thinking about our exercise interventions and how to prioritize, making physical change while keeping in mind we know there's a cognitive component. Sometimes a cognitive component ends up being more critical than the physical component for some of our older adults. We're talking about safety. We're talking about independence and their ability to manage their home environment, for example. This can be huge. The reality is a lot of us don't know where to start when we're thinking about how do I do both get the physical training piece and keep in mind they've got some big cognitive impairments on board that I'm concerned about. There was a 2019 article titled, Preferred Type of Exercise for Cognition Enhancement in Older Adults. It did just this. It broke down what types of exercise we should be focused on. Once you get through this article, and I'll share it in the caption as well if you want to look it up yourself, but there were two types of exercise that we're going to cover. The third thing we're going to do is just talk about the practicality of how to get those cognitive changes for our older adults in our sessions. The first type of training that was most beneficial for driving cognitive enhancement was a category called physical training. If you're familiar with CrossFit or not, I'm going to describe a workout to you that would be very squarely in this component of physical training. So MERF, very common Memorial Day workout done to honor a fallen soldier. The workout is one mile run. We've got 100 pushups. I'm sorry, 100 pullups, 200 pushups, 300 air squats. So that would very much squarely fit into the grunt workout. You're grinding. It's a long workout with high metabolic demand. So the first category was physical training that was intense. High intensity physical training was the number one thing that they found was beneficial for enhancing cognition for older adults. So many of our patients are not going to be doing MERF. So the question is, what's this look like clinically? So any workout that's using compound functional movements and you're moving at high intensity where you've controlled the work rest ratio, you've controlled the number of repetitions or the volume, and you've controlled the pace, you can modulate to get up to high intensity. But high intensity training is superior for cognitive enhancement. So for a patient that may be doing a remom, every minute we're doing different activities. We've controlled the amount of work and rest time. The patient is going to pace that themselves. So say minute one, we're doing 10 sit to stands. Then the next minute we're going to do carries over and back across the room with the weight that's challenging. So there's maybe 10, 15 seconds of rest. And on the third minute, maybe we're going to be doing some supported jumping. So grunt work type movements. There's not a whole lot of thought involved. Hold this walk, stand up, sit down, put your hands here, jump. Very simple, basic activities, but their nature of them being compound functional movements where we've controlled rest, we're going to drive intensity and we're going to drive metabolic adaptation, which was key for enhancing cognitive benefits in training. So that's what we want to be thinking about. Category one, physical training. They found that the change happened because of changes in the metabolic system and hitting intensity was key. So high intensity grunt work style training improves cognition. That's good news. That follows right in line often with what we're trying to do with our older adults because we know most of them are sedentary and need physical training. They need to be stronger. They need higher cardiovascular capacities to really keep themselves on a healthy trajectory as they age. So the second type of training that was beneficial for enhancing cognition was a category they just called motor training. So a good example of this would be a Turkish getup. So maybe you've never done a Turkish getup, but if you can imagine yourself laying on your back, you've got one arm pointed at the sky with the weight in your hand. You're going to move from lying on your back all the way up to standing with the weight overhead. You're going to be balancing the weight the entire time and then going all the way back down to lying on your back. That would be an example of motor training. It's a complex task. There's actually 14 steps in a Turkish getup for just one side. A lot to think about, lots of positions to hit, complex movement, a novel task for a lot of people in general, but especially older adults getting up and down off the floor without using an arm, but also adding load and having to balance that weight makes it complex from a motor training standpoint. So maybe our older adults are not doing Turkish getups. Some definitely can. There are research articles that have shown that older adults can do Turkish getups and it's beneficial for them, but maybe a more practical example for a lot of us would be working on floor transfers. Many of our patients need to work on getting up and down off the floor, doing that where we're working around a cranky joint, a knee, a shoulder, maybe a hip that is super stiff or doing this at a novel environment. Maybe we take them outside on the grass where maybe they don't have furniture or they've got limited furniture where we've just created a complex, novel task. It's motor training that's complex and that's what's going to drive cognitive adaptation. This motor control category, the driving factor was complexity and it was direct neuroplasticity. So directly impacting neuroplasticity when we do complex motor tasks. So getting up and down from the ground in a different environment would be a great way to drive neuroplasticity directly. So we've got these two categories. We've got high intensity physical training and then we've got high complexity motor training. Those are the two different avenues we can use with exercise to improve cognition for older adults. So the question is, well, what do we do? Which one is most important? And if you've been around the ICE community very long, you've probably heard this before. Or if you're new to following along with the journey here on what we're doing with our clinical approach, you're going to know the answer to this. And that is and not or. We want to do both. So we want to be greedy when it comes to our patients. We want to give them the maximal benefit, the maximal value out of every single session. And we can do that by driving intensity while driving complexity of task. And the easiest way to do that is a strategy we call layering. So a good example of this would be, say we want to drive intensity with gait training. Lots of great ways to do this. We can put a gait belt on our patient and hang on to it and add some resistance that way. We can do the same thing with a resistance band. We can throw a weighted vest. We can have them hold weights. Gait training just got much more intense at whatever resistance is appropriate to challenge our patient by just adding resistance to that walking. So we've already achieved intensity there. So how do we add this motor training piece? How do we add complexity to also enhance cognition at the same time? Lots of different ways to do this. You could do a weighted vest and maybe we've got someone with two cups in their hand and they're transitioning water from one to the other while they're walking. Man, we've just layered on a dual motor task while we're hitting intensity with a vest. Another great example, we can ask simple preference questions. That's usually an easy way to ease in on the cognitive load. Just ask them some random questions that sound like conversation. You may already be doing this, adding a cognitive layer and not realize it, but asking them questions while they're concentrating adds a cognitive component. We can scale that up. We can ask for mental math while someone is doing intense gait training. That can be super beneficial. We can ask, what's your favorite color? We can ask them to subtract three from 74 out loud while they're walking under intensity. We can move them to novel environment. There are lots of different ways we can add that in. You want to control the two things you've got to do to put these things together. For physical training, you've got to control intensity. You can increase load, you can decrease rest, you can increase work time or volume. All those things will help you reach intensity, which is crucial for cognitive changes. The second piece is adding a dual motor task like we talked about the water back and forth. You can add the cognitive layer by asking questions, preference questions, mental math, those type of things. Moving them into a busy environment. Maybe you have your sessions in a quiet one-on-one room. Maybe you move out into busy clinic space or into busy hospital hallway, or maybe you're in home health and you can take someone outside or into busier environment where there's unpredictable things and there's some cognitive load on just skating and keeping yourself safe. That's another great way to add cognition. That's what I've got for you, team. You want to hit intensity through physical training. You want to add complexity with motor training. The third thing is you want to add layers. You want to layer up your intensity and cognitive difficulty as much as possible to get the most bang for your buck, especially when there are cognitive deficits on board. If anyone's got any cool strategies, layering tips, tricks, things they've done that they found fun and beneficial, or you've just got questions or comments, drop them. I'd love to see those and interact with you. I hope that was helpful for someone out there. Have a great rest of your Wednesday, team. See you later. 

14:52 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. 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.



Jul 5, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey discusses how to empower patients with osteoarthritis by shifting their mindset and behaviors. She emphasizes the importance of treating patients with MEDS (mindfulness, exercise, diet, and sleep) to combat systemic inflammation. Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 DR. LINDSEY HUGHEY, PT, DPT
Good morning, PT on Ice Daily Show. How's it going? Welcome to the PT on Ice clinical podcast. Today is clinical Tuesday. I am so pumped to be with you all. I'm Dr. Lindsay Huey. I guess that would help if I actually introduced myself. Today, I am going to chat with you about how we let freedom reign in our patients with osteoarthritis. Last clinical Tuesday, I hopped on here and I wrapped on the underlying battle of systemic inflammation that we are fighting with these folks with hip and knee away and the importance of treating them with MEDS, which stands for mindfulness, exercise, diet and sleep. Check in for more information there from last week on what MEDS and how we can unpack that and prescribe it for our patients. This week, this clinical Tuesday, we're going to dive a little deeper into the trenches of battle by really discussing how we can impact our folks with osteoarthritis. Whether it's the shoulder, hip, knee, hip and knee are more common things we'll treat from an extremity management perspective. But this battle involves a lot more than manual therapy and exercise. It actually involves less. Today, I will discuss how shifting our patient's mindset and behaviors really helps fight that underlying systemic inflammation battle that our patients have. But before I tell you and dive in a little bit about that, I'd love to share with you some courses extremity management has coming up. So our next upcoming course is July 15th, 16th. So in a couple of weeks, we'll be in Holmes Beach, Florida. I've hopped on a couple Tuesdays and just let you all know what beautiful beach that is. It still ranks the top beach I've been to so far. Crystal blue water, I'll be with Melissa Reed out there. There's lots of spots left. So join us if you want to do some summer extremity management learning. And then July 26, 23, I'll be in Simi Valley, that course is now to 15. There's probably only three to five spots left. So if you're on the fence, definitely sign up for that course. And then onward Madison is July 29th and 30th. So lots of opportunities to hop in in July. And then in August, we are going to be in Rochester Hills, Michigan, and then the 12th and 13th. And then August 19th, 20th, we will be in Fremont, Nebraska. So be on the lookout if you're on the fence for signing in just because these courses are starting to fill up. And then other courses in the beginning of fall in September and October. We hope to see you out there. All right, let's dive into the topic at hand. So last week, we really last Tuesday established that hip and knee osteoarthritis is becoming one of the leading causes of global disability. So worldwide, this is affecting our society. And there are so many challenging aspects of treating these folks. The battle is not just in modulating their pain. It's not just an increasing range of motion and addressing strength deficits, you know, in their hip and in their knee. And it's not just about prescribing meds. And I really made a solid case for that last week. That mindfulness, exercise, diet and sleep. It's really about confronting the uncomfortable conversations. It's about challenging and changing thoughts and beliefs with these folks and some of their daily living behaviors. I think this is our hardest job as physical therapists, whether you're in outpatient or home care, even acute care. But it's our hardest job and our greatest opportunity with these folks to really address how they think about their body and then just daily behaviors. These conversations that I'm going to bring up, they are really uncomfortable. Addressing harmful thoughts and beliefs, behaviors, we know humans, we are kind of entrenched in our beliefs and our behaviors and it is really hard if we can reflect on our own challenges. It can be so uncomfortable. And so I acknowledge that this is very uncomfortable, not only as the provider, but for the patient. So some thoughts that we really need to start addressing. And I alluded to this last week a little bit, but the patient that thinks and says to you that first visit, I have bad knees, my dad had bad knees, my great grandfather had bad knees or I have bad hips, right? My great grandmother had bad hips. So it's just inevitable, right? That I'm going to have bad hips. You are not your ailment or your pain is one of the first things that we have to establish and break down with our patients. The thoughts of this is just inevitable, this is my path, right? To be in pain, which leads to disability and dysfunction. These thoughts take a human's mindset captive. It takes captive their whole way of living and being. If you think about some of these patients and they don't just often just have osteoarthritis, diabetes, hyperlipidemia, they might even have heart disease or history of MI, stroke, these are unhealthy systems. Every thought and decision and behavior starts to be planned around their pain experience. Going out with family or friends is planned around pain. How long does it take me to get to the front door if we're thinking about going out to eat or going to the movies? Can I actually make that distance? Or will I be in too much pain to even enjoy the dinner or the movie? Or I cannot do this because it hurts. Or I can't go to that family gathering because it hurts. Or because my knees or my hips are bad. Pain, OA, osteoarthritis starts to become the patient's identity. How they do everything in life is surrounded by this. This is all super uncomfortable and enslaving for your patient. If we're honest and we even think deeper about this, it starts to become the normal. So this discomfort, right? This pain starts to actually become the patient's comfort. It's how they do life. It starts to become their identity. I need you to start as clinicians and this charges to myself as well to start thinking about how we can help our patients do less harmful mindset. Do less thoughts about how much they're in pain and how much their knees are bad. How can we help shift their mindset to be healthier? To be more productive? Can we shift and say my knees have an opportunity to be stronger? Or yes, my knees hurt but I'm on the path to recovery. Yes, my hip hurts and it's limiting how I can walk right now. But I know with doing my program from Alex Drumano, our MMOA faculty, I know I'm going to be able to walk a little bit longer every day. Helping patients shift how they think right away is a must. If we cannot shift how they frame their pain experience, how they frame their range of motion deficits, how it impacts their life and amount of walking, we will never make an impact here, right? We can have the best manual therapy, the best exercise dosage prescription and it won't make an impact if they don't believe it can help. If they are telling themselves every morning they wake up, my knees suck, I don't want to get out of bed, my hip hurts, I don't want to do this today, they're not going to be successful. And so we have to give them little phrases to help them keep going, right? Yeah, it hurts right now but here's what I can do to help that, right? And it seems small but if we're not addressing this at all, we're really doing harm. We're not doing enough and so we need to implore less harmful thought patterns in our patients to help make an impact, to help really make our exercise and manual therapy be worthwhile. So I just want you to pause and think about what are some things or reframes I can start giving my patient in their mindset. Doesn't just stop though with our mindset shifts, right? It's not just thinking that influences our beliefs about our body. We also have to shift some of our daily behaviors and here's where it gets really tough. Folks with OA have a lot of comfortable behaviors that are quite destructive. And addressing these conversations by the way are nuanced and we have to do it in a loving way and of course we first have to build rapport with our patients before we start diving in to behavior shifts. And so it won't be our first conversation with our patient but it has to be a conversation that happens in our bout of care and it has to be ongoing. And it's behaviors regarding eating and exercise habits. They have to be addressed. It becomes really comfortable that person that's in pain, right? That's coming to see you maybe three days a week, right? They worked out with you for an hour. It's a lot more comfortable to sit around and watch shows. It's all day. It's a lot more comfortable after a big meal, after dinner, to turn on Netflix and binge watch Netflix, right? Two or three episodes. If you're a big Ted Lasso fan it's really hard not to just watch the whole season in one bout. It's really hard if it's in your process and family process to have dessert after every meal that you have, especially dinner, right? And then compound that with Netflix and sitting. Extra calorie consumption kind of goes under the radar with these folks. The eating piece and our behaviors around eating have to be addressed. And you know, the Netflix, the eating, this might not be your patient specific thing that they need to worry about doing less of, but I'll tell you in a lot of our folks with me and HIPAA, there is some very familiar trends surrounding our eating and our extra calorie consumption. Things that bring us comfort like Netflix, like that extra helping of food or dessert. We have to acknowledge that this is so complex and hard. These things are often tied to family, right? They're tied to connection and community and identity, especially if that's the time where you all kind of get together, right? You share a meal, you share dessert, and then you go watch your shows. Let's all come together and rewrite some of the ways we gather and do our meal time together or handle stress, right? Some of us are stress eaters. Sub that extra helping or that extra Netflix episode with taking a walk after dinner with your family. Or maybe instead of that dessert, right? You're already feeling full, but somehow you think there's a little bit more room for that dessert. Go for a walk with your family, right? Or go for a bike ride, right? These kind of behaviors help get that food moving and processed better, and then it subs those extra calories or it subs that extra sedentary time where you're just sitting. How about some of our folks with HIPAA and NEOA that are retired, right? Where they're watching their shows throughout the day, right? They love watching Price is Right. Yes, Bob Barker is better, but Drew Carey is doing his best, right? But these kind of behaviors, maybe it's a midday walk, right? Or suggesting they walk their dog midday. I know these HIPAA close to home, folks, and I'm going to tell you a lot of the behaviors I'm listing hit close to my direct family. I am sprinting away from metabolic disease. It runs on books, both my mom and my dad's side. Diabetes, heart disease, cancer, hyperlipidemia, myocardial infarction, stroke. Whatever list that you've probably seen on your patient list, my family has it. And so I totally, I am listing out behaviors that I know my family and myself has taken part in. I've witnessed them firsthand, but I also know they can be changed gradually, and I also know the change is uncomfortable. I want to fight this battle of OA because it hits so close. It hits for me, it hits for my children and my surrounding aunts, uncles, grandmothers, right, that have passed because of this. So I don't take the battle lightly bringing up this shift in beliefs and behavior. Think about this. And I know I touched on some hard ones, right? Everyone loves a little extra Netflix episode, dessert sometimes, that extra helping of food. It is comfortable. But no one says, I wish I hadn't taken that walk last night after dinner. I wish I had had that second helping, second and third helping. I wish I had had that extra slice of apple pie. I wish I had stayed up till 1 a.m. watching Netflix. I wish I had binged, watched all my shows all day and sat in a chair for three hours. I wish I had had that another beer. No, people don't really reflect and say that, right? They're usually the next morning, oh, I wish I would have had that earlier. I wish I wouldn't have had that extra helping. I didn't really sleep well. I wish maybe I would have gone on a walk or that bike ride when my kid or grandkid asked me to do it. Instead, I just sat here and I watched these shows. No one says they wish they didn't do that uncomfortable behavior. Uncomfortable shifts in mindset and behavior, they are always uncomfortable, especially when you're making the decision, especially when you're actually doing the thing, right? When you don't really feel like taking a walk after a meal or going for a bike ride. But there is nothing more ironic, more peaceful than doing the thing that's uncomfortable. While it may not feel great during you, if you can think about some uncomfortable decisions you've made and your patients, they will feel better after. They will be thankful after when they made these shifts in their mindset or in their behavior. There is so much reward in the discomfort. Of course, it's delayed and that's what's hard about human nature, right? Our psychology wants comfort, especially when we're in pain. But just think each day, the compound reward of making one to two uncomfortable decisions surrounding our mindset and surrounding our behavior around food and our eating behaviors. One less thought of my knees suck, I don't want to get out of bed. One less helping of dessert or Netflix binge. Imagine that compounds day after day, 365 days and that becomes a year and then you do it again, right? 365 times two, right? And it patients start to see the healthy reward of these shifts in mindset and behavior. Let's stop the acceleration of OA as one of the leading causes of disability worldwide. Let's help our patients handle and battle this low grade systemic inflammation by leaning into the hard belief and behavior shifting conversation. We have to fight for our patients, our loved ones and ourselves to have these conversations because we're not doing enough. It's still going up the levels of disability, right? Lifespan is increasing, right? But our health span, the quality of life is not. These are hard and uncomfortable conversations, right? But discomfort tends to birth opportunity and change and really only always for the better. If you can think about most of the uncomfortable decisions that you've done in your life, if you can think about the yield, the reward, we can and we must start to battle beliefs and behaviors if we want to impact this space. One little mind shift and behavior shift at a time. Freedom comes in the form of less for our folks with hip and knee OA. Yes, our primary drug of choice is exercise for our folks with hip, knee, shoulder OA. But if we want to have the greatest impact, we need to deal environmental modulators to manage symptoms, to maximize fitness. We need to deal mindset and behavior shifts that change lives. It will be hard, it will be uncomfortable for both parties, clinician and patient. But along the way, we also deal encouragement. We deal hope. We deal laughter, right? We laugh in PT and we are a partnership and alliance as the patient negotiates these new mindsets and behaviors We're there every step of the way when it's hard. Free your patience. There is freedom in choosing less harmful mindsets and less harmful behaviors. New beliefs and behaviors are for sure uncomfortable. But help your patients think about their hip or their knees more positively or help them walk instead of that extra episode of Netflix. Show your patience there is freedom in discomfort. Show your patience there is freedom in the reframe in their mindset. Let freedom and independence reign for your patients through introducing them to healthier mindsets and behaviors. Help them indulge less in destructive thinking and behaviors. There is so much untapped potential in this space. I'm hitting the 20 minute mark I need to shut up. But I want to say a final thank you to our military and our vets who have fought and continue to fight for our nation's independence. Happy Fourth of July. I'll thank you for letting me rap on something I'm super passionate about. Happy Clinical Tuesday.

19:30 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 CU's 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.

Jul 3, 2023

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

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses when and how the tailbone/coccyx may be a contributor to a patient’s symptom behavior, as well as how to begin to assess & treat the region if appropriate. Take a listen to learn how to better serve this population of patients & athletes.

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.

EPISODE TRANSCRIPTION

00:00 INTRO
What’s up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let’s chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you’re looking for an easy way to navigate payments, here’s what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane’s support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you’re ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you’re in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today’s PT on ICE Daily Show.

01:27 DR. APRIL DOMINICK, PT, DPT
What is up PT on ICE fam? Dr. April Dominic here. Today we are starting our two-part series on pain in the butt. And today you will learn how you as a clinician can screen for tailbone pain, some general assessment and treatment strategies, as well as in part two, next in two weeks we’ll cover soft tissue structures that may contribute to pain in the butt. Before we dive into tailbone pain today, let’s talk about some course offerings from the ICE Pelvic Division. So we have our eight-week online cohort that starts July 10th and we still have some spots left. So please hop on in and join us for all of that fun. And then we have our live course and this course is going to give folks the ability to learn pelvic floor basics and about the pregnancy and postpartum changes of the body. We’ll definitely dive into the internal exam in supine and standing with an option to learn another way if an internal exam is not for you. Then in day two, we are in the gym and we’re applying what we learned day one into all activity types such as impact work, rig work, barbell and more. And we learn how to coach and come alongside and offer modifications for this population and keep them in the gym during pregnancy if that’s what they desire, as well as help them feel confident returning back to the gym during postpartum. So our next course is actually going to be with myself and Dr. Alexis Morgan. It’ll be here in Denver, Colorado. That’s going to be July 29th and 30th. And then you can hop into our next course offering, which is in September 23rd and 24th, I believe, and that’s going to be in Scottsdale, Arizona. So tailbone pain. We’ve got people with pain in the butt and we’re thinking, hey, it may be coming from the tailbone. So what do we know about tailbone pain right now? Well, true to the pelvic health research world form, we are still learning and growing. We don’t know a lot about incidence rates for tailbone pain. It is under reported. It is multifactorial in nature. There are a lot of psychological and physiologic factors that are involved in tailbone pain. So with that, it is just a trickier diagnosis to treat. But I wanted to share about all of the things that you can do from a general assessment and treatment strategy today. So one study did find that comparing female to males, females tend to be affected by tailbone pain about five times more than male counterparts. We also know that typically speaking, tailbone pain can resolve within weeks or months with time. However, we do know that conservative treatment strategies are welcome and definitely help reduce that duration for some. So what is the tailbone? Or I’ll sometimes call it the coccyx. The word coccyx actually originates from the Greek word for the beak of a cuckoo bird. So like a tailbone, the beak and the tailbone have a triangular shape. The tailbone is three to five fused bones that articulate to the bottom of the sacrum. So everyone listening right now, let’s go ahead and orient ourselves to where the tailbone actually is. With your fingertips, I want you to try right now, locate the edges of your sacrum, which is going to be that bone that kind of sits inside of the center of the buttock. And I want you to head inferiorly or towards the toes and towards midline. You’re going to follow that bone until it ends. You’ll bump into a small bone and that is the coccyx. You might be like, whoa, April, I’m like right near the anus. Well, then you’re in the right spot because the coccyx is just superior to that anal opening. So the coccyx may be tiny, but it is mighty and it is not insignificant. I like to think about the coccyx as a leg of a tripod. And that tripod is going to consist of a sit bone on one side, a sit bone on the other, and then the tailbone in the center. It is the anchor for the posterior pelvic floor muscles. So there are all kinds of muscles that attach to the coccyx itself all around. Specifically, the coccygeus muscle is going to attach on either side of the coccyx. But wait, there are more. So what is really important and why I wanted to come on here today to talk about tailbone is that there are other structures that are not actually pelvic floor specific that are attaching directly to the tailbone. Those are the glute max. So we have hip insertions as well as the sacro tuberous and sacrospina ligaments. So if you’ve got someone coming in for tailbone pain, it is important to assess above the joint and below, of course, but assessing above the joint, like at the hip and the low back due to these attachments. Functionally speaking, the tailbone is dynamic. It’s going to move as we move throughout our day doing our activities of daily living. So when the pelvic floor contracts, the tailbone is going to draw in and come forward or come anteriorly. So let’s chat about actual functions that the coccyx is involved in. More specifically, the coccyx is involved in sitting, bowel health, so it helps to keep poop in or get out of the way to get poop out. It is involved in childbirth, sexual play, and transfers such as sit to stands. So let’s put ourselves in the subjective exam. You’ve got someone that came in and they’ve got some kind of hip pain or tailbone pain. So what are we going to hear from a traumatic mechanism of injury or a non-traumatic mechanism of injury? I’m also going to talk about aggravating factors here. So what are some things that you might hear during your subjective or things that you might want to dive deeper into in order to maybe put coccidemia or tailbone pain onto your hypothesis list? So from a traumatic mechanism of injury standpoint, we most commonly hear of tailbone injuries during labor and delivery. The tailbone should move out of the way to allow for the fetus to slide on down the birth canal as if it was that easy, right? And simple. But sometimes that birth doesn’t go according to plan and someone may need to have an instrument assisted delivery with the use of forceps or a vacuum. And that is going to put someone at a higher risk for a tailbone injury. Another traumatic mechanism of injury would be a fall. And that can be a fall during your sport, during an activity, or from a horse, which we hear often. So now I’m going to dive into eight common non-traumatic aggravating factors or contributors to tailbone pain. We have pregnancy. So during pregnancy, things are a-growing and that’s going to put a lot more force down into the sacrum, onto the tailbone. So some of those folks may start to say, hey, I’ve actually got a lot more pain when I sit during pregnancy. But you don’t have to be pregnant to have pain with sitting. So one of the biggest, biggest complaints of, or aggravating factors for tailbone pain is going to be pain with sitting. So especially for a prolonged time. The tailbone assists with weight-bearing support, especially in sitting. So let’s bring it to real life. In real life, we’re thinking truck drivers or maybe people who have jobs who you are sitting without any brakes or with minimal brakes. So just constant pressure and force down onto that tailbone. And then I also want us to take a minute and think about the social implications of someone who has pain, severe pain with sitting. So what is that going to prevent us from doing? Hey, maybe going on a dinner date, right? Or comfortably going to a movie with your grandkids or any sort of event at work or your job duties itself. So people who have tailbone pain and it is severe, just have some grace for them because we do a lot of sitting in our daily lives. Think about like even transportation, we’re sitting in a car, right? Not everybody has subways in their region of the United States. So just extend some grace to these folks because they, this is definitely interrupting their life quite a bit. Other reasons, or contributors to tailbone pain, rapid weight loss, increased stress might increase some overactivity of the pelvic floor muscles that surround the coccyx. We also have some sometimes tailbone pain after spinal injury. If someone has hypermobility, that is going to play into the mechanics of ligaments and of the tailbone, as well as oftentimes people will complain of pain in the tailbone with sexual play due to certain positions causing a little bit more force down into the tailbone. And then finally, exercise. You know, you’ve got those folks who are like, oh, it’s summertime, I’m going to get my hot girl summer on or whatever kind of summer they’re wanting. And they are recently starting some sort of exercise routine, whether that is doing a lot of orange theory or 45 where they have or CrossFit where they have a lot of biking or cycling or rowing that they didn’t used to have. And that’s a little bit more pressure on the tailbone or maybe the Pilates person who is doing like a hundred boat poses, right? So exercise can play a big role in a new onset of tailbone pain. And then from a medical perspective, bone spurs, infections and cysts can also contribute. So what are some easing factors? What are these people are going to say that may lead you to be like, oh, maybe if this is what’s relieving their pain, maybe I should be considering tailbone pain. They are going to say, you know, if I change positions or they might report being on their belly or standing or sideline, those are the positions of comfort. And that’s because we are not weight bearing onto the tailbone. So from an objective standpoint, let’s run through what are some bony structures we should be looking at. So hip and low back. Hopefully I’ve made that clear to you that those need to be screened out. Pelvic specific structures. We’re looking at the sacroiliac joint as well as the tailbone itself. And in our live courses for our pelvic class, we dive deep into assessment and treatment and help you just dial in those skills. So hop on into our live course for that. I’ll walk us through verbally how we would palpate the tailbone itself. So first, first, first, first, make sure it is actually the tailbone. I had a patient one time who is a health care provider and they were all through other subjective exam. They’re saying, yeah, you know, tailbone this, tailbone that, blah, blah, blah. I get to the objective exam. I’m doing my P.A. mobs on the spine. I get down to L3 through five. Boom. That is their pain. Tenderness. Ah, that’s it. That’s it. And so I’m like, OK, noting for later. And then we continue on into some tailbone palpation and nothing. Any sort of tailbone pressing or mobilizations does not reproduce the pain that they came in for. So just make sure that we’re all on the same page about what the tailbone is. Now, let’s just call it what it is. Palpating the tailbone is awkward. It can be uncomfortable for the client, but to quote Finding Nemo, just touch the butt. OK, touch the tailbone. You wouldn’t avoid palpation or assessment of the hip if someone came in with hip pain. Right. So we shouldn’t think any different about externally palpating the tailbone. So let me give you some options for how to do that. When we are palpating the tailbone, we are looking for reproduction of pain. And sometimes after you get a feel for a few tailbones, you can appreciate that some positions, some tailbone positions are a little more flexed or some are a little more vertical. And that usually comes with a little time after palpating a bunch of them. But the tailbone palpation, we’ve got three recommendations. So number one is externally, you can palpate as a clinician, you can palpate the client’s tailbone in prone, side lying or sitting. And in prone or side lying, it’s going to be the same way that I just walked us through how to palpate your own tailbone, except you’ll have as a clinician, a pincers grasp on that tailbone and you’ll be able to do some mobilizations and manipulations there. So these do make it difficult for getting a solid grasp on the bone. And then in sitting, I love this because this is a little more functional for the person. So you can have your fingertips on their tailbone in sitting and ask them to sit upright and then also slump. And that’s going to give you a good appreciation of the movement of the coccyx itself. And then another way to palpate the tailbone is they may be like, uh-uh, you are not getting anywhere near my tailbone. That is my tailbone. So that is okay. You can come alongside them and you can just walk them through how to palpate their own tailbone again in sitting or side lying. And you can ask them some subjective questions about what it is that they’re feeling and make sure they’re in the right spot. And then the final way to palpate the tailbone would be internally or interactively. And those with pelvic floor specialty, especially trained in inter rectal examinations, will be able to do that. So from a general conservative treatment strategy standpoint, let’s talk through some of those things. You’ve got someone that came in, you’re like, yes, they definitely have tailbone pain. Now what do you do? We’ll talk through manual therapy, exercise and education. So from a manual therapy side of things, you can do some direct coccyx mobilizations, whether that’s externally or interactively. So you’ve got your pins or grass and you are applying some mobilizations to that structure. You can also do it indirectly where your pins or grass stays on that tailbone. And then you ask them, maybe they’re in side lying, hey, can you do some posterior pelvic tilts, anterior pelvic tilts of the hips or can you move your hips while we are stabilizing the tailbone? That is obviously a more active way to get some manual mobilizations in there. We can also supplement with dry needling, cupping, e-stim. We definitely want to hit the glute max, the lumbar spine. And if you’re trained in it, the pelvic floor as well, especially those coccidius muscles that attach nearby, that touch directly to the coccyx. And then from an exercise standpoint, I’ll talk through some stretches, strengthening and aerobic activity. So my three favorite stretches for promoting down regulation of the nervous system for the tailbone pain is going to be throwing some diaphragmatic breathing in with these three exercises. So the first, I like my clients to be on hands and knees doing some rock backs. The second is happy baby. You can be in happy baby, maybe do some lateral movement side to side, but I love a good modified happy baby where the feet are actually on the wall that frees the client’s hands to actually spread the cheeks. It is okay to touch your butt. It’s your own butt, right? So spreading those cheeks is actually going to put a stretch onto the tailbone itself and for some people relieve some of that pain. And then a deep supported squat against the wall is going to be wonderful for those pelvic floor muscles that may be, again, a little overactive and pulling on that coccyx bone. Of course, in the long term, we’ll want to do some general loading, whatever that patient can tolerate and especially if hyper mobility is on board, loading of the hips and back and pelvic floor can be wonderful for these humans. And then finally, let’s blast them with some high intensity interval training of whatever they can tolerate. So bike and rower are probably going to be out the window, but they may be able to do some standing, arm bike intervals, brisk walking, treadmill incline, pull walking, anything to really hit the system to address that increased inflammatory state and promote some blood flow and healing. And then finally, education. Education is huge for these humans. So we’re going to talk about positioning, positioning in sitting. Let’s encourage a neutral or anterior pelvic tilt because that’s going to put a lot less pressure down onto the sacrum and the tailbone. Let’s identify the threshold that the patient is able to tolerate in sitting. So if they’re like during the subjective, they say, yeah, you know, around 30 minutes is when I start to feel my tailbone pain. Great. We’ve identified a threshold. below that and say, if you wouldn’t mind, let’s do some, some standing breaks or movement snacks around 20, 25 minutes of sitting just so that we don’t keep hitting that threshold of pain and continuing that ripping the bandaid off cycle of I sit for hours and hours and I have pain and then it starts all over again. So let’s do something about it. And then cushions. I love recommending a lumbar support cushion like a half McKinsey slimline roll. They can tuck that below the low back and that’s going to give them a little more anterior pelvic tilt and then also tailbone for the cushions for the tailbone itself. So some of my favorite models are the cushion your assets, tailbone support, the kabootie or a donut. And then during intimacy. So using pillows for support or maybe opting for positions with decreased tailbone compression like hands and knees or legs up or side laying. Those may feel better for that human. And then it wouldn’t be an ice podcast without talking about lifestyle factors. We want you to be talking with them about nutrition, reducing processed sugar intake, and especially for this population, stress management, increased stress with job, family, whatever can be a huge factor for keeping this tailbone pain around. So we want to make sure that we get them hooked up with someone or using some sort of stress management techniques to address that part of this diagnosis. And then finally, remind these people that it takes time. Tailbone bruises, tailbone pain, all of that. It just takes a really long time. And so it will get better, especially if they can implement some of these strategies. But unfortunately, they are going to have to be a little patient. So let’s review what it is that we talked about. Tailbone pain is tricky. It’s tricky to treat. It’s understudied and it’s underreported. But it is involved in so many life functions, including weight bearing support, especially pain sitting, bowel sexual function, labor and delivery. Due to the attachment sites to the tailbone, it should be part of your hypothesis list for folks coming in with back and hip pain. Actually touch the butt, but really touch the tailbone. Make sure that it is the tailbone that is possibly a structure that is involved. If you feel that the tailbone is involved, give it some manual therapy with some mobilizations, soft tissue love, and then supplement that with whatever kind of modalities you prefer. Cupping, dry needling, some supportive stretches like happy baby, quadruped rocking, getting some gentle loading in, and then offering some cushions for solutions for positioning. And finally, refer to a pelvic floor PT in your area or get yourself to one of our live courses because we dive deep into pelvic pain assessment and dialing in those skills so that you feel confident when you have someone like this in front of you. So happy Monday, everyone. Happy Fourth of July. And I will see you all in two weeks to discuss the soft tissue structures that may contribute

24:37 SPEAKER_02 to some pains in the butt. 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 PT on ice.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 PT on Ice dot com and scroll to the bottom of the page to sign up.

Jun 30, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines cold plunging, discusses the research behind cold plunging, and how to practically approach practicing cold plunging. Take a listen to learn how to discuss cold plunging with your patients or athletes.

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

00:00 INTRO
What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show.

01:25  ALAN FREDENDALL
 Alright, good morning PT on ICE Daily Show, happy Friday morning. Hope your morning is off to a great start. My name is Alan, I'm happy to be your host today. Currently, I have the pleasure of serving as a faculty member here in our fitness athlete division and the chief operating officer here at ICE. Fridays, our fitness athlete Fridays, we talk everything related to the recreational athlete, whether that's somebody in the gym doing CrossFit, powerlifting, Olympic weightlifting, bodybuilding, out on the track, the road, running, biking, swimming, whatever, that person who is getting after it. Four to six days per week is the focus here on fitness athlete Friday. We're biased, but we would argue it's the best darn day of the week. Courses coming your way from the fitness athlete division. Taking the summer off, we have some live courses coming up in September. You can catch Mitch Babcock out in Bismarck, North Dakota. That will be the weekend of September 9th and 10th, so the first September of the fall. And then you can catch Zach Long, aka the Barbell Physio out in Newark, California. That's the Bay Area. That's going to be the weekend of September 30th and October 1st. Online courses from us, our Essential Foundations, our eight week entry level online course starts back up September 11th. We're currently halfway through the current cohort. And then our Advanced Concepts course, our level two course that requires Essential Foundations, that drills down deep into things like Olympic weightlifting, gymnastics, programming, both for CrossFit and strength, injured athletes, all that sort of fun stuff. That starts September 17th. So you can find out more about our courses at ptenice.com. So today's topic, let's talk about cold plunging. You can't trip over a rock in public these days without finding somebody trying to get neck deep in some cold water somehow. Everybody's doing it. They're posting about it. There are probably a million ads you've seen on social media for this tub. This thing that looks like a bourbon barrel. This thing that looks like a fancy bathtub. All these different ways to essentially cool down your body. So I want to attack this topic from three different angles. I want to talk about defining a cold plunge and how probably most of the people cold plunging currently or certainly what we see happen on the Internet is not true cold plunging. I want to talk about the research supporting, not supporting the use of cold plunging. And I want to talk about the practical application of what we can recommend to our patients and athletes when they come into the clinic or the gym and ask us what we know about cold plunging. What's the best way to cold plunging and all that sort of thing. So let's start from the beginning. What is a cold plunge? We need to start at the top and understand that humans have a really large tolerance for heat at rest and a very poor tolerance for cold at rest. You can imagine it's much better to sit outside on a 90 degree day than a 30 degree day. So our perception of temperature is a little bit different. It's skewed based on if we're active or if we're resting. It flips entirely when we are active. You can imagine how terrible it would be to run on a 100 degree day versus running on maybe a 50 degree day. We would all probably much choose the 50 degree day because our bodies lose heat tolerance as our activity level increases, which is all that to say of we have a really poor tolerance for cold at rest, which means when we define the parameters of what's used for cold plunging in research, we'll quickly recognize that most of us, most of the people we see aren't doing it cold enough. They aren't doing it long enough and they aren't exposing as much of their body as they need to to the cold plunge. So a cold plunge is defined by the research is going to be exposure up to your neck or possibly your entire body for 10 minutes at 40 to 50 degrees Fahrenheit. That's a large portion of our body. That's a really long duration of cold exposure for a human being at rest. And that is relatively cold. Again, we have a really poor tolerance to cold at rest. Now, imagine we've we've all taken a bath. Imagine you you take a hot bath or sit in a bathtub and then you get that feeling of, oh, I'm getting really cold. Like this water has cooled down significantly. Again, our perception of temperature is really skewed. When we decide it's time to get out of the bath because the bath water has become too cold, we've probably started in bath water of maybe one hundred and five to one hundred and ten degrees. And it has only cooled down to maybe 90 to 95 to the point where we say this is cold, quote unquote, cold. I'm going to get out of the bathtub now. But really, 90 to 95 degree water is remarkably warm compared to what we define as cold plunge in the literature. So most folks are probably simply not getting their water cold enough to even define cold plunging. Again, the duration of support in the research is cold plunging of 10 minutes. So if you are doing it for 30 seconds or one minute, just know you are not anywhere close to reaping the effects or the positive or negative that we've seen in the research. If you're only dipping your toe in for a few minutes or jumping in up to your knees or your waist and hopping back out again in the research, exposure would define itself as being exposed up to the neck, at least. So many folks just putting their legs in a cold plunge, just going up to the level of maybe the knee, going up to maybe the level of the waist or maybe belly button mid chest or something. Again, if you're doing that to slowly gain tolerance, that's OK. But if that's what you're calling normal cold plunging, just know you're probably not reaping as much of the effect. Again, positive or negative that we'll talk about here in a second as you could be. So cold plunging 40 to 50 degrees up to your neck, duration of about 10 minutes. So all that to say, most people are probably not actually cold plunging when we do it ourselves or we watch others do it. Excuse me. Simply not cold enough, not enough for their body to get in effect and not enough for a long duration. I do want to give a special shout out to ICE faculty members Dustin Jones and Jeff Musgrave. They are unashamedly posting their cold plunges every day on social media and they really get after it. You can see that they have a bunch of ICE in their backyard cold plunges and they're sometimes exposing their whole body to the cold plunges. So they are doing it right. That's the way to do it. So let's switch gears and talk about what does the research say. The research in this field is becoming overwhelming of just looking at the trend and volume of research. Eight hundred and seventy articles published on what the research would call cold water immersion since 2008. So an exponential growth in the people studying, the amount of people studying and the volume of research studying this particular area of what we might call athletic recovery. I want to talk about just two journals today, two journal articles. There are literally like we talked about hundreds and hundreds and hundreds and hundreds. But I really want to talk about two. What I like about these two articles I want to share is that they are 30 years apart and they essentially say the same thing. So first, I want to go way back. 1985, I wasn't even alive yet. Journal of Applied Physiology, Peterson and colleagues talking about cold plunging exposure after exercise. These folks did three sessions a week of what the again the research calls cold water immersion or cold plunging. They did do it at 50 degrees Fahrenheit. They did it for 15 minutes instead of 10. So they went up to their neck. They did it for 15 minutes and they did it cold enough. 50 degrees Fahrenheit. They did this three times a week after resistance training. Evaluation here looked at a lot of different things. One rep max leg press, one rep max bench press and some ballistic things, counter movement, jump, squat, jump, ballistic push up. And this article really wanted to focus on what happens to muscular hypertrophy. This journal article, 1985, now 38 years ago, said you can expect to have less muscular hypertrophy if you expose yourself to a cold plunge after resistance exercise as compared to control. Control in this group was people who just sat at room temperature like you might sit on the boxes at CrossFit class or on the curb after a really long hard run. They just sat and kind of cooled down for 15 minutes compared to the cold plunge group. Fast forward 30 years, 2015, Journal of Physiology, Peking Colleagues, very similar parameters. That's why I picked these two papers. They are perfectly 30 years apart. They use almost exactly the same parameters and they found pretty much the same thing. Peking Colleagues in 2015, very similar parameters, twice a week of cold plunge exposure, 10 minutes at a time, also 50 degrees Fahrenheit. They followed folks a little bit longer. Peter Peterson in 1985 followed those athletes for seven weeks. Peak in 2015 followed them for 12 weeks. Almost same exact parameters, though. They looked at almost exactly the same stuff. They looked at leg press strength, knee extension strength, knee flexion strength, both one rep max and eight rep max. So they're looking at maximal strength and they're also beginning to look at kind of what is your ability to produce force over time. So what we call maybe endurance, which really is indicative of hypertrophy. This team also did some muscle biopsies and what they found with the group exposing themselves to the cold plunge after resistance training compared to the control group, in this case, a group doing active recovery. So not even resting, just doing active recovery for 10 minutes after the resistance training session. The control group, who continued to exercise at a low level, had a 17% improvement in hypertrophy, a 19% improvement in isokinetic strength and a 26% improvement in myonuclei per muscle fiber. So the control group blew the cold plunge group out of the water. Now, that is not to say that the cold plunge group got weaker or smaller. They did not get as strong and big as the control group. And it's led to believe because they were the cold water immersion group, that it's the cold plunge, that something about that cold exposure seems to blunt the body's natural response for healing to encourage hypertrophy gains and strength gains. The big takeaway from this study is the myonuclei per muscle fiber. We can think of myonuclei as if one myonuclei per muscle fiber is great, but more is better. It's almost like having a personal assistant for everything in your life. Your life would be a lot easier if you woke up in the morning and someone was there who had your clothes ready for you. If someone was there who had already prepped your shower for you, if someone was there who already made your breakfast for you, right? The more people you have assisting you in your life, the more efficient you will be at running your life because they're doing everything for you. That's a lot of the role of the myonuclei in our muscles. The more the better. The interesting thing about myonuclei is they stick around even during a period of training, whether it's injury, whether we get busy with life, whether we switch training modalities, maybe we start prioritizing endurance training to train for a marathon or something. Those myonuclei stay around and that's kind of what creates that strength across life of that person who comes into the gym who says, I haven't worked out in 10 years and then deadlifts 400 pounds. You're like, where did that come from? That took me years to build to that strength. This person just naturally has it. Yes, they may naturally have some genetic strength, but what they probably had in the past from training was myonuclei that are now living in their body. And so losing those myonuclei or rather not gaining them through cold plunge exposure not only affects strength and hypertrophy in the short term, but affects really long term fitness gains over time. So very interesting study from PEEK and colleagues showing that cold water immersion after resistance training seems to really have a negative effect on strength and hypertrophy. So it doesn't seem to help. It maybe seems to have a negative benefit, at least after resistance training. Most people aren't doing it correctly. What is the actual practical application? What can we recommend to patients and athletes who ask us about cold plunging? The first thing is to make sure that they understand what it actually is and that they're doing it correctly. Of, hey, if you're going to do this, you should have a way to expose yourself up to the neck, your whole body up to your neck. You should build up your tolerance to do it in sessions of 10 minutes at a time. And the water should be really uncomfortably cold, 40 to 50 degrees Fahrenheit. We don't like to see colder than that. That can be a little bit dangerous, but we also don't like to see warmer than that. Right. Remember, cold bath water is technically hot, 90 degrees Fahrenheit. So we need to see somewhere between 40 to 50 degrees Fahrenheit. We need to talk about timing of cold plunging. The research would really suggest we should never do it after training, especially if we're just training once a day. We're training for life. We're training to be strong and be training for life. And we're not training to be competitive athletes. We're not training multiple times per day. If you're somebody that just exercises once a day, you should not finish that exercise session with a cold plunge. Maybe you start your day with a cold plunge or maybe you cold plunge before you exercise to get the effects that cold plunging can have aside from apparently blunting our strength and hypertrophy gains. And then there's a little bit of a caveat there for competitive athletes, folks who are, you know, let's think of a CrossFit Games athlete. Let's think of somebody running multiple races, an Ironman, a long cycle race. Maybe between events is the time for a cold plunge. We need to recognize those events are already really destructive to the body. Nobody goes to the CrossFit Games and comes away fitter. They come away significantly beat up with probably weeks or maybe even months of repair time needed to recover from an event like that. So at that event, we're not as concerned about not gaining as much strength and hypertrophy as possible because of the short duration. It's only a couple of days or maybe even a one day competition is only a couple of hours. So maybe that is the time between events to use cold plunging. But after regular training, we should not use it. We need to recognize the point of exercise is to create a micro injury that your body will repair and heal from. Your tissues get stronger from a tensile strength perspective and your brain more effectively learns how to use those muscles so that we get stronger and bigger over time. We become more adapted to the stress. We have an increase in tensile strength. We have an increase in myonuclide per muscle fiber. And that's what really creates robust lifelong strength. I love the quote from Pique and colleagues. Remember that anything intended to mitigate and improve the body's natural ability to improve resilience to physiological stress with exercise may actually be counterproductive to muscular adaptation. Cold plunging, NSAIDs, antioxidants, anything that can slow the chemical reactions, the natural chemical reactions in our body to respond to that micro injury is going to affect our ability to recover and be more resilient to that stressor in the future. So a lot like discouraging folks from taking a bunch of maybe ibuprofen or injectable steroids, we should say, hey, if you're going to cold plunge, make sure you start your day with it. Make sure you do it before training. You should really try to avoid finishing that workout and jumping right out into that maybe that cold plunge in the in the gym parking lot, because this research is really so profound of you're leaving maybe 20% improvement in strength and hypertrophy on the table when you cold plunge after training if you don't. So cold plunging, what is it? How does it work? Does it have a negative effect? Yes, it seems to. But also, that doesn't mean that we should say just don't do it. If you enjoy it, if it helps you start your day, if it helps you feel less sore, by all means, cold plunge. But let's rearrange when you cold plunge in your day to make sure that we're not doing it after training. And let's make sure we're doing it correctly up to our neck in the water, cold water, 40 to 50 degrees Fahrenheit. And duration should be at least 10 minutes, right? If you're just up to your knees in 60 degree water for two minutes, you're not actually cold plunging. You should feel good. You're probably not going to get a negative effect from that because you're not doing it correctly. But you're also leaving a lot on the table by not doing it correctly. So cold plunging. Hope this was helpful. We just revamped week five of our Central Foundations course to include a whole bunch of different training modalities like cold plunging. We talk about hot tubs now. We talk about saunas, both infrared and traditional saunas. We talk about compression therapy, massage, pneumatic boots, massage guns, everything folks have a question about. So if you've already taken the Central Foundations, head on over, check out week five for that update. If you haven't taken it yet, remember, September 11th is your next chance. So have a fantastic weekend. I hope you all have a lovely long four day weekend for 4th of July. We'll see everybody next time. Bye everybody.

18:00 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 CU's from home, check out our virtual ice online mentorship program at PT on ice dot 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 PT on ice dot com and scroll to the bottom of the page to sign up.

Jun 29, 2023

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the idea of letting an audience grow around the passion you have for a particular area of practice versus continually trying to change your approach in the clinic or with marketing to attempt to reach an infinite number of potential audiences. Take a listen to today's episode. 

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

00:00 DR. JEFF MOORE, PT, DPT, OCS, FAAOMPT
Alright team what's up? Happy Thursday, happy Leadership Thursday. Welcome back to the PT on ICE. Wherever you're taking this show in thank you so much whether it is here live on Instagram or YouTube or whether it's on the recording we love having you all with us. It's Leadership Thursday but if it's Leadership Thursday it's Gut Check Thursday. So let's talk about the workout. It is a doozy. So it is the last workout in the I Got Your Six. The Warrior Water. Friends over at Warrior Water have their virtual competition going on so our Gut Check Thursday has been mirroring that. So we've been loving the videos of all of you in groups of two nailing these workouts. This is the last one so it's going to be it's gonna have a time cap of I think it was 23 minutes in teams of two and you've got to do 10. So athlete one will do 10, 8, 6, 4, 2 box jumps. Only one athlete working at a time. Athlete two has to bang out 10, 20, 30, 40, 50 double unders. Then you both accumulate only one athlete working at a time a hundred deadlifts, 225, 155. Then you switch athlete rolls to finish up the box jumps and the double unders. So if you want to see that workout I know it's a bit more complex. It's over on the Ice Physio Instagram as always and please if you do it throw a hyperlapse on there. Grab a pic. Ice Train. Ice Physio. We love seeing that stuff pour in on Instagram. So cheers to Warrior Water. Hope the virtual competition went awesome. I hope that you were able to as always raise some funds for for veterans who are being helped by getting that fitness and nutrition stimulus as opposed to maybe more aggressive medications to help out with all things psychologically and quality of life. So cheers to the Warrior WAD crew. If you aren't following them get on that they're doing great things. Okay team let's jump in. So Gandhi once said that happiness is when what you think say and do are all in harmony. When what you think say and do are all in harmony. When what you're thinking is what comes out of your mouth. When what you say is backed up by action that proves that you believed in what you said. When all of these axes are in perfect alignment that is when you are truly profoundly at peace happy. Now in today's society it's hard to get that right in some level we are always trying to adapt to our environment. It's really hard. You come off as a bit of an oddball. If you had those perfectly executed all the time it'd be really challenging to fit in. So there's some level of kind of massaging those or working with malalignment which is probably why there's some level of disharmony in most people. Right you can't have this perfect pure energy flow between what you think say and do and still be functional in modern society. But the closer you can get to that undeniably the better because we are at our best. We are our most energetic. We are our most uniquely valuable. When we are sharing, when we are doing, when we are serving what we absolutely must. Right when those things are all in perfect alignment with our beliefs we are undeniably at our most uniquely valuable. So the first charge and I think if you look back at all of my episodes up to date this is probably the thing that falls out of solution most commonly. But our first charge is always to figure out what is that? Like what does line all of those things up for me and how do I figure that out? Well you figure it out by reflecting in real time on when you're in your flow state. Right when after doing anything you are more energized than you were before you did those are the moments of reflection when you've got to say whoa whatever I just did first of all felt effortless and second of all I think I have more energy now than before I did the activity. Those are your things team and a simple awareness of what are the activities that put you into that flow state. A great tip off can be when other people say boy you made that look easy and you think to yourself well it was easy but clearly to them it wouldn't have been. So when people start helping you identify these asymmetries when you're making something look effortless that to most people is not these are your activities whatever you're sharing right now whatever you're talking about whatever you just did those are your things that are aligning all of those axes and if you can identify what those things are and spend more time in that lane and drive fast you're gonna be not only more successful but significantly more energized and excited and useful in those activities that you're participating in. That classic quote the riches is in the niches which nobody in sales denies the reality of that right specialists win when it comes to business but a lot of people think that's totally explained by market dynamics and I do agree that if you can market a really specialized niche you can get the attention of people who need you but there's a whole other half to that when you're doing a really niche activity that you're particularly great at where you're spending a lot of time in flow state because you've drilled down to realize oh this is my thing a big part of why long term the riches are in the niches is because you're doing what you're in harmony while doing and that gives you unbelievable longevity it allows you to bring incredible enthusiasm to the plate so it is a combination of market dynamics in the fact that you're doing an activity where those axes are all lined up and in that space you are going to be unstoppable which brings me to today's message you gotta stop trying to please your audience and I mean this across all sorts of domains and I'll unpack that a bit in a second but you gotta stop trying to please your audience you gotta do you and let the audience be formed by those who resonate with it I'm gonna say that one more time you gotta stop trying to please who you think is your existing audience you gotta just do you and let your audience be formed by the people that resonate with that where I see a huge obvious sign of deviation from this is when we say things to our audience is like what do you want me to talk about that is one way to ensure that whatever you wind up talking about is not in perfect alignment because what are the odds right what are the odds that the answers are things that are absolutely in perfect alignment for you that line up what you deeply believe in that where you believe it you're the most useful to add value where you believe the greatest need exists what are the odds that what somebody else answers to that lines up perfectly with your needs now team this is not to say that the occasional call for topics or the occasional Q&A does not have great value because you can pick through what comes back and try to identify which things are in line but in general be a little bit wary of that method certainly is a primary component of your business be wary of that it is ultimately professional people pleasing right hey tell me what you want me to do and I'll dance right like this idea takes you out of alignment it doesn't put you into it the reframe to this is I'm going to talk about X because I have to right if you feel like that message might serve you please tune in or if you feel like this message might serve somebody that you know well please tune in but I don't have a choice right this is what's in alignment I have to talk about this I really hope for some of you that it resonates I tell ice faculty this all the after classes because oftentimes when we're recapping if I go to a live course and I'm and I'm trying to give some notes to see if we can't make the content even sharper a lot of times our faculty will say well I really feel like I need to talk about this and immediately my response is you don't need to talk about anything besides what you deeply feel you want to talk about what is real and organic and honest for you that's what you talk about this is a big part of the reason whole other conversation but it's a big part of the reason why ice since day one has never had close partners or accreditation or tied into other groups because I always want our faculty to feel at any given moment when something doesn't feel authentic to them they can drop it with no thought and change and say this is what I really need to talk about I have to say perfect that's our content whatever follows I have to say this that's our content it goes for ice faculty but it goes for all of you it goes for who you market to it goes for where you do workshops it goes to the topic of those workshops it goes to what population you want to treat you know who you need and want to treat you know who you are uniquely valuable for you know who after you engage with them you feel energized team 100% of your effort goes to that niche identify that and just stay in that lane you don't need to do what people want you to do what you need to do is what you have to do what is in harmony with what you're always thinking about with the words that you're always saying with your actions in your own personal life those things need to line up with whatever direction you choose in that direction doesn't have a whole lot of options right so it's like look this is me I've got to do this and I hope that some folks resonate with it I hope that some folks respond well to that treatment paradigm I need to be in this space it is what it is we got to stop asking our audience what they want we got to start doing us and let the audience or the patient base or the customer solidify around that now how do you know if you're doing it right how do you know if you're staying in your lane in driving fast the answer is a little bit uncomfortable but it's that your audience should be unstable you should be dropping people and gaining people if you're not trying to please everybody that's an inevitability but what you're gonna notice is that a core group in your audience solidifies and becomes unshakable team if you aren't losing people regularly especially early you're being inauthentic because authenticity should always offend people this isn't wrong it's just that people who have drastically different beliefs when you present yours in an undecorated fashion it should be moderately offensive and people should be like oh that's not my tribe great right that's the whole point of the drill right that's why your audience should be relatively unstable early on but you're gonna see that what people want is an authentic person delivering value in their area of need and they're gonna feel that match so while your audience is gonna be unstable on the outskirts you're gonna see that this tribe is crystallizing out of solution in the middle because people that do need to hear what you have to say that you need to say they need to hear it you need to say it when that match happens when those ends plug in together your true tribe crystallizes out of solution that's the only way that great cultures are created the person delivering it is being raw inorganic inauthentic and even though that offends some people the people who need to hear that message who belong in that tribe gravitate towards it and that match is made as soon as we start trying to please everybody nobody can actually connect because nothing real is actually happening and this is what happens with what can I say for you today as opposed to here's what I need to say and I hope it lands for some of you generally speaking in your marketing in your outreach as you're trying to build followers be real suffer the consequence of an unstable early audience and what you're gonna see is underlying that your true tribe is developing all along stop trying to give your audience what what they want say what you need to say and let your audience form as a result of that hope it hits team we'll see you next week PT on ice calm all the courses are on there tons of online courses starting up in July we had a little bit of a hiatus there in between our first q1 and q2 online courses they're starting to drop right now by the way we have finished our live calendar so if you're waiting for a new live course to show up in 2023 it's probably not gonna happen because all of our division divisions are done booking so if you've got your eye on a live course a new a new one that's more convenient probably isn't gonna show up this year so grab the one you're thinking about alright team have a wonderful week we'll see you next week

13:09 SPEAKER_00 on leadership Thursday 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 CU's from home check out our virtual ice online mentorship program at PT on ice calm 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 PT on ice calm and scroll to the bottom of the page to sign up

Jun 28, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the effects of terzepatide on older adult patients.  Take a listen to learn how to better serve this population of patients & athletes.

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

00:00 INTRO
What's up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.

01:43 Dr. Julie Brauer, PT, DPT
Good morning, Instagram. Happy Wednesday. Welcome to the Geri on ICE segment of the PT on ICE Daily Show. My name is Julie Brauer, member of the older adult division. We are going to jump right into our topic this morning. It's Wednesday, so all Wednesdays we talk all things older adults. This morning, we are going to talk about terzepatide and the older adults. And this is going to be a case study type discussion. So what is terzepatide? You probably have heard it all over the news by its brand name, Mount Jaro. So terzepatide is a FDA approved drug for glycemic control in individuals with type 2 diabetes. The problem is that many folks, including my 72 year old patient who does not have type 2 diabetes, these folks are getting their hands on it for weight loss. And many of these folks, including my clients, is not considered overweight. So this morning we are going to talk about what this drug is, what we know from the clinical trials, how it works, what are the side effects. We will briefly touch on that. And then I am going to tell you the story of my client Martha, who experienced some pretty negative side effects and consequences from taking this drug. And we will talk about how to navigate this challenging situation where your client is doing something that you know is probably not good for them. You don't necessarily support the decision, but you need to support your client in general, through this decision. We will talk about how you have to be a master of scale and adjust your exercise interventions to keep an individual safe as they are going through something like this. And then we will talk about the scary and unfortunate event that occurred for Martha to finally decide that was the nail in the coffin and she was going to go off of this drug. Okay, so Mount Jero Terzapatide has gotten a lot of attention in the media about how it potentially can be more effective as a glucose lowering therapy over other glucose lowering therapy drugs like Ozempic and Wigobi, or others that you have probably heard about. Those are just the brand names for the drug Semiglutide. What are these drugs and what is the difference here? Semiglutide is a single receptor agonist. Mount Jero or Terzapatide is considered a dual receptor agonist. What you will see in the literature is that it is a dual GIP GLP-1 agonist. What those are are hormones. These are hormones that are released from the gut that regulate insulin response to a meal. What they do is they increase insulin secretions, increase insulin synthesis, they decrease gastric emptying, which in turn promotes this feeling of feeling really full. And then it promotes a decrease in appetite. So individuals are just not hungry. They're not eating as much. And so why this drug is getting so much attention is that because it's a dual receptor agonist, it's having this synergistic effect of having an even more potent dose on decreasing glucose as well as weight loss than the more commonly known drugs of Ozampic and Wigoby. So that's the basis there. Now let's talk side effects because that's really important to know that what are the side effects that come along with this drug. So many of the side effects are primarily having to do with GI discomfort. And now there are so many, like nine plus clinical trials, they are called the Surpass and Sermout trials that are going on, looking at the safety and efficacy of turzapetide. And they're looking at the safety and efficacy of individuals who are on glucose lowering therapies already. And then they're looking at it in individuals who are not on glucose lowering therapies. They're looking at individuals who are also doing intensive lifestyle and exercise interventions. I think those studies would be really interesting to actually see what those exercise interventions are. They're even looking at the cardiovascular benefits and then just the benefits in individuals who are considered obese and looking at the benefits for weight loss for individuals who are not even living with type 2 diabetes. Okay. So what they have found in terms of side effects, those GI side effects. So you're going to see individuals who are going to have really extreme nausea, diarrhea, vomiting, constipation, and you see this dose dependent response. So the higher dose that people are taking of turzapetide, and this is a once weekly subcutaneous injection, you're seeing those side effects increase with the higher doses that people take. And so some of the clinical trials, even up to 66% of individuals were experiencing GI distress. And so many individuals who start taking this drug actually stop taking this drug because of those adverse GI effects. They just feel like crap, literally. Okay. So that is an overview of the drug. I will post a article link to the Surpass and Surmount clinical trials. If you guys want to get into a little bit more detail about these specific drugs. Okay, let's talk about Martha, my client. So she is someone who started working with me. She has severe arthritis in her knees, very, very weak. She's a yoga gal, never lifted any weights. She could barely do a sit to stand from a workout bench without using her hands. It caused a lot of pain. We have been working together for months and got her to a point where she is lifting. She's doing goblet squats, 35 pound dumbbell for 12. We've been working together for months. She is doing high intensity interval training. She is repping out burpees and slam balls. I mean, she's absolutely crushing it. Like we were building her reserve and resiliency, her arthritis in her knees. That pain was starting to decrease. She's starting to feel really, really good. She is so on board. It's been this beautiful, beautiful journey. And then one day, Martha hits me with, so I'm going to start this weight loss drug, Mongero. And it took everything for me to not automatically question that and show on my face that I was upset about this decision. And so I want to emphasize to you all how to go about this, how to react, how not to react. I know that we're going to have some regression here. I know that we're going to have some challenges. The important thing to remember is that we need to be the guide and not the hero. Be the guide, not the hero. That doesn't sound or look like this when Martha drops that bomb. You do not say, Martha, wait, huh? Why? Why would you do that? You don't need to do that. We're crushing it. You're doing so well. You're going to lose weight by exercise and lifestyle intervention and nutrition. What are you doing? That's going to make you feel like crap. Don't do it. Don't do it. We do not want to do that. Even in our head, if that's kind of what we're feeling, we do not show that. We do not say that. That is not being the guide. It does sound like this. Being the guide sounds like this. Got it. Martha, I'm so curious. This is totally new to me. Tell me a little bit more. Why have you decided to go on this? Hey, Martha, we may experience some challenges here. There may be some side effects. We may have to switch some stuff up with our exercise approach, but we will get through it together. That is what being the guide sounds like. We have to remember that older adults are allowed to assume their own risk and they're allowed to make their own decisions. For some reason, when it comes to older adults, and this is based in ageism, this is based in ableism, it's like we believe that they're little children who don't have fully developed frontal lobes. We assume because they're old, they need us to make decisions for them. That's not the case with many older adults. They are fully, fully capable of making their own medical decisions. We have to remember that this is not our life to live. This is not our journey. It is a journey for us to come alongside our clients, not to decide what that looks like. We want to gently try to get them back on track into our fitness forward lane, right? It's not a time to drop them from our care because they're not following along with our philosophy. I remember a very specific day. I was in the gym. I was on the GHD. Why I was looking at my phone, I don't know, but Martha texted me. She had been on this job for a few weeks now. She's like, I have such low energy. I feel awful. I just can't do the intensity that you're putting me through in these workouts anymore while I'm going through this weight loss period. I just can't do it. That was so upsetting, right? Because it felt like a failure. It felt like we were going to go backwards so many steps. My gosh, what had we worked so hard to get to? I was glad I'm at the gym, right? Because then I was like, you know what? I'm just going to go lift some heavy weights and I'm going to feel better. Obviously, 10 out of 10 times, you always feel better when you're stressed out and you lift some weights. I started to think about it and I was like, okay, I can't drop her. Even though it felt like, well, what skill am I bringing if I'm not appropriately dosing her? What else can I do here? I had to reflect and be like, no, I'm with her. Martha, I'm with you regardless of what you decide to do and how this looks like throughout this journey. And why is this important? Because when we spend so much time getting someone into a fitness forward lane, we're doing this because we want to build this long lasting relationship with them. Martha is going to get to a point where she's crushing it again. And I probably back off and I don't see her anymore for a while. But what do I want for our relationship? I want that if anything else comes up with Martha, right? She has an injury, she has pain, she's hearing some, you know, maybe some things are discouraging from her doctor. I want me to be the first person she thinks of. I want her to think, I want to run this by Julie or you know what? I know Julie could help me. We went through a lot together so far. I trust her. She's with me. I'm going to make sure to contact her. That's what we want guys. Like we want to develop that long term trusting relationship so that when something else comes up, we can get her right back into our fitness forward lane and we can keep her there. Okay. So that's number one. We have to remind ourselves that we are the guide, not the hero. All right. Now, how did I have to adjust for these regressions? How did I adjust our exercise interventions? So number one, she's right. I had to decrease the intensity of these exercises. I had to cut out a lot of the high intensity interval training. She had zero energy. She was feeling a little bit uncomfortable, a little dizzy. I mean, vitals and everything were fine, but she just felt like crap. And I would see her, you know, get a little wobbly when we were exercising. So I'm like, all right, we got to switch this up. So decreasing the cardiovascular intensity, I stopped having her do exercises that were high intensity with a lot of positional changes. So burpees and mountain climbers, supermans, hollow holds, thrusters, all of that took that out. And I just kept her on the bike. I just went back to getting her on the bike and just pedaling and maybe taking that RPE from an eight or nine down to a four to a five, right? She's sitting, she's safe on the bike, but I can still get a little bit of intensity there. Next, what I did is increase the amount of just raw strength training that we were doing. So taking away the high intensity interval, the full body functional movements, and I went more towards isolation and really just tried to focus on strength, right? Heavy, low amount of reps to where she's not getting a cardiovascular stimulant. It's more just muscular fatigue. So we started just going really heavy and really slow. And we became, I put her closer to the ground with all these positions. So instead of doing a standing press, I had her do a sitting press. We did a lot of supine, like hamstring, sliders, many times at tempo, right? That was another way to increase intensity without driving cardiovascular stimulus up. Supine chest press in a bridge position, sitting tricep extensions. Instead of bent over rows, that could get her a little bit dizzy. I had her do some standing banded rows, right? So I'm just changing things a little bit. I'm being a master of scale. I'm meeting her where she's at, prioritizing that raw strength training over intensity intervals. Next, I had to remind myself that something is better than nothing. When Martha texted me to say, I just don't think I can do anything. Like, I don't think I can do much. Should we still get together? Should we still meet? And part of my brain was like, again, it was like, well, what's the point? But then I'm like, you know what? Yes, something is always better than nothing. And 10 out of 10, Martha's been doing nothing. Her joints are becoming more achy. Her energy is getting lower because she's not moving. I know that if I help her just move her body and give her things to do that don't exhaust her, but make her feel good, that is going to make her emotionally feel better, physically feel better. It can be a gateway to opening up a little bit more activity because she had become so sedentary. And so that's exactly what we did. I modified everything for her. I gave her a workout specifically that was called, when Martha feels like crap, like, here you go. Here are the things you can do that make you feel good. And at the end of that session, she was so thankful. And she said, you know, I am so glad we met. I feel so much better that I did a little bit of something. So something is always better than nothing. Next, we have to talk about the nutritional aspect here because she got to where she was only eating a smoothie in the morning. And then she would eat like a spoonful of cottage cheese and maybe some crackers for the rest of the day. And she was telling me she was having these weird cravings for like hemp hearts and artichokes. Very strange. And she said, I can't really eat solids a lot. Like, I'm too full to eat solid food, but I really like my smoothie. So I was like, cool, let's make that smoothie as calorically dense and packed full of protein as humanly possible. We know that malnutrition is so, so detrimental to older adults. We know how that can lead to clinical geriatric syndromes like frailty and sarcopenia. So I wanted to try and make sure that I was making the food that she could eat as nutritionally dense as possible. So packing that smoothie with chia seeds and flax seeds and peanut butter and making sure it's high protein, full fat Greek yogurt, all of that. Really trying to make that one smoothie as nutritious as possible. So remembering when folks are, they don't feel like they can eat their calories, can they drink those calories and tolerate that a little bit better? Lastly here, the most important thing to remember is that you want to be thinking about maximizing reserve and resiliency, even when things are going really well. Like even when you're crushing it with your clients, your older adult clients, the job is not done. All right, I think about Kobe Bryant and the 2009 NBA Finals. They were 2-0 over the Magic and the reporter at the end of the game was like, you don't look happy. Like what's wrong? And he's like, what's there to be happy about? The game's not finished yet, right? The job's not finished yet. That is the attitude that we have to have, is that even when you have built reserve and resiliency and things are going well, you do not want to take your foot off the gas pedal. You want to continue to instill this person becoming robust and resilient because something's going to come along, right? It could be that they decide to go on this darn weight loss drug and they lose a lot of their strength and their resiliency or they get sick or they have a family member who passes away and they become emotionally depressed and they become, they socially withdrawal, right? All of the complexities that can happen in our lives. Like we want to be building reserve and resiliency and do not take your foot off that gas pedal, right? The job is not done yet, okay? All right, so what happened to Martha? What is this scary ending that happened? So Martha has a partner and her partner was also taking Mongero. He was outside working in the yard, something that he loves to do. He had lost 20 pounds over a period of six weeks, whereas Martha didn't lose any more than just a few pounds, but her partner really experienced significant weight loss. He wasn't eating, he wasn't hydrating, he was trying to maintain his normal level of activity. He was outside in the yard, it was really, really hot and he passed out and like fell down an embankment, rolled a bunch of times, bruises all over the place. I mean, went to the emergency room, bruised a bunch of ribs, got a bunch of x-rays, he's okay, but Martha said to me, he's like, Julie, if that would have been me, I don't know what would have happened. I mean, he's a big strong guy. I could have gotten seriously hurt and even more so, I mean, if I hadn't built the strength that I had working with you over the past however many months, I don't even know. Maybe I would have died. Maybe I would have died if that happened to me. So she's seeing something really awful happen to the person that she loves. She's thinking if it had been her and she's saying to me, you know what, I just, I love being active, right? I miss how strong I felt. This sucks. I don't like this, right? And she wasn't even someone, she didn't have negative GI effects. She wasn't having nausea, vomiting, all of that stuff. She simply wanted to feel good again and full of energy. She was sick of feeling like crap, you know, and obviously saw something really awful happen to someone that she loves. So she has discontinued this medication just recently and we are going to be seeing each other again next week and we're going to just have to rebuild, you know? But she was able to come to her own conclusion. I didn't have to tell her not to do this. She decided to get off this drug on her own because she had built up this belief in this fitness forward philosophy. She knows how good it feels to work hard, to do her high intensity intervals, to lift those heavy weights. She wants to get back to that. And so this was a beautiful example of how we have to let people make their own mistakes and come to their own conclusions. All right. That was a long one. That is all I have for you all. So some things to think about. I hope this helps if any of your clients are taking this drug or you're just trying to navigate a situation where maybe they are doing something in a way that you don't fully support and how do you continue to support them on their journey and maintain a good relationship? I will end things here by telling you guys a little bit about our courses that are coming up in the older adult division. In July, we are in Connecticut, Idaho, and Georgia. In August, we are in Maryland, Kentucky, Minnesota, and Texas. And our next eight week online course, Essential Foundations, starts August 9th. So PTI Nice is where all of that information lives. Feel free to reach out if you have any questions. Have a wonderful rest of your Wednesday.

Jun 27, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey highlights the four pillars of healthy living behaviors: mindfulness, exercise, diet, and sleep. These pillars are essential for improving overall health and wellness. Mindfulness involves helping patients become more aware of their beliefs and mindset towards their body, and providing them with strategies to think about their body in a healthier way. For patients with hip and knee issues, mindfulness should also involve reframing their mindset to view their bodies as having opportunities for improvement through strength and flexibility.

Exercise is crucial for meeting physical activity guidelines, which recommend 150 to 300 minutes of physical activity per week. The WHO recommends aiming for 300 minutes as it is more beneficial. However, prescribing physical activity for patients in pain can be challenging. The episode suggests starting where the patient is at and finding ways to infuse physical activity, such as starting with five-minute bouts. Therapeutic exercise is also helpful but may only result in small to moderate size effects on pain and disability due to variability in patient response.

Diet involves adding healthy foods to a patient's diet, rather than taking away harmful foods. This is especially important for those who have received negative messages about their body. Sleep is also crucial for tissue healing, and strategies such as sleeping in a cool, dark room and going to bed at the same time daily can help improve sleep quality.

Overall, addressing these four pillars may be challenging, but they are essential for improving brain tissue and making the body more resilient. The goal of mindfulness is to help patients become more mindful of their bodies and to frame their mindset in a more positive and proactive way. Meeting physical activity guidelines is a must, and therapeutic exercise can be helpful but may only result in small to moderate size effects on pain and disability. Adding healthy foods to a patient's diet and improving sleep quality are also crucial for overall health and wellness.

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

EPISODE TRANSCRIPTION

00:00 Dr. Lindsey Hughey, PT, DPT, OCS, FAAOMPT
Good morning PT on Ice Daily Show, how are you? I am Dr. Lindsay Hughey, one of our lead faculty from our extreme management team coming to you live from Grass Valley, California. Kind of an atypical place to see you all, but I'm just finishing up teaching a course here with body logic. What a weekend and about to take off to Delaware a day of travel, but I'm so happy to be with you all this morning. Today I'm going to chat with you about hip and neo-a and really the unspoken battle we have with these folks when we're treating them. But before I dive into the topic at hand, I would love to review just briefly some courses that Mark and I and our extreme management team have coming up this summer. So our next offering is July 15th, 16th, we will be in Holmes Beach, Florida. And then July 22nd, 23rd, we will be in California again, but now we'll be in the southern part, almost the most northern part. So we'll be in Sydney Valley, California, and there are still spots in both of those courses. So we'd be delighted to have you with me. And then July 29th and 30th, we're going to be at Onward Madison. I think there's only one or two spots, maybe zero. Check it out though, because we are filling up because that's right before the CrossFit Games. And one of our faculty, Kelly Bempi, is competing in the CrossFit Games. So I'm going to teach that weekend and then stay the whole week and cheer her on. I couldn't be more pumped and a lot of ICE faculty would be there. So think about that as one of your weekends if you're wanting to go to the CrossFit Games as well and kind of make a week out of it. And then check us out on ptlnice.com in our extreme management division because we also have courses in August and then early September. But I'd love to unspoken battle. So in this episode, I want to briefly review what we know helps hip and knee away, which we in the last couple of years keep seeing studies that really just confirm exercise is the way. It's not injections. It's not surgery. It is exercise medicine. And just recently, a 2023 systematic review and meta-analysis on hip and knee away just came out out of the Lancet Rheumatology Journal reiterating this. The exercise is superior to no exercise. And kind of the challenge and this study in particular, its title was Moderators of the Effect of Therapeutic Exercise for Knee and Hip Osteoarthritis, a Systematic Review and Individual Participant Meta-Analysis. This involved 91 RCTs and they compared exercise versus non-exercise strategies and they included both knee or hip or included studies that actually looked at both or looked at each individually. And really the outcome measure is pain and disability, right? The number one things patients are coming to us for. And then the study just really reiterated the importance of therapeutic exercise. What we often just say exercise, but what this article defined therapeutic exercise to be was it involves participation in physical activity that is planned, that is structured, repetitive, and purposeful for the improvement or maintenance of a specific health condition such as osteoarthritis, right? So this has to be purposefully planned and it has is multimodal and in nature. This article not only reiterated that therapeutic exercise, in fact, that combination of multimodal treatment is helpful, but it also further demonstrated that we always see small to like moderate size effects or effect sizes as it relates to pain and disability. Meaning not really huge shifts and necessarily changing that patient's world and then implying it to the broad population because there's a lot of variability in patient response. We are just still missing the target here is what that's telling me, right? We're missing the target in this patient population because we're not even though we know exercise is the way, we're not reaching everyone. People are still going on to getting knee replacement. They're still going on to having pain and disability. And I believe it's because our focus is really misdirected and what the underlying battle here is. And it's not just about strength, range of motion, access. It is a much bigger underlying systemic issue because we're not even reaching the target. Because what is happening under the surface with hip and knee away is a really complex process. And while it's complex, I'm going to just unpack it for you in like a minute. But when we see folks that are inactive, not moving, and whether it's because they first started having pain and then they stopped moving or because of being sedentary, they started kind of developing osteoarthritis. What came first, the chicken here, but what we do know is there's this cyclic cycle where when you stop moving and you have underlying osteoarthritis, sarcopenia starts to happen, right? We start to see muscle wasting. With this inactivity in this sarcopenia in our tissues, we start seeing accumulation of visceral fat. And then macrophage infiltration throughout our body, hanging out, low grade. We see links to osteoarthritis and then this cycle where this leads to Alzheimer's disease. Our brain cells, our brain tissue starts to become unhealthy because of this low grade systemic inflammation. This starts to affect these immune cells are hanging out in our blood tissue. We have unhealthy blood. So we get atherosclerosis, right? We get buildup along our arterial walls. This starts to lead to insulin resistance and glucose just hanging out in our blood because it's not being uptaked as much as readily as it needs to because again, the blood is unhealthy and this leads to type two diabetes. We see cyclical links and then guess what? Then our blood no longer is oxygen rich. We see links to then anemia and osteoarthritis and this cycle of low grade chronic inflammation continues leading to other major diseases that affect our whole ecosystem. We know this, right? This is a like this cycle I'm describing came out in 2018 from school at L&T and JOSPT just talking about the importance of if we don't get our patients moving and physically active, this low grade inflammation, it's just going to hang out there. And if we pair that with what we know is happening in our society at large, I don't just mean the United States, but globally, when we look to the WHO, right? The World Health Organization and you look at the top 10 causes of death, right? Guess what just got added to that top 10 list recently? Diabetes, diabetes, diaphragm, diabetes, right? And we have our folks with hip and knee osteoarthritis, not in pain, so they're not moving. And then this low grade systemic inflammation cycle, which leads to diabetes and things like Alzheimer's, which is also on our list of top 10 issues are things leading to death. We are dealing with metabolic disease with hip and knee away. We have to address the hard conversations around metabolic disease if we really want to impact our humans, our patients lives with hip and knee away. Think about most of your folks that have it. Most of those folks have diabetes on their past medical chart, right? We have an opportunity to not just impact joint health, right? But we have an opportunity to impact their blood, how their blood takes up sugar, right? And uses it for their body. We have an opportunity to ward off risk against developing Alzheimer's. We have an opportunity to work against leading towards anemia and sarcopenia. Our job is pretty huge here. So we have to do better. And I'll tell you, these conversations are so hard, right? But our society, we are, yes, living longer from a longevity perspective and lifespan, yet we're getting sicker. And you can look to the Who for data about that. I'll tell you at ICE, any faculty member, it doesn't matter what specialty division. Mine is in particular extremity management. We have pelvic health, we have CMFA, we have modern marriage with older adults, spine health, right? If you really ask each one of our faculty what we're really fighting against, what is ICE really doing? We are fighting against metabolic disease. We are championing and fighting for healthy living behaviors because we see this sickness in our society that we are getting more unhealthy, even though we're living longer. And it's because of sedentary behaviors. And we have to have these hard conversations surrounding how do we change these unhealthy living behaviors? How do we get these patients moving? Because again, it's not just about symptom management of their hip and knee pain. And it's not just about via exercise. It's really about infusing fitness into their life, into their tissue health. And when you think about that cyclical cycle I just described and that School.L article in 2018 gives a great visual. But this includes, when we think about fitness forward, we think about healthy living behaviors that help improve brain tissue, that help improve your blood, making your blood healthier. And we do that via cardiovascular physical activity. We want the ecosystems of our humans to be more healthy and more resilient. And really the best and most efficient way to think about how do we do this in the clinic, right? Because I mentioned this is a hard, hard conversation when we think about how we change patient lifestyles, how they eat, how they sleep, and how they move. The best way to think about this is through meds. Thinking about the four pillars. And med stands for mindfulness, exercise, diet, and sleep. When we think mindfulness for these folks that come in with hip and knee, or think about any patient you've ever had, what is our greatest responsibility here in mindfulness? When we think about mindfulness, I think we typically think about breathing strategies, taking a walk in nature, maybe journaling, some physiologic sighing, meditation. And yes, when your patients are stressed, yes, we want to give them this and give them those tools. And for our folks with hip and knee, this is fair game. But I'll tell you with these folks, when I say mindfulness, I'm thinking about how you frame their mindset, how you help these folks be more aware about what they believe, right? The folks that say, I had bad knees, my mom had bad knees, my great grandmother had bad knees, my great great grandmother had bad knees. They're the people that sit back, open up that hip angle, and you know you're about to get a long story that first visit, right? About this history. And this is deep ingrained beliefs, right? About their knee health. And we have to also acknowledge that this is probably deep ingrained lifestyle behaviors, right? When it comes to our food choices, our sleep choices. So there's some really entrenched shifts that we have to make. But we have to let them know, no matter what, like really let them tell us those beliefs, and then allow a reframe, a mind shift that these are knees that aren't bad, right? Please stop saying your knees are bad, Betty. Your knees have an opportunity, your hips have an opportunity, your hips have an opportunity to blank, right? To be stronger, to be more flexible. Your body has an opportunity to move more. Yes, we can help them manage stress with some of those techniques that I mentioned earlier, but it's really more about helping them be more mindful of how to think about their body in a healthier way, and giving them strategies to do so, right? So they're no longer a victim, but a victor. Exercise is that next, so we did mindfulness, and then exercise is that next pillar we have to address with these folks. Meeting physical activity guidelines. 50, 150 to 300 minutes, right? Of physical activity is a must. And the WHO acknowledges that 150 is on the low end, right? That we want more towards 30, which means 300, excuse me, which means 30 minutes at minimum, but probably 30 to 60 minutes of physical activity five days a week. If they're doing higher intensity exercise, right, 75 minutes is fair game. But this is so tough, right? Because these patients are coming to us in tons of pain. So what do we do? How do we get them moving? And this is the hard part, right? If Betty can only walk three to five minutes, and it's painful for her to just make it into your clinic, and she needs a rest break, it's hard to prescribe, okay, 30 to 60 minutes of activity a day. And so we have to start where they're at and figure out ways to infuse physical activity. Maybe initially that's that five minute six bouts, right? And some of you are like, Lindsay, you're freaking crazy. My patient, Betty's never doing that, right? Maybe we start off small at 50%. Maybe the first goal is just five minutes, three times a day, right? We have that dose, and we see her response to movement. The real key part is we figure it out. It doesn't matter. It doesn't have to be walking. It could be dancing to music, right? It could be calling, Betty could be calling her grandson and going for a little walk so she's a little bit distracted. It could be marching in place. It could be an exercise video. It could be linking them to their community. It doesn't matter what it is. You have to figure it out. And it is hard, but you have to partner with that patient and figure out a way to get them moving. And then that's not enough. It's not just the physical activity piece. It's then adding in strength, flexibility, endurance, neuromuscularity, right? Kind of the things in our wheelhouse and figuring out what really helps their tissues feel better. That also respects irritability. In extremity management, we talk a lot about the rehab dose, which is an irritability respecting dose. And that part is really key in these folks because you need that initial buy-in, right? Our CEO, Jeff Moore, says we manage symptoms to maximize fitness. If you don't first get that modulating buy-in window of opportunity by dosing exercise well to show patients that actually exercise, right? You do about an exercise and then you retest some maybe knee flexion, knee extension, hip flexion, or maybe how fast they're walking and show them, right? Oh, wow, you're now moving faster. Oh, wow, you now have more motion, Betty. That's awesome. You have to give them that show me moment. So our test retest strategies have to illustrate that exercise is medicine. Exercise is the thing making tissues feel better, right? Not just our manual therapy. So that's a big thing that we can do to help with this exercise pillar. And then diet, right? This is probably the hardest one and these folks have been told they're obese and they need to lose weight and that's not the answer, right? Please don't say that to those folks, right? They've heard that time and time again. They've heard it from providers that haven't even looked up from their chart or from their computer to look them in the eye. What I want you to do is a weight neutral strategy where we add resistance training. We add things that increase basal metabolic rate and then start chatting about things they can add like half their body weight in ounces of water, right, for a diet and then maybe adding a little bit more protein, right, for tissue healing and to help as they continue to increase their exercise activity level, right? So it supports their activity level. Talking to them when they're open to it, eating more plants, right, more colorful, diverse diets. That's kind of where we go with our diet discussion. It's not right away take away the soda, take away the bowl of ice cream because you're going to lose buy in with those folks, right? And we know the harmful inflammatory effects of sugar but with these folks that have been told a harmful message about their body already, let's add to these folks with hip and knee away before taking away. Sleep is our final pillar so we've talked mindfulness, exercise, diet, sleep and I'm pushing my time limits a little bit here. Sleep, we need to help our folks work on sleeping better, right, in a cool dark room that's 60 to 65 degrees. Use blackout curtains, go to bed at the same time daily. Those are just a few of our strategies that we really love to help with quality of sleep, right? While seven to nine hours is ideal and I would love sleep quantity on board for tissue healing, work on sleep quality before quantity first with these folks. And again, yes, these pillars, addressing these pillars are hard and no, we can't address them all at once, right? We'll dose our education just like we dose exercise. But we have to have the hard conversations with these folks. Behavior and lifestyle change, I mentioned earlier, they are hard but they have to occur to make our society healthier. Diabetes was just added to the top ten killers of our world, not just the United States. That's a big deal and most of our folks with hip and knee away have diabetes so don't miss that link, right? Fitness forward is not just about lifting heavy shit with your friends. Although barbell medicine is a key part of it, right, because it brings on intensity for our tissues and that pumping effect for good healthy blood, right, and it tends to make a patient feel pretty bad ass when they start getting heavy. But we are here to wage war on metabolic disease with our hip and knee away. It is plaguing our system, it's plaguing our country and our world. Hip and knee away is associated with diseases like diabetes and Alzheimer's. It will not go away without engaging the hard, it will not go away without engaging the hard conversations and the hard behavior change. We have to wage war here and we as physical therapists that have that experience, as our patients, probably have the greatest opportunity to wage war on the underlying tissue inflammation that is there in these folks, the sedentary lifestyle that's associated with that pain and the poor mindset of I have bad knees. Take this opportunity with your folks this week to address one of the pillars, mindfulness, exercise, diet, sleep. I suggest starting with the M and getting some buy-in with the E. Thank you for your time this morning everyone. Joining me in Grass Valley in an atypical spot here. It's been a pleasure. Have a great, happy Tuesday.

19:32 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 CU's from home, check out our virtual ICE online mentorship program at PTOnICE.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnICE.com and scroll to the bottom of the page to sign up.

 

Jun 26, 2023

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 physical therapists don’t need to be the masters of movements in order to teach them to others, or help others begin their progression towards achieving them. Take a listen to learn how to better serve this population of patients & athletes.

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.

EPISODE TRANSCRIPTION

00:00 INTRO
What’s up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let’s chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you’re looking for an easy way to navigate payments, here’s what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you’re ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you’re in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today’s PT on ICE Daily Show.

01:27 DR. RACHEL MOORE, PT, DPT
All right. Good morning, PT on ICE Daily Show. Welcome to our 1500th episode of PT on ICE. We are incredibly honored that you guys tune in and listen to our crew rap about everything from pregnancy and postpartum to fitness athlete management, from pushing the envelope on Geri Care to evidence based orthopedic care, whether that’s from our spine division or our extremity crew and the latest and greatest about dry needling and then gaining some leadership insights. We are so honored that you guys choose us to listen to for all of the information. ICE wouldn’t be what it is without you guys. So thank you so much for hanging with us on Instagram, on YouTube, on your podcast apps and in our courses. We love connecting with you all and working together to push our profession towards PT 2.0. Today, I want to ring in our 1500th episode with a topic that honestly might seem a bit random, but don’t worry, I’m going to explain where it came from. Today, we’re going to be talking about lessons we can all learn from the man, Ted Lasso himself, both as physical therapist and honestly, just in life too. Before we do that, I’m going to dive into our upcoming courses in the Ice Pelvic Division. Our next online cohort starts July 10th. This is our eight week course where we dive into everything from preconception and relative energy deficiency in sport to pregnancy, making modifications for pregnant athletes. We talk about birth, we talk about the fourth trimester, we talk about postpartum, we go over how to get athletes back to the barbell, back to the gymnastics rig. It is a lot of really great information and that cohort starts July 10th is when our next one kicks off. Our next in-person courses, we’ve got three coming up in the next few months. July 29th and 30th, we’ve got a team going out to Parker, Colorado. That’s going to be with Alexis Morgan and April Dominic. September 23rd and 24th in Scottsdale, Arizona. That’ll be with Alexis Morgan and myself. And then September 30th and October 1st, Christina Prevot is going to be hanging out in Ontario. So if you’ve been looking for a course north of the border for the pelvic division, check that one out. Head to the website, sign up for those courses. While you’re there, head to the resources tab, sign up for our newsletter to stay up to date on all of the latest pelvic and pregnancy and postpartum information and research. All right, guys, here we go. We’re kicking it off. Why are my here on Pelvic Monday talking about Ted Lasso? In our online cohort, we cover a lot of different topics like I just said. In week six, we talk about gymnastics and we are talking about helping our patients get back to the pull-up bar, working on pull-ups and chest to bars and bar muscle ups and ring muscle ups and all of these like advanced gymnastics skills that we learn how to do in CrossFit that are all super fun. We always ask the crew in the class kind of towards the end of our meetup, what is the biggest barrier that you perceive in helping patients get back to these skills? In every single cohort, we always get the same answer across the board and it’s that I can’t do this skill so I don’t feel like I can teach it. I’m not confident in the ability to be able to teach it. While we do encourage people to be about it and we want them to get themselves into whatever area of fitness they love and we always encourage them towards the CrossFit side in particular, we also always have a conversation that you don’t have to be able to teach things in order to be able to do things in order to teach them. So in past cohorts, I always make the reference of like a coach and a sport team. I admittedly do not watch sports at all so I’m always trying to like pull a random name out and it never really works out very well. I’m like, oh yeah, like you know the football coach on the sidelines, he’s probably like scrawny but then the football players are over there. And last cohort, in the middle of trying to explain this with my very poor background in sports, it hit me that Ted Lasso is the perfect example of this. This leads us beautifully into lesson number one. And don’t worry, I went through all of these examples with a fine tooth comb to make sure that I don’t spoil it if you are still finishing up Ted Lasso or maybe you haven’t watched it. So lesson number one, you don’t have to be able to do the thing in order to coach it. We all know this is a prime example from Ted Lasso because he has never played soccer and has never coached soccer and he moves to London to coach a soccer team after having a background working with college football, athletics. So that kind of resonates with me personally, I coach CrossFit and I’ve never done a ring muscle up for example. However, I understand the component pieces of a ring muscle up. I know what the points of performance are. I can record somebody doing a ring muscle up and I can break down where in the movement maybe we need to tweak something or the mechanics are changing. Being able to take a step back and watch a movement and help an athlete clean up the pieces of the movement matters. Being able to jump up on the rings and do it yourself doesn’t. Your patients are seeing you for a reason. They’re not there to watch you just bang out a bunch of reps. They’re there to get your expertise in the physical therapy realm and help connect to the dots of fitness and rehab. And again, we absolutely want you guys being about it and pushing yourselves in your own fitness domains. So spending the time to learn these movements both by like watching videos of people doing these things, pulling up YouTube, following athletes on Instagram, getting comfortable with seeing movement variability and what some of those common faults are, but also by working on them yourself. You don’t have to be the best athlete out there. We actually had a whole conversation in that most recent cohort about how sometimes the best athletes do not make the best coaches because they can just jump up and do the thing. They don’t really understand how to break down those component pieces. They’re like, yeah, you just do it like this. So sometimes it can make you an even better coach if you don’t know how to do the movement or you’re not proficient in it, but you’ve taken the time to kind of break that down and work on it in and of yourself. Put the time in to work through it yourself and that’s going to help you troubleshoot what you’re going to be eventually teaching. You want to get to know the things your patient’s wanting to do, understand them well, and then understand how to break that down to the key points of performance. If that is in the fitness realm or realistically the functional movement realm, we really encourage you guys to hop into our CMFA courses to learn what those points of performance are with a physical therapist kind of scope on them or hop into a CrossFit level one course or take a CrossFit specialty course. If you know you want to hone in on your gymnastics coaching specifically or maybe your weightlifting specifically, there’s specialty courses that break that down seeking out the knowledge along the way, but that doesn’t have to be a barrier to getting into the thing. You can start it. You can learn it. We want to make sure that we understand the component pieces, but you don’t have to be able to be a master of it on your own physically in order to be able to teach it. We’re going to head into lesson two. This is my favorite lesson. Be unashamedly enthusiastic in celebrating your patient’s victories. Within the very first few minutes of the first episode of Ted Lasso, there is a video of Ted dancing in the locker room with a college football team that he led to victory in his first year of coaching after they won the division two national title. This is what Ted is known for before he becomes the coach for AFC Richmond and moves to London. This is his reputation. If that’s not what I hope every single one of us is doing in clinic when our patients tell us some positive progress, I don’t know what it is. Maybe we’re not busting out fully into a dance, but we need to be enthusiastically celebrating the wins with our patients. Vision this. You have a patient named Sally. She’s coming in to see you. You’re chatting with her. You’re catching up on your asterisk signs. You ask her how things have been since the last visit, asking how her leakage has been because that was her worst symptom at your first visit. She tells you, like, yeah, things are okay, I guess. I’m still leaking when I work out though. So naturally, you follow this up by asking her more details. What was the workout? What movements were in the workout? When did the leakage happen within that workout? She tells you it was in her third round of a METCON that had 200 meters running and 50 double unders. And you’re looking at her chart and you’re scrolling through and you look at her last asterisk sign and you see that previously she was leaking at 10 double unders, but she just made it all the way to the third round of a workout that had running and double unders in it. You’re going to freak out, maybe not freak out, but you’re going to tell her, girl, that is amazing. You’re doing fantastic. Look at all of this volume that you just did. We used to be here and this was our buoy. And now your buoys all the way up here. What we’re doing is increasing your functional capacity. It’s increasing the amount of work that you can do before your symptoms kick on. And that is fantastic. You are crushing it. That is what we want to be doing. We want to be celebrating our patients. Another example, maybe you have Lucy on your schedule and Lucy used to have three out of 10 pain with her sit to stands every single time when she was getting off the couch with her newborn. And the other day she sent you a text message because she back squatted 70% of her one rep max pain free at three months postpartum. And she wants you to know maybe you’re not seeing her in the clinic. Maybe she’s just excited to tell you in between sessions. We are going to respond to that text message with all of the party emojis. We’re going to tell her great job. You are crushing it. You are doing so awesome. We want to pump her up and make sure that she knows that she is doing fantastic. We can take this concept and we can apply it across so many different realms in the physical therapy world, not just in the pelvic space. Our job is to guide our patients. Our job, particularly in the PT 2.0 realm, is to load our patients and make them stronger and more resilient humans. And dang it, our job is to celebrate with them when they are crushing it. And if they are struggling to find those victories, our job is to help point them out and again, celebrate all of these victories with them. This leads us into our third lesson of the day. Our final lesson of the day from Ted Lasso is to not be afraid to pivot. If plan A isn’t working, plan B is there. This is another topic we talk about a lot in the pelvic space because there’s kind of a dichotomy between high tone versus low tone and how you address the presentation. This is another topic that does come up a lot in our online cohort. We typically ask students, like, if you’re new to pelvic, what are you worried about or what is a barrier? What kind of things are you nervous about with getting into this space? And a lot of times people say that they’re nervous about doing the wrong thing or giving the patients the wrong exercises. So for example, if there’s somebody that the therapist sees and they’re like, we’re going to do down regulation and really work on calming that tone down and you see the patient the next time and nothing has changed, it’s okay to pivot. It’s okay to say, okay, great, we tried to downtrain, we did that and that was fantastic, but that wasn’t really exactly what landed for us. So now we’re going to switch gears and we’re going to focus on loading. The downtraining stuff is okay and we can still continue it, but now I want to see what happens when we introduce some load to the system. As PTs, our job is to test, treat and retest within session is great, but also between sessions, right? So if we give a patient intervention and they take that home, they work on it for homework and it doesn’t quite do exactly what we were hoping, it’s okay to change gears and do something different at your next session. It doesn’t make you a bad therapist, it makes you somebody who is consistently creating hypotheses, testing them, retesting them and pivoting for the best interest of your patient. So there we have it, lessons from Ted Lasso. I hope you guys enjoyed this topic. If you haven’t watched Ted Lasso, I highly recommend adding it to your list. If you have watched Ted Lasso, feel free to drop a comment of your favorite Ted Lasso in the comments below and you guys get out there and crush your Monday. Bye! 

14:16 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 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 5 research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

Jun 23, 2023

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

In today’s episode of the PT on ICE Daily Show, Fitness Athlete instructor Guillermo Contreras breaks down the difference between the different types of training shoes for the functional fitness athlete that are currently available on the market. Take a listen to learn how to recommend the best shoe for your patient or athlete (or yourself!)

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

00:00 INTRO 
What’s up everybody? Before we get rolling, I’d love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you’re looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They’ll be able to show you the features I just mentioned and answer any other questions you may have. Don’t forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show.

01:33 – Dr. Guillermo Contreras, PT, DPT, CF-L2, Cert-CMFA, Cert-ICE 

All right, welcome to the PT on ICE Daily Show Gang. Welcome to the best day of the week, Fitness Athlete Friday. I am here with you, Guillermo Contreras, physical therapist and faculty, or on the team under Fitness Athlete Division of the Institute of Clinical Excellence. Excited to be on this morning to talk all things near and dear to my heart, fitness footwear or shoewear as far as it goes with the fitness athlete. Before we dive into the extensive topic at hand, where you can catch us next, most, next, I can’t even talk today, for Fitness Athlete Central Foundations, if you’re looking to take the online course and learn all things squat, deadlift, press, pull-up, and even medcon and remod start some introductory programming, the next cohort of Central Foundations kicks off on September 11th, so you have about a month and a half before we start that one up. That course, as well as our Advanced Concepts courses, tend to always sell out before the course begins. So if you’ve been looking at taking it, you’re considering taking that course, make sure to sign up early, especially Advanced Concept, because that course has less seats in it and it’s a lot bigger, like heavier, denser material, so make sure you’re jumping on that as soon as you can. Speaking of Advanced Concepts, that starts up on September 17th, so again, about another month and a half before that one kicks off. If you’re looking to catch us out on the road, we have a handful of courses throughout the fall, and then the summer is a little bit quieter. The only course right now we have going on this summer is June 24th, 25th in Loveland, Ohio. That’s where we leave with Zach Long down at Onward at downtown in Ohio, and then we move on to September, so starting in the fall, a lot of courses going through until the winter ends. Bismarck North Dakota on September 9th and 10th, Newark, California on September 30th and October 1st, Linwood, Washington October 7th and 8th, a double course weekend on November 4th and 5th in either San Antonio, Texas or Birmingham, Alabama. November 17th and 18th, we are in Holmes Beach, Florida. I’m not sure where that is. I believe it’s up near the Sarasota area, and then a double weekend again on December 9th and 10th in Louisiana as well as Colorado Springs, Colorado. So if you’ve been looking to take those courses, if any of those courses are in your area, if they’re nearby, you can drive to them, quick flight, pop over, right? Hope to see you there on the road in the next couple months. Again, my name is Guillermo Contreras. I’m on the staff of the Whitney Fitness Athlete Division, Help Out With Essential Foundations. It’s one of a lot of courses, and if you’ve taken Essential Foundations in the past, you know that I’m commonly like jokingly referred to as the shoe guy. I’ve met people who have way more shoes than I do. They collect them, they put them in boxes and store them and things like that. That’s not my style. I buy them, I wear them, I train in them, I circulate depending on what I feel like wearing that day, what my outfit is going to be, like weird things like that, things that aren’t really necessary as far as training goes, but it’s important for everybody here. And what I’m doing here is I’m basically going through all the shoe options that we have now available to us in the fitness athlete realm. The most common question we get around shoes is not like, oh, what material do you recommend? What’s the heel drop? It’s usually, hey, gearmo or hey, gang, if I have someone who’s just starting CrossFit, what shoe do you recommend they start out? Or, hey, I’m into this CrossFit thing now, I think I really enjoy it and I want to keep doing it. What shoe would you recommend I start out with? What shoe would you recommend I buy? What shoe should I purchase and use? Those are the questions we kind of get. So that’s what I’m going to go over. I’m going to do my best to keep this in a short format because this is something I could probably go on a long tangent about. I enjoyed doing my write-ups for this and getting all my research listed out for me so I can kind of really make sure I hit all the points. And by all means, if anyone ever wants me to do a long version of this in like a vice lecture, as long as the crew is okay with it, please let me know. Happy to do slides and everything as well. So we’re going to start with the most commonly known brands, most commonly known shoe that people are aware of that’s out there and maybe basically go down to the least known. And at the end, I’ll give my recommendation for my favorite shoe, like the thing I wear the most for training, as well as probably the most common shoe we see in and out of the CrossFit sphere. So starting off with the shoe that kind of started it all, I would say, well, technically, it doesn’t matter, the Reebok Nano, right? So Reebok Nano, this is the Nano X2. They now have the X3. The X3, from what I’ve heard, actually delivered a little bit better with this shoe, a little bit more flexibility, more bounce, more comfortable with running. The Nano X3 has a seven millimeter heel drop. So from heel to toe, seven millimeter heel drop. So more comfortable for lifting, gives you a nice base. The back here is nice and firm and stiff. It has this cage thing here, which helps with support. And then this weird line thing is supposed to be some sort of weird spring bounce. So that’s some of the little features. It’s got a lift run chassis is what it says it’s called. But it’s an overall solid training shoe for interval training, for high intensity training, for CrossFit. It’s got a solid base for lifting. And I would argue it’s got a, it’s a decent shoe, especially the X3, where it’s a little bit more comfortable, a little bit more cushioned, especially through the forefoot, midfoot. It’s a little more comfortable for runs. Would I recommend training for a marathon, doing long duration, long distance running in it? No, I would honestly probably limit this shoe to somewhere around the 800 meter, maybe no more than a mile. If you’ve gotten used to it, you’re comfortable with it. You don’t mind a slightly heavier shoe. This is what I would recommend for you if you’re comfortable with it. So if you are looking for a very, very good running Nano from the CEO of himself, Alan, he recommends the Nano X1 Adventure. So that one came out two series ago. I think you can probably get those for like 70 bucks now on sale for everything that we’re seeing there on the Reebok website. Only thing else I have with this is, again, slightly heavy and the cost is around 150. It used to be 130. They’ve jacked up the price. I’m not sure why, but the Nano is about $150 now to buy on brand new. But sometimes you find pretty good sales as far as like family, friends sales or previous versions. The X2 is pretty good if you want to go with that. Number two, again, this is not the newest version because I left my pair at the gym, but this is Neki Metcon. So Neki Metcon came out shortly after the Nano. It was kind of like the biggest competitor as far as a CrossFit shoe. The Metcon is stylish, right? It’s got a lot of durability to it because it has like this really big rope guard is what they call it for rope climbs and such. The newest one, the Nano, I believe, or sorry, the Metcon, I think they’re on eight now. The eight is more built, right? It is made to be the quintessential fitness shoe. It’s functional. It’s 100% about function. It looks kind of sleek, but I’m not a huge fan of the look of it than you are one. But again, it’s a very functional shoe. This has a four millimeter hill drop. The older ones have a four millimeter and they came with like a lift thing you could slide into it. This is a Metcon 5, I believe. But then the Metcon 6, 7, 8 come with like it’s already in there. So it’s a thick TPU heel. This one isn’t as stiff as the newer ones, but they have a really stiff heel and that I would say is the biggest con about this shoe. It’s very good for lifting. It’s good for wall balls and such because it’s a nice, stiff heel. You can elevate the back a little bit. It’s flexible, which is very nice. It’s got an advantage for hands and pushups because it’s got this like weird TPU plastic heel clip thing that’s supposed to slide up the wall a little more easily. But again, it’s a very blocky shoe when you think about the heel. So if you’re someone who is a heel striker, the Metcon is actually one of the worst shoes for running at any distance more than maybe a 200, 400. So sprints probably fine. 400, 600, 800 in a workout is probably fine. But if you’re doing a 5K day, if you’re doing Merve, the Metcon is probably not the shoe you want to go with for that there. So this is the Nike Metcon. These run, I think 130 is what they run. And you can get customs for 160. So if you ever want to customize a shoe, 160 is not bad and a good option for most people there. A lot of people wear these. So those are the most common shoes you probably see in the gym because they’re the most well-known brands. The next, what am I going through? Five, six here are less known or just less worn more than more is probably the better thought here. And the first one is right here. This is the Innovate, which people probably know Innovate for their old school barefoot minimalist kind of shoe wear. This is the Innovate F-Lite G300. In my opinion, this is the best crossfit shoe that Innovate makes. They make a couple other people. I believe the F235 is another option that people really like. And I believe there’s another one that I can’t recall all the letters and numbers, but Innovate makes these pretty good shoes. This one here has a six millimeter heel drop. So a higher heel height than the other shoes they have. It’s definitely not a minimalist in that it doesn’t have that heel drop there. It has what they call a booty style here. So there’s no tongue. It’s just you slip your foot in and you’re over it again once you’re in it. I never untie or tie the laces and it’s pretty snug for me on my foot. It has a wider toe box, but not super wide. So if you like that, like the ability to display your toes, this is kind of nice here. It’s lightweight. It’s flexible, right? So you can bend it, you can turn it, you can go both ways. That’s not as flexible as I thought it was, but I feel it’s pretty flexible. It’s got a stable heel, but it’s not so stiff that you can’t run in these either. These are actually very comfortable to run in, in my opinion. One con or con that this one has is you can kind of see this plastic cage on it there. And for those who are watching, just listening on the podcast, there’s like a plastic cage around like the midfoot. That plastic cage, quote unquote cage, provides some more stability in that midfoot, in that midsole, but it also can be a con in some people who do not like, or who have slightly wider feet, because it’s going to restrict that midfoot a little bit more and it’s not the most comfortable thing. So if you’re someone with more wide feet, not so narrow midfoot area, this shoe is probably not going to be the most comfortable because of this plastic cage, but overall it’s a nice solid shoe. My biggest qualms with it, again, are the cage, if you’re not into it. If you’re not into that boot style, kind of slip on shoe, this is probably not going to be for you because you like to cinch up those laces and cut blood flow off to your feet. And honestly, they claim that the durability is very good on these because of this plastic cage. But if you look here, this fiber here, which is meant to be breathable and really flexible and nice, is actually one of the downfalls. That is not as durable. So I have a couple of friends who own these who have like little holes in them. And despite this being a rather expensive shoe, it can run anywhere from, I think, let’s see, you can get them on sale for like $75, but they run up to like $155. I think these were like $150. For something that cost $150, you would expect it to last and do pretty well with road climbs and everything crossfit. And then customer service is not ideal. So little things that we don’t need to dive into here. But again, good shoe, 6-millimeter heel height. So keep that in mind for your athletes. Next up, we have the Rad 1 Trainer. This one came into the market, I think, two years ago. It started off not so hot because it came out and it was extremely narrow, really sized poorly. So everyone was buying them and they needed to go with a full size. But they’ve actually fixed a lot of their sizing issues at this point. The Rad 1 Trainer has, again, another 6-millimeter heel drop. It has what they call a multi-directional outsole. So you can do a lot of different agility type things. It’s good for jumping. It’s good. It’s really, really solid and stable for lifting. Cushion for plyometrics. It’s actually fairly comfortable for running. Again, I wouldn’t do a 5K or anything like that. But again, it’s comfortable for your shorter runs, maybe max of a mile, mile and a half. So Merck would probably be really comfortable in these. High density, they have something called a Surge Energy Foam Midsole. So it’s a very comfortable shoe. I personally actually really enjoy wearing these for working out, for crossfit workouts. I like them for lifting. So I kind of recommend them. They’re a smaller brand too. So if you’re into that whole helping smaller businesses and not just the mega ones like Nike and Reebok, this is a cool brand to get into. Price point, again, a little bit high, $150 when you’re looking at them. It’s aesthetically pleasing, which is always nice. Something that kind of looks kind of good, looks kind of cool and good options there. And the one thing they do have is similar to, if you’re familiar with Noble, is that they’ll have different colorways come out. But unlike Noble, I think they do re-releases. With Rad, when they run out of a colorway, that’s it. They don’t remake them, at least at this point they have. They’re probably still early on enough where they’re not going to, but they might in the future. But they start off with a colorway, they release it, and that’s pretty much it. When they sell out, they sell out, they’re done. So again, really solid shoe, really good for weightlifting, really good for crossfit, HIIT style workouts. Again, aesthetically, it looks nice for some people because of all the different colorways. Some colorways I think are hideous and I don’t understand, but again, to each their own when it comes to what they wear on their feet for that. So this here, again, is the Rad One Trainer. Next, we have probably the newest brand out there that we’ve seen in the crossfit sphere. Athletes like Pat Velner, who else are wearing these? Pat Velner goes to mind right away. There’s a bunch of like mayhem athletes who have it. I think Guillermo Maieros, shout out to the Guillermo’s of the world. This is the Tier CT One Trainer, and it is CXT One Trainer, whatever. Again, this runs about 129, so about average for most crossfit style shoes. This one has a big old heel height. So this is a nine millimeter heel height. So this is fantastic for anyone who has stiff ankles looking to have that little bit of a jump in height to be able to squat a little deeper. To not have to worry about the stiff ankle, not have to worry about inserts or something that’s in between like a weightlifting shoe and a training shoe while still having like flexibility, which is it’s a very flexible shoe. It’s actually really comfortable too. It’s got a good cushion to it. I made a mistake when I said the Energy Foam Midsole that’s in this shoe, not in the Rad One Trainer, but the Rad One Trainer is still comfortable. So it’s got there. So it’s responsive for like jumping, plyometrics, everything like that. It’s breathable. This is like, it looks dense, but it’s actually very breathable through the fabric on the top there. And it’s just a good quality shoe. My cons with this one is I don’t know if you can tell. Let’s see if we can compare it to like the Nano. If you look at the difference, it is significantly more narrow, especially through the forefoot down into the toes. So I personally like wearing these for short lifting sessions. I don’t do them for a lot of plyometric workouts. I have a slightly wider foot. My toes splay pretty nicely. So I don’t like having my pinky toe kind of crushed into here. I could go up a size 12 and a half, but I also like to wear my laces loose and therefore it slips off my foot. So for me, this one’s out. If you have narrow feet, if you have a narrow toe box and you don’t have like big toes and like the splay and spread out, this one’s actually probably a solid shoe. And I would say it’s a very good, very comfortable training shoe for most individuals. Breathable, comfortable, really good for lifting. Again, sprinting short runs, but because of that high heel height, stiff heel, probably not the best for like really long runs if you’re someone who’s doing longer runs. And then some people on the internet say like durability because the fabric is soft, because it’s breathable, durability might not be the best. But again, quite a narrow toe box. So keep that in mind for your athletes who like that wider toe box. Also a caveat, but surprisingly they have such a narrow toe box on these when their lifters are basically publicized as like the best natural minimalist wide toe box lifting shoe there is. So surprising there, but again, very comfortable, good to go there. Last ones we have, I’m going to say is, or not the last one we have, the next one we have is not the actual trainer itself, but it’s one of the pairs I have from the same company. And that is the Strike Movement Haze Trainer. This is not the Haze Trainer, this is the, what is this, Strike Movement, I don’t remember, Transit Trainer, I’m sorry, it’s the Transit Trainer. But the Haze Trainer is the same company, so that’s the brand, Strike Movement. I would probably say I use this shoe to train in more than any other shoe I have. I have them at my clinic at the gym, so I work out there a lot with those. This one has a four millimeter heel drop. It is known as the, some claim it to be the most underrated shoe on the market as far as CrossFit or fitness athlete training shoes. A really cool little feature that which I love, because I, for some reason, I have this thing where I don’t like my laces over the top of the shoe. It’s got this little shoe pocket where you can, or shoelace pocket, where you can tuck your laces into it and hide them. So you just see that logo and it just looks really clean and fresh. These shoes are that minimalist feel. So it’s got a minimalist feel in that it’s not super heavy, it’s not super dense, it’s very flexible throughout the shoe, while still somehow maintaining a really solid heel cup and stable heel for weightlifting, for squatting, for deadlifting, for pretty much all of your heavy lifts. Oops, sorry about that. There’s a slightly wider toe box on all of their shoes, so they have enough space for your toes to really spread out. It’s a little wider through the mid-foot, which gives really nice kind of plushy, really nice kind of splay and play for your feet throughout all your lifts and your workouts and everything like that. And it’s actually pretty good for distances anywhere from 100 meters to a 5K, just because of the comfort of the shoe, the flexibility of it. Good for daily wear, because it’s a good looking shoe too. Lots of colorways coming out now. They have a lot going on. They just released their, what is it, their Bomb Pop packs. So there’s a red shoe, a blue shoe, and a white shoe in case you’re interested in that kind of thing. They do run a little pricey. They are $150 and they come from Canada, so the shipping is a little slow, but it does get to you and it’s totally worth it. They’re a lighter shoe. And again, the biggest cons with these are, one, the price. They’re a little pricey. Two, the durability. Because they’re a lighter shoe, a very breathable shoe, a very comfortable shoe, they might have a little durability issue if you’re pretty rough with them. But again, I’ve had mine for probably almost six months and a year, and I’ve had these for at least three and a half years. And you can see that there’s nothing wrong with them. I did an entire open with them. I work out with them. I go to work with them. They’re just a good shoe to wear. I travel with them and everything like that. So they’re pretty good. And some people say that if you need a custom orthotic in the shoe, it’s probably not the best shoe for that. Just the way that the shoe is built, the orthotic fitting in there. So keep that in mind if you’re someone who wears custom orthotics every time they work out. And that’s that there. Okay. So those are the shoes I have in my possession. The two that I do not own that I want to mention quick are the Goruck Ballistic Trainer. That one is a very good shoe. It has an eight millimeter heel drop. So again, a fantastic shoe for weightlifting for someone with stiff ankles or limited ankle mobility. It’s a very durable shoe. It is bare bones construction. It has, I believe it’s like the fabric is like a cordura. So something like you would see in the military. And it’s going to last forever. It’s very comfortable for daily wear. It’s very comfortable for working out. It’s comfortable for weightlifting. It’s very stable. It’s a solid, solid quality shoe. The best, the only cons we see in that one are that it’s not the best looking shoe for some people. Like some people think it looks, because it’s so bare bones, like it’s very minimal. They’re not trying to be flashy. They’re trying to just be functional. So it’s not the best looking shoe. And I’ve also heard that it’s a little bit hot and sweaty. So if you wear it for all day, your feet get really warm in it because of the fabric of it. And it’s not the most breathable thing, even though I think they claim it’s very breathable. And it does take a little bit of a longer break in period to kind of get the shoe loosened up and to feel like it’s best, but it does get there and it’s worth it once you get to that point. So the shoe can also be a little heavy at times, which people are not a big fan of. And lastly, the only other shoe that I no longer own that people still wear occasionally are your Noble trainers and the Noble Now Trainer Plus. These have a four millimeter heel drop, whether you’re going with a Noble Trainer or the Trainer Plus. They have abrasion resistance. Kind of the fabric on the outside is like that ripstop fabric or I can’t remember what it’s called. And they have tons of colorways. So there’s so many options in black and whites and polka dots and flowers, pretty much anything that you want, they probably make both in the short and the thicker sold Trainer and Trainer Plus. The pros for me are it’s a good looking shoe for someone looking for that shoe that can do fitness as well as go out, hang out all day for wear with jeans, things like that. There’s so many options that it’s a durable shoe, a good material. Some people, if you have perfect ankle mobility, everything like that and strong feet, it’s a comfortable shoe to wear to work out. The cons for the Noble Trainer is that it’s a very narrow shoe. Our COO Alan, he’s a very tall, tall shoe. Our COO Alan, when he wore his, he would basically flood out the sides of it. He’s got very wide feet, good solid arch, so he’s not like this over pronated or flat feet thing. It’s just a very wide foot that just cannot be contained by the material of the Noble Trainer and especially their runners, which don’t have any real material support there. So if you’re someone with flat feet or a lot of pronation, probably not the best shoe there. These are terrible to run in. I’ve heard people, like immediately they get them and they hate them for running, so they take them off and put other shoes on for running, even like 200 and 400, so not the best there. Not ideal for a lot of high volume plyometrics too, because again, there’s not a lot to the shoe. It’s a very, I would say, minimalistic shoe with a hefty price tag for a shoe that hasn’t really changed in style since its inception in 2014, 2013. And if you go with the Trainer Plus, which came out recently in the last year or so, it’s got a much thicker entire sole and it actually makes the shoe about 20% heavier. So it’s a heavy dense shoe if you go with the Trainer Plus. What I will say though is people do seem to love these shoes. It’s going to depend on the person. I personally used to wear these a lot. Then I started wearing other shoes and I’m like, man, I really don’t like these. I sold them all. No longer wear them. Don’t really recommend them to most people unless they have like really skinny feet and they want to go with more of a stylistic shoe versus like a very good functional shoe they can work out in. But if you’re going to go for the Noble, the Trainer Plus is going to be more of your comfort and spring. So more plyos, running, jumping, things like that. If you’re looking for a more stable trainer, go with the regular trainer. Honorable mentions, I want to make sure I mention here that Alan told me to say the Ultra Lone Peak. So if you’ve heard of Ultra, it’s a minimalist footwear company. They make something called the Ultra Lone Peak. It’s a fantastic shoe for running, hiking, everything like that. Wouldn’t do rope climbs in it, but it has its nice wide base. It’s not a CrossFit shoe. It’s not a fitness shoe, but it’s still a shoe that you can use in fitness if you’re looking for that realm. Yes, it definitely is a cult. I was a big part of that cult for a while there, Audra. Narrow feet, narrow feet. There you go. So that’s it. So my recommendations here, gang, I’m going to finish off because I’ve been going for quite a while here. The biggest things I want to say is if you have someone that has really stiff ankles, limited ankles, go back to the episode, which ones did I recommend? Right? The Reebok Nano has your nice heel height. It’s got the seven millimeter heel height. The Go-Rek has an eight millimeter heel height and the Innovate here has a six millimeter heel height or heel drop. I’m sorry. Those are going to be the ones that are going to be great for the ankle. And then number one overall home is going to be the tier one, right? So if you have someone with narrow feet who’s comfortable with that, who needs all that ankle extraness there, nine millimeter height, the tier one is going to be your best weightlifting shoe. The shoe I would recommend the least to people I already mentioned is the Noble, but again, some people love Noble. It’s very cultish. They look good. So again, if someone has narrow feet, they like that style. It’s worth trying to see how it works for them. And then my number one shoe, the one shoe that I love, that I wear more than anything else, is going to be the Strike Move and Haze Trainer. That is my favorite shoe to train in, to treat in the clinic, to do short runs in, whether it’s weightlifting. I’ve PR’d my snatch in those. I PR’d my deadlift in those. I hit a heavy squat in those. The Strike Move and Haze Trainer, even though it’s got a little bit of a price tag, it’s worth it. It’s one of the best shoes out there. I think it’s less known in the fitness community because you don’t see it very often and it’s kind of a smaller brand. They do a lot of cool things with even like parkour athletes, which is kind of a unique thing. But a great shoe there. And if you want to go with like a comparable second place with me, I would probably say my second is going to be somewhere between the Innovate FF G-Lite, or GF Lite 300, whatever, and the Radwin Trainer. It’s a very good shoe. They’re both quality stuff. You got to play around with it, but feel free. If you want me to do some sort of like write up with all these details, I’m happy to share it in like a comment or on the iStudents page. Again, I’ve gone way over on time. I can go on for a very long time about this stuff. So thank you, gang, for tuning in. Again, we hope to see you on the road. Hope to see you on an online course soon. If you have any questions, feel free to reach out and have a wonderful Friday and have a great weekend, everybody. Thanks.

27:30 OUTRO
Hey, thanks for tuning into 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 CU’s from home, check out our virtual ICE online mentorship program at ptonice.com. While you’re there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 22, 2023

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

In today’s episode of the PT on ICE Daily Show, Brick by Brick lead faculty & ICE COO Alan Fredendall discusses tips & tricks for working with Medicare including the ins & outs of documentation/billing. Take a listen to learn how to make more money billing Medicare while spending less time on notes.

If you’re looking to learn more about live courses designed to start your own practice whether you are considering accepting insurance or not, 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

00:00 – Alan Fredendall, PT, DPT
All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. Hope your morning’s off to a great start. My name is Alan. I’m happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at the Institute of Clinical Excellence and a faculty member in our Fitness Athlete Division. We’re here on Thursdays, Leadership Thursdays, All Things Small Business Management, Ownership, Clinic Practice, all topics related to that. Today we’re continuing our series on getting more familiar with Medicare, whether you are not a clinic owner, whether you want to become a clinic owner, whether you just want to get more polished at the Medicare patients and documentation you’re already working with, or whether you are a future clinic practice owner who is considering taking Medicare or not learning the ins and outs. So if you go back, we’ve already done three parts on this series. Every two weeks back, part one, part two, part three, we talked about what is it, how to take it, what it pays, is it worth it to you? And today we’re going to kind of have a cornucopia of things to talk about related to documentation, expectations, that sort of thing. Before we get too deep into the episode, some announcements coming your way. It’s Leadership Thursday. That means it’s Gut Check Thursday. We’re continuing with workout number two from the I Got Your Six virtual competition held by the WarriorWOD, which is a nonprofit group that looks to give six months of functional fitness gym memberships, nutrition coaching, and peer mentorship for our combat veterans. So we’re big supporters of WarriorWOD here at ICE. We supported them last year with our ICE Foundation dollars, and we’re supporting them in this virtual competition. It is a series of partner workouts. If you were here last week, Jeff explained the first workout completely incorrectly, so hopefully you actually read the caption or you went to WarriorWOD and read the actual workout instructions and you did not approach that as a solo workout. These are all intended to be partner workouts where you are sharing some of the workload between you and your partner. This week’s workout, we had the quote unquote pleasure of doing last week. It is a couple of rounds of bike calories. So the workout is going to start. Partner one is going to do 90 seconds on a fan bike, eco bike, a soft bike, whatever you have. Switch. And then you’re going to repeat that. Partner one does another 90 seconds. Partner two does another 90 seconds. So you’re each going to do two rounds of 90 seconds on the bike. You’re really trying to find an aggressive, moderate pace that’s not going to redline you there because your score for the first part of the workout is going to be all the calories you get on that bike. Then you’re going to transition. Partner one is going to go their own way. Partner two is going to go their own way. Partner one is going to have three minutes to find a max load of a complex of one snatch, one hang snatch, and three overhead squats. Yes, those snatches can be power. While partner two is working their way through an AMRAP of eight toes to bar, 12 wall balls and 16 alternating dumbbell hang clean and jerks. And then at the three minute beeper, partner one and partner two switch. The person finding the complex is now doing the AMRAP and the person doing the AMRAP is now maxing that complex. That fatigue from the bike adds up. If you’re doing the AMRAP first, the fatigue adds up when you go to max your complex. You will find that that complex feels significantly more heavy than when you’re warming up. Be kind to yourself. Put up a number that you know for sure you can hit and then maybe have some extra time to go a little bit heavier. That is workout number two for this week and we’ll release and participate in workout three next week. All your scores are due by June 30th. If you do want to participate, you and your partner can sign up. Go to warriorwad.org and sign up through the competition dashboard. It’s $100 for you and your partner. You both get some swag and all of the money goes to support WarriorWOD. That is Gut Check Thursday. The course is coming your way. We have so many to mention. We have a very busy summer and fall. Hundreds of courses coming your way live and online. Head over to ptownice.com and click on courses to see what’s coming your way. Today’s topic, okay, I’ve decided to take Medicare. Whether it’s a participating provider, is a non-participating provider, now what? This is basically a bunch of different questions that you all in the community ask that we’re going to answer in a way that addresses a lot of the hot button issues around Medicare, particularly documentation and what you can bill and not bill for. Just so you know, before we get started, everything I’m referencing is from a document called CMS Pub 100-02. This is the Medicare policy manual. This tells you everything you need to know about taking Medicare, billing Medicare, documentation, expectations. This is straight from Medicare to us as healthcare providers. In this policy manual, it’s 951 pages. In this policy manual are sections related to inpatient, outpatient physical therapy, home health, skilled nursing, all the different settings that you can work in as a physical therapist and how to interact with Medicare based on your setting. I’ve gone through this manual many, many times now and I’ve pulled out answers to your questions and also just general information that I think you all would like to know if you have decided, hey, you know what? I think I am going to start working with this population and I want to know better how to more efficient with our documentation. What’s nice about this is that all other insurance companies, if you’re an insurance based clinic, anchor their expectations off what Medicare puts out. Medicare is considered the gold standard. So if you follow this standard, your documentation will be clean and for any other insurance that you take. So this is the gold standard. If you adhere to this, you’ll never run into problems. Quote unquote, your documentation will become bulletproof. So let’s start from the beginning. So you should know, I’ve heard this, I’ve experienced this myself as a staff clinician that you cannot bill for both evaluation and treatment on the first visit with a patient using Medicare. That is completely untrue. This is from section six, subsection C, sections 220.1.2, part A. So go ahead and peruse yourself to that section. And I quote, the evaluation and any treatment may occur and are both billable on the same day. It is appropriate that treatment begins as a plan of care is established. So yes, you can build a patient for evaluation. You can also build timed codes, manual therapy, therapeutic exercise, gait, balance, neuromuscular read, whatever you’re doing, you can build all of that on the first visit. Now what if you see patients in their home and you do a home visit, but you’re not a home health clinician? This is still a part B visit. This is still an outpatient visit. What’s the difference? Home health is generally covered under Medicare part A, and it allows a little bit more money from Medicare to a lot for your travel to that patient. If you are an outpatient clinic that offers home visits, you should just know you’re not going to be as profitable if you drive to somebody’s house because the money that you receive does not include any extra money for gas, for wear and tear on a personal vehicle, a company vehicle, anything like that. So yes, you can see patients in their home as an outpatient clinician operating under Part B, but you should know it’s just not as profitable. But all the other rules apply as if that person was in your clinic as far as you seeing them, billing them, working with them for physical therapy. Now let’s talk about caps. People have questions about caps. Jess Garcia sent this question in. What about caps and payments? So as of a couple of years ago, there are no more caps, kind of. We have a modifier that goes into your documentation called KX. This allows you to go above the current cap of $2,150 per year. Now there is technically no more cap. You can see a patient as long as it’s medically necessary. That being said, you should know when you cross $3,000 of billable, reimbursable time with a patient, you go on a list where your visits might become subject to medical review. Now this is not the same as an audit, just that somebody working at Medicare might want to look at your notes and make sure that the treatment that you’re rendering above and beyond this $3,000 soft ceiling is medically necessary. Related to billing, you should know about something called MPPR, multiple procedure payment reduction. Many of you are familiar with this, but you’re not sure why you do it or the how and why behind why you do it. This is basically a rule that reduces the amount of money you receive per billable code the more you bill that same code. So multiple charges of the same code. For example, if you bill four units of Therax, you will get paid less for every subsequent charge of therapeutic exercise. So for example, if you would normally have been paid $40, the second, third, and fourth charge will only be paid at half or $20. So you will get $100 total for that visit versus for example, if you had done one code of manual therapy, therapy of exercise, therapy of activity, neuromuscular re-ed, and you got 40 for each of them, you would have made $160 for that visit. So we’re kind of familiar with this. Maybe our manager told us this or we heard it in school or from a friend or something of vary your treatment codes. This is the reason why that when you do the same thing over and over again, you get paid less. This is essentially a system in place to punish low quality clinics. Of Doris comes in, she writes the new step for 20 minutes, she walks for 20 minutes and she does some bandit exercises or some knee extension for 20 minutes and then she goes home and she gets billed four units of Therax. This is punishing that clinic saying, hey, you need to actually do something more productive with your time. You need to vary up your treatment and it should be skilled one-on-one treatment that is progressing that patient towards their goals. So you should know that you should vary up your codes. If not, you should know that you will make less money the more charges of the same code you use each visit. Now there’s another billing problem, quote unquote problem called sequestration. This is essentially a reduction in payments across the board from Medicare to healthcare providers. The amount for physical therapy is an overall 2% reduction in your payment. So if you’re clear on the MPPR and you bill out $100, for example, you should know that you will get 2% less, $2 less sequestration. This is budget management. This is coming down from Medicare. This is balance the budget type legislation that takes place in Congress. Overall it’s really not that much money. As long as you are following the MPPR guidelines and billing a diverse code set. So that’s a little bit nitty gritty behind the scenes with billing. Mainly relevant for those of you who are going to open your own clinic, running your own clinic, already operating your own clinic and you want to know a little bit more about the billing. Now what about referrals and prescriptions? Can I see a Medicare patient direct access? Yes. The answer is yes, provided it’s allowed within your state practice act. Every state allows for direct access. Some states are more liberal about this than others. Some of you, you can only see a patient for the evaluation. Some of you can see a patient indefinitely and most of us are in the middle. You can see a patient for a certain number of time and or visits and then you need to get a signed plan of care or a referral. You do not need that to begin your first visit in any state as an outpatient physical therapist practitioner. A signed plan of care after you complete the evaluation that you get over to the doctor, email, fax, whatever, as long as they sign that and say, I agree to your plan of care, that counts as your referral or prescription. As long as that’s done usually in 30 days. So when Betsy calls and says, I don’t have a prescription for my doctor, can I still come see you? The short answer is yes, you can come see me. We’ll need to do some paperwork on the back end, but you don’t need to go have a doctor’s visit before you come see me with physical therapy. And as long as they have a primary care physician or specialist, whoever they’re working with that knows them that will sign that, then you’re in the clear. This comes from section six, subsection B, section 220, part A. So there’s your reference if you’re looking to see that reference in the Medicare manual. Now this is a question from Megan Long. This is a question about documentation requirements. This is probably the number one question that most physical therapists have, regardless of taking insurance, taking cash, Medicare or not, what do I actually have to write down? It seems like I’m doing notes forever. I’ve had positions where I was told I needed to write a paragraph for every section on my EMR and I submitted novels every day for notes. I spent three or four hours after work every day doing documentation. I will tell you your daily note, regardless of what type of insurance your patient is using or not, if you’re a cash-based practitioner, should be about two minutes. Your evaluation, regardless of the types of insurance you accept or not, if you’re a cash-based practitioner, should be about eight minutes. We’ll talk about what you need to put in there and why the vast majority of you are over-documenting for no reason. Again, these requirements come straight down from Medicare, from the Medicare policy manual. I’m going to quote what needs to be in your evaluation. A separately payable comprehensive service provided by a clinician as defined above, that requires professional medical skills to make professional clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of both patient performance and their function. Evaluations are warranted for a new diagnosis or if a condition is being treated in a new setting. How we teach it in our lumbar and cervical spine management courses when we talk about the symptom behavior model, what are the subjective and objective asterisks for your patient? What are they reporting to you subjectively that they’re having trouble doing functionally? I can’t go up the stairs. I can only go up 10 stairs before I get too weak to continue or I have too much pain. I can go upstairs but not downstairs. Any of those subjective reports of what’s limiting function in their daily life. And then our objective asterisk signs. Things that you can measure clinically. Knee flexion range of motion, five times sit to stand speed, max reps of sit to stand in 30 seconds. Your objective measurements are going to go on your objective asterisk signs. You really don’t need to say more than that. You don’t need to report on the patient’s attitude. You don’t need to tell us what the patient had for breakfast that day or their overall constitution. Right? When we read a lot of notes, when people ask us, hey, what does this note look like? It looks like a bunch of nothing. Right? Doris presented to the clinic today. She had one egg McMuffin for breakfast and she’s feeling kind of fatigued. Nobody cares. What are her progress or non-progress towards subjective and objective asterisk signs since the last time that she was in the clinic? That’s really all you need to say there. On top of your evaluation, you do need to do a progress report with Medicare patients. Again, straight from the Medicare policy manual, I quote, you need to provide justification for continued medical necessity of treatment. That’s it. You need to do this every 10 visits or every 30 calendar days, whichever comes first. You can do this more frequently and this can be done by someone other than yourself. It can be done by another therapist if you’re not there and it can be done by a physical therapy or occupational therapy assistant. This is a quote, description of patients, subjective statements and objective measurements of changes in functional status. It’s literally what has changed since you measured this stuff at evaluation. Again, it does not have to be this long novel about how their grandson moved away and they’re very sad. Only stuff that’s relevant to their lack of progress or the progress that they are actually making towards those goals and those subjective and objective asterisk signs that you’ve already measured or that you’ve introduced since their evaluation. Quote unquote assessment of improvements made or lack thereof towards their goals. Keep it simple and then your plan for continuing treatment. We’re going to keep doing what we’re doing. We’re going to keep progressive overload. We’re going to keep progressing Doris’s deadlift. We’re going to keep progressing her aerobic capacity as measured on the six minute walk test, whatever. And then any changes you may have made to the plan of care since the last time you did an evaluation or progress. No, again, evaluation progress. No, it should not be a 30 minute thing. Should not be a 60 minute thing. It should maybe be a 10 minute thing. What has changed since the last time we tested all this and how has it changed? And if it hasn’t changed, what complications might have been this patient had covid and did not come to physical therapy for a month. Okay, that’s relevant to put in the note. They went on vacation and they didn’t come to physical therapy for a month. Okay, relevant to put in the note to justify why they’re not making the progress you would expect them to make. But again, keep it simple. Stick to that symptom behavior model. Keep your notes short and sweet and just state the subjective and objective data that’s relevant to that patient and that you want to see them make progress in the clinic. Re-evaluation. What about this? We have questions about reevaluation, very similar to evaluation and progress note quote provides additional objective information, not include another documentation. It’s separately payable periodically indicated during episode of care when the professional assessment of clinician indicates a significant improvement or a significant decline in the patient’s condition or functional status that was not anticipated. Maybe the patient was hospitalized for a period of time. Maybe they’re making such great progress that you need to basically rewrite their entire plan of care. You wrote a goal for them to deadlift nine pounds and walk 100 feet on the six minute walk test and they blew that out of the water early on and you’re updating goals, updating goals. So sit down and have a reevaluation. Gather what you think is relevant to the patient. Ask the patient what they think is now relevant to their goals. Now that they’ve met their goals, you’ve already established reestablish new goals and then continue with your care. What should go in the plan of care section? Your diagnosis, right? What’s wrong with them? Don’t say signs and symptoms indicative of 10,000 different things. Keep it simple. Keep it ICD 10 based. This patient presents like they have right knee pain. I’ve ruled out their back. I’m convinced their knee pain is actually knee pain. Boom, done, right? Your physical therapy diagnosis, your goals, specifically only your long term treatment goals. You only need long term goals. You do not need short term treatment goals. Again, straight from the Medicare policy manual. Write out goals, six, eight, 10, 12 weeks and measure your progress against those goals. If they meet them, great. Once they’ve met most or all of them, again, going back, that’s time when you maybe sit down and do a reevaluation. Hey, Betty, you’ve met all your goals. What are the goals you have? Let’s write some more. Let’s take this to another level. So long term treatment goals and then how often you think the patient needs to be in the clinic. You know what? You’re doing really well. I think we can drop to once a week for the next six, eight, 10, 12 weeks. You know what? You’re not making the progress you want to, but you’ve only been here once a week for the past six, eight, 10, 12 weeks. Let’s bump that up. Let’s write and see if two or maybe three times a week will really bump up the frequency, and get the change that we both want to see for you. So that’s our plan of care. Now evaluations done, progress notes done, reevaluations done, whatever you’ve done. And now in between those benchmarks, you’re doing just a daily note. This again, this is relevant for every physical therapist, regardless of if you never say plan to take Medicare, if you’re completely cash based of what needs to be in a note just to basically cover your own butt. And again, all of this from the Medicare policy manual quote, the purpose of these notes is to simply, and it’s bolded in the policy manual, simply create a record of treatment and intervention provided and to record the time of these services to justify your billing. Medicare is telling you, you just need to tell us enough to cover your own butt. Please don’t tell us anymore. No one is probably ever going to read this in your life. So keep it simple. It’s bolded, simply bolded. Quote, treatment notes are not required to document the medical necessary appropriateness of continued physical therapy service. You do not need to write a paragraph every time you do a note about why that patient needs to come back to physical therapy. If they’re in physical therapy, it’s assumed that your evaluation, your reevaluation, your progress note is going to justify why they’re there. And the physician signing off on that is going to be kind of the double stamp that between you and them, the medical system has decided that this patient needs to be in physical therapy. You do not need to explain to anybody or yourself every note, why they need to keep coming to physical therapy. If they don’t need to keep coming to physical therapy, then that’s, you know, when we consider maybe a discharge note instead. But you don’t have to write a paragraph about why physical therapy and how physical therapy can help this person. It’s already implied by them being on your caseload and you measuring goals, visit over visit, note over note, progress note over progress note. Specifics in a daily note such as the specific number of repetitions or sets of an exercise or other fine details already included in your initial plan of care are not needed to be repeated in treatment notes. Again, Medicare is saying stop writing so much junk in your notes. It’s worthless and time wasting for everybody. Stop quote mandatory elements of a daily treatment note include the date of the treatment, the identification of a specific intervention or modality provided. We did dry needling. We did spinal manipulation. We did active exercise. We did aerobic capacity training. We did gait training. Whatever specific thing you did, you should list that, but you don’t need to itemize it. You should have the total time in coded treatment minutes put on your note. That’s it. Hey, we did 20 minutes of exercise. We did some dead lifts and biking. We did 10 minutes of balance training. We did some clock yourself. You don’t need to itemize and be that specific. And then you need to have the signature of a qualified professional in the note. So that’s it. That’s how you get yourself to a two minute daily note. You stop writing dumb stuff that nobody’s going to read. You write literally what they tell you you need to write that they’re looking for if they happen to audit you and want to see your notes. Okay. Kind of segueing from documentation into more nuanced things about treatment. What about treating somebody for more than one condition simultaneously? What about maintenance therapy, those sorts of things? Let’s talk about treating more than one condition. If you’re like me in school and your early career, you learned that somebody needs to go all the way through a plan of care for one condition. Then you need to do an evaluation for the second condition and then see them all the way through there. This is mainly a scheme to get more money out of people. Medicare, again, from the policy manual, section six, subsection B, part A. You can see somebody for more than one condition simultaneously and bill for both at once in the daily note. You don’t need to do two notes for two different diagnoses. You don’t need to see somebody for 12 weeks for knee pain and then see them for 12 weeks for elbow pain. You can do knee and elbow pain at once. I quote, during an episode of care, the beneficiary may be treated for more than one condition, onset that happened after the current episode has already begun. For example, a beneficiary receiving physical therapy for a hip fracture who, after the initial evaluation, develops symptoms of low back pain could also be treated under the same PT plan of care. Now for rehabilitation of their low back pain, you can treat the whole person. They’re telling you it’s okay. So do it. Treat the whole person at once, please. What about maintenance therapy? We have in our mindset as physical therapists that once somebody says, you know what, I don’t have any pain anymore, we freak out. Oh my gosh, get off my caseload before the government comes in here and puts me in prison. Get out of here. Medicare pays for maintenance therapy. Let’s talk about it. I quote, Medicare claims and coverage cannot be denied based on the absence of the potential for improvement or restoration beyond what skilled physical therapy service provides. to improve a patient’s condition or if it’s necessary to maintain the current condition or prevent slow deterioration of current condition. If your patient would get worse leaving your care, then they can be seen for maintenance therapy. If they would regress in function without coming to see you, then maintenance is needed and justified. Especially we know those patients, sometimes they’re upfront about it. Sometimes they’re not of, hey, I’m not going to do this at home. Like, I should come here two to three times a week, right? We see this with patients of all backgrounds and populations of people who are just not self motivated, who need to come and basically get their butt kicked at physical therapy. That is okay. You can continue to treat that person. This is a settlement agreement from January 2013 that covers maintenance therapy in skilled nursing and home health and in outpatient physical therapy. So that’s almost all of you listening right now. You can see patients for maintenance if you are convinced and you can justify that this patient would get worse or regress to where they were before they started physical therapy if they did not continue to see you for physical therapy. How long can we keep that going? For the patient’s entire life? Maybe quote, as long as all of the coverage criteria are met, maintaining the patient’s current condition or the prevention or slowing of further deterioration are covered under skilled nursing facility, home health and outpatient physical therapy benefits. As long as you are setting goals, meeting goals, reestablishing goals, writing progress notes and obtaining that recertification from the primary care physician, then you are good to go. You should not be scared that just because Doris is coming twice a week and she’s doing an upper body split on Tuesday and a lower body split on Thursday and you’re working some balance as accessory work or some cardio or something, you should not be worried that a SWAT team is going to bust down your front door and take you to jail. It’s not going to happen. If it’s justified, if it’s truly justified and you know that you can justify it, you are good to go. How do I frame this to the patient? How do I frame this to other healthcare providers? How would I frame this to you all if you came up to me and asked? I would have you look at the cost of physical therapy versus the cost of pretty much anything else in the healthcare system. Medicare is looking for, I quote, the greatest possible improvement for the most efficient plan of care. They want to know what’s the biggest bang for the taxpayer dollar, for the government’s dollar. Let’s look at some common surgery costs. A heart valve replacement is $170,000. A triple bypass is $150,000. A spinal fusion is $100,000. A hip replacement, $40,000. Knee replacement, a little bit cheaper, $35,000. Angioplasty, $30,000. And just a debridement of the hip or knee, $30,000. So look at the costs of those surgeries and ask yourself, would my patients stay away from that if they came to see me twice a week and they paid about, Medicare paid me about $250 a week, about $1,000 a month, about $12,000 a year? The answer overwhelmingly is yes. Physical therapy, getting strong, staying mobile, staying active, working with a physical therapist, a high quality physical therapist, overwhelmingly is the greatest possible improvement for the most efficient plan of care, the best bang for the government’s dollar. Medicare spends about 33% of its overall budget, about $1 trillion per year on inpatient hospital stays. The average person who goes to the hospital spends $13,000. That’s more than coming to physical therapy twice a week, every week of the year. Just think about the cost savings of that. If you’re thinking, how do I justify this to myself, to my patients, maybe to the manager, the owner of my clinic, to other healthcare providers of why this person should come see me once or twice a week, maybe forever, because it is the most efficient way. Exercise is the most efficient medicine for almost everybody. So that’s the justification for maintenance therapy. So a lot to wrap up here. Documentation, if you’re doing too much, do less, right? Do what Medicare tells you to do, which is not as much as probably most of you are doing. A daily note should maybe take you two minutes. An eval or reval or progress note should maybe take you 10 minutes. Make sure you understand the justification of why we’re billing multiple treatment codes so that you make more money if you are providing high quality physical therapy to that patient. You don’t need a referral prescription to see somebody on their first visit anywhere you live in the United States. You just need to get that plan of care signed at some point and that’s going to vary based on your direct access laws. Again, you’re documenting too much. Document less. Better. Make sure that you understand that maintenance therapy is supported and that you can treat more than one condition at a time and that is supported, justified, billable as well. In summary, you’re doing too much documentation that’s taking away from your time with the patient and you’re probably kicking patients out the door a little bit too early over an unnecessary fear of getting in trouble for things that Medicare says that you are allowed to do. So understand some of these rules. If somebody asks you for your proof, CMS Pub 100-02, 951 pages. Get after it, boss man. Let me know your questions, right? So I’ve gone through this a lot. It’s pretty cut and dry. It’s pretty straightforward. It’s a government manual, right? There’s no fluff about it. It’s pretty in the clear what we’re allowed and what not to do and I would say in general, we over document under bill and we don’t see our patients long enough and see them through actual long-term functional change when they’re in our clinic. So let’s start changing that. So that wraps up our Medicare series. Thanks to everybody over the past couple months who sent in questions. It’s been a great series. It’s been really helpful for you all, I hope, and we’d love to do something like this again. So have a great Thursday. Any questions related to stuff like this, throw them on Instagram, email us, throw them the ICE students Facebook page. We love to get podcast episodes out to you all that are based on the things that you want to hear and see about. So have a great Thursday. Have a great weekend. You’re going to be on an ICE Live course this weekend. Have fun and if you’re going to hit up Gut Check Thursday, have fun, quote unquote fun. Bye everyone.

Jun 21, 2023

Dr. Alex Germano // #GeriOnICE // www.ptonice.com 

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses the different types of implantable cardiac devices that might be encountered when working with patients & how to guide your treatment sessions accordingly. Take a listen to learn how to better serve this population of patients & athletes.

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

00:00 INTRO
What’s up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today’s episode, let’s chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they’ve made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can’t miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you’re ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today’s show.

01:43 Dr. Alex Germano, PT, DPT, GCS, CF-L2
All right. Good morning, everyone, and welcome to the PTI and ICE Daily Show, brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today’s segment of Jerry on ICE. I’m Alex Germano, member of the older adult division. Once again, being inspired here by our current cohort of MMOA advanced concepts in today’s episode topic, we just finished up our Cardio Pulmonary Week and the topic of pacemakers came up. What’s the deal with them? Should we be nervous about them? What should I expect them to do during exercise? How does high intensity interval training work for people with pacemakers? These are all great questions, and we felt like it warranted a podcast in order to dive a little bit deeper. First, let me tell you about some of the current offerings of the older adult division before jumping out into these incredible questions. Coming up this summer, we have MMOA Live on the road. We are in Watertown, Connecticut, July 15th and 16th, Watkinsville, Georgia, and Boise, Idaho, July 29th and 30th. We’re back in Frederick, Maryland on the East Coast, August 5th and 6th. We have our MMOA Summit, which is not to miss because we’ll have a revamp of all the new live material in Lexington, Kentucky, August 12th and 13th. We also have courses in Minnesota, Texas and California to round out August. So summer is looking busy for the older adult division. Okay, let’s start talking pacemakers. And really the term isn’t pacemakers, it’s implantable cardiac devices. This sounds like something maybe a bit boring on the surface, but these do have profound impacts on our patients’ exercise tolerance. And as providers who see people with these pacemakers more, we see them more regularly than say their cardiologists. And we should be aware of when these devices work well, when they don’t, and then when we need to communicate back with those providers. So first we can have four different types of implantable cardiac devices. We can have loop recorders, pacemakers, implantable cardioverter defibrillators, which I will just call ICDs from now on, or cardio-resynchronizers. The use of these devices is very high in older adults and will only continue to increase as our lifespan continues to increase and as this older adult population continues to grow. Over 80% of pacemakers out there are actually implanted in elderly individuals. So we’re guaranteeing that you’ve either worked with plenty of people who have these devices or will in the near future. So let’s go through each device and we’ll talk specific considerations surrounding each one. Loop recorders first, potentially the least sinister, I guess. Loop recorders, these are devices that are implanted to monitor heart rhythms over a few years, so up to three years. Especially in, and they put these in people who they have difficulty finding and catching these arrhythmias that they’re having, right? So maybe they put that monitor on them for a few days, but it still didn’t catch an arrhythmia because it’s so infrequent. Or maybe this is somebody who’s had symptoms of arrhythmias but had normal ECGs when they were done. So these get implanted so that they can monitor over longer periods of time. Sometimes these are paired with pacemakers if they think that the patient needs the pacemaker on top of it, so our patients might have both. But the key feature here, something to consider if somebody has a loop recorder, you need to ask them how they’re supposed to monitor when they feel symptoms. They are either going to have an app on their phone, they might have an external little button they’re supposed to press. What they’re trying to do is pair the familiar symptoms the patient’s having with potentially an odd heart rhythm to make sure that they can sync this data up and be able to diagnose the patient’s abnormal rhythm. Now, these abnormal rhythms could definitely happen during exercise, so it’s absolutely worth it to have that button nearby during exercise, have that app ready to go, that if your patient starts to experience that familiar symptom, they can record that event. Okay? So that whoever’s looking at the data can see that symptoms happened and maybe this weird heart rhythm happened and then they can get a diagnosis. Next, we’re going to move on to the single lead pacemaker. Usually the lead is attached to the right ventricle but could also go to the right atrium. These devices are used to control heart rates and rhythms. They’re typically implanted in those with bradycardia or other rhythms that can cause long pauses between heartbeats. This could include chronic aphid, sick sinus syndrome. Pacemakers can work continuously where they’re going to give somebody a fixed rate. That means the patient’s always going to be paced at 60-62, somewhere between 60 and 70. It’s important to know that because you’ll be checking their pulse throughout the session and be like, this is never changing, and that’s because they’re on a continuous pacer with a fixed rate. Then we have some pacemakers that only work when needed or when they sense that the pulse is getting too low. You might see people with pacemakers that their pulse does increase during exercise and that might have confused you, but that’s okay. That’s how a lot of pacemakers are actually, is that they only start to work when the pulse gets too low. Now a very cool feature of modern pacemakers, and modern being a bit, I don’t have a great definition of what modern means. I don’t know the history of the pacemaker, but it seems like in the last decade or so we have these more modern pacemakers that have rate responsive functions. Meaning that they allow the heart rate to increase during exercise, which is absolutely phenomenal. This is what we need, right? If somebody is on this fixed pacemaker and their pulse is always kept at 60, no matter how hard they’re working, that’s not really ideal, right? As we exercise, we need blood to pump faster throughout our body to get into all the places it needs to get in a timely manner. Patients actually benefit the most physically from this rate responsive function. If you feel like a blunted heart rate is really limiting your patient’s progress, maybe they’re not able to really achieve higher intensities, that could be something you discuss with the cardiologist. Now there’s another option for a pacemaker. We’re talking biventricular pacemakers, or also known as cardiac resynchronization therapy, or CRT. This has established use in populations of people with heart failure. And it’s used in older adults. Honestly, with these types of pacemakers, it continues to increase. With these pacemakers, instead of just a single lead attachment into the heart, we’re going to have two leads attached to the atria and ventricle. This allows for more control over the timing of the complete cardiac cycle. With more control, this helps to improve cardiac output up to 25%. That can be something very profound for people with these low ejection fractions and really struggling to maintain cardiac output with either medications or just a regular pacemaker. Now, patients with these biventricular pacemakers tend to have a better functional capacity than those with single lead pacemakers. So they tend to be the more optimal device for most folks. And usually, since this cardiac resynchronization therapy is used in patients with heart failure with pretty significant symptoms, you may think, oh, this is like really scary to exercise with these people. Like, I don’t feel very comfortable pushing them to high intensities. However, moderate to high intensity aerobic exercise can be applied to people with these safely without significant risk of adverse events. I think that is such a win and so positive. We shouldn’t be afraid to work out these folks. In fact, they absolutely need it. So I’m giving you the green light. Alright, lastly, we have implantable cardioverteral defibs or ICDs. These are perhaps like the most, I don’t want to say scary because they’re really not that scary, but they’re the most serious devices to work with as a rehab provider. Something that we should absolutely know that our patient has on board. Because we need to know what is going on with these things and what are the limits set on these devices. So ICDs are used to detect and treat life-threatening ventricular tachyarrhythmias. They are typically paired with a pacemaker. So they come usually together, which is good because it’s going to pace the heart a bit lower and avoid these really high heart rates. Now these devices administer shocks to people who have a serious cardiovascular event. So if this device starts to sense a very fast heartbeat, like ventricular fibrillation, the ICD could go off. It is recommended that when you hear about one in your patient’s history, or if your patient didn’t think to mention it because they’ve had it for a while, they don’t think it’s a big deal, but you see the large bulging device on their chest, that is something you should be asking about and asking about the limits of the ICD. A lot of my patients know their upper limit on a heart rate for that device. Like they are actually quite familiar. Sometimes they don’t, and I think that warrants a call to the cardiologist to make sure you’re aware of that. Once that device starts to sense that upper limit, it could administer a shock. Like I said, most of these are paired with a pacemaker, so I’ve never seen my patient’s heart rates get out of control with these devices. But I think it’s something to be aware about and document for. We need to be aware of that upper limit. Try to stay 10 to 30 beats below it. Don’t be afraid to exercise with these people. I’ve never been. It’s just really nice to have that awareness. Exercise actually exerts a really protective effect for these patients, and they end up having less shocks from their ICDs versus people who don’t exercise. So this is actually a very positive thing for patients to have. We want them to be having less shocks from their ICDs, so we need to get them exercising. Now, we should also be aware of not only the device types, the loop recorder, the pacemaker, the ICDs, or the resynchronization therapy. We need to be aware of symptoms that our patients might start having if their implantable cardiac devices stop working, which can absolutely happen. This is technology. We know it’s not perfect. These symptoms that we’re looking out for include dizziness, lightheadedness, fainting, palpitations, shortness of breath, maybe some twitching in the abdomen, chest, or frequent hiccups. Maybe that lead is now not where it’s supposed to be anymore. These symptoms are not going to be there anymore. These are signs that our patients need to talk with their cardiologist as the pacemaker might be malfunctioning or moving. So be aware. If you’re seeing a big change in status, maybe think of the usual things first. Is it a UTI? Did they not sleep well? But also, if it’s somebody with a pacemaker, we might need to ask if they’re experiencing these specific symptoms and then refer them back to cardiology to make sure that pacemaker is working. Also, be alert for beeps and other noises. Remember that these devices are battery powered and sometimes they do like to make noise. There is something a little bit disconcerting about a beeping noise coming from your chest. So I’ve had many patients talk to me saying, hey, my device made a noise this morning. I have no idea what it is. I’m worried about it. What it could mean is the battery is going to go out soon. These devices all have different timelines on when you hear beeps. You can actually look up some handy charts about what certain beeps mean. Like the battery is going to go in six months, etc. So it’s a good idea to have an idea of what’s going on. Reassure the patient that it’s probably okay, but they should contact their provider to make sure that their pacemaker or their ICD is okay and that noise was normal. So the more you run into pacemakers, you’re likely going to be asked what was that beeping noise they just heard. Don’t pay attention to that. Don’t panic. It’s likely all good. But just make sure they contact the cardiologist. I hope you learned something new today about implantable cardiac devices. I know I did as I went to put together this episode. It made me feel more comfortable when I go to work with patients with these. It actually just makes me feel like a more skilled provider knowing more about these devices. So I appreciate the questions that came from our Advanced Concepts cohort about these devices that really elevated all of our practice. I hope you have a great rest of your Wednesday and rest of the week. Bye now.

Jun 20, 2023

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

In today’s episode of the PT on ICE Daily Show, our dry needling division leader, Paul Killoren, talks about how and why patients may faint during a dry needling session as well as the approach to take if this happens in your session. Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

0:00 – Dr. Paul Killoren, PT, DPT
Morning team, welcome back to the PT on Ice Daily Show. I’m your host for the day, Paul Killoren. It is clinical Tuesday. If we’ve never met, I’m the head of the dry needling division. So today we’ll talk some dry needling. Very excited to discuss fainting during dry needling today. Not a topic many people want to talk about until an event occurs. And actually, what kind of prompted the topic this morning was one of the techniques that we teach, one of the go-to techniques that we teach on our upper dry needling course, is a seated position. And I think it’ll be a topic for another day, the advantages of this position, allowing access to post here and anterior, honestly getting a more supported, more comfortable position for the shoulder. But what that post, the expected response from certain camps out there, the expected response was, aren’t you afraid that your patients are going to faint? And I 100% know if any of you were trained out there by other organizations, honestly, up to current day, but anytime in the past decade or so, you were probably told, we always needle prone or supine on the first visit. That’s how I was trained. That’s how I taught for a long time. But I’m going to challenge that today. Before we get deep into the positions for dry needling, the topic for today will just be fainting from dry needling. We’ll talk about some of the numbers. We’ll talk about if there’s some things we can do to avoid it. But let’s talk about fainting. And first of all, to qualify, what is a fainting event from dry needling? It’s vasovagal sympathy, syncope, not sympathy. We are sympathetic to their syncope. But it is a hypotensive, it’s an autonomic nervous system, hypotensive. Basically, your heart rate drops, bradycardia, and your blood pressure drops at the same time, which causes a very brief loss of blood flow cerebrally. So I mean, if we say fainting, it’s not just feeling dizzy or feeling faint or nauseous, it is a loss of consciousness, which can occur. But I think we have to immediately qualify how likely is it to occur. First of all, my own sample size. I personally have had two of my patients faint in the past decade. I’ve been dry needling since 2011. I mean, you can do some napkin math there. I’ve been teaching dry needling courses since 2014. And I’ve probably seen a handful more, maybe five to seven people, actually lose consciousness. So quick napkin math, we’re getting upwards of maybe 10,000 people that I’ve seen being needled. And I have less than 10 that have fainted. So first of all, we can’t say that it’s impossible. But I think we have to immediately qualify, what is the risk? People can faint. Some more data, there are 12 billion injections done throughout the world every year, we’re talking injections. And honestly, most of our needle phobic or needle related vasovagal events, our blood draws, there is something slightly more autonomic to our vessels and some of our nerves like our median nerve, tibial nerve. So we can immediately say, if we have a large needle like a hypodermic, and we’re intentionally puncturing a vein, the risk of an autonomic nervous system or a vasovagal event is probably slightly higher. People faint when they give blood. Most people are aware of that, if that’s them. First of all, let’s qualify that we use a smaller needle and we’re doing our best to avoid vessels. So immediately just the mechanisms of a vasovagal event, we should assume would be slightly less with our dry-neeling procedure. But we also have to say there is a large psychosomatic, psychological aspect to this. Rough numbers, I went off on a tangent and just looked at all these vasovagal fainting events, but just needle related phobia and needle related events research. So broad strokes, there’s about 10% of us, of people in the general public, who have a needle related phobia. And honestly, if you’ve been dry-needling long enough, or it doesn’t take very long, you probably know this. Whether we’re actually screening them or not with our words or with our intake questionnaires, I’d say one in 10 people probably do say like, all right, I hear you’re the dry-needle guy, I really don’t like needles, but I’m here to give it a shot. I think that kind of fits. I think one in 10 makes sense. But let me dive into some more, I won’t even say dry-needling because some of it’s acupuncture, but some more monofilament data as far as feeling faint or actually fainting from dry-needling. First of all, McPherson in 2001, this is acupuncture, but it’s European acupuncture, which includes some physical therapists, 0.22% feeling faint out of 34,000, not actually fainting. I say that because Boice 2020, which is American dry-needling, American physical therapists, over 20,000 treatment sessions, 0.78% of patients, which categorically they said was a minor adverse event, 0.78% felt faint. Only four people out of those 20,000 sessions, so 0.02, actually slightly less, actually fainted. So again, I think we need to acknowledge this can occur, but I’m immediately going to say that is a very rare risk. And again, what I’m trying to get to is should this risk of fainting guide our practice patterns, should that very low percentage that I just mentioned to you mean that we should always needle prone in supine on the first visit? I’m going to say no. I’m going to say there are a handful, there is a large majority of my patients where I feel very comfortable doing a comfortable seated dry-needling procedure on the first visit. And I’ll talk about that a little more as we get through this. One more publication, because I thought it was actually kind of funny. It was, again, it was acupuncture. Christensen was the author in 2017. They actually surveyed, retrospectively, over 18 months, all of these people that had acupuncture treatment, and they finally found eight people that had said they fainted from acupuncture. So over a year and a half, they finally found eight people who fainted. What’s unique is they kind of tapped into duration of symptoms. Almost all of them were very transient, recovering almost spontaneously. As soon as there was a loss of consciousness, they immediately regained it. What’s unique here, and what I wanted to point out, is that of those eight, three people actually said when they came to, when they regained consciousness, their primary pain complaint was improved. I think that’s a great stat. I mean, I think we’re going to say fainting or feeling faint, a vasovagal event, we’re going to call that an adverse event for sure. That’s not our goal, but I think it’s also pretty amazing to say nervous system responded for sure. We’re saying it’s an adverse response, but it responded, and that massive adverse response actually decreased the pain experience for those patients. I just wanted to throw that in there, because we’ll talk through now about how to avoid it, and what we can do clinically, but I think we always have to say that nervous system response has benefit, or we should at least screen the patient for saying that was a pretty intense response. How do you feel right now? And don’t be surprised if some of those patients feel better. So first of all, this is probably going to be obvious data, but who are the patients out there fainting? Again, going through some big systematically reviewed stuff, age is a component. So younger, younger patients faint more often, and we’re talking kiddos getting injections. Number of attempts was a significant correlation for venue puncture. So they’re trying to draw blood. A lot of you have probably had similar experiences of like you’re in the hospital, it takes the nurse three or four attempts to truly get that IV into the vein. Number of attempts was directly correlated to fainting events. And then the last one is probably the most obvious, but probably the most important, and I’ll come back to this, is that if there was a history of a needle phobic or an adverse event from needling, if they had fainted previously, the risk of fainting again was significantly higher. So age, number of attempts, and history. So those are probably obvious things as far as risk factors, but I’m going to immediately parlay into that and say, are we screening our patients? And again, the challenge that the contest that I’m trying to put out against kind of the typical conservative narrative is I’m okay treating my patients first visit, first time being needled seated, if I do some screening questions of have you ever felt nauseous? Have you ever felt faint or actually fainted from a needling procedure, from giving blood, honestly, anything from a piercing to blood draw to a tattoo? And if they’re like, Nope, never had an issue. I feel much more comfortable versus that person that says, Oh yeah, I mean, I’m pretty anxious to be here because yeah, every time I get my blood drawn or every time I get a vaccination, you know, I get a little dizzy and I feel like I’m going to pass out or I have passed out. Those are the patients where I think that 10 to 30 seconds screening verbal screening says, okay, that’s cool. Good news is the needles we’re using today are much smaller, much different. I’m also trying to avoid all of the large nerves and vessels. But you know, it’s your first time let’s start supine or prone. I think that simple mechanism of a screening question, you can do it written on your consent form. But basically, have you had an event or not? Or I guess to add into it, if it’s a kiddo, maybe we start them supine or prone. The absence of all of that, the absence of a previous event or the admission of feeling faint from previous needle procedures, as well as age makes me feel very comfortable to needle that person seated, visit one. And again, that is challenging a narrative out there that says, we would never do that. What if your patient faints? That’s why we always do it supine and prone. I don’t think we have to do that. First of all, the data, the incidence rate doesn’t support it. Second of all, what I just said is that if we have a simple screening process, we can pick out the people that are much higher risk of fainting. And the last thing I’ll add here is that I already mentioned that the majority of this adverse event data fainting like vasovagal response needle born data is from injections and blood draws. And any of you that have had an injection or blood draw recently know how it goes. You walk in, they don’t overly sensitize, honestly overly screen you. They also don’t put you supine or prone. You’re seated in a chair. And I mean, you depending on how compassionate your nurse is, she’s probably, you know, putting the little strap on your arm saying, you ever get squeamish from needles? And then half of us are like, yeah, a little nervous and they proceed anyways. So let’s just, I’d like to infuse a little bit of that. I don’t even know the right words, not cavalier. It’s not aggressive. I just want to apply a little bit of that mindset to our dry needling. And again, if we’re picking up answers or body language that they’re highly anxious about needling, then we can lay them supine or prone. But the truth is injections, vaccinations, blood draws are all done seated. And that’s one of the reasons I think we should be more willing earlier on to do seated dry needling. But let’s say, let’s say you subscribe to anything I’m saying right now. I was like, okay, I’m going to try, or if you’ve taken our upper dry needling course, you know that one of those go-to setups is the seated prop position. So let me put a few barriers, buoys in the water for that initial session coming in for shoulder pain. Maybe they’re post-op surgical or post-surgical shoulder pain. We’re going to prop them up on a chair. And first of all, I think a few buoys worth putting in the water. I like using a stable chair, so not a wheelie stool. It’s a chair with legs. It has armrests. It has a firm back. So they are more or less able to completely relax. They’re putting, you know, my sarcastic script is I want you so comfortable, like you could take a nap here. Like I don’t want you holding yourself up. I don’t want you feeling imbalanced. I want you comfortable, stable, but honestly relaxed. You should be able to stay here for five minutes, 10 minutes, 15 minutes. So that is very helpful. Secondly, I think if we reduce the number of needles, so again, if it is their first session, we’ve done kind of a brief screening. We’re not picking up on anything, but it’s still their first session being needled. We’re probably not going to put six, eight, 10 needles in that patient, in that seated position on that first visit. So maybe two needles, maybe four needles. And not that we want to think worst case scenario, but how quickly could you take those needles out if an event occurred? Again, they’re in a bailout position. They’re seated, but they’re supported against a table in a chair with an armrest. Those shoulder needles, could you take those two to four needles out in two to three seconds? The answer is probably yes. So I think the environment, so the table, the chair, the patient position, and then the number of needles really makes us more willing to go to a seated position quicker, even in the event of fainting. One more thing I’ll add is that if we said that potential vessel interaction or nerve interaction might slightly increase the chances of fainting, I’ll add what I add to most discussions these days is that if we minimize the amount of mechanical needle work, if we minimize pistoning, that anxious, that sensitized, and that kind of psychological aspect of the needling will be less. If we piston less, the risk of almost every adverse event goes down, and that applies to fainting. So I think if we follow those rules, and so far I’m saying the data doesn’t support us always being supiner prone, I think we can go seated quicker if we screen better. Is there a history? Is there an age or any other reason why that patient might faint? And I guess I’ll add one more anecdotally. It’s not from the research, but both of my NF2, both of my patients that fainted in my clinic, first of all they were early 20s, very fit Division 1 soccer guys. Both of them were either late morning, early afternoon sessions where they hadn’t had breakfast. I think there might be a blood sugar component to this as well. That wasn’t from the literature, but I think if we’re talking about an autonomic or a nervous system response, because I think you guys, if you haven’t seen it before, I mean the symptoms that are going to key you into vasovagal syncope are diaphoretic, so kind of cold, sweaty, very pale, so paler or green skin, feeling nauseous, bradycardia. If you take their heart rate it’ll actually be lower and their blood pressure will be lower. So those are the symptoms that are like, you don’t look so good. And again the data will say that there’s going to be a few people that have that feeling faint, feeling dizzy without actually fainting. The number of people that actually faint from dry dealing acupuncture is very, very low. But let’s say it happens. What do you do with the patient in the clinic if they faint, if they lost consciousness? Honestly, whether they’re seated or if they’re supine or prone, what do you do? This is legitimately an algorithm from a publication, and I say that because it’s going to seem like such obvious stuff that we don’t need to cover it, but here is the algorithm. And first of all, this was dry needling. It’s international. It was actually from the Turkish Journal of PT, but they specifically said what is the algorithm and what are the positional considerations for trigger point dry needling in the context of patients fainting of vasovagal events? And first of all, they were talking upper trap needling and levator needling. They said that yeah, you can do it prone. There might be an orthostatic component to this vasovagal, this hypotensive event, but they actually said that’s probably unnecessary. You can do this seated just like all the other injections and blood draws in the world. But what they said is if a patient faints, the response should, number one, create a safe environment. So again, I think that just speaks to, I guess, not the extreme opposite of doing this anywhere unsafe. Maybe that speaks to what I said of not being in a stool with wheels, but being in a chair with legs, with a back rest, and creating a safe environment. To say it another way, a bailout position. If this patient fainted right now, where are they going to go? That answer should be there. Or if they’re prone or supine, there. They’re in a bailout position. We’re not standing. We’re not, again, on, I don’t know, I’m trying to, crazy clinical apparatus. We’re not needling on a Swiss ball the first visit. So safe environment is number one. Number two, it says clinicians should not overreact. There is a major psychological component to this. Whether the patient faints or is near fainting, the reassurance from a clinician not overreacting to that situation or seeing the sympathetic responses actually reverses course. So if they’re like, oh, how you feeling? They’re like, I don’t feel so good. Like, okay, take the needles out. Let’s just rest here for a minute. That quick reassurance, that not overreacting, very quickly reverses course for our patients. If the patient loses consciousness, if it’s convenient, you can elevate the legs. Again, we’re trying to get central blood flow restored quickly, but otherwise safe position. And then depending on how long they have lost consciousness, we turn their head to a side to just help breathing, depending on the size of your patient. But again, all of that’s pretty obvious stuff. That’s the algorithm, those four things. This publication said that almost all of these events recover almost immediately, spontaneously. Perhaps we should take vitals in the clinic, again, being at least heart rate and blood pressure. Perhaps if there was a true loss of consciousness, there should be an observation period. Depending on your clinical setup, it’s like, hey, do you mind hanging out here for a little bit, 20 minutes, 30 minutes or an hour before you drive, just to, you know, you did lose consciousness for a second. I just want to make sure you’re okay before you head out. But that’s it. I mean, rarely, I only have one event that really lasted more than a few seconds throughout my teaching, driveling courses for a long time. And that time we did keep, we kept monitoring, we did alert EMS and they showed up. So they did the leads and all of that, the patient was discharged immediately. So I think there’s a medical diligence here, but it’s a pretty obvious one that if they lose consciousness for a second or two, then they recover. First of all, you’ll see that they recover pretty quickly. Maybe we can do some of the orange juice, the snack, just resting there. Again, if there does seem to be a blood sugar component, but really they recover very quickly. And really, I mean, that’s all I have for today. So my challenge for you is based on the incidents of vasovagal events and fainting, how willing should we be to treat seated initially? I would say we should do it initially, as long as we screen well, which could be just a verbal, like if you ever had a reaction to needling, if you ever fainted from a blood draw injection, piercing anything else. I think we need to have a control environment. Really, that’s just the chair, the setup, maybe having a table to support the arm in, reduce the number of needles and pistoning. And then I guess just knowing how to respond, but really that response should be reassuring, if anything, and then positional if needed, knees up, head to the side, that sort of thing. So I’m sure that prompts more questions. If you’ve ever had a patient faint, maybe it looked a little different. When we talk about nervous system responses, it could have not just been fainting, it could have been anything else from voiding bladders, that sort of thing. If you have other questions, send me a message and that can be at DPT with needles or at Icephysio, it’ll get funneled to me. But thanks for jumping on this morning to talk about fainting with dry needling. There will probably be a follow-up series, maybe more so as to why we’d like not just, um, avoiding adverse events from needling seated, but what are the benefits. I think the benefits far outweigh the risks that we discussed this morning. So thanks for tuning in, and I’ll see you down the road.

23:02 SPEAKER_00 Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram, at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you’re there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 19, 2023

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

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses how to return to loading the core during the first 12 weeks of the postpartum period. Take a listen to learn how to better serve this population of patients & athletes.

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.

EPISODE TRANSCRIPTION 

00:00 INTRO 

What’s up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let’s chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you’re looking for an easy way to navigate payments, here’s what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane’s support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you’re ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you’re in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today’s PT on ICE Daily Show. 

01:27 DR. JESSICA GINGERICH, PT, DPT
Good morning PT on ICE Daily Show. It is rainy and humid here in South Carolina, so I am already sweating this morning. My name is Dr. Jessica Gingerich and I am on faculty with the pelvic division here at ICE. Dr. Alexis Morgan and Dr. Ellison Melrose and myself are coming off a fun webinar with the CrossFit Affiliate Southeast team where we were talking about coaching the pregnant and postpartum athlete, trying to keep those athletes in the gym as long as we can throughout their pregnancy and get them back in the gym as early as we can in that postpartum timeframe. I wanted to take this opportunity to continue the conversation more specifically around the benefits of training the core during the first 12 weeks postpartum. As always, we want to just highlight some wonderful opportunities to learn. We are coming your way. Go ahead and head over to ptonice.com to see when we are close to you for our two day live course. That is where we take the internal exam and we bridge it with return to sport, return to endurance training, return to strength, gymnastics and so much more. We also have an eight week online course. That is wonderful. We have an online course for eight weeks. So if that is something that you want to hop on, if that’s easier for you to get to, head over to PT on ICE.com to snag your spot. So we are in a really exciting time within that pregnant community. We are starting to see women push boundaries and challenge the norms around exercise. However, the question always continues about returning postpartum. When to do it? We often hear what is safe and unsafe. Here at ICE we like to not use those words because it is more so about what you are ready for and what you are able to do in that snapshot of time. So we know that every pregnancy, birth, prior fitness level and so many other factors vary per person. However, we also know that returning to exercise postpartum has massive mental and physical health benefits. So what I want to do is I want to define that fourth trimester. So this is the time period between zero and 12 weeks postpartum where those physical, mental and emotional changes are huge. They’re huge in so many ways and exercise can be such a massive benefit to mom. And so we want to make sure that we’re doing them justice. So as we make recommendations for core training, we need to respect certain factors. So that’s going to be tissue healing timeframes, pain levels, the amount of help someone has at home, maybe sleep, how much sleep they’re getting, how they’re eating, what they’re eating, are they trying to get their breakfast in as soon as baby starts to cry and they’re getting their lunch in as soon as baby cries and moms are really good at putting themselves first, right? But most importantly, we have to respect function. As hard as we fight for maternity rights, for example, longer maternity leave, mom still has a job at home. She’s caring for a newborn, potentially other children are at home and likely has physical demands of a job waiting for her eight to 12 weeks later, which means she needs to strengthen her core and she really needs it now. Too often the recommendation is taking that six to eight weeks off after birth, which encourages a significant amount of deconditioning, making motherhood, return to work and a whole lot of other things a lot harder. So here at ICE, we love encouraging physical therapy to begin at two weeks postpartum. With this recommendation comes some exceptions, like how is mom adjusting to motherhood or adjusting to adding another baby to the family? Does it give her anxiety to leave the house, which virtual sessions are great for that? Does she need sleep when her appointment time is? You know, that’s a big deal. We want to encourage sleep. Or are the baby’s appointments just adding up and it’s making it hard for her to add this appointment on top of that? So during the first visit, we addressed several things, but core is absolutely one of them. That is looking at diastasis, that is looking at her ability to sit up, a full sit up. We’re going to talk through three planes of motion acting on the spine. You all probably know these from school, but we have the frontal plane, transverse plane, and the sagittal plane. There are a lot of exercises to be utilized in these planes of motion that are important throughout the plan of care for improving strength and function. But where do we start? We love teaching a transverse abdominal contraction along with the pelvic floor contraction, but it never stops there and it usually is something that we move on from fairly quickly. So we do those in supine, we do them in standing, we do them in hanging quadruped, we do them in a trunk extended position, but then we add all of those wonderful layers. So our top three exercises to begin and to start with are the Paloff Press, the Supported Sit Up. This is such a great movement, right? It encourages that full range of motion. Mom is having to sit up out of bed multiple times in the night to feed. And then the Unilateral Farmhouse Carry. I always get a kick out of moms coming into the clinic holding the carrier. That thing is heavy. I’ve carried it out for a couple of moms just to kind of get an idea of how much it weighs with baby inside. It’s heavy and they are having to carry that immediately postpartum to appointments because they can’t leave baby at home. So here we had all three planes of motion with an isometric type of load aside from the Supported Sit Up. There’s plenty of room to progress range, length, load, and then time under tension. As well as these movements mimic those physical demands of life. So again, holding the carrier, rolling out of bed, sitting up for feedings. We often get asked the question, but what about diastasis? So we are assessing that in that first visit. But the goal around diastasis is to coach points of performance. So if you are seeing coning or doming in the midline with a certain movement, can we take a step back, coach those points of performance, and then modify if your client is unable to maintain those points of performance. If they are unable to, you adjust. We need to get the core stronger. And if they have a diastasis, we have to get the core stronger. And we have research on this. So first of all, 57% of people have a gap greater than 2 centimeters. And this is not just in the pregnant or postpartum population. Therefore, we really don’t even have an accurate definition of what constitutes a diastasis. Furthermore, Hills et al. found that diastasis recti was associated with decreased sit up strength and decreased torque generating capacity. A literal weakness issue. So to recap, the fourth trimester is defined as weeks 0 to 12 postpartum. Early core intervention can and should begin at two weeks postpartum per the mom in front of you. Begin with isometrics, then build range, length, and load. As always, we monitor symptoms of leakage, heaviness, pressure, bulging in the vagina, pain, and an increase in bleeding. So with that, I hope you guys have a great Monday and I will see you next time.

10:27 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 CU’s from home, check out our virtual ice online mentorship program at PT on ice dot 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 PT on ice dot com and scroll to the bottom of the page to sign up.

Jun 15, 2023

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

Jun 14, 2023

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

Jun 13, 2023

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

Jun 9, 2023

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

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