Dr. Ellen Csepe // www.ptonice.com 

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick shares a case of an OBGYN client with lumbar radiculopathy and the unique approach to core training that increased the client’s tolerance to sustained positions with less pain in the OR.

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

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

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

EPISODE TRANSCRIPTION

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

APRIL DOMINICK
Good morning, PT on Ice Daily Show. My name is Dr. April Dominick and I am here with the Ice Pelvic Division to talk to you about a current client case I have on cutting to the core, a case of the low back pain in the OR. So today I'll talk to you about a doctor with lumbar radiculopathy. radiculopathy that I've been treating, and the unique approach we took to core training that increased her tolerance to sustained positions in the OR and reduced her pain. a bit about my client. She is a cheerful female obstetrician in her early 30s who lives a very healthy, active lifestyle. She is strong. She loves to ski, hike, lift. She also lifts really heavy, which we love. And she came to me with a myriad of complaints of TMJ pain, headaches, cervical thoracic pain, and reports about 80 to 90% improvement with those issues. And then for the purposes of this podcast, we will just focus on her hip and low back pain. So she described it as aching, stabbing, and she, that was for the low back pain, as well as her right-sided hip pain. It was a six out of 10 at worst and three out of 10 at best. that intermittently worsens. And her pain originally started after she had to sit for a prolonged period of time in order to study for her boards for residency, something that we all are very familiar with. And she sought PT care with me about six months after when the pain had been steadily worsening. And then the final straw was she had 10 consecutive days of pain in her hip and back after a really long shift in the OR. So things that made it worse, exacerbating factors, prolonged sitting, prolonged standing, so any sort of prolonged positioning, sometimes heavy lifting days at the gym, especially leg day, and work days. And then easing factors, stretching, changing positions, supportive shoe wear at work, or sometimes exercise would help it, So after her subjective and objective exams, signs and symptoms pointed towards lumbar radiculopathy, coupled with some right hip labral pathology, and she had moderate irritability. So I took her through the typical lumbar radiculopathy and intraarticular hip treatment, including manual therapy like manipulation, dry needling plus stem, I dialed in some back and hip strengthening and mobility. And then she also responded really well to a little EMOM that I gave her for when she had acute severe flare-ups in between our sessions, which included some cardiovascular bike intervelling to address her chronic inflammatory state, nerve glides, and isometrics. So after a few sessions, she made really awesome improvement in, she had improved in neurodynamics testing. Her weekly frequency went from having pain daily to every couple of days, which was great. And then her intensity and duration of those pain cycles also reduced. Love it. And then her progress stalled, and she continued to have some low-level symptoms that would flare. And the culprits seemed to be work. Particularly, we narrowed it down to her labor and delivery shifts, where she had to hold sustained positions, as opposed to when she was working in the clinic and she was getting up and down from her stool or moving between patients' rooms.

THE HIP & PELVIS SHARE MUSCLES
So it wasn't until we unpacked two key pearls that we began to make another difference. So during initial eval, she had, when I asked her, she had denied any bladder, bowel, or sexual dysfunction. And given that I was able to reproduce her pains, why she came in, with specific exam of the lumbar spine and her right hip capsule and surrounding musculature, Pelvic floor dysfunction wasn't high on my hypothesis list, but given our roadblock in progress, I decided to go ahead and screen the pelvic floor externally. And when I palpated her obturator internus externally, and then we did some further testing internally, it reproduced her lingering secondary hip pain on the right lower extremity. So she had like a major hip pain. And then we found out she had, um, another hip pain that she hadn't really noticed as much, um, because of the other pains had kind of been so overpowering. So, um, she also had some difficulty, um, from the pelvic floor side of things and in relaxing, she had some hypertonicity throughout and then, um, some coordination issues. So we treated the pelvic floor, did manual therapy, dry needling to the obturator internus, along with some circuits with her low back and hip. And that seems to have really helped her quite a bit as well. So that was the first thing that helped us in this stalled progress was lesson number one, don't forget that there are bits and pieces of the hips that share a wall with the pelvic floor. and that the OI lives in that pelvic bowl and it's a direct connector over to the hip via the greater trochanter that it inserts on and it influences hip stability, hip rotation, and that was one of our key pieces in helping her get some more improvement.

ADDRESSING JOB-SPECIFIC DEMANDS
The Second piece that really helped move the needle and address those lingering back and hip symptoms was getting more specific about her job demands and environment. So specifically when she is working in the OR, our operating room, if we can't change her job duties, like she has to deliver babies, that is her job, what can we affect? Can we set her environment up for success, specifically as it relates to VOR. So in the clinic, we set up her operating room using what we could, and we went through things like, what is the table width and the height? We positioned her tools. I asked her where her coworkers stand in relation to her. We talked about the amount and direction that she's leaning over the OR table. She ended up describing a really common position that she ends up in, which is a right side bend and rotation. And that is, if you remember, her hip pain is on the right side. So that was really helpful. And then we also looked at the percent of or we kind of labeled it in an RPE way of the isometric pull during retraction of the abdominal tissue for her C-sections. So I basically had her try out different percentages of pulling and and she kind of landed on, okay, this is about how much I have to pull when I am either using my own strength to do that retraction, or if I'm using tools to do that retraction. So we then, after I got her table set up in my brain, I also asked about detailed information of the surgeries itself. So of the C-sections in particular, about how, With the C-section itself, how is time split up? You have to do a lot of retraction. That seems like the thing that she's doing in a sustained position. When does that happen? And come to find out for her, it happens in two-thirds of the time that she's in the C-section. So there's like a first retraction and then there's some other things and then there's a second retraction. So that was helpful to know that there were some breaks, so to speak. And, um, then we, uh, we talked about her, uh, average time it takes to have her symptoms come on during the C-section. And, um, she has to do multiple C-sections a day, uh, intermixed with some vaginal deliveries. So we, we talked about, is it within the C-section if it's a particularly long one for some reason, about when does your symptoms come on or after about how many. So all of that was really helpful information. And then we, we did some treatment. So we brainstormed strategies that she could use in the OR. Can she Use the retractor tool instead of her actual hands or her own strength to help reduce some of that burden on her body. And then can she use tools like a step stool to increase her height or get closer to the table, redistribute her weight, use the step stool to put one leg up on top, or even the bottom of the table sometimes has that. And then an anti-fatigue mat or supportive shoe wear. And then I asked her if she would be able to sneak in some lumbar extensions or side bending just in the OR when she's not actively assisting with the retractions just to give her body a break from that sustained position. And then increasing reliance on the other staff on her residence to give her a break prior to her reaching that symptom threshold of more than five or six out of 10. So that was super helpful for what she could do in the OR. And then we talked about what she could do before her surgeries. And this is where the core piece comes in. So she sometimes is able to return back to her office or back to the floor between her C-sections and vaginal deliveries for her shift. which led us to creating a quick core rehab EMOM, every minute on the minute, that focuses on multi-planar core strengthening and endurance for those long duration positions. It's that duration piece that seemed to really exacerbate her symptoms. So the core remom we came up with includes neutral and extended trunk work, side bending and rotation of the trunk. And we threw in some isometrics as well as mobilizations just to help with both the pain from an analgesic effect with the isometrics and then some mobilization given that she is just in that sustained position for so long. So for the core remom, I gave her basically three to four categories that she could choose one exercise for to do for a minute. And she could do anywhere from a three to four minute remom all the way up to 12 to 16 minutes, depending on what time she had. So for the core remom, in the neutral slash extension category, she could do a reverse plank for a 45 second hold. And then we talked about having a tote bag filled with a bunch of the medical textbooks that are just collecting dust in her office, two tote bags actually, and that was going to be her load for some of these exercises. So she could put the tote bag on top of her for that reverse plank to add load. We also did a side plank plus a top leg raise hold. She could use her loop band that she brought if she wanted. And a loaded windmill. So that was the, sorry, the loaded windmill is actually in the side bending category. So for the neutral extension, she had the reverse plank for about 45 seconds. as well as prone press-ups. And we found out that the prone press-ups tended to make her feel better from the discogenic symptoms she would have after the surgery itself. From a side bending category, so next category side bending, we had her do standing heavy farmer's carry with a band on her feet. So she'd have to work her hip flexors during that time and anterior core. and obliques. And then she had the side plank with the leg raise and then the loaded windmill. And then from the rotation category, we had her pick, or actually we just had her do a banded doorway. She could either do diagonal chopping, so that P and F pattern, or lifting. And that was really helpful because it really mimicked the retraction kind of pull that she had to do. And so I had her do it in different positions, tall kneeling, all upright, tall kneeling, half lunging, and then standing. And I had her match the percentage of pull or the RPE that we talked about, I had her either match it or go a little bit higher that she has to use her own body weight or the retractor tools in surgery. So we could kind of get her used to practicing that pull with good breathing mechanics and then also good awareness of her core. And then a bonus, was some hip and back mobility, like banded long axis distraction, quadruped rocks, or thread the needle. So that's a bonus if she wanted as well. So all that, she only needed a long band, a loop band, and then her tote bags filled with the medicine textbooks. And with that, She's been able to incorporate that into, um, before some of her C-sections or at least before the first couple, as well as, um, in between. And she has had some really awesome results in terms of reducing her low back pain, hip pain, and being able to tolerate standing in the OR and working on these individuals as much as she could. Um, so love that. And it was really cool to be able to, brainstorm and put ourselves in her actual environmental situation as best as best that we could to figure out what it was that she was doing with her body and how we could use her core to better support her so that her hips and low back didn't have to do all the work as well.

SUMMARY
So Our pearls from today don't underestimate the power of a 30 second external pelvic floor objective screen, even in the absence of bowel, bladder, sexual dysfunction, when there's hip involvement on the table. Even me as a pelvic floor PT, I missed that in this particular case, she did have a lot of other things going on, but it was interesting to find just a little bit of that secondary hip pain that we hadn't uncovered initially. And then taking that deeper dive into understanding the nuts and bolts of someone's job duties and environment to paint a clearer picture. And then with this case in particular, OI-focused obturator internist-focused treatment, as well as brainstorming strategies to alter the environment during the case itself, as well as priming the anterior core and hip with that focused multi-planar remom, helped her diminish some of her lingering hip and back symptoms. And we were able to raise the threshold that she could tolerate in terms of the number of C-sections that she could complete. So, success all around. If y'all want to dive deeper into the latest research on the core as it relates to pelvic health and some examples of actually some of these remoms that you can practice with early core management or advanced core management, then join us live. You can grab a seat on PTOnIce.com. Our next courses are in Kearney, Missouri this coming weekend, May 18th and 19th, and a double header June 1st and 2nd will be in Anchorage, Alaska and Highland, Michigan. Everyone have a wonderful week and I hope that helped you out with some of your cases.

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses how to earn more as a PT working with fitness athletes, including learning to understand how much you're currently generating & earning, as well as ways to increase your take-home pay.

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

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

EPISODE TRANSCRIPTION

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

ZACH LONG
Good morning, everybody. Welcome to the PT on Ice Daily Show, the May 10th episode, Fitness Athlete Friday, always the best day of the week here on the podcast. Excited to chat to you all today about a couple of different strategies for us to earn more money as physical therapists. We all know how much money that the average student is coming out with in terms of Debt when they graduate and that's we're constantly as a profession complaining about these declining reimbursement rates while it's becoming more Expensive to become a physical therapist But I think we're missing the boat on a lot of different things that could actually help us generate more money Whether we are a business owner or an employee. So I want to hit a couple strategies for that For you all today Before we jump into that topic, I do have to mention one thing that we have coming up inside the Fitness Athlete Division. That is June 22nd and 23rd in Fenton, Michigan. We are hosting our first Fitness Athlete Summit. So we're going to have the entire team there. All of our instructors are going to be together for one course. That one is going to be an absolute blast. Check that one out at PTOnIce.com. Alright, so we're going to talk about a couple things specific to the fitness athlete in terms of earning more income. But before we get to those specific things, I want to talk a little bit more big picture on some things that I think are incredibly valuable for us to research and know and think about if our goal is to earn a little bit more income here.

UNDERSTANDING WHAT YOU'RE GENERATING
And so the first, whether you're an owner or an employee, and this is going to be more particular to employees, most owners hopefully already know this, is we need to be educated on how much money that we are generating for our clinic. Or if you're an owner, you need to know how much money is each one of your employees generating for you. But I really so frequently don't see employees understanding this. And so one thing that I did throughout my career when I was working for different people, now I own my own businesses. But even when I was an employee, I was always diving in these numbers because I wanted to understand what I was doing for the company that I worked for. So, you know, depending on what software your clinic uses for billing and things like that, that might just be a couple of clicks to be able to see how much money you've generated over this entire year. Or you might have to do a little bit of math yourself. I've been in situations where that number was readily available. I've been in situations where that number was really hard to find. But in general, if it's hard to find, then you just have to figure out what your average reimbursement if you're in network is per visit and multiply that by how many visits you see per year. And you're going to get a decent idea of how much overall money that you're generating for the clinic. And then what you wanna do is you wanna take that number and compare it to your income. How much of that money that you're bringing in are you taking home? And I don't, you're gonna find a lot of variation in that number in terms of what you're taking home versus what you're generating. I will say that the number that I've heard thrown out repeatedly is the 30 to 40% number. At Onward, we're at a network, Onward Physical Therapy. So we believe that that number should be 50%. or maybe even a little bit more than that, depending on a number of different factors. But 30 to 40% is the number that I've seen thrown around the most. I'm always really shocked at how often when I'm traveling and teaching and talking to different physical therapists, at how often some of them are in a model where they're seeing four patients at once. And if we do four times $75 times, you know, however many patients per week, that is times, however many weeks per year you work, I've run into a number of physical therapists that are out there generating 500, $600,000 a year for their clinic. while making about $80,000. We'll make it like 20% of that number, which is just insane. And you have to be educated on this so that when you go in for your next contract negotiation, you kind of have an understanding of where you sit here. Now, again, that number is going to slide back and forth quite a bit. And I think one of the things that that would slide back and forth considerably on is if you were taking a salary, a set in stone salary versus you having a deal in place where you take some sort of percentage of revenue or you're paid per visit or something along those lines. And that tends to scare a lot of physical therapists that tend to want that set in stone salary. But I'll say like, if you really want to have the ability to make more money, then I think a lot of times we need to do a better job of just betting on ourselves and being willing to say, yeah, I'm happy to take a percent of my revenue. I know that up front that might be a little bit harder as I'm building my caseload. But on the back end, I could potentially make more money as long as I'm doing a great job providing clinical outcomes to people so that more and more people want to come see me. That is a great way to make more money as a physical therapist. The first time I went from a set salary to that, it obviously took me a little bit of a while to build my caseload up. but it resulted in me making $30,000 more per year. Once I got past that first year of rebuilding my schedule, that helped me pay off my student loans dramatically faster because I was willing to bet on myself and take a percent of my collections rather than a fixed set in stone salary. And I'll also say, if you're an employee, there are a lot of owners that love that idea as well, because they're not going to have a fixed expense. They're going to have somebody that's in this eat what you kill model. And they know that that's going to keep you hungry. That's going to keep you working a little bit harder, things like that. So it can oftentimes be a very big win-win for all parties there. And, you know, if you're an owner, one of my favorite parts about being a business owner is being able to pay my employees really, really well. And so I love to see when they're really dialing in on their clinical skills or doing a great job marketing and selling, and then they're getting rewarded for their hard work. And I wanna pay them so much money as a reward for that hard work that they never want to leave my clinic because of the finances of it. I want them to stay with me forever because they know that I'm gonna do the best job I possibly can of taking care of them financially. So think about betting on yourself and taking a percent revenue instead of a flat salary. With that one other tactic that you should consider is are there things in your contract? It that you don't need So let me give you an example of this a few years ago I was working for a clinic and I was making 40 of my collections from that company That resulted in me again making a big jump from my previous salary, but they also offered a couple other things They had a health insurance plan that they offered and they also gave me 15 sick days Valued at 150 dollars per day. So I don't remember the exact math on that. But when I ran the numbers here I recognize that number one I could use like a religious medical sharings insurance option instead of their insurance option And that would cost me less money and get rid of the fixed expense for the business And I also recognize that this was earlier in my career before I was married I wasn't taking that much vacation time and I wasn't taking any sick days. So I'd get to the end of the year and I'd have all these sick days at $150 per day. And I recognized that, goodness gracious, I could take those five sick days, but I generate more money when I'm in the clinic than $150. So I'd rather work. This was when I was trying to really aggressively pay off my student loans. And so I actually did the math on this in terms of the insurance versus the sick days. And if my My percent collections went from 40 percent to 41.5 percent That was like my break-even point there So I went to my boss and I said look you've got these fixed expenses of sick days And my insurance and I don't need either one of those So what if instead of that we just change my percent collections to 43 percent? My boss was thrilled. He was happy to get rid of a fixed expense And so just by doing those numbers and thinking through what I valued and didn't value as much I was able to come up with a strategy that made me several more thousand dollars per year probably resulted in about Probably results in about two and a half to three thousand extra dollars per year, which is wonderful So negotiate those things away that you don't need And then another thing that I think is really important for us to do when we just talk big picture numbers here is to set your goal income, then backtrack to the amount of money you need per hour. And this is one that's really important for both employees and owners. But like if you're an owner of a business and you're trying to decide how much to charge for different services, especially the ones that we're going to talk about here in a minute, what I like to think of is what's my goal salary for that year? Divide that by 2,000 hours and that needs to be the net income that I make per hour. So let's say just for simple math, you want to make $100,000 per year divided by 2,000, that's $50 per hour that you need to be taking home. And so that means that you then have to factor in your admin time, marketing time, your expenses, et cetera, et cetera. But that gives you a really good idea of where to start from your pricing standpoint. And you got to have that in mind if you really want to grow financially a little bit. Final big generic thing before we get into a few fitness athlete specific tactics is that I think overall, we need to worry dramatically less about the alphabet soup behind our name. Our patients don't really care that you have the ABC and the XYZ certification, et cetera, et cetera. What people are looking for now more than ever, especially as people are more and more educated, there's more information available online. They are looking for specialists in the areas that they are having issues with. If they're having hip pain, they want to see the best hip physical therapist in the area. If they're struggling with running, they want to see the best running physical therapist out there. If their shoulders hurt with snatch, they want to see a physical therapist that understands the needs of the fitness athlete. So worry less about the alphabet soup and more about building an undeniable skill set with your target demographic that you can then market to and have basically a guaranteed nonstop, um, influx of patients into your door. That's why ICE is really working on revamping our course logistics here. We're really pushing people towards our certification, such as our fitness athlete certification or older adult certification. We just want you to start to become known as the go-to person in your region for X or Y. That way you can really market that and leverage that in growing your business.

CHARGING FOR ADDITIONAL SERVICES
That then brings us to our fitness athlete division. And some of the specific things that I think that we teach in our courses, that we think that a lot more physical therapists should be marketing and selling to add additional revenue into their clinics money, or maybe some of these things become a side hustle that you do. So I'm gonna throw just a couple of different ideas out at you. Number one, mobility programming. Especially in the fitness athlete space where we're doing some really complex movements that take our muscles and joints through more range of motion than we see in almost any other sport. So take somebody that's working out trying to improve their strength at a global jump. Maybe they're doing lat pulldowns. Well, that pulldown usually take your shoulder to about 160, maybe 170 degrees of flexion. If you join CrossFit and you're doing kipping pull-ups, bar muscle-ups, etc, your shoulder is being taken to absolute enrage. If you don't have 180 degrees of shoulder flexion, you're going to be in really poor positions. You're not going to perform as well. It's going to often lead to some little aches and tweaks. So writing mobility programming is something that so many CrossFit athletes are looking for. And if you have that skillset, you should be marketing that to them. It doesn't take a ton of time. You could do really quick, you know, once a month, 30 minute follow-up sessions and you write them, you know, three or four days a week. Here's your 10 minutes of mobility work that you should be doing before or after or on your off days in relationship to your workout. So think about mobility programming. Alongside of that is accessory programming. Like say somebody comes and sees you for, for back pain. You analyze their squat and they've got a good morning squat pattern. You recognize that they need a little bit more quad emphasis, a little bit more quad strength and hypertrophy to help improve that movement pattern a little bit and reduce those aches long term. write them some accessory program. So that could be like two or three days a week. You're writing them, you know, 10 to 15 minutes of work to do after class. It could be that maybe they're dropping one day a week across it and they're doing really specific work on the areas that they are held back in a little bit. Because I think a lot of times we forget, you know, CrossFit's broad general fitness. So if somebody comes into CrossFit from an endurance athlete background, they're going to have a big hole in their game, like their strength is going to be behind their aerobic capacity. So maybe they need more strength bias in their programming and maybe one day a week you program that for them. Maybe somebody comes from a powerlifting background, they need the opposite. And so you start programming them some accessory Zone to work to really build that aerobic base There's a lot of stuff that we could do in the accessory programming standpoint, too And I honestly I don't see a whole lot of CrossFit gyms doing this right now So most of the time you won't be stepping on your local CrossFit gyms toes by doing this because they just simply usually don't have the time to handle extra programming. I also have a friend that does full programming. So like when he discharges his patients, he offers them fitness programming on the back end of that. So he works for a standard clinic and he's adding, last time I checked in with him, $20,000 extra per year that's straight to him. His company doesn't mind him doing this at all. Straight to him an extra $20,000 a year, just programming for people that he's already discharged. So a lot of these things don't even require that much more work, that much more marketing, and simply just offering this to your existing customer base as a little bit of add-on. In terms of like the specific like fitness athlete, you know, crossfit or powerlifter, limit weightlifters, I think one other thing that we should really look at is regular maintenance work. And physical therapists always get really up in arms when we talk about maintenance work, but I think we need to recognize something about this. So many individuals out there are actively seeking out regular maintenance work. They see a chiropractor once a month to get adjusted. They see a massage therapist once a month. They talk to a personal trainer and they're paying for accessory programming online, something like that. Why not offer doing all of that in one spot? Like why would you not say, okay, Jimmy, I know we took care of your low back pain, that upper back still stiff, your pain's gone, but we need to get that upper back unlocked a little bit. So why don't we follow up once a month for the next few months, I'm gonna write you some accessory mobility work to do. But once a month, we're going to crack your upper back. We're going to spend some time doing some mobilizations there. We'll do some soft tissue work, et cetera, et cetera, et cetera. We can put all of that together in one package for them rather than them having to go out to multiple different places. And it's a win-win there. We're still providing valuable services that's helping out their performance, that's potentially preventing future injuries and issues from happening while simultaneously growing our business. So I think we dropped the ball quite a bit on maintenance work and we Need to be a little bit more open to that in certain situations when we're providing value to people still. And then finally, I want to mention a couple of things from the more endurance side of the fitness athlete division here, and that's things like bike fits. So we have a bike fit course at ICE. We also have a running evaluation course, but both of those are things that people are more than willing to pay cash for because they understand how much it's going to help them perform to their absolute best and reduce, you know, a little bit of those aches and pains that they get with those sports that do have a decent injury rate there. And then with that population too, we should also be thinking about programming for both. We all know that runners aren't doing enough from a strength training perspective. And so often they have a running coach that they're hiring that's programming their running. And usually when I look at the strength work that the running coaches program for them, it's air squats, unloaded lunges, glute bridges, things like that, that we all know are not heavy and intense enough to drive adaptive changes in that population that needs the heavier loading. So why do we not offer that? Can we not really quickly write twice a week, a 30 to 45 minute program to get those individuals a little bit stronger and help stay ahead of issues that they have going on? So I hope that gives you a lot of different ideas that you can do and market to your business. The question that I always get asked when we talk about different ideas like that is then how do I know what to charge for that? And that goes back to setting your goal income. So you set your goal income, how much money that means you need to generate per hour. And then you look at all of these different extra services and you say, how long would it take for me to do this? So let's say bike fit, for example, let's say a bike fit takes you 90 minutes. It also takes you on average, about 30 minutes of marketing to get every new person in the door. So we're saying it's two hours for every bike fit. Two times the amount of money you need to generate per hour plus your expenses results in you understanding exactly what you need to charge for these services. So I hope that really helps y'all understand a few different things. And as always, we look forward to seeing you on the road at Fitness Athlete Courses in your area. Have a great one, everybody.

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

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the concept of poise, poise gone wrong, and poise gone right.

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

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

EPISODE TRANSCRIPTION

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

ALAN FREDENDALL
All right, good morning, PT on ICE Daily Show. Happy Thursday morning, hope your day is off to a great start. My name is Alan, I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at Ice, and the lead faculty in our fitness, athlete, and practice management divisions. Leadership Thursday, we talk all things business ownership, practice management. Leadership Thursday also means it is Gut Check Thursday. So this week's Gut Check Thursday, we have a partner workout. We're working our way with a partner through five rounds, 20 or 15 calories on that rower. Ideally, that's together, side by side, two different rowers. Coming off the rower, moving through 15 synchro toes-to-bar, and then finishing with a little you-go, I-go, working our way through 10 total sandbag cleans. I do one, you do one, until we've done 10. and then resting a minute after each round. That's gonna feel a little bit like anaerobic intervals, a little bit like maybe doing 400 meter repeats on the old cardiovascular system. Our goal there is two to three minutes per round, a minute per rest, get done with all of that work right around the 20 minute mark. I tested that yesterday in the garage, was able to hang with about 230 to 245 per round. My toes to bar are not the best, but a really nice workout, very simple, very easy to warm up. So that is Gut Check Thursday. Speaking of working out, May is Mental Health Awareness Month. We're happy to be partnered with Forging Youth Resilience. You may have seen at the Ice Sampler a couple weeks ago, we did the Ignite workout, a fundraising workout designed to support FIRE and support Mental Health Awareness Month. So all throughout the month of May, you still have time to donate to our campaign, which is for Forging Youth Resilience. We're trying to raise $10,000 to help some of those kids go to camp this summer in July up outside of Boulder, Colorado. So you can find more information about that on our link tree on Instagram. Find all about Forging Youth Resilience. Find all about the Ignite Workout and our fundraising campaign for FIRE.

EMOTION CAN SPREAD LIKE A DISEASE
Today we're talking about the concept of poise, the definition of poise, of staying in balance or staying in equilibrium. And in the context of today, we're really talking about staying balanced, staying composed, representing poise as it relates both to leadership within the clinic, you and your colleagues and your teammates, but also poise in front of our patients. So the idea of this topic came upon me actually several years ago. Two years ago in June, I had the pleasure of watching Dustin Jones and Jeff Musgrave teach Older Adult Live. down in Kingman, Arizona, and then we took a trip up to the Grand Canyon to do a rim-to-rim hike. So if you have never heard about that, you've never done it, rim-to-rim is half of the hardest thing you can do there, the other being rim-to-rim-to-rim. So starting at the top of the Grand Canyon, hiking down to the base of the Colorado River, and then hiking back up. Some individuals hiking south rim to north rim and then coming back. So many, many miles of hiking, very rough terrain, And this time of the year, spring, summer, very, very, very hot. So stepping off around 4 a.m., hiking down to the Colorado River. If you don't know anything about the Grand Canyon, it's really mentally defeating. It can be because as you come down in elevation, the heat actually goes up, which is not something our bodies are used to happening. So as you get closer to the river, it actually gets very, very hot, sometimes approaching 120 degrees. And then at the hottest point of the hike, at the hottest part of the day, you turn around and hike back up the Grand Canyon. So very, very tough, both physically and mentally. And as Jeff and Dustin and I were making our way back up the Bright Angel Trail, very wide trail, very exposed trail, sandy, not a lot of shade, very hot, very dry. And again, you're already halfway through the hike, so you are already pretty fatigued. And overall, I think it's fair to say that coming back up to the rim to finish the hike, most people are just trying to finish. They're looking forward to being done. And along the Bright Angel Trail, as you come back up, what you encounter along the trail are these things called rest houses. These are just little brick houses for shade that have a well pump nearby so that you can top your water off. And so, Jeff and Dustin and I, coming back up from the base of the river, making our way back out of the canyon, about halfway up, passed by one of these rest houses, decided to stop, take a break, top off our water. And we walked in this rest house, It was packed full every every inch of space had somebody sitting and hiding in the shade. And as we looked around, we realized a lot of these people probably had no business doing that hike. If you've never done the Grand Canyon hike, what you experience when you start the hike is signs everywhere. telling you, asking you, begging you not to do that hike, warning you that usually somebody dies every day hiking the Grand Canyon. It's very tough. It's very hot. And so as we're sitting in this rest house, we were sitting among some folks who maybe should not have been out on that trail. who were in a really tough spot physically and mentally. And unfortunately, on that hike, you're not really in a position where you can give much help to people. You certainly could not throw somebody on your back and carry them out. You're really not in a place where you could afford to give somebody any of your water or your food. Those folks, unfortunately, are just gonna have to wait until the sun goes down, until their body has recovered enough to hike back out of the canyon. And so my first experience with poise and with negative emotions was in that rest house, watching all those people really, really suffering and the three of us kind of sitting down, not as deep in our tank as some of those folks. But really, the longer we sat there, the more we realized kind of how quiet, how defeated those people were, and how that negative emotion, those feelings of maybe hopelessness, of extreme physical and mental fatigue, were actually starting to get into us. The longer we sat there, the longer we rested, the more we kind of let the whole vibe bring us down, even though when we walked into that rest house, we were definitely not in the same mood. And I'll never forget Dustin standing up and saying, okay, let's go. We have to get out of here. It smells like death in here. And what he was saying was, hey, we're actually not as bad off as these people, but if we sit among them for too long, we will convince ourselves that we are. So let's get going. Let's keep making our way Kback out of the canyon. We don't need to sit and rest here and feel bad about ourselves and how tired we are and how much we just want to be done. we can't let those negative emotions affect us. So, realizing that our poise, our balance, our equilibrium, our confidence can rub off on other people near us, and especially the larger group of people that is around, the more people feel a certain way, we can almost palpate those emotions, right? We've all felt that at a concert, or maybe you felt that at church during worship or something, you can feel kind of positive and negative emotions start to infect you almost like a disease. And so recognizing that is a concept that can happen and that we ourselves are in charge of not only how we pick up on other people's poise, but how we demonstrate our poise to someone else.

KEEP YOUR POISE: GRIPES GO UP THE CHAIN OF COMMAND
And so my second point today is learning a little bit about leadership in the military, going to non-commissioned officer academy, and really learning a foundational leadership concept that when you are frustrated, when you are upset, when you have suggestions, when you don't like the way things are going, your suggestions, your feedback, your complaints, your gripes, call them whatever you want. should always move up the chain of command, they should never move down the chain of command. And very similar to the Grand Canyon story, the idea behind that in the military is poise, is confidence, of we don't want to mislead people, we don't want to lie to them about the current situation, but at the same time, complaining to people beneath us about how tough our job is, or how bad things are going, especially if they think things are going well, and otherwise putting a damper on the situation again, can really bring in those negative emotions, can really start to fester, and really start to spread and infect almost like a disease. That if we're not careful, that if we complain too much about our business, about our clinic, about our patient caseload, about financials, about taxes, about any of the different things that we can have suggestions to improve, that we can have wishes that they were better, that we can have complaints about why they're not better. All of those things When we voice those things, especially to people in leadership positions beneath us, we need to recognize that we're just fostering that environment of negative emotion. And my final point is, why does this really matter? Even if you don't consider yourself in a leadership position, even if you're not in a leadership position in your business, in your clinic, you are in a leadership position with your patients. And just like complaining downstream can really have a lot of negative effects on a whole organization, having that same mindset individually with a patient about your business, about your clinic, about how busy you are, all of those things are concepts, are thoughts, are emotions that our patients are very easily able to pick up on.

POISE WITH PATIENTS
So my third point is, your poise matters probably the most with the patient in front of you. I truly believe it's our job to make that person feel welcome, to make them feel like their concerns are valid, and that we do have a way to help them, and probably most importantly, our poise is that we are excited about helping them. Not every patient that walks in is a high-level athlete and it's really fun to help them improve their snatch or their clean and jerk or something like that. Some folks come in and we know those patients. They are very deconditioned. Their therapy protocol can look very low-level to us, but it is our poise. It is how much We make it seem exciting to do things like sets of sit-to-stands, and one-pound dumbbell bent-over rows, and really partial range of motion burpees, and that we clap it up the first time that person's able to transfer on and off a bike for the first time, for an example. and that our poise, our balance, is always, if not neutral, erring on the side of positive. And when we really step back and question what are the benefits to having negative poise, to letting this person know how busy we are, how many patients we have on our schedule, how far away we think they are from the finish line, that really does not do anything to meaningfully move that person closer to their goals. If anything, it might keep them or slow them down from their goals if they pick up on the idea that they are not doing well, that their function is not great, that they are maybe making slower progress than we'd like to see. If they're able to perceive that, then we know those emotions can spread and those emotions can become reality. So being very careful with our own poise, making sure that when we have complaints about what's going on in the clinic, what's going on with our schedule, whatever is happening in our life, that those complaints go up the chain of command, that our patients don't hear them, that folks who work with us in leadership positions beneath or to the side of us don't hear about them, that those gripes, those complaints, those suggestions, those feedback things go up the chain of command so that the poise of the organization at least again stays neutral, ideally trending towards positive. Knowing the effect that those negative emotions can have. Despair, bad mood can really spread like wildfire if we're not careful to control it. And so recognizing when you show up for that patient your poise really, really matters. How steady you seem, how confident you seem, even how confident you seem and maybe not knowing something plays a big role into your poise. Hey, you know what? I don't know the answer to that question at all, but I'm going to look into that and as soon as I find out the answer or I find out somebody who maybe has the answer, I'm going to put you into contact with that person. So just trust me, that even if I don't know, it's okay that I don't know, and I'm going to help you find a solution. Just that poise, that level of confidence that we display, can go a really long way in patient buy-in. That if they leave the clinic and they feel like, man, my therapist knows what's going on, they know what I need to work on, they're happy, they're excited, they're stoked, they're measuring my progress, they're letting me know how I'm doing towards working towards my goals, and that overall it feels like a really positive environment, It's no surprise that those patients tend to show up for more therapy, they tend to do better in their plan of care, and even when their plan of care is done, they tend to be the folks that recommend new patients for us. And so, in those cases, having a really strong, confident, positive poise rewards everybody.

SUMMARY
So think about that the next time you're getting ready to stand up from your desk, you're getting ready to start your day, you're getting ready to restart your day after lunch break or something like that. Check your poise. Are you excited to work with this patient? Are you gonna clap it up that they do that one pound strict press, that they get eight cals done in a minute on the rower? No matter how low level it seems, no matter how basic it seems to you, maybe compared to your normal clientele, check your poise. I promise, the more you work on this, The more folks will have fun, the more you will have fun, and not surprising, you'll find yourself having more patients wanting to see you, then you have time on your schedule as well. So poise, think about it a little bit. That's it for today. I hope you have a fantastic Thursday. Happy Mother's Day to all those moms out there. Mother's Day, if you didn't know, is coming up Sunday. Still time to go get a gift if this is brand new to you. And then we're happy to restart live courses after a little bit break next weekend. So check out ptinice.com for all the live courses coming your way throughout the summer and into the fall. Have a great Thursday. Have a great weekend. Bye everybody.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the brand new "Build your own older adult fitness class" starter kit now available on the ICE Physio App.

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

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

EPISODE TRANSCRIPTION

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

JEFF MUSGRAVE
Welcome to the PT on Ice daily show. My name is Dr. Jeff Musgrave, doctor of physical therapy, proudly serving the older adult division. And today is Wednesday. Wednesday means it is all things geriatrics. So it is Jerry on ice. I am super excited to be sharing with you today. some of the hard lessons learned and I think some helpful steps for building your own older adult group fitness class. So, getting more and more questions about this stuff, my business partner and I, Dr. Dustin Jones, who also is faculty in the older adult division, have built a community for people 55 plus and we have learned a lot of hard lessons along the way. I'd love to share those learnings with you and then also pitch a couple free resources that are coming your way that you can get when you download the PT on Ice app. So all that being said, super excited to share this with you, but we would be completely remiss if we just blew past and got to the nuts and bolts of building the program and not touch just a little bit on, oh, we've got some people on that are interested in doing the same thing. I love this. super remiss not to just share why we would want to do this. And the reality is, our older adults' lives are being destroyed from a lack of resiliency, that lack of reserve, that lack of extra physical strength. And it comes in many names, right? We like to call it one rep max living. We talk about limited reserve, limited resiliency. But they come in diagnoses like sarcopenia, right, dynopenia. We've got potentiopenia, that loss of power, loss of strength. We've got type 2 diabetes. We've got heart failure, cardiovascular disease, heart attacks. I know I'm preaching to the choir here, team, but it's just so sad to see the long-term outcomes and how that changes the trajectory of someone's life when we know that most of it's preventable. If we could get someone to high intensity, they've got a safe place to exercise where they can get the options that they need, then we could make these things go away. We have the solution. It's not like we're waiting on scientists to bring us a solution. We're not waiting on research here. The research is very clear that most of this is completely avoidable. Completely avoidable. So team, if this has got you pumped up, if you're curious about what it would look like to build this, I've got some simple steps and some considerations and then I'll share with you about a couple free resources we've put together for you. So the first step I feel like… We've got to be very clear about who we want to serve. You've got to know who is your best customer. Sometimes people will reference these as avatars or personas. Who is that person that you are best suited to treat? Who do you want to treat? The reality is, unless you're in a very rural community, a small community, you need to get very specific about who you want to serve. You need to know where they eat. You need to know what kind of car they drive. You need to know where in town they live. You've got to figure out where that geographical area in your community is you want to serve. You've got to know how to serve a very specific customer well. Let's be honest, the person that is maybe coming off of outpatient caseload, who is just barely above independent, community dwelling, older adult, Their interest in fitness and what is going to draw them in versus what's going to push them away is going to look very different than someone who has been a lifelong athlete, a master's athlete that's coming into your clinic because they've got an achy knee or an achy shoulder or something like that. I mean, those customers are going to be interested in a different intensity. They're going to have interest in different equipment, and we need to know how to speak that language. We need to know how to identify that very specific customer we want to serve, and then we've got to create an environment that is irresistible to them. It's got to be equipment they can use. It sounds like such a simple thing, but it's all fun and games in your older adult group fitness class until you try to get someone on a bike and you realize they physically can't get onto an assault bike or they physically can't use a rower anymore. What are you going to do with them during that class? Do you have a plan? But that is a completely different customer that's more like that person that just came off outpatient caseload versus someone like that Masters athlete where they're going to be able to use all the equipment that the general population in a CrossFit gym is going to be able to use. But you've got to be very specific about who you're going to serve because I truly believe you cannot serve everyone well. You've got to be very specific. You've got to niche down as much as possible. If you're in a small rural area, you may have to widen your lens just a little bit more, but be very specific. So the who is the first part. You've got to know who you want to serve. The second part of who is with whom. So the with whom is, are you going to do this alone or are you going to find a partner and partner with somebody? I'm very excited to say that I've got a wonderful partner. Dustin Jones is gonna be really upset that I said this, but I trust the guy with my life, okay? I don't have to worry about the decisions he's gonna make for our business. He is a very strong, has great character, he's dedicated to excellence, and he's gonna challenge me. He's gonna push me. outside of my comfort zone based on the mission that we're serving and the people that we're serving. And that is crucial. A great way to summarize that goal, and depending on the project you're trying to put together here for your older adult group fitness class, you may be able to do it solo and that may be fun. But I'm gonna give you some advice via Jeff Moore, via an African proverb, and that is, if you wanna go fast, go alone. If you want to go far, go together. And we found this true because we launched right before the pandemic. And I think if we hadn't had each other's support, there may not have been a stronger life. And man, what a huge missed opportunity that would have been to the people that we get to serve. So that's the first part. Who and with whom is what you've got to figure out. The second piece is you've got to know, you've got to start figuring out what model you're going to use to serve in this older adult fitness. You've got to figure out your space. You've got to figure out your equipment. So if we're thinking about different models that are out there, you could, um, Start like we started in a CrossFit gym, maybe in off hours. You want to make sure it's a place that's supportive. We were lucky that we were at CrossFit Maximus in Lexington, Kentucky, and they were all about having us in there during the hours they weren't using class. The equipment's there, the space is there. Team, these business owners, they're paying the rent. They're paying utilities through this whole time, but they're not getting any income during that time. Usually what you're going to find in those gaps, mid-morning and early afternoon, are you're going to find open gimmers who are paying the maximum price, but they're using maximum equipment, maximum space. And if they could get someone that was going to generate exponentially more income during that time, they'll probably take a shot with you on that. So that's one way you could do it. You could also choose to do a virtual model, where maybe you're using Zoom or you're using Google Meet, and it doesn't really matter where your customer lives, as long as your customer's tech savvy, right? They could be all over the world. So you're probably gonna have to build some type of following. You're gonna have to get your name out there. But a virtual model frees you up from having to have a brick and mortar space. It can free you up from the geographical barriers of not being able to get to your customer or your customer get to you. A lot of studies say people are only willing to drive 10 to 15 minutes for their group fitness classes. So if you take wherever you're targeting to put your spot, and you kind of draw a circle, that's how you can start looking for real estate in that market as well. You need to figure out, are you going to do only group fitness? Are you going to do personal training and offer one-on-one sessions? Will those be in person? Will those be online? You can mix and match these things as they meet your needs and the person you're trying to serve. Is that a good method to serve your ideal customer? So something that's probably gonna ruffle some feathers is equipment. So this discussion about equipment and space. So the thing we've got to get focused on is being focused on results and serving that customer well. Every piece of equipment that you find will not necessarily serve your customer well. Can they physically get on it? Can they use the piece of equipment? or not. You've got to figure out weight limits for things. Are you going to serve customers? Are you going to serve larger bodied athletes and patients that just came off caseload? Kind of like the C2 bike. I think the post can only hold like 200 or 210 pounds and it's tiny. If you're a larger bodied athlete, that is super uncomfortable. and you're probably going to break the equipment. Can you think about what's going to happen to your business early on if one of your larger bodied athletes breaks the equipment in class? How embarrassing that's going to be for you, for them? That story, unfortunately, is going to be shared very quickly and probably very widely. So you've got to figure that out about equipment, but also how much space does that equipment take up? How many people can use it? And is it gonna be an attractor or a detractor to your target avatar? Now, if you're working with more of a master's athlete population, they've been in the weight room before, they're maybe not gonna be upset about seeing dumbbells and barbells and all these different pieces of equipment in the environment that seems a little bit harsher, a little more, well, most of us would consider pretty badass, right? But you've gotta consider in a group environment, if you're trying to onboard people, that are terrified of a barbell. They've never seen it. Say you don't have training bars. Man, this one hit us really hard. We didn't have enough training bars when we launched. We had several members that couldn't even get the empty barbell out of the holder and move it to their spot. We're trying to build autonomy. We're trying to build their confidence and their strength. They can't even move the frigging piece of equipment around. Like, how upsetting would that be? You're terrified. You go to your first group fitness class and not only can you not use a piece of equipment, you can't even pick the thing up. It was, man, lots of hard lessons learned there. But we want to figure out with our model and our space and our equipment, how are we going to use these things? Does everyone need everything all the time? Do you need, if you're going to do a class of 15, do you have to have 15 rowers? Do you have to have 15 Ski Ergs. Do you need 15 GHDs? I love GHDs. They're fun. I use them all the time. But they're not the best to serve our avatar at Stronger Life. You will not find GHDs lining the walls in Stronger Life. Most of our members would not be able to use that piece of equipment. And it wouldn't give them the most bang for their buck on their time. So you've got to figure out, like, how accessible is your equipment? How much of it do you need? programming for stronger life, and the reality is you can program these problems in, or you can program these problems out. I mean, if you do a, if anyone is in the CrossFit space and done, shoot, Filthy 50, man, you gotta have a box, you've gotta have barbell, you've gotta have jump rope, you've gotta have rig, you've gotta have all these things. Like, the amount of equipment and space you need is incredible to run that class, if you're thinking about building out your own space or leasing your own space. But think about a workout like Fight Gone Bad, where you're rotating through stations. You need a fraction of the equipment, you need the fraction of the space, and if anyone's done any of those five gun bad workouts, you can get a tremendous workout that way. And I'm not saying that's the only format, but that is one example of where you can program in lots of expense, lots of overhead cost to make it really hard to open your space that's gonna push you into a much larger footprint than you need, and then you're gonna have hanging over your head a big lease a large utility cost, insurance, just the whole thing. And the more equipment you have, the more you've got to buy and the more space that takes up. So this takes me to a term when we're trying to consider all these things and figuring out if we can build a profitable business, we've got to consider things like operational capacity. So operational capacity is when you're looking at your space and you're trying to figure out, okay, I've got, say, 3,000 square feet and I've got this many square feet of bathrooms. I've got this much square footage in the lobby. I've got this much square footage for equipment storage. How much of the space that you're going to be leasing or using can actually produce income? You've got to figure that out. You've got to know how much revenue you can produce in your space, how you're planning to program with your customer. Because if you don't know how much income you can produce, like maximum capacity, then I mean, we've kind of turned this into like a volunteer job, right? And there's nothing wrong with that if you want to volunteer and do this for free. But if you want to build a healthy business, you've got to figure out your operational capacity. And this was first, I learned from Stu Brower's podcast, WTF Gym Talks. Now, if you don't like four-letter words, you may not get through his podcast episodes, but some very savvy business learnings there. WTF Gym Talks, Stu Brower. Brilliant guy. He's actually got a short episode on that that is really helpful and very eye-opening. I actually go through an example of looking at different operational capacities on the free resource on the ICE Physio page I'll tell you about at the end. So, that leads me directly into profitability. The reality is, team, if your business fails, you can't help anyone. So do your math up front. Figure this stuff out. Who am I going to serve? What kind of equipment am I going to use? What do I have the capacity? How many people can I serve? You've also got to figure out your pricing. You've got to be reasonable to the market, but also value what you can offer as a physical therapist or a physical therapist assistant or a fitness pro that has gone through older adult training to know what in the world is going on. What we need here is we've got to figure out where that intersection goes. When are we going to become profitable? Based on the number of people I can serve, how much I can charge reasonably, how soon I think I can fill this out, when can I expect to not be losing money but making money? And we've got on the PTI and ICE free resources, you can get access through the ICE Physio app. We're sharing with you a break-even spreadsheet where you can put in all your costs, what your pricing is, how many people you're expecting to serve. to figure out how many weeks until you have a break even point, when you're not losing money, but you're actually, you're floating. And the reality is this idea of reserve and resiliency dovetails very beautifully. with a business. If you've got high financial reserve, you're making way more money than you're spending, then your business is profitable. If your business is profitable, then you can invest in more equipment. You can invest in more advertising. You may be able to bring on a second person to help you or another coach that you can train. Those things are beautiful to be able to consider and to be able to share this dream and this vision with someone else. We like to call it building a bigger table, dreaming big. I would argue to say, once you have some level of success, you should be thinking about how you can share these opportunities with other people around you who are also passionate. But you've got to figure out the break-even point, and that can also help you figure out what profitability can you expect at a certain price point at a certain membership level. So once again, that's on the Ice Physio app under free resources. you can get access to that.

SUMMARY
So what we've actually got, I've got a lecture that's a little bit over 20 minutes long, going through these items in detail with some more examples of what your operational capacity would look like, what your profitability would look like, based on two different models, more of kind of the extremes like, master's CrossFit class that everyone needs a barbell everyone needs a rower and then an example of more like a cycling studio where it's like you've got a very small footprint you can really pack the house so you can kind of just see compare and contrast. I'm not saying either one is right or wrong it's just you need to be informed before you make decisions and move forward. You've got to know who you're going to serve and with whom. Are you going to do it solo or are you going to partner up? You've got to know your model space and equipment, a.k.a. the operational capacity of your business, if it's going to survive. You've got to figure out how long until you become profitable, how your equipment, how your programming feeds into whether you're going to be profitable or not. and make decisions as needed. You need to know your break-even point. That's going to give you your financial runway. How long can I operate and keep this dream alive financially until I've got to make money? And you can't do that with rose-colored lenses, team. You've got to take a hard look at the numbers and repeat these steps as many times as possible until you've got something that's really going to work. So team, that's it. All of that is wrapped up in more detail with a free lecture and that spreadsheet to figure out your profitability. That is the free starter kit on the Ice Physio app with the free lecture. Should be very helpful. So please check that out. Reach out to us. We'd love to hear your thoughts or questions. I wasn't able to keep up with the comments. I probably didn't answer any of your questions live on the call. I love that you ask questions, but please ask them in the comments and I will get back to you. If you have questions about this stuff, I love this. This is my passion, getting to live my dream. Love this. Check out the free resources. Ask your questions in the comments. If you're looking to see us from MMOA out on the road, we've got a few seats left in Level 1. That's going to get started on the 15th of May, so grab those seats. Level 2 already sold out this cohort. You're going to have to wait until October if you're trying to get into L2. Don't let that happen if you're looking for L1. Live on the road, we're going to be in North Dakota and Richmond, Virginia in the middle of May and then Scottsdale, Arizona early June. Team, I hope this was helpful. I hope this got your wheels turning. Check out those free resources and we'll see you next time.

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

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

In today's episode of the PT on ICE Daily Show, Dry Needling division lead Paul Killoren describes his ideal setup to travel with all the supplies & equipment needed to perform dry needling on at least 2 individuals.

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

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

EPISODE TRANSCRIPTION

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

PAUL KILLOREN
And good morning, Instagram. Paul Killoren here going live broadcasting worldwide PT on Ice daily show. If we haven't met before, I am the current division lead for dry needling division. And today I want to tackle a big FAQ, one of the top frequently asked questions. It comes up almost every course. It comes up during holiday season and travel season. And really any time that someone says, here is a box of needles and you're flying anywhere. So we're talking travel guide for dry needling. And to give you some background on myself, I had a brick and mortar clinic cash pay for almost 5 years, many years ago. Since that clinic closed, I have more or less been mobile, and mobile really means getting on airplanes to treat pro athletes. And that brings up a lot of questions. So whether you are truly traveling with needles, we'll talk TSA, baggage, all of that stuff, or you're just more of a mobile setup and you're looking for some solutions that maybe aren't your typical, like you don't have a cabinet, you don't have places, brick and mortar in a clinic. So we're gonna talk the travel guide to dry needling today. And first of all, I get zero kickback, zero financial incentive, but what I'm wearing here is actually the Go Rucksack, the GR1. I've actually traveled with this heavily teaching for a long time, almost nine years, and this thing has held up. So it gets my stamp of approval. It is an expensive bag, but for me, it has been more than valuable, and this is traveling consistently across the country. So this bag is, is just your standard backpack. And if you are traveling, let's say getting on a plane to see a, uh, an athlete, or if you're traveling for vacation to see family members, that bag is large enough that I have my laptop, all my normal personal travel carry on stuff. Um, but that is where I put a lot of my non needling supplies. So, I mean, if you're doing cupping or scraping or taping, any of your other things, that GoRuck gives me plenty of space to stick stuff in. But today, this is the pack that I think most people have questions about and will talk about the most. So this is my travel kit for dry needling. You can see the logo there, Instagram, YouTube. Medpack is the name of this company. Again, I have no financial incentives. Honestly, I've been wanting to carry their stuff for a long time, and I dry needle, but it's been just a tough distribution setup. But I do give this my endorsement, and the pack I'll show you today is actually the one I've had the longest, it's the smallest, and actually the least expensive. meaning if you go to Medpack site there are lots of different options and really they're kind of EMT or athletic trainer quality bags meaning they are durable, they do have nice sturdy locks and straps and holding longer straps I guess for carrying but they are high quality and they are medical grade bags. This bag specifically is their 300 series bag. It's their cheapest one. It's less than 100 bucks right now. And honestly, I like this better than some of the larger bags that I've used. And I'll show you everything this can fit in a moment. The larger bag has enough, it has more space, it has enough space really for more needles, but for two of the ES-160 e-stim units, which is nice. Larger means it doesn't always fit as easily in the overhead bins of some of the regional jets that I've been on or underneath the seat. And if anything makes me more uncomfortable and nervous on a plane, it's watching Bob try and cram his carry-on bag right next to my med pack that has two ES-160s. You know, you picture them spinning it around, cramming it in, doesn't fit, doesn't fit. There's been a few times where I'm just like, it's made me nervous enough that I prefer to travel with the smaller bag because it fits better, at the very least, underneath the seat in front of me. So this is the Medpack bag. Again, no financial affiliation by me. This is the one I've liked the best. The 300 series is less than 100 bucks. So let me walk you through it. And I've got Instagram here, YouTube over here. Try to give you the best angle. So again, what I like about this is it has sturdy straps. And you see big pocket one side, other side, these outer pockets. One is where I have my new gloves. So it's full of gloves that are unused, will be used. And the other side is my garbage. So during a treatment session, I travel to an athlete's home, I have gloves, I have swabs, I have all the needle debris. I'm sticking all of that in my garbage pocket during the session. I mean, really, I'm not trying to leave any waste or trash, even those tiny little shims, at a patient's home. So I'm constantly sticking that in here. Those are the two outer pockets. If we unclip here. First of all, I just have your standard cord pouch, I guess. Nothing fancy to this, but this is where I keep all of my lead wires for the ES160. And I will say that it's worth having extra of everything when you travel. That's batteries, that's lead wires, that's almost have a second everything, because what you wouldn't want to do is travel to a client and not have a functioning unit for whatever reason. So here are my lead wires, including a few extra and some extra batteries for my e-stim unit. If we take that out, another clip here you can see, here you go, inside of the purse. I'll try not to dump it out entirely, but what you see is that there are little compartments for almost everything. This middle one is actually customizable, meaning there's Velcro that I can make this smaller or larger. So I made it perfectly sized to actually have a pretty secure hold on a quart-sized sharps container. And then there's my needle, the main needle compartment. So I have 105-75s, and if you want a pro tip, I mean I'm biased, I use iDryNeedle, Needles, which means they have a shim tab. I really like having max packs for being in a patient's home Again, if the goal is not to leave any of the shims or any garbage much less clutter with the multi pack I like having those and then let's see if I can tilt this up even further two front pockets have my swabs so my skin prep swabs and You saw there a little gel electrode. If you know, you know that it's kind of nice to have one of these with the metal button. You can put it on a patient's skin, clip up an alligator clip to that metal button and then to a needle. So it's nice to have a few of those handy. And then in this front pocket is just more needles, smaller individual size needles. So needles, sharps, kind of cleanliness, skin swab stuff, more needles. And in the back, this is really why I like this bag specifically, is almost a perfect size compartment for the ES-160. So there is my 6-channel e-stim unit, slides right in back. Behind there you see that there's a little pocket or another compartment where I have the e-stim 2, so a smaller e-stim unit back there. There's a larger pocket where you can fit more supplies there if you need. That's where I used to keep my extra batteries, but then I kind of got the cord carrier. And then up top you have a zipped pocket, I guess. And I guess since real early on, like the first year that I started needling, Someone terrified me into carrying a hemostat just in case a needle would ever fracture. So that's what's in there right now. I've never used it, never had to use it, but a zipped pouch for whatever you'd like to put up there. So again, that is the Medpack 300 series bag that I travel with. Again, there are larger ones. If you're not getting on a plane, there are roller bags and backpack bags like there are MedPak makes a nice, again, more durable, more resilient, and almost healthcare grade pack, kind of EMT, ATC bag quality. So that's me getting on a plane. I have my GORUCK, I have my Carry-On. So let's talk plane travel specifically, because again, this commonly comes up. First of all, whether you've heard or not, you are allowed to carry on needles. They can be in a closed box. They can be in their loose sleeves. They can be in a sharps container. You are allowed to have needles. I know that from experience and also from Delta Airlines policy. So again, that bag I just showed you, I'm going through TSA pre-check goes through there. I will admit that 50% of the time it gets kicked to the side. So you're sitting there waiting for your bag. The person is going to ask, like, whose bag is this? Is there anything sharp or that's going to poke me? And that's when I say, yep, it's full of needles. Ha ha. And they don't believe me until they open it up. But once they do, there's been no issue. They basically say, like, oh, are you a health care provider? Are you an acupuncturist? And you say, I'm a physical therapist. It might be worth carrying or having a copy of your license should there be more questions, but me doing this for several years, there's never been more questions. They basically nod along. Honestly, why my kit gets kicked to the side half the time is either a hand sanitizer that I carry with me or a cleaning, like a table cleaning bottle, basically a fluid that's more than three ounces. They actually let you keep both of those after they test them. So even if your hand sanitizer or your cleaner is larger than three ounces, they will run a little swab test on it. Typically they give it back. I'm not sure if that's because we are health care providers or because there's some exclusion for sanitizer, but that is why it gets kicked to the side or it does look a little suspicious to have all sorts of wires and batteries under x-ray so half the time they don't even realize or care or know that your bag is full of needles they see eight nine volt batteries or eight c batteries with a bunch of wires and that looks kind of suspicious. So every once in a while, you'll get questions on what is that unit? And I say electrotherapy device, electro stim device, therapeutic device, whatever answer you want to say, but that is why half the time when I'm carrying through that pack, it gets kicked to the side. But honestly, never had any issues from there. Again, I travel pretty frequently. So those are the common frequently asked questions. I already gave you the pro tip that if you are traveling two clients on a plane or even driving, you should have extra everything. And that's needles, batteries, lead wires. Learning over the years only from one or two failures, but it is pretty embarrassing to show up and not have extra batteries. You're basically asking your patients if they have batteries. So just have extra batteries, have extra lead wires. Unfortunately, if you do travel or you are mobile for your treatments, It puts a little more wear and tear on your stuff. As far as stem units go, I actually haven't had any issues durability wise with the ES160. Aside from the wires, I've replaced a couple over the years. The E-stem 2 is one of the smaller, cheaper units that holds up really well. The Pointer XL and the E-stem, sorry, the ITO ES130, the 3-channel unit, do not hold up as well. So as far as the plastic inputs on the ES-130 or the wires, if you're looking for more durable units that really don't wear as quickly with travel, I like the eStim 2 and 3 and the ES-130. But that's what I got for you supply-wise. Again, no issue with TSA or otherwise with needles or sharps containers or e-stim. Really, I'd just be prepared for maybe one or two follow-up questions, but there's never been an issue. Other things that are worth having if you're just more of a mobile setup or if you are getting on a plane, I would always have extra consent forms or maybe a one pager for what is dry needling. You'd be amazed if you are mobile how it's not even a word of mouth referral. You're traveling to see one person or a mobile session with one person and they have a friend or a family member that just happens to be there during your session. Whether it was planned or unplanned, they just want to watch it, ask you all the questions while you're working with Gladys in her living room. So I would just have some reading material for that person First of all, to avoid distractions from them, but also to answer their questions, potentially gain a new client. Otherwise, consent forms, same thing. You find the opportunity to potentially do a trial treatment. I would always have extra consent forms with you, or just have an electronic version that's easy to pull up. I still do the paper. I have extra ones with me. I do scan it with a PDF scanner and can send it to the patient right away. But otherwise, I do the old school consent forms. But that is what I have for traveling with needles. Once this episode drops on Instagram, I'll drop some links for the bags. If you have any questions on travel, I think I hit the big ones. I think one other question that comes up, um, less so for the more formal like mobile or travel client, but more frequently with I'm at home at Christmas with uncle or grandma. Um, some other questions that come up are, is there kind of a less formal way to dispose of sharp needle or dispose of sharps? Um, and the answer is yes. And even depending on the state you live in, some states would say this is entirely legal, which is you should just put them in a water bottle with a cap that you can twist, and then dispose of it in recycling. Maybe put duct tape over the top of it. But maybe if you're at home on the holidays, you have a few needles in your bag, whether you are going to do gloved clean needle technique on family, that's up to you, like whether you have those sorts of supplies, but I would certainly dispose of the needles semi-properly, which might just be a water bottle and some tape.

SUMMARY
All right, team. So that's what I hope that answers some of the main questions you have. I know summer means you're going to be traveling a little more. Um, we're coming right off of sampler and honestly, the number of folks that came up to me and ask questions about treating athletes or, or travel treatments or mobile treatments were high. I think it's just becoming a model that even healthcare consumers are more intrigued by, you know, having the option of us driving to them, even if we charge them a premium. So when it comes to needling, there are some pretty nice setups. Again, I like this bag. If you want to know some of my failed or my less desired travel tips, I kind of went through the plastic tote phase that had a snap-on cover. I tried kind of, I guess, a makeup kit or a taco box. Nothing really seemed to fit quite as well as what I just showed you, which is the Medpack bag. But there are other options out there. So if you have questions on travel tips for needling, drop them once this goes live. Again, I'm Paul Cloran. I'm the division lead for dry needling. If you're trying to catch a course with us on the road, May we actually only have two courses and they're both the weekend of the 18th and 19th. Ellie will be in Virginia Beach. I'll be out here in Seattle. And really throughout the summer, we have some big courses, but we have a lot, we have fewer courses throughout the summer. We just know that you all are out there being active, friends, family, a vacation. We want our faculty to kind of decompress a little bit, but if you're trying to find courses throughout the summer, they are there. If you want more options or you're looking for something more convenient, check out our summer, but also our fall options for needling. All right team, thanks for tuning in. Drop any questions you have on traveling with needles. Signing off.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses two different presentations of pelvic floor patients who may present to the clinic.

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

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

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

EPISODE TRANSCRIPTION

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

JESSICA GINGERICH
Good morning, PT on ICE Daily Show. I hope everyone had a great weekend. It is Monday, so that means that you are live with the pelvic division. My name is Dr. Jessica Gingrich, and today we are going to talk about the most bang for your buck pelvic floor addition. So I'm going to present today two separate presentations. So I don't want to talk about necessarily a case study or two separate case studies, just different presentations that you may see in the clinic. if you are a newer pelvic floor clinician, you may feel stuck. You may feel, oh, I haven't seen this or haven't seen this many combinations of things. Where do I start? And so, that's what I want to talk about today. So, the first thing or the first patient we have is going to be the person that has pain. That could be back pain, that could be hip pain, SI joint pain, tailbone pain, pain with penetration, and that may be during intercourse, during a vaginal exam, whether that is a speculum or digital exam. They may even have a history of this with tampon use. Even bedroom toys can be an issue. They may also say that they have issues with bowel movements. They have difficulty emptying or they do have a bowel movement, but when they're done, they don't feel quite empty. From the urinary standpoint, they may feel like they pee all the time, so they have frequency. Or when they get the urge to pee, they really have to go, so more like urgency. And then this also may present with or without urinary incontinence. On the flip side of that, we have the weaker pelvic floor. And so this is someone that comes in and maybe when you're talking to them about their activity level, Well, I haven't worked out all that much or I like to walk. I don't really lift weights. I haven't done it in years. And they may also present with leakage. They may even have heaviness in their vagina or dragging sensation. All of these presentations may come with, um, babies or, or no babies, right? Back to our first presentation, that person also may have that type A personality, where they like structure, and they feel like they have to work out all the time. I wanna kinda go off on a little bit of a tangent about that personality. We tend to say that, oh, well, they have that type A personality, and that's not a bad thing, right? If we didn't have that personality, what would our world look like? What we wanna do is we want to help that person Um, lean in to how they can best just function, right? And so when it comes to working out for a type a person, it may be a lot of education, right? You don't need to work out seven days a week, but this is what it can look like. Here's what programming looks like to really maximize things. There's a great book that I'm currently reading. It's called A Guide to Losing Control or Type A, I'll have to post it in here. I can't remember the title of it. But it's a really great book around just the structured Type A personality and how to really lean into that and help that person just feel better and function better, really optimizing recovery, stuff like that. So I'll drop that in the comments here when I'm done. So what I wanna talk about is where can we start with both of these presentations if we don't know where to go? So with that weaker person, they need to be loaded, right? They need to get stronger. So that's the first and foremost. But maybe they're not ready for that. So what we're gonna talk about, there's a thousand different ways to do this, but we're gonna talk about relaxing, okay? This is not the, well, you need to just relax your pelvic floor. You need to just relax. No, it's more about knowing how to relax. So, the first thing that I want to talk about, and I know this is everywhere, but is the squatty potty or getting your feet elevated to some capacity. What this does from a mechanical reason, and I love talking about this in the clinic, is give them the reason why they're doing it. Don't just say, hey, when you go to the bathroom, elevate your feet. Okay, see you later. Tell them why. So what this does is it decreases that anorectal angle. So when that angle decreases, now we're not having to fight against natural angles in our rectum to help keep us continent. The other thing that it does is it allows that puborectalis muscle to relax, to just unkink the base of the rectum. So two biomechanical reasons as to why we are suggesting that they get their feet up. Now you may be asking yourself, why are we talking about a squatty potty to relax the pelvic floor? Cause that's maybe one or two times in a day, depending on the patient in front of you. So that is going to allow the pelvic floor to just work optimally, right? You're getting the pelvic floor. When the pelvic floor needs to be off, you are helping that to be off rather than sitting and without your feet elevated and your pelvic floor might be on a little bit, or if you're bearing down, maybe your pelvic floor reflexively kicks on. And so that's just optimizing your pelvic floor on day-to-day functions. that need to happen, right? Now, I will say that some people don't feel great with having their feet elevated, and that's okay. Also, the angle of which their hips are is different per person. Also, I feel like you guys can hear my dogs barking. They're making their PT on Ice daily show debut. Sorry about that. The second one is a diaphragmatic breath. And we hear this one all the time too. Well, let's just teach our patients how to diaphragmatically breathe. Yes, that's a really important thing, really for anyone, but we need to teach this well, right? We can't just say, here's how you breathe. Okay, go do it. We need to have them focus on what they are trying to feel. And so when we are diaphragmatically breathing, when we inhale, our pelvic floor should descend. Have them focus on that. Where does your pelvic floor go when you inhale? Focus on that movement. And also just… and have them do this in different positions. You know, they may be on all fours doing it. They may be in a deep squat. They may be sitting on the floor. And this is likely going to be a static thing that we're doing. So, having them be still really focusing on it. Don't watch Netflix and do this as you're starting to learn. Now, different cues that I like to use around where your pelvic floor is, it looks different for everyone. So, does your pelvic floor descend? Some people, they're like, yeah, it does. They kind of understand that they are aware enough about that. Sometimes people aren't, and so you have to give them one structure to focus on. One of my favorites, and I know you guys have heard me say this a thousand times, is feeling your butthole open. We know where that is most of the time, right? When we have to go to the bathroom and we are not by a toilet, we know where that muscle is because we squeeze it. That's certainly not everyone, but it's a good place to start, okay? Now, the third thing is incorporating that diaphragmatic breath that we talked about after a workout or even before intimacy. And that can be a really powerful thing if someone is having pain with insertion, painful orgasms, painful arousal. And that could work for people who own a vagina and for people who own a penis. So give those three things a shot. But remember, we always want the end of that plan of care to look like that person lifting weights. They also may be doing Kegels, right? They may need to have that base strength of where, or I say strength, Kegels can increase strength for someone, but it's probably going to be short-lived, right? Because A, it's really kind of body weight, and B, we don't function just under body weight, we function under load. And so, ending with your plan of care of teaching this person basic barbell movements, dumbbell movements, Kettlebell movements, maybe that's where they're starting and encouraging them to lift weights. This looks different per generation, right? We may have to convince some people that this is a really good thing. And then other times we may not need to, right? People are going to be a little more into it. So, go out and try these three things. We've got the Squatty Potty, we've got Diaphragmatic Breathing, and we've got Diaphragmatic Breathing following a workout or before intimacy. Give those a shot and let me know how they go. I will see you in a couple of Mondays.

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko tackles the difference between grip endurance & maximal grip strength. Joe also provides several programming examples to help clinicians know what to program, who to program it for, and when to program it.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app slash switch. And if you decide to make the switch, don't forget to use the code icept1mo at sign up to receive a one month free grace period on your new Jane.

JOE HANISK
Good morning crew. This is Dr. Joe and it's going to One of the lead faculty of the fitness athlete division here at ICE. Coming off a great weekend last weekend out in Carson City, Nevada at the Sampler. It was fantastic to see 150 or more PTs from the ICE community there. Great times, great learning, and looking forward to next year as well, which I think is sold out. So if you are interested in going, hop on and grab a waitlist ticket. Pay attention. Jeff will be throwing out some dates for hopping on that waitlist as well. So today, though, team, my plan is to cover… One second, I got a camera issue here. My plan is to cover advanced grip strength. So about a year or so ago I did a podcast on grip strength and it predominantly focused on what I would say is the nuances of grip strength using more of accessory training to build a grip strength within a fitness athlete or just an individual specifically who was looking to build grip strength. But the more I've sat back and thought about it, The more I've independently tried to train my own grip strength, which I find to be one of my weaknesses in the sport of CrossFit, I really believe that there's two versions of grip strength, strength that we need to focus on, depending on what our athlete or our person is looking for to develop there. Basically, what I'm going to get at today is specificity of advanced grip strength. And what we're breaking this down to essentially is two categories. Either someone is looking to build grip strength from more of an endurance perspective, and in the world of CrossFit, I would say that would be like in the gymnastics world. we're often really taxed on endurance grip strength. That is, while we are on the bar doing things like pull-ups, toast the bar, or possibly on the rings doing more than likely ring muscle-ups of some kind. That is typically what we're going to hear athletes complain is one of their breaking points is that they just couldn't hang on or that their grip strength was weakening and therefore when we know through a lot of research now that when the grip goes so do a lot of the other power producing muscles because the energy transfer is just not as clean and clear there. So when I think about endurance grip strength, we're thinking about gymnastics grip strength training. So that's one silo. The second silo is going to be more in our weightlifting world of CrossFit, moving maximum loads. But I think that the thing that we haven't really thought about as much is that when we move max loads, we're not doing it for long durations. The bar is in our hands for only a few seconds or fraction of a second from the time that the bar leaves the floor until the weight lifting movement, the clean or the snatch, for example, is complete. In other movements like the deadlift, we have strategies like a mixed grip that seems to not be a limiting factor for most once they've figured it out, meaning that many people can deadlift their maximum capability with a mixed grip on the bar and their posterior chair and their legs their back are not though are the limiting factor I should say that their grip strength is not the limiting factor so we have a resolution to that in the deadlift but when it comes to the clean and the snatch which require hopefully a hook grip position oftentimes people's grip strength can be a limiter they may not realize it but often again similar to the gymnastics world when the grip goes our power and our connection to the bar is dampened and when we're looking to create speed through that mid zone through that second pull of the olympic lifts Often people lose that torque, that grab on the bar, and they lose power production, and the lift may eventually be failed because of that. So certainly it's not the only thing to consider with weightlifting, but when we're talking about grip strength, we're going to look at max grip strength on the barbell as a separate training thought process than we would look at max grip on a gymnastics movement, which tends to be more endurance based.

GRIP ENDURANCE
Let's talk about endurance first. When I think of endurance-based grip training movements, the one that jumps to me right off the bat is just long-duration bar holds, dead hang or active hang holds on the bar or on the ring. That would be the most obvious one because it's the most specific to the gymnastics positions and that we are moving on the bars or on the rings. You could add in some dynamic challenges like hip swings or beat swings while doing long duration grip and hold. We could add weight or loaded holds active and dead hang holds from the bar and maybe you would even consider things like farmer's carries in this group where you're sustaining a grip on an object for long durations but often the load tends to be relatively moderate compared to our maximum effort, meaning that if you're hanging from a bar for a minute, that clearly wasn't, it may have been a max effort for that one minute, but it wasn't a max effort overall in total grip, like max grip strength there. So those are some of the ideas of how we might choose certain movements, but they're certainly going to look more like the movement itself, meaning the gymnastics movement as the basis. I wanted to give an example in each of these categories as like a programming idea that we could use so that it kind of comes into play. So lately what I've been playing around with on my grip strength training for endurance in the gymnastics world is mechanical drop sets basically, or even just loaded dropsets I guess would be the better word here because we're not changing the movement as much, but a drop set. Meaning that we're going to start with something that is significantly more challenging. and then we're going to try to maintain work output throughout the following sets but we're manipulating a variable in this case it'll be load so that even though we're fatiguing we're able to maintain high work output over the span so A drop set of active hangs for me lately has looked like this. I have determined what my maximum effort of around 60 to 70 seconds of a hang is loaded, and I picked that one minute mark for a couple reasons. I feel like it's an easy trackable number that we can repeat over and over again. It is a long enough time in the bar where very rarely are we going to see an athlete maintain more than a minute on any type of gymnastics movement that would be kind of at the peak. So I chose that 60 to 70 second mark and I've over time I've tested what my max ability to hang in that one minute mark is with adding load onto my body. So let's say in this situation that I can do a 45 pound plate hang for 60 seconds. That would be set number one. I would then give myself about a minute of rest following that 45 pound hang. I'll let the grip recover, but not too long. We're thinking endurance here. We want to repeat this again and I'm hopping back on the bar, but this time I'm dropping by, we'll say maybe 10 to 15 pounds. So we go from 45 to maybe a 30 pound a dumbbell or a kettlebell that we're now hanging from. Repeat that one minute. There's the drop set that we dropped load, but we're still doing one minute of output here. Rest 45 to 60 seconds. Then maybe we go to a 20 or 25 pound weight. And ultimately I've been doing anywhere between four to five sets. So if I start at 45 pounds, my very last set over those four or five sets is going to be just my body weight and I'm trying to hang. My goal is 60 seconds. But often what I'm doing here now is just providing a opportunity for me to really test my max grip hold on the bar or on the rings at body weight after hyperloading it in the three to four sets prior to that. So this is an example of grip strengthening for the endurance training of gymnastics, but you could do a whole lot of other things. But again, as a summary for the endurance grip strength, we're looking at moderately challenging loads, for longer durations, simulating ultimately the experience of having to hang on to the rings or the bar for long periods of time. We could consider dynamic movements as well, like kipping to challenge the grip or load. Those would be my two best suggestions. And if you're really, you know, in a bind, we could consider things like farmer's walks or carries as well too.

MAXIMAL GRIP STRENGTH
So now this has to directly, sort of oppose the next scenario in which we talked about silo number two being grip strength training on a barbell we're looking to move maximum weight the literally the the absolute max of load that we can hang on to and move effectively and then how we change our ability to have a stronger grip during those movements and So for me personally, I mentioned this briefly before, I believe and I feel myself that often if my grip is going, it's not that I physically couldn't necessarily hang on to the bar, it was that it was starting to break my ability to hang on to the bar effectively and energy was leaking out of my hands and therefore as I was trying to create speed on a clean or snatch, once I got past the knees more than likely in that second pull, into triple extension through the following third pull movement that I wasn't able to create enough energy through the bar to keep it accelerating upward at the appropriate speed or height and I was failing to get my arms up and under it. So I've been working on training grip strength on the barbell in really heavy positions on the bar and not only incorporating load but also considering speed because i think speed will challenge the grip as you start to move upwards and everything in the world is trying to push that bar back down towards the floor that has a unique dynamic that needs to be offset by incredible grip strength so here in the olympic lifting world i like to treat this more like strength training max strength training. If I were trying to improve a one rep max back squat, bench press, whatever, I want to kind of treat grip strength training in this scenario very similar. So this could be movements like Simply put, maybe even if you're warming up your deadlift, we start working on deadlifting with a regular grip, not even a hook grip, just a regular hand over hand grip, which is often going to be the most limiting, but this is a great opportunity that as you're working from 135 to 225 to 275 and maybe into that 300 pound range as you're warming yourself up for your heavy loaded deadlifts that you're just doing a regular grip. That is one option of training grip strength on the barbell. You're only getting those three or four seconds of each movement. If you're doing multiple reps in a row, you may have to re-grip the bar and you'll also realize how quickly that fatigue in the grip comes into play with that. But it's certainly an option that we could think about building grip strength on the barbell during our deadlift and our deadlift warmups. If you are a trained deadlifter, you will probably run into the scenario that eventually Your body could move more, but your hands can't hang on to it. And that's usually when we go to a hook grip, a mixed grip, or possibly straps. But more recently, the way I've been going after this is doing rack pulls or heavy barbell holds with rack pulls. So in a rack pull, I can set the barbell height to be starting at around the knee level, which is right after that transition zone of the Olympic lifts. And what I'm often looking to do here is pick a load that I can regular grip that i can move with some sort of speed and intent and i'm moving through that second pull position quickly but just from the rack so grabbing the bar really gripping it standing up with good technique good form and pulling into that essentially hip crease position that power position taking the bar right back to the rack letting go and then repeating it is a short burst a short intentional burst of grip strength that I'm looking to train at loads that are often similar to the amount of weight or even slightly heavier, we'll say 90 to 110% of what I could clean or snatch. You could do this in a wide grip or more on your clean grip, either one would be fine. But essentially what we're doing is doing short bursts at high loads. So if we're thinking about building out like a working set for somebody, I've lately been doing anywhere between six or seven, upwards of maybe 10 sets, depending on how I'm feeling, of just sometimes one to two or three reps in a set. So let's say I have 300 pounds on a bar in that rack position. I grab the bar, squeeze it like hell, pull to power position, set the bar back down, and depending on how that load is feeling, I'd either re-grip and repeat for rep number two, or possibly three, or maybe I'm just doing eight to 10 sets of singles at my max effort. It's unique in that it won't be overly taxing from a stamina standpoint, but it certainly will start to train the grip from a speed, power production, and we'll just call it an integrity position, where it really has to commit to doing what you're wanting it to do, which is hang onto that bar as it's moving fast through your transition zone. So that's an example of a working set that I would do, six to 10 sets, one to maybe two or three reps total at anywhere between 90 to 100, 110% of your Olympic lifting capabilities to start to build confidence and strength in that second pull, or possibly off the floor if that's where you feel like you're weakest, but the second pull seems to be where that speed change is occurring, which will challenge the grip the most. The third phase of grip strengthening, I guess, would be back to my original podcast that I'd done a while ago now, which I think a lot of us are becoming more familiar with, which is just accessory grip strength training. And this is the things like, you know, doing forearm work, doing plate pinches, doing spherical or dumbbell head holds, where you're grabbing on the top of a dumbbell, training our grip in different positions, narrow to fat grip. There's so many different ways we can go after that. But if we're only focusing on the unique, accessory grip strength training, I think we're missing the ability to be more specific and whether that specific need is in endurance, long duration, moderate holds, or if it's in more of a strength world where it's maximum loads, quick, fast bursts, I think we need to be thinking about what our athlete is looking for, what we're looking for as individuals and starting to train within that bubble. So hopefully that was helpful guys. It's been certainly helpful for me to train this way. I've been really putting some time into it. I'm hoping to see some changes because I've worked on a lot of grip work for years on and off and I felt like, you know, pound for pound, my grip was okay, but it was starting to inhibit my ability to move barbells faster. So I've been putting a lot more of my energy into this max barbell grip and hold position. Um, Good luck with it. It's challenging. I think you'll learn from giving it a go. And it certainly fits that mold of specificity, which is always important in our strength training world.

SUMMARY
So last thing before signing off, CMFA live courses coming up here in May. I think Mitch is out in Bozeman, Montana. I'll be in the Duluth, Minnesota area here in the next few weeks. So if you're looking to get a course last minute and you're out in Montana or you're in Minnesota, Michigan, Midwest area, that Duluth course would be awesome. It's a cool town. We're already filling up out there. And then in Fenton in June, the third weekend of June, we are doing a fitness athlete summit, which we are pumped about. It is going to be myself. It'll be Mitch Babcock, Zach Long, Kelly Benfield will be there, Guillermo will be there, Jenna will be there, Tucker, all of our lead faculty and TA are gonna be there. We're gonna try to implement more fitness, but you'll have tons and tons of opportunity to learn from some of the best in the business, so I would absolutely get onto that course. It is filling up super fast, people are excited about it. Mitch's Gym, CrossFit Fitness is an amazing place to be. It'll be a great time, so if you're looking for anything this summer to get into, I would say don't miss your opportunity there. Have a great weekend, we'll talk to you later.

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

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

In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses using dry needling for recovery, including e-stim parameters using the ES-160 unit.

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

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

EPISODE TRANSCRIPTION

ELLISON MELROSE
Welcome to the PT on Ice daily show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of ICE. I am here to talk to you guys today about recovery, so dry needling for recovery. We are coming off of Ice Sampler Weekend, and we had two pretty intense workouts this weekend, and we're feeling it, I think. So we are pretty sore in the quads, so what I wanted to demonstrate today was a recovery method for primarily the quads. We're gonna go over recovery mechanisms, how to choose the muscles when you're thinking about setting up a recovery circuit, and the e-stim parameters that you want for dry kneeling for recovery. So there are three main mechanisms of action when we're thinking about recovery.
The first is pumping, so hemodynamics. We're getting big muscles to pump. There are some muscles that are better pumps and better sponges, so they do a better job at the fluid dynamics. The second mechanism is washing out cellular debris from in that intracellular space. So thinking a little bit more microscopic than just vasohemodynamics or moving fluid. We're thinking cellularly. So we know that active recovery and facilitated recovery can do both of those things. What's nice about dry needling when we're thinking about recovery is that we're not putting any mechanical stress on the tissues, loading like we would with active recovery. Third, we have an autonomic nervous system response.

DRY NEEDLING FOR HEMODYNAMICS
So one thing that they saw throughout the research is that dry, or e-stim, facilitated recovery with e-stim, there is a longer base of dilation effect after we removed the e-stem from the tissue. And so what they postulated from that is that we have an autonomic nervous system response, so we have increased vasodilation, which is just going to improve our body's natural ability to pump fluid. When we're thinking about choosing muscles, again, as I mentioned earlier, there are some muscles that have better capacity to pump, but also absorb fluid and that is based off what we call O2 flux capacity. We're not going to dive super deep into that today, but pretty much what it means is that there's increased capillary density in those tissues and so they act as better sponges and better pumps. When we look at the lower quarter, there are two main muscles that are going to be pretty good or have higher O2 flux capacity. One is the medial gastroc and the other is the quadriceps.

CHOOSING THE RIGHT MUSCLES FOR RECOVERY
Another way to think about what muscles to choose are thinking about following the venous system. So again, we're trying to improve hemodynamics. So we want to follow the venous and lymphatic system to encourage that fluid to work its way back up towards the heart. And so thinking about a lot of the bigger venous structures, the lymphatic tissues run immediately. So when I'm thinking about setting up an entire lower quarter circuit. Sometimes, depending again on why I'm choosing these, we may be doing medial gastroc, medial quad, adductor magnus is a huge pump for the lower quarter. And then working into the glutes as well. And then, last but not least, is we have sport-specific muscle fatigue. So when thinking about, a great example I like to use is in CrossFit. After a really grip-heavy workout, we may be just specifically treating the forearm flexors, so the muscles that we're using to grip, right? In this case, we did a lot of thrusters on Sunday, so we are gonna be doing a quad recovery session for Sam today. We're just going to demonstrate bassus lateralis. When we look at e-stim parameters, so we want things to be a pump. So we need to have the intensity at a motor response. We also need it to be a non-fatiguing stimulus. So if our goal is recovery, we are thinking we want it to be non-fatiguing. So we're going to keep the frequency low. we are limiting pistoning. So we do not want to piston the tissue. Every single time we move a needle around in the muscle, we are creating a little bit more micro trauma to that tissue. And that is the opposite of what we want to do when we're thinking about facilitating recovery. So I'm going to get two needles set up in the vastus lateralis here, and we'll kind of go through the e-stim settings and, um, dive in a little bit deeper there. So for the, the needling technique, ready cleaned her skin here. We are going to be using a needle for the vastus lateralis that we feel like we have the most access to that tissue. So when thinking about choosing needle length for a larger muscle, we want to be using a longer needle where I'm going to be threading through the muscle here as I can have access to more muscle tissue. where I'd be going towards the femur. I am floating the needle in. I am not pistoning. If we get a twitch response, great. I'm not necessarily looking for a twitch response. Because we want a motor response with the e-stim parameters, we do want to be localizing our tip of the needle at a muscle spindle interaction, which is what elicits the twitch response. So what we're going to be doing instead of pistoning is a little bit of live redirecting of the needle under e-stem. We'll talk about that. So I'm just going to choose two big portions in the vastus lateralis here and thread across the tissue to have access to more. Oh, nice little twitch there. Because I did find a twitch, I'm going to leave my needle there as again, that is going to be the closest to that muscle spindle interaction where we can have better motor response. Then I'm going to choose a spot up a little bit more proximal, threading across the tissue. Perfect. Okay. So no twitch response there. Again, not necessary. We're not going to be pistoning to find that motor response.

E-STIM PARAMETERS FOR RECOVERY
So, I'm just going to be setting up a circuit here. And we are looking for, I'm gonna just pull these cords out of the way so we don't have that blocking our visual here. We are using the ES-160 today. All right, so e-stim parameters.. Low frequency, so we're thinking below 5 hertz. We want a motor response. Duration. So the longer the duration, the better. So when we're thinking about this, the research looked at 10 minutes versus 20 minutes, and they had almost double the biochemical clearance with 20 minutes compared to 10 minutes. And so we are thinking we want to set these up for longer duration, so thinking greater than 20 minutes here. We're not gonna be doing that for the podcast this morning, but we will set up that circuit and look for that motor response. So I'm gonna be increasing the intensity. Sam, let me know if it's strong, but still tolerable. Okay, we're looking for that motor response. And if we're not getting that motor response, we are going to do a little bit of live redirecting. So I have switched the, and parameters to just constant, you can do alternating frequency, but it's not necessary in the recovery session. So really whatever's the most tolerable for the patient is what we're going to want to do. So I'm increasing my intensity until we get a nice, strong muscle pump.

DRY NEEDLING FOR RECOVERY
So, this is what we're looking for when we're thinking about creating that muscle pump. Again, non-fatiguing, so we're thinking lower frequency, longer duration. Our muscles that we're choosing are either based off of following the venous system, looking at the O2 flux capacity in the muscle tissue, or sport-specific fatigue. Our mechanisms here, again, we're creating a pump. It's just a pump, it's really that simple, right? We're pumping fluid throughout the system. We're clear at a cellular level. We're clearing some of the, we're washing out the cellular debris. And then we are also facilitating vasodilation through the autonomic nervous system. If you have any more questions about this, feel free to check us out on the road. So we have a couple courses coming up on the third weekend in May. So the 17th and 18th is, you can check us out on the road. I'll be down in Virginia Beach. And then we hit, I'll be back in Florida, so maybe Florida first weekend in June and Longmont, Colorado on the 20th, the weekend of the 20th of June. So feel free to check us out on the road and have a great rest of your Thursday. See ya.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer translates lessons learned from training for a 50k trail run into strategies to use when working with older adult clients to help them become the person they want to be as they journey through life.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app slash switch. And if you decide to make the switch, don't forget to use the code IcePT1MO at signup to receive a one month free grace period on your new Jane.

JULIE BRAUER
Morning crew. Welcome to the PT on Ice daily show. My name is Julie Brower. I am a member of the older adult division, and I am going to be talking to you all this morning about my favorite thing in the world, running. So this morning I am going to share with you some lessons that I've learned from training and running a 50k that I just ran this past weekend and I'm going to translate some of the lessons I learned and give you all some advice on how you can use those lessons with your older adult patients. So This past weekend, I ran a 50K, that's 31 miles, in New River Gorge, West Virginia. It was absolutely beautiful, absolutely brutal, and I was out there for seven hours and 14 minutes. That gives you a lot of time to reflect and learn some life lessons. So I'm gonna share some things with you all, and hopefully you can translate these to be using with your patients this week.

LESSON 1: THE TRUE FINISH LINE IS AT THE END OF YOUR LIFE
Okay, so first lesson. The true finish line is at the end of our lives. The true finish line is at the end of our lives. This is a quote by Sally McRae. If you all have not heard of her, she is my absolute idol. She is a professional ultra mountain runner. She is known for her mental fortitude and crazy accomplishments throughout her career. She just did the Grand Slam of 200 mile races, which are four 200 mile races in the span of five to six months, which is absolutely insane. So she has a, her own podcast called the Choose Strong Podcast. And I started listening to her as I was starting to train. Um, when I first started trail running like a year plus ago, a little bit over a year ago, And I remember I'm running on the trail, I'm listening to her podcast, and she said that, quote, the true finish line is at the end of our lives. All of these start lines and finish lines and belt buckles and medals that we acquire, they're just adventures along the way. They're lessons learned along the way, the triumphs and the failures. What matters is the end of our lives. And it's a story that we get to tell. So I, as I was listening to this, I was thinking back to when I was younger and I ran track when I was younger. And when I was running in a race, it was first place or last place. My entire world hinged on me winning that race. If I didn't come in first place, I was gonna have a bad several days, my family was gonna have a bad several days because I was miserable. And so as I'm listening to Sally talk about this, and I'm training, I'm realizing that life is not a singular race or a singular goal to conquer, and then we're done. It's a journey. And it's not about winning, it's about becoming someone who endures. So that's my thought about this is a journey in our lives, that the end of our lives is the actual finish line. It's about, for me, becoming someone who endures. Developing the mindset and the habits and the lifestyle of someone who can go out and run 31 miles in the mountains. Okay? So when you're thinking about this with your patients, especially when we work with older adults, it's never just about their one episode of care with you. From day one, when you're sitting down and you're talking to your patient or your client, you want to be speaking to them as if this is a journey that you're going to go on together. This isn't, we're just creating goals for you to accomplish at the end of our eight week plan of care. This is about connecting with their life journey. Who do they want to become? How are you going to help them develop the habits and the lifestyles to become the person that they want to be so that the next several decades of their life are happy, purposeful years? Start that conversation early. Start talking about what's next. Again, it's not we are ending this relationship in eight weeks. What's going to be beyond that? Do you have a side gig that you do private wellness in folks' homes and you're going to then provide personal training for them? Are you going to refer them to a gym and you start that process early so you find the right fit for them so they can continue on with fitness? Start talking to your older adult clients as if this is a long-term relationship and this is a lifelong journey. Start talking to them about who is the person that they want to become and how you are going to help them get them there. Okay, that's number one.

LESSON TWO: PAIN IS MORE EASILY ENDURED WITH FRIENDS
Number two, pain is more easily endured with friends. Pain is more easily endured with friends. Team, I have never experienced pain like I have when I was out there on the trail this past weekend. There was about 5,000 feet total of elevation gain and loss. You're climbing up rock scrambles, like vertical rock scrambles, treading through water, slipping on mud, rocks and roots the whole entire time. The terrain was absolutely brutal. I've never felt this type of pain before. I mean, my ankles and my knees and my feet were just absolutely destroyed and screaming at me for a long time. I went out on that second 15.5 mile loop and I knew, I was like, this is gonna hurt the entire time. It was not my cardiovascular system holding me back. It was the pain in my joints. Every single step was grueling. And I started to think, as I'm in this much pain, I'm starting to think about our older adult clients who have aches and pains and arthritis, and I'm like, man, this may be a little bit of something that they feel on a daily basis, right? I know that this pain for me is temporary. When I finish this 31 miles, it's gonna be over, for the most part, until the DOMS sets in, which has definitely happened. But older adults, pain may be a part of their lives. Now, we know that we can get people strong and we can influence their environment and help with their diet and their stress management and their sleep. Like, we can do a lot of things that can help with pain that they feel, right? However, I don't think it's fair to come at someone with rainbows and butterflies and tell them, like, you're never gonna experience any pain. I don't think that's fair. Pain may be a very real experience for older adults, even amongst them doing all the right things and getting really strong. And we have to realize that. So this is what I want you to think about. Pain is better endured with friends. And I will tell you when I was out running and I was on that second 15.5 mile loop, just miserable and miserable amounts of pain. The one time that I wasn't feeling it as severe were the times when I was running alongside someone. When I was having a conversation with someone else on that trail who was experiencing the same thing as I was. When I was meeting people and hearing their journey of their training and why they signed up for this race, and who's waiting for them at the finish line, and what they were experiencing in that moment, and you're distracting each other, and you're learning about each other, you're making friends with strangers. I did not feel that pain as severe as when I was spending time with someone else on that trail. And I will tell you one moment in particular, I was running with this one guy pretty consistently at the last like five, six miles of the race. And I was telling him like, I ran a 20 miler and then I jumped to this 50K. So skip the marathon. And at one point, we're continuing on and he turned around and he says to me, hey, you just ran a marathon. And I was just so taken that this individual, who's trying to concentrate on his own footing and his own race, turned around to give me the benefit of, hey, you just ran a marathon. You just PR'd. And that right there, I didn't feel any pain. I was so grateful for this human. I didn't feel a darn thing. So when you are starting to work with your older adult clients, I want you as quickly as you can, starting day one, try and get them to be a part of a community. I said it before, how are we going to plant that seed early to get them to discharge to fitness, right? To go on to their second part of their journey, start getting them a part of a community as quickly as possible. The pain that many older adults experience throughout the day is because they're bored. They're bored. They're not doing anything. They're not spending time with anyone. Try and find them friends as quickly as possible, whether that is a fitness facility, a walking group, a church group. Find them community ASAP. Get them to be socially interacting with others more than just you for that one time in the week. Because their pain they're experiencing, I promise, is going to be able to be endured easier when they are spending time with others.

LESSON 3: FORWARD IS FORWARD
Okay, next one. Forward is forward. Alright? Forward is forward. I had to keep telling myself that. especially before I was heading out on that 15.5 mile loop, that second one, because there's no way I was like, I am in so much pain. There is no way I can be in this much pain for 15.5 miles, especially knowing how much climbing I was having to do for the last five and a half miles. I couldn't believe that it was possible. All right. But when I kept on going back to focusing on becoming someone who can endure, Focusing on that goal. It's not about winning this race. It's about becoming. I am focusing on becoming someone who can endure. I am having people along the trail who can distract me along the way. Even amongst insane amounts of pain, you can move forward. And I had not experienced that until this past weekend. It's incredible what the body can endure if you just focus on continuing to move forward. regardless of what that looks like. There is so much grace in forward. For me, it was, okay, running quick, like my first 15.5 miles, I was zooming, I was flying, it felt awesome. The second loop ate me alive. Running quickly became jogging, okay? Jogging slowly, my jogging slowly became hiking. all right my hiking became i am leaning up against a tree hunched over absolutely miserable and making deals with myself like julie count down from 10 and then keep moving and i out loud was counting down from 10 and then i would say go and then i would just continue moving forward it is insane how you can chip away at miles and chip away at time and chip away at pain if you just focus on forward but you give yourself grace as to what forward means so applying this to your patients especially when you are putting them through an emom or an amrap have options for them, especially those who are high achievers and they want to be able to do the level one, the highest level of the exercise you're giving them. So have options for them. So I have a fellow right now, he was just diagnosed with pulmonary fibrosis, idiopathic pulmonary fibrosis, incredibly sad diagnosis, but cardiovascularly he's very deconditioned, but also he just feels like there's an elephant on his chest that he can't get air in. And so he gets very tired very quickly when we start exercising. But I know that it's so important to build his capacity any way we can. So I will say, OK, I want you for two minutes. burpees, okay? That's the goal. When you can no longer do burpees, then I am going to have you do some jumping jacks. Take away that transitioning from up to down. When those jumping jacks become too hard, I want you to march in place. When marching in place becomes too challenging, I just want you to walk. I want you to walk down to the driveway and back up. The only thing I care about is that you continue to move forward. Give your patients options and make sure that you let them know that whatever type of forward it is or moving that it is, it has value. Continuing to move forward through discomfort, through pain, giving a lot of grace there, that's going to build a lot of confidence and mental fortitude with your patients.

LESSON 4: SOMETHING>NOTHING AND DONE>PERFECT
Okay, last one, last one. I could do this forever, but last one. We're getting close to where we're getting too long. Okay, so last one. Something over nothing and done over perfect. Something over nothing and done over perfect. So this is another quote by Sally McRae. Something that I have just had etched in my mind ever since I heard it on her podcast. Team, the consistency of chipping away at a goal every single day. and saying yes to yourself versus no is so much more important than hitting your A goal every single time that you go out to train or you go out to compete. I wrote myself a note. It's right here. I put it on my fridge so I could see it every single day. I'm going to read it to you. Hey Julie, remember last time you felt like shit before going on a run? Consider not going, but walked out the door and went for it anyway. Data shows that when that happens, you regret saying yes to yourself 0% of the time. Say yes, start moving. xoxo that's exactly what this says and i looked at it every single day every single day because no matter how bad you feel and how much you want to say no when you say yes and you do something something it doesn't have to be My goal was to do six miles, and if I don't do six miles, I'm throwing the day away. No, that could be I do two miles. That could be I stay and I do 20 minutes of strength in the garage. When you say yes, and you continue to build that consistency, you build resiliency. You are building reserve. Every single time you say yes, you are building mental fortitude. And 100%, You will feel better when you say yes. You will never feel bad for saying yes. You always feel better. So when you are working with an older adult, You're making sure that, again, you give them options. Maybe they don't do their entire HEP, and instead of them, well, I wasn't gonna do the HEP, so I just didn't do any exercise. Make sure they understand that saying yes is so important. It's the same thing. Forward is forward. Yes is yes. If they don't want to do their entire HEP, my goodness, just do five minutes of it. Five minutes. Guys, they said yes. And yes is so incredibly powerful. If we know that we wanted them to do that high intensity EMOM, we're trying to increase their aerobic capacity, but they just weren't feeling it that day, they can do yoga instead. It's still movement. We know with older adults, something is always better. than nothing. And the more you say yes, and what I did, I started to tally up the amount of times that I said yes versus no. And every single time, how did I feel afterwards? I felt so happy and proud that I said yes, and physically and mentally I felt better. Once you elicit that same feeling with your older adult clients, and maybe you write something for them too, you write them a note to put on their fridge, and they track the amount of times they said yes, it's momentum. It's going to be so much easier for them to continue to say yes every single time.

SUMMARY
All right, guys, that's it. We've been here for 20 minutes. I could talk about running and lessons learned forever, but let's recap. Number one, that true finish line is at the end of our lives. It is about the story we want to tell. It's about becoming someone who endures. becoming someone who endures. Make sure you're connecting with an older adult's life journey and who they want to become. Two, pain is more easily endured with friends. Make sure day one you are starting to figure out how to decrease social isolation and help your client find friends to work out with, to experience different sorts of pain and competition and training with. They're going to experience their pain at a lower severity, I promise. Next, forward is forward. There's so much grace. Make sure that they understand that they've got options and you are hammering in that if you can't do that level one goal, We've got options for you and as long as you're still moving, it's still forward progress. And lastly, something over nothing and done over perfect. If we're not going to reach that A goal, it doesn't matter. Just say yes to yourself consistently every single day. It's going to build resiliency and reserve and confidence moving forward and saying yes is going to become a lot easier. All right, y'all, I hope you have a wonderful rest of your Wednesday. The last thing I will leave you with are what courses we have coming up. We've got both of our online courses coming up in May on the 15th and the 16th. 15th, level one starts. 16th, level two starts. And then on the road between May and June, we are in North Dakota, Virginia, Arizona, and Texas. PT on ICE is where you find all that info. Hit us up if you want to talk about 50ks and running. I'm here for it. Have an awesome day, guys.

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division faculty member Cody Gingerich discusses the importance of focusing on the subjective exam during the first 2-4 follow-up visits to ensure patients are making appropriate progress.

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

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

EPISODE TRANSCRIPTION

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

CODY GINGERICH
All right, good morning PT on ICE daily show. My name is Cody Gingerich. I'm one of the lead faculties with the extremity management. What I wanted to come on here today on our clinical Tuesday and talk about is when things are not going to plan. Specifically the subjective exam on visits two, three, four. Okay, so when people come in and they say, hey, you know, I don't think this thing has gotten any better. I'm feeling potentially even worse, or they had a flare up since the last time you saw them on that initial eval. And what then does that subjective exam look like when they come in on visits two, three, four? How do you dive into, do you need to make an adjustment on your plan of care? Do you need to make an adjustment on dosage? Do you need to make an adjustment on anything? Or do you stay the course and you dive into really heavily on what exactly happened? Okay, so that's what we'll talk about today. If you did a good, really good initial exam, right? And you're like, man, this thing presents like I expect. We're going after it. You choose a dosage and a diagnosis that you feel confident in what you have given that person leaving your clinic. And let's say they come back in in one week. Most of the time I'm seeing people on a once a week basis, but even if they come in later on that week and they come back in and they're like, ooh, you know what? We are not really feeling any better. They come back in, something happened, flared back up, and now you have a pretty difficult conversation, right? Because on an initial eval, if you felt confident, you probably provided that confidence to the patient of like, Hey, you know, I think we found this thing. This is definitely coming from your shoulder. Probably the more of those muscles in the back of your shoulder. And you know, if we do these two, three exercises over the course of the next couple of days, I really think things are going to get better. Right. And then they come back in and all of a sudden that confidence is not as high because they're like, Hey, you know, this is not getting better. And then what, where do you go? Where does that conversation lead you?

GATHER MORE INFORMATION BEFORE YOU ABANDON SHIP
So a big thing that I want to emphasize today is you need a lot, a lot of information from that person subjectively before you decide to abandon ship on what you were doing. Okay. And the reason being is there are so many variables that can happen in that time from when they left your clinic to when they show back up. Okay, and if you did that really good initial exam and you're thinking like, hey, I'm really on this thing, then your first initial thought when somebody comes back in, shouldn't always be a, oh, we did the wrong thing. More times than not, you want your curiosity to be, hey, okay, what did you, first of all, did you do the things exactly as I prescribed them? Secondarily, what did those couple days in between actually look like? A lot of times our patients have no real understanding of what actual movements can be their aggravating factors. When you did their exam, their subjective exam, and you asked for aggravators, then you did your objective exam, you found their aggravators. That does not necessarily mean that the patient understands then that those particular movements are going to aggravate them. They know the two or three that they told you, but there are so many other things in life that could potentially also be aggravating factors for them. And they're not going to be able to always put those pieces together. So go into that first conversation with curiosity and be saying, Oh, okay. You know, that wasn't exactly as I expected it to go. I thought we were really on the right track, but I want to dive into what did those couple of days in between here look like? Like, what, what did you get into? You know, what did you, um, spend your time doing? What did you do at the gym? If you were going to the gym, all of those types of things. Did you do those exercises we talked about as I prescribed them, or did you feel like you needed to do extra because they weren't hard enough? or did you not particularly do them? And that is going to start that conversation in a much better way than you just saying, oh, okay, in your brain, like, oh, okay, well we definitely did the wrong thing and we need to fully go back through an entire new eval and figure this thing out again. A lot of times those patients somewhere in that subjective are going to give you some clues on what actually was going on in their day-to-day life. A couple examples of that, okay? A big one, if we're talking about like a gluteal tendinopathy, okay? So think glute med tendinopathy. Potentially you've given them some kind of leg lift, maybe a side plank, some kind of glute, maybe side steps with a band, glute need, strength training, blood flow type of thing. Okay. Well, let's say that person also, you did not tell them, you didn't really even have this discussion of like other things that they potentially could be doing, or a lot of people try to manage their own symptoms. Okay. So if you didn't potentially give enough explanation of, Hey, this blood flow thing is the thing you need to do when you are hurting. I have seen many, many times where they are consistently stretching and stretching and stretching that glute med, bringing their knee across their chest into more of that like pigeon pose stretch. And if we're dealing with the true tendinopathy where irritability is fairly high, that can be a pretty significant aggravator to those tissues, even though the patient feels like it is helpful because it's tugging on the thing that is bothering them. Okay. So then they come in and you're like, man, they did the exercises. This is a pretty clear cut. Like this is glute tendinopathy. I don't know exactly what else it could be. Cause my hypothesis list, like we checked off, like we cleared the back, nothing's going on there. Um, but then they start talking about like, Oh, the only thing I can get relieved for, like, I spent all day just like yanking and yanking, trying to stretch. I'm stretching a bunch. And so then that has to be a, oh, okay. That conversation goes into, hey, I know right now that feels okay, but what we really need to do with those tissues is get some blood flowing to them. And what is actually happening is when you're sitting all day and then stretching, we're actually almost occluding blood flow and taking away more blood flow than what can get to it. And so all of those exercises that I gave you, although they feel like work, are also the thing that's going to make it feel better And you can use that as a symptom reliever. But we need to pause on stretching for the time being. And that language needs to be also relatively clear on this is a temporary pause. Temporary pause on this thing, it is not a you should never stretch your hip end of conversation, is a right now that is something that's aggravating you. So we still have a really good plan in place, but we need to control that variable and decrease that stretching time. Another thing that you'll start hearing is like, they'll be like, you know, I didn't do anything. If maybe your conversation the first day was around like gym movements and not life movements, um, You know, same type of conversation with the glute med temnopathy. I've had patients come back in where they were climbing a ladder all day. They were doing some housework, they were up and down on a, you know, a ladder and they don't really bring that up when you're saying, when you're going through your subjective, you know, what did, what did you do? And they'll say, well, I, you know, I avoided squats for the time being and I didn't do any deadlifts, but I did your exercises. So I just don't know why, you know, things could have flared up. But then you dive a little deeper. Oh, what did your weekend look like? And they're like, Oh, you know, I had a, I had a bunch of yard work to do. I was up on the, up on the house doing gutters and it was up and down standing on that ladder. And that position of the ladder has them essentially loading that glute, glute tendinopathy all day long, a ton of time under tension. And so now all of a sudden you're saying, okay, well now we need to pull back on that. Or over the course of this next week, you don't have any more yard work to do. So now let's go after this plan that we had in place. Okay, so subjective exam on days two and three or visits two and three when they come back in are vitally, vitally important to be able to really take a deep dive. Like that conversation may take an additional 10, 15 minutes if they are not moving in the direction because you want to be as curious as possible because you already did your due diligence on the initial exam.

CONTROL EVERY VARIABLE BEFORE YOU CHANGE YOUR PLAN
So don't immediately assume that you're in the wrong and have that patient conversation of what did exactly your day look like? What have you been doing to try and self manage this thing? And you know, what have you done in the gym? You've also can talk to people, they have no real understanding. I've had patients where they go to the gym and they did a rope climb, sandbag carry, Ski erg workout because they felt like it wasn't a shoulder heavy Exercises they were avoiding their shoulder because everything they thought sandbag was mostly back, you know Skis like core type of thing and rope climbs you're using your legs to pull yourself up. So you're not really pulling I And again, it's just one of those things where you have to educate those people significantly on like, look, I know you don't feel like it is, but the reality is you're using a ton of that shoulder, especially the posterior, your cuff on all of those exercises. And you are not really avoiding any of those aggravating factors. So be a little bit more explicit on your, what movements could potentially be aggravating. That's also when you learn the type of human you have in front of you and how much you need to give them reins or really pull back on those reins. Most of the time I try to err on the side of giving people a little bit more leeway. I don't ever like to tell people there's nothing that they can't do. It's just a matter of like how much and the volume and intensity and those type of things. Visits two and three is when you actually learn that person and how much reins you can give them. And you might need to start controlling more variables as a therapist for them, okay? And so that might be the time where you say, hey, this movement is out. I need you to really pay attention to when you're standing and when you're sitting and where that hip is in space. I need you to completely avoid this particular set of movements for these next two weeks to make sure we can calm symptoms down. That's when you learn if that person has an actual like throttle on them or not a self throttle Can they actually? Determine on their own what they can push through and what they can't and if you can determine that they come in and they are worse and they did a bunch of stuff that you would say, man, that was pretty reckless given the thing that you were dealing with. Now you as a therapist and the expert in the field can say, you know what, this is out, this is out, this is out. I need to make sure I'm controlling every variable in your life right now until this thing gets a little bit more calmed down. Okay. And that's where you need to put your foot down every once in a while with a few patients and say, Nope, that's not happening this week. You're taking this time off or you are going and doing more cardio based exercises or you are doing XYZ, not a, hey, I want you to pay attention to this and that. This could aggravate it or could not, but give them leeway and they come back in and it's worse. and you're like, man, that was pretty reckless. Now, as a therapist, you're saying, nope, we're doing this, this, and this. This is a temporary thing, but in order to get this under control, now I'm telling you what you're doing and what you're not doing, okay? Because that is your expertise now on the line. If you give them a bunch of leeway, and they come back in and they're worse, and you don't ever have that conversation of, you know what, nope, this needs to happen this way, then they just assume physical therapy doesn't work for them, right? Well, it's not physical therapy. It's not what you've chosen. It's all the other variables that you don't have control over. So you need to start having a little bit more control as much as you possibly can. You can't control everything, but as much as you possibly can on what's going on there. This is also the time where you ask about food, sleep, nutrition, and stress, okay? Hey, over these last three, four days, how did your sleep look? Were you getting good sleep over these last three days? What does your nutrition look like? Is it as you typically do or did it change at all? Did you go to any parties? Did you go to anything outside of the norm? Are you having any type of particular high stress environment right now? Do you have a deadline at your work that you're trying to get done? Is your kid sick? Is whatever the case may be, all again, factors in that subjective exam that need to be dove into if things aren't going well. Okay? These are all just making sure that you are on the right track and aren't abandoning ship too early. The other thing is if they come in and they're worse, you also want to be like, give them confidence in saying, Based on what we found the first time and based on the exercises that we gave and this thing that you did over the weekend or whatever the case may be, I can actually give you more confidence that we are on the right track. We just need to dial that in a little bit closer. We either need to cut the exercises that I gave you in half, like let's say all those variables have been controlled and they're still coming in like, man, I'm just really flared up. Well, then that was your fault on giving them a little bit more, not reading that the irritability quite as well. And that happens. I've done that plenty of times. That needs to be like, Oh, okay, cool. You know what? We're going to cut those exercises in half, or we're going to pull one of them totally out. That one was a little bit more than I think you were ready for. We'll bring it back in and maybe a week or two, but over this next week, now all of a sudden we need to just dial that one exercise in and make sure that that's not aggravating and your tissues can tolerate that. If everything else has been pretty clear and there wasn't anything out of the norm that you weren't expecting, then you just overdosed their tissue a little bit. Great. You know what? Sorry that you were a little bit feeling rough the last couple days, but I know that if we pull this back, we should be in pretty good shape moving forward. Okay. All of those things need to happen before in your brain you say, oh I messed up, we treated the wrong thing, and we need to fully switch gears and go to our second hypothesis. Until you have controlled all the variables, you have asked all of the questions related to nutrition, sleep, stress, plus what they did in their non-gym, just daily life, Have they done your exercises? You need to have all of that information, and it needs to be in your brain, like pretty much, hey, everything is pretty close to exactly as I would expect it, before you'd say, I think we should recheck this exam, and might go after that second hypothesis on our list. So that's the big thing, is trust your instincts first, whatever you found, if you did a really good initial exam, whatever you found, When they come in that second, third, fourth visit on those subjective exam, when they come in, make sure you're super curious. Go after all of those variables, figure out all of those variables. Once that's all been controlled and they're still not going as you would expect, that then is the only time where you would start to switch that hypothesis list. So overall, Be curious on make sure that that second, third, fourth visit, that subjective exam is is very stout and make sure that you are really doing a good job on understanding that person in front of you. Where's their headspace at? Are they able to tolerate what you've given them? Do they know how to pull back on exercises if they need to? Or do you need to be the one that says nope, you're pulling back on this thing you have you know, shown me that you don't have that ability. So for the next couple of weeks, I'm your boss on, you know, what you can and can't do. Always making sure that it's a temporary thing.

SUMMARY
Okay. So that's when things don't go as planned, right? Make sure that that subjective exam on the second through fourth visit is super dialed in and you know that you can, uh, have a good solid impact and still give your patient the confidence that they need moving forward. And it's not a, um, you know, hope, just hoping for the best and throwing things at it and, and hoping it sticks. And now your brain is all over the place. Okay, looking forward, extremity management. If you want, there's a couple seats left in Bellingham, Washington, May 18th and 19th, and then we got two courses running on June 1st and 2nd, one in Texas and one in, oh man, I just lost it. I believe it is. in Wisconsin. All right, Texas, Wisconsin, June 1st and 2nd. So jump on both of those. There are courses, there are seats open on both of them. So check us out. Find Mark Lindsay or myself on the road with extremity management and we will see you tomorrow.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the concept of "fitness freedom" as it relates to helping patients & clients embrace the ability to "choose your hard" in customizing rehab & fitness exercises.

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

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

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

EPISODE TRANSCRIPTION

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

INTRODUCTION
Good morning, PT on Ice Daily Show. My name is Dr. Alexis Morgan and I am thrilled to be here with you all this morning. I am here in my Airbnb in Carson City, just coming off of the ice sampler and Wow, what a weekend we've had. We have had so much fun learning from all the different divisions here at ICE and learning from all the different instructors. And let's be honest, having a blast, having a blast with each other. It has just been an incredible weekend that we are still running high from. Today's topic is fitness freedom. And it really is fitting for today in reflection of this weekend, just because the 150 people that have been all together this weekend, of course, we're all different fitness abilities, right? We all have our different fitness goals.

WHAT IS FITNESS FREEDOM?
And as I was thinking about this topic that is fitness freedom, which comes from our street parking friends, Miranda and Julian Alcraz. As I was thinking about this concept of fitness freedom, to discuss with you all this morning. It was beautiful how really the last two days here at ICE, it was just laid out perfectly. And so I wanna talk with you all a little bit about what fitness freedom is, what it means, and where it came from, and how we can implement it in our lives, as well as our practices, ultimately for our communities all across the nation. So, as I mentioned, we just got off of Sampler, and over the past two days, we've had various divisions talking. We went through different labs, and when our pelvic division did the lab on bracing, Rachel said, choose your heart. We did pushups, and we worked on bracing within pushups. But for every single person, a variation of push-ups is going to be appropriate. For some people, we may need to do the push-ups on our knees. For other people, we may need to have weight on your back. I'm giggling because if you saw the reel at ICE, you saw Dave Finkelstein laying backwards on top of Zach Morgan as he was doing the pushups. So maybe your weighted pushups is a human. If you missed that little scene, watch the latest reel, because it was hilarious. But choose your hard. That was what Rachel told us. Choose your version of hard, because you're gonna get the best out of this lab if it is relatively difficult, Not too difficult to where you can't do it, of course, but also not so easy to where you can't get what we're needing out of this lab, which is a brace. We need to find that moderately difficult heart. Choose your heart. Then in extremity lab yesterday, we went through so many exercises for the shoulder and so many ways to improve our clients, ourselves, our overhead athletes shoulder capacity. And as we're going through these exercises, they said, pick your poison. They said, choose your own adventure. You choose the internal rotation option and you choose the external rotation option that works best for you. Choose your own adventure. The same concept. We're not gonna tell everybody to do the exact same thing because there's so many options here. Let's individualize it for that person let's let them have fitness freedom. The freedom to choose what is right for you and your body at this exact moment in time, which applies to your goals, which may be different than what you would have chosen a year ago and is probably going to be different than what you'll choose next year. Fitness freedom. Do what you need to do right now. And Mitch, at our group workout, running 150 people through a group workout, which did include barbells, and he said, I like to ask people, what is your seven minutes of burpee time? Reps, how many burpees can you get in seven minutes? It doesn't matter the score that you get. It matters that you know. He said, as we're working out today, it doesn't matter what your score is. It matters that you're here, that you're sweating, that you're working out alongside each other. That is what matters. That is fitness freedom. I did a different weight than the person next to me. We did a different, it's all freedom within and it's all fitness. We choose it differently based on our own goals, based on our own needs. Now this idea, this term, I did not coin, this term of fitness freedom, I use all the time. If you've been to our live courses at Pelvic, you've heard me say this, because as we're giving various exercises, various versions of squat and pull-ups, we say it's fitness freedom. Do what you need to do to make it hard for you, to make it easy for you. Maybe you need that, whatever that is, but you've probably heard me use their term fitness freedom. I'm going to read a quote from street parking from Miranda and Julian. because I think it just so beautifully describes not only their company and their vision and their values, but also something that I think you all will resonate with as well. They say, consistency is one of, if not the most important values here. Doing with fitness freedom, in parentheses, embracing the ability to customize and make the workouts for you. and more than nothing, getting rid of the all or nothing mentality. It is so beautiful. I've been doing for the last three months street parkings programming and when you sign up for their programming, you get their emails and I read almost every single one of their emails. Their wording to describe to people this fitness freedom, to describe to people how to get fit. And that is consistency before intensity. It is choose what you need to do for your fitness so that you will be consistent. Because we know that consistency is what drives changes in humans. Consistency is what allows for these individuals to make life changes. We're changing lives here, not back pain. We're changing lives here, not peed pants. What is it that will allow people to exercise, to feel the freedom to do what they need to do on a regular basis to ultimately change their lives? Let's help them find their freedom within that. It's a beautiful saying. We use it all the time. Live this, embrace this. As I've been doing this programming, I have really learned to understand exactly what they're talking about. They have four different versions of every single workout. You choose your heart. You choose your own adventure. Sometimes I'm working out at the clinic at Onward here in Hendersonville, and I don't have I don't have an echo bike. My echo bike is at home. So maybe for that portion of the workout, I'm running outside. Or maybe when I get home, I've got my echo bike and I've got a box, but I don't have barbells. So I'm gonna use the dumbbells. Use what you have. We're changing up the equipment. We're customizing it for ourselves. But the same can apply to that mindset. Maybe for my… pregnant mama who wants to exercise, who wants that fit pregnancy, but she's sick and she's low on energy. Maybe for her, that fitness freedom is just moving through without even touching any weight. We all know what ideal is. We all know where we want to go, but that's a goal. How do we reach those goals? We don't just start doing it. We don't just climb the mountain, right? We train to climb the mountain. Part of that training to climb the mountain, so to speak, is to just move your body through that workout for that individual. Don't even touch the weight. Have a no sweat day, where you're just moving through that exercise, but you're not even sweating. Any of these concepts to break that down, to allow them to feel The freedom to choose whatever it is, is such a beautiful thing. So many individuals do not have that freedom, or at least they don't know about it. They don't mentally have that freedom. They think that they have to do everything as hard as possible, or else it doesn't count. I have to do that RX way, or why even bother? They're saying to themselves. I have to do better than so-and-so. I always do better than them. And if I back off at all, they're going to beat me. Well, maybe for a time, that's okay. We would rather you show up and be consistent in your workouts than not show up at all and not do the effort, not do the work. Allow for that fitness freedom. If you come to ICE courses, you are definitely going to experience that fitness freedom. You're definitely going to experience that group workout at the end of every Saturday, every day one at ICE. We always do that group workout. You are allowed to customize that workout for you. You have that fitness freedom. We'll make suggestions, we'll make ideas, but at the end of the day, it's your workout, and we're just here to guide that. Embrace this, learn it for yourself, and ultimately teach your clients about that. Teach your clients to where they can, at the end of the day, take those baby steps all the way to reach their goals.

SUMMARY
Thank you all so much for being here and listening this morning. Just wanna do a quick little notification for you all who are listening live. Probably by the time you're listening to this on the podcast, next year's sampler will be sold out. So if you're listening live and you want to go to the sampler next year, which you want to go to the sampler next year, 91 people are already signed up. This just went live on the website, um, 24, 48 hours ago. 91 people are already signed up. We only have 59 tickets left. Today is Monday, April 29th and they will sell out today. So if you want those tickets, if you wanna enjoy this beautiful place that is Carson City right outside of Lake Tahoe, come join us, buy that ticket to where you can join us. Today marks day one of Pelvic Online Level 1 and Level 2 starting out. This is our very first cohort for Level 2 and we are amped to have so many people who are ready to provide this fitness freedom this fitness forward pelvic health to their communities in this level two. And we're of course excited about all of the folks who are joining us with the level one as well. Some people have taken the live course before, some people are brand new to pelvic, taking this online course to understand a little bit more about how they can help themselves maybe, their family members maybe, and their communities about pelvic health. So if you are interested in joining us, we've got some online courses coming up in a couple of months. They will sell out, they always do. Level one starts in January, level two starts in, I'm sorry, not January. Level one starts in July, and level two starts in August. So be sure to sign up for those, we would love to have you. And then lastly, if you want to join us in May or June for Pelvic Live, we are going to be in four different cities. We are gonna be in Kansas City, Missouri, Anchorage, Alaska, Highland, Michigan, and New York, New York. So we would love to have you join us for our live course as well. Thanks for joining me this morning. Enjoy your fitness freedom and hopefully we'll see you next year at Sampler. Take care.

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the why behind the footwear recommendations they make and why minimalist footwear may not be the best choice for many fitness athletes to start with as well as how proper footwear can have an added benefit of improved strength, hypertrophy and fitness

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

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

EPISODE TRANSCRIPTION

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

GUILLERMO CONTRERAS
Here we go. Good morning, fitness athlete crew. Good morning, PT on Ice Daily Show. Welcome to the PT on Ice Daily Show and the best day of the Fitness Athlete Division of the Institute of Clinical Excellence. Super happy to be with you here this Friday morning. fitness athlete footwear. And that's a little teaser there. Hopefully you get excited for that. Before I start jumping though, I want to say anybody headed to Reno, Nevada, in Reno, Nevada for the ice sampler, have an awesome time. Have an epic time. A little bit of FOMO not being able to be there, but hope you all have a wonderful time. Take so much out of that weekend. It's such a great weekend. So much to learn. So many to learn from. And I've done this topic in the past. I've talked about my shoe recommendations for fitness athletes, whether it be the Rad One Trainer, the Strike Movement Trainer, the Nano, the Metcon. I've gone deep dive almost too long into episodes with that in the past. And today's actually a more of a, let's call it a response, a response PT on this episode, discussing why we don't, or why I don't personally recommend barefoot in the fitness athlete, whether it's the level one or the live course, we get asked, hey, what are your thoughts on barefoot shoes? Or why aren't you recommending minimalist shoes to allow the foot and the ankle to naturally do what the foot and ankle should be able to do? And this is where we're going to dive into, right? This is the topic I'm discussing because we know there's different shoes out there, right? I have somewhere in front of me right here. This would be a minimalist shoe, right? This is a zero drop shoe. it allows the foot display so a really nice wide toe box. It allows the foot to move naturally, allows the ankle to move through a broad range of motion. Why is that foot, why is that shoe wear not something we recommend to the majority of fitness athletes? to explore that full, broad range of motion that we wanna see with squats, squat cleans, wall balls, air squats, you name it. Why is that? when we look at shoe wear, we know that there's aspects to it, right? There's the forefoot, there's the midfoot, there's the heel, and we have something called a heel drop. And the heel drop, essentially, I'm gonna grab another pair here, is the amount of drop a four millimeter heel drop from the back of the shoe to the front of the shoe. That means that when I put this shoe on, my heel is lifted up just a little bit, just about four millimeters difference. What that does for me as an athlete, when I am squatting, is that it gives something we like to coin a dorsiflexion buffer. on board so that when I squat, I have maybe a little bit more available ankle dorsiflexion range of motion for me to squat with. When we take that away, when we go into that minimalist where we have a flat, fully flat shoe, if I am limited at all in ankle mobility, ankle dorsiflexion, that shoe is not going to allow me to have as much anterior transition to that tibia. it's then going to reduce the depth with which I can get into my squat, or it's going to push me into some more funky motor patterns, what we call the immature squat pattern, where my shin moves forward, but then it stops, which means my hips can't go any further without me losing balance or falling backwards, which means my torso needs to dive much further forward, which leads typically to a significant increase in stress on the posterior We're going to increase the loading, uh, the, the, the, the torque on the hips and the posterior chain when we significantly limit that anterior translation of the tibia. We know that from research, right? We know that it's no longer recommended or should be recommended to teach to restrict amount of increased stress to the lumbar spine, the posterior chain, and the hips when we do that with a very minimal decrease in stress to the knee. If you look at the data from the research, it's about a 53% decrease in the knee. 1,000% increase in torque to the low back, hips, and posterior chain, right? That's a huge trade-off. Whereas if we allow that tibia to translate forward, that knee to move forward, it allows for a more upright torso, a more vertical descend into that squat, and improved motor pattern there. So all that to say, when we give minimalist footwear, and we don't know what the individual's mobility is like, or we do know, like, hey, I know this person has really stiff ankles, And what we see both anecdotally and pretty much everywhere is that the ankle is one of the most difficult joints in the body to create mobility. And it can take years to improve ankle dorsiflexion range of motion. If you don't believe me, you can talk to our COO, Alan Fredendahl, uh, who's been working on ankle dorsiflexion for darn near a decade now, probably. And he's, he's doing much, much better now, but it's, it's been a journey for him to try and improve his ankle dorsiflexion. that athlete's ability to sit deeper into that squat with that more mature vertical squat pattern. And when we're talking about CrossFit or fitness athletes, that means that we're limiting the squat, including the back squat, the front squat, the overhead squat, squat cleans, squat snatches, pistol squats, wall balls. There's all these movements where we want to have a vertical torso, a more upright torso when we're performing it or receiving And when we take away mobility from the ankle, we restrict that motion because we're saying you need to go barefoot at all times to really work on it. You need to work on your mobility. Okay, you're not gonna go to depth until you can have better ankle mobility. We are significantly reducing that athlete's ability. to improve, strengthen the knees, strengthen the hips, strengthen the trunk because they can't load that barbell as much. We're reducing fitness level because now they're doing less work in the same amount of time as maybe their counterparts in the same classes or following the same programming and such. So we use the shoe to allow for that dorsiflexion buffer to allow for a deeper squat. We also recommend TO Slide a pair of VersaLifts, of heel lifts underneath the insole, they sit in there. Now instead of a four millimeter, maybe they have more like, I believe VersaLifts are eight millimeter or so. So it'd be like a 12 millimeter, which is, it's pretty high up, right? But it gives so much more mobility in that ankle to allow them to sit deep into a squat with good mechanics, with good motor pattern, and really, really hit the deep ranges that are gonna allow them to train a greater amount of the glute max, a greater amount of their quad to a broader range of motion, right? powerful hip extender that most people don't realize only really gets targeted when we're hitting those deep ranges below parallel to the squat. Again, this is not me saying barefoot or minimalist shoes aren't for nobody, right? There are individuals who have fantastic mobility in their ankles, great mobility in their hips. By all means, if they want to wear a two millimeter heel drop like Vans or Chuck Taylors, or do you want to wear a New Balance Minimus or the, I think the Xero, X-E-R-O, whatever those are. Those are fine for those individuals if they have the adequate prerequisite mobility in their ankle, their hips to be able to perform these movements are really good quality patterns. But for those of us who might have a limitation in the hip or limitation in the ankle, we have should be recommended. right? The two I have right in front of me, right? The strength movement, his trainer, four millimeter heel drop. This is someone who maybe has pretty good hip mobility. Um, and they can make up for a little bit of lack in ankle mobility with that, but they still have more than like 10, 15 degrees of ankle dorsiflexion. Um, me personally, I have like 30, 35 degrees of ankle dorsiflexion. I have decent hips. These work really, really well for me. These are my favorite training shoe for They fit more true to size than they used to. This has, uh, the rad one trainer, um, has a seven millimeter heel drop. Uh, and it is much larger. It's different. The heel is really good for lifting. It's good for Metcons. I have a lot of people at our gym who love these shoes. Uh, really high recommend these for those who maybe need a little bit more ankle dorsiflexion buffer or limited in their ankle mobility because of that. And one I don't have with me right now, if you have more of Um, and you don't like your toes display a whole lot, uh, tier T Y R their tier one trainer has a nine millimeter heel drop. So the biggest heel drop and they just standard training shoe that you can find. And that is the one I recommend to my individuals who like, Hey, I have horrible ankle mobility. Um, I always struggle to hit squatting full depth without my either my ankles kicking in or my going up on my toes. What do you recommend? Um, that's uh that's tier one trainer um excuse me first ones are called oh i'm sorry these are the uh strike movement haze trainer strike movement haze trainer so there is a strike movement right there uh strike movement without any vowels in the movement um so the haze trainer uh good quality shoe really really solid uh great for med cons i love them for weight lifting as well um and again nice and like a wider toe box not too wide but not too narrow at all either so really comfortable i love these for So hopefully that answers your question. And if you're looking for the evidence, right? Like, oh, well, like you gotta be able to use your feet. You gotta be able to use your ankles. In 2022, a study from the Journal of Strength and Conditioning Research came out on the effects of footwear and biomechanics of the loaded back squat to exhaustion in skilled lifters. So these are people who are already lifting, who probably already have really good mechanics and strength and everything on board. And they made one group lift barefoot or minimalist as barefoot style shoes. One group had to lift in like heel elevated shoes. And what they found was there's no difference more in like a novice athlete or beginner athlete or maybe people who maybe don't have that same mobility but in these skilled lifters people have been doing it for a while there was no significant difference in that either shoe reduced joint loading or improved joint range of motion for them they already had the adequates on board so the reason I even always emphasize, more than anything else, in the level one, in the live course, when people ask about shoe wear, about are we going to restrict someone from squatting until they have adequate ankle mobility, do we give them a shoe like this, is this okay, or do we give them a minimalist shoe right away, and if they can't do it, do we let them do it? It's always and, not for. I'm going to recommend something like a Rad1, and if they need it, a Rad1 with a heel insert, a VersaLift in there, while they work on ankle mobility, while they work on their hip strength, to work on their squat, to continue being a part, a participant in their CrossFit class, in their group fitness class, without needing to worry about scaling every single time, without needing to worry about modifying every movement every single time, and then they are also going to continue working on their ankle mobility diligently to get to a point where maybe they can take that heel insert out and they feel really comfortable here, and they can move to something like this, and then they can move to minimalistic. That is their end goal. It's always and, not, or with this type of If you want to learn more, if you want to ask this person live and really have a debate with me one-on-one, we have courses coming up where you can meet us on the road, where you can talk all things shoe. Like I love talking shoes. I love talking footwear, worn them, almost all of them. Love doing it.

SUMMARY
But we have courses coming up. Our CMFA online level one just sold out. So if you've been looking to take an online level one course with Fitness Athlete, we are not having another one until fall of 2024, but you can sign up for that now. So if you want to register for that now, this course always sells out. We always sell out before we start the course. We have a course in the fall. You can sign up now. You can wait until the summer to sign up whenever you want to. Our next level one one if you've taken the live course and you just have the level two to finish up your CMFA cert or if you just want to continue down the path of that CMFA cert we have CMFA level two starting up in September uh on to a year. So again, if you're looking to get that certification, if you're looking to learn more about Olympic weightlifting, programming, modification, even some business type things, check out the level two CMFA course on September 3rd. That one also always sells out before it starts. So if you're looking to take that, sign up sooner rather than later. If you want to hit us up on the road, you're looking where we're at. CMFA Live is going to be on May 18th and 19th in two different locations. Proctor, Minnesota. I believe Joe Hnisko will be leading that one up in Proctor, Minnesota. And then that same weekend, I'll be hanging out with Mitch Babcock in Bozeman, Montana. That is, again, the weekend of May 18th and 19th. And that's all we have right now in May. And then June, on June 8th and 9th, you can hang out with the barbell physio, Zach Long, in Raleigh, North Carolina. And then on June 22nd and 23rd, we have the first ever annual Fitness Athlete Summit. You're going to see every single faculty and TA and every member of the fitness athlete crew. You have Mitch, Zach, Joe, myself, Kelly, Jenna, Tucker. We're all going to be coming together in Fenton, Michigan at CrossFit Fenton for an epic weekend, more fitness and fun and sweating and learning than any course you've ever done in your career. So we would love to see you at the Fitness Athlete Summit on June 22nd and 23rd. I believe it's about 45 minutes, an hour, something like that away from Detroit.

null: So quick flight in. You can also

SPEAKER_00: to fly into Flint, I believe, which is a shorter, even shorter drive from there. But we would love to see you there and have you join us for the Fitness Athlete Summit in June of, June 22nd and 23rd. Gang, thanks so much for tuning in this morning. Have a wonderful weekend. Again, if you are at Sampler, have an absolute blast. Enjoy yourself for me as well. And we will catch you on Monday for the PTNX Daily Show.

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

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the history of non-compete agreements, relevance of non-competes to PTs, and recent law changes banning non-competes.

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

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

EPISODE TRANSCRIPTION

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

ALAN FREDENDALL
Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day is off to a great start. Good morning. If you're listening on YouTube, Instagram, the podcast, we're happy to have you. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness, Athlete, and Practice Management Divisions here on Leadership Thursday. We're going to talk about non-compete agreements today. But first things first, Leadership Thursday also means that it is Gut Check Thursday. So, Gut Check Thursday this week will be the Ignite Workout from our friends over at Forging Youth Resilience. FIRE, we team up with them every year. They support kids learning CrossFit, using CrossFit to help themselves with mental health, and other things they have going on in their life. So this year, they are doing the Ignite workout in the month of May for Mental Health Awareness Month. And we're going to do this workout this weekend at the Ice Sampler here in Carson City, Nevada. And so the workout, what is it? It is a two-part workout. It has a conditioning piece and it has a weightlifting piece. So it starts with an 18-minute running clock for the whole workout. So start at 18-minute clock and then work your way through 21, 15, 9. Thrusters at 95 for the guys, 65 for the ladies. Lateral burpees over the bar and then ab mat sit-ups. And then in whatever time you have left in that 18-minute window, you're going to max a complex of a power clean and a hang squat clean which must be performed unbroken. So cycling that power clean back down to the hip and then moving through a hang squat clean for a max load. Now this year at The Sampler we're going to do this in teams of three where three folks each do the workout at the same time. They have a combined time and then they have a combined load on their weight lifting piece. And what we're asking folks to do at the sampler, and we're asking you all to do as well if you hit this workout, is to consider donation to FIRE in whatever amount, one cent, 50 cents, one dollar, for every second you are slower, and every pound you are less on the complex than the team that FIRE has assembled of CrossFit Games athletes. So EZ Muhammad, Noah Olsen, and Sam Dancer have teamed up to represent FIRE. And the challenge to all of us is to try our best to beat them. And so we ask you all to consider donation in the seconds you are slower, pounds you are less on your lift. And then ICE will donate $1 per second and $1 per pound to any team whether you're here at The Sampler this weekend on Sunday or whether you're doing it at home in a team of three, we will donate $1 per second that you are faster and $1 per pound that you are heavier on your complex than that team of CrossFit Games athletes. So a little challenge flag for you all. If that is your team and you are not here at The Sampler, we would love to see a full video posted somewhere, shared with us, and then we'll make a donation on behalf of your team to fire. So that is the Ignite Workout. We're super pumped about that. Today on Leadership Thursday, what are we talking about? We're talking about non-compete agreements. So most of us are somewhat familiar with these. Some of us are unfortunately very familiar with these. We may have a non-compete looming over our head that we're worried about. So my goal today is to talk about the history of non-competes, the purpose of non-competes, and then talk about some recent changes to non-compete agreements that are really in our favor on the employee side of the equation.

WHY NON-COMPETES?
So first things first, when and why did these begin? These have been around for a while. These are becoming more prevalent in healthcare certainly, but these are primarily designed to limit the ability of somebody to leave a job and take not only their experience, but maybe knowledge of technology or systems to a competing company. So that is why they were created. So you might say, well, that seems like a pretty good reason. But in reality, what happened is that non-competes just became so prevalent that pretty much every person at every job, no matter what they were doing at that position, ended up being asked to sign a non-compete agreement. And what we've seen and what the government has done a lot of research on over the years is, is this good or bad for workers? And is it good or bad for the American economy in general? And what they have found over the years is that it is very bad for the economy. Why? Two reasons. It suppresses wages and it increases worker dissatisfaction. So obviously if you're working at a position and you're asking for a raise and you're not getting a raise, you're asking for a bonus, you're not getting a bonus, you're asking for a promotion, you're not getting a promotion, The answer when you have a non-compete agreement has always been too bad. You can't leave anyways, right? So we have no reason to help you further your career along. And now you can imagine how that part influences worker dissatisfaction of feeling like you are stuck, feeling like you have no mobility in your career, feeling like if you leave you might end up with a lawsuit, you might end up in a really bad position both personally and professionally. And the thing to know about non-competes is they are not in effect everywhere. There are some states that have never allowed them, and there are some states over the past couple years that have begun to ban them, either across the state or for specific workers. So a good example, California and New York, a couple other states have completely banned them. And then a lot of other states, about 25 states in total, have restrictions on who they can be applied to. And they can't be applied to specific professions or people making under a certain amount of money. And the whole idea is we cannot control the ability of people to have upward mobility in their career. That's obviously bad for the individual, but it's also bad overall for the economy. People who make less money, spend less money. People who make less money, pay less taxes. So the government is very interested in seeing what happens when non-competes are in effect and when they're not in effect. Your thoughts on California notwithstanding. California is a great example of what happens when non-competes are not allowed. They have been banned in California for a very long period of time. And you can imagine an area like Silicon Valley where all of our technology is essentially created and invented would simply not exist with non-competes because people would not be able to leave and have upward mobility in their career to join a different software company or something like that if they had non-competes in effect. And because non-competes are banned in California, we see higher than usual income for workers in California. Yes, unfortunately that's offset by cost of living because California has a really nice climate and everybody wants to live there. But that is the reason why wages are higher on average. And thinking about world economies, The United States is number one. We have about 25% of all the world's economic output happening just in our country. But not too far behind is the state of California itself. So if we look at largest economies in the world, United States is number one, China is number two, Japan is number three, Germany is number four, and actually the individual state of California is number five. And part of that is favorable worker laws like having non-competes banned. So that is the history of non-competes.

RELEVANCE OF NON-COMPETE AGREEMENTS TO PT
Why have these never really been appropriate for us as physical therapists and for healthcare workers in general? As physical therapists, we are not really using a lot of proprietary software or technology or systems that we could leave a position and move to a different employer and really have, you know, inside secrets. We can all agree there are really not a lot of inside secrets and technology and stuff like that inside of physical therapy that would offer a competitive advantage. The primary reason employers are upset when PTs leave is that they're now generating revenue for somebody else and not for them anymore. And when we think about what does it take to become a postgraduate professional, especially a healthcare provider, a physician, a physical therapist, a dentist, whatever, it takes a lot of time and it takes a lot of money. And non-competes for healthcare providers have never historically stood up in court anyways to begin with because it is so limiting on our career mobility to say that you cannot work for another physical therapy organization. You cannot create your own physical therapy company for five years within 50 miles of your current employer. All those restrictions that we see in non-compete agreements make it very, very difficult to continue to work. in physical therapy in general, let alone close to where you currently live. Some of them are so restrictive, folks either leave physical therapy entirely, or they have to essentially move very far, potentially out of state, to get around their non-compete agreement. And knowing that they're not held up in court, they're primarily used as a scare tactic of People don't want to be in court. They don't want to be sued. They don't want to potentially lose their license. So even if they've been told, don't worry about that non-compete, they worry about it. In our brick by brick course, our practice management course, this is one of the biggest concerns with people starting the course of, hey, I don't want to start my own business yet. I signed this non-compete for two years, three years, five years. We have met people who are working in fast food, who are waiting tables as physical therapists because they are so scared to leave a position as a physical therapist and work somewhere else. that they decide to just at least temporarily leave physical therapy entirely, which is devastating. That is a significant reduction in the income you could make as a physical therapist if you decide to wait tables or if you decide I have to move out of state to continue to work. And so they have never historically held up in court and they have primarily been used as a scare tactic, especially for physical therapists.


NATIONWIDE BAN ON NON-COMPETE AGREEMENTS ISSUED APRIL 23rd, 2024
So, the history of non-competes, the relevance of non-competes to physical therapy, what has happened recently as of this week that is a great change. On Tuesday, the Federal Trade Commission, the FTC, announced that non-competes were banned nationwide. And so they have been watching this issue for a while. They have been doing a lot of research on this issue for a while, and they have decided it's in the best interest of the American people and the American economy to ban non-compete agreements everywhere. So as of that issuing of that rule on Tuesday, April 23rd, 2024, Any current non-compete, so if you're sitting here right now and you're listening to me talk and you have signed a non-compete, it is invalid. It cannot legally be held up in court ever. And you cannot be asked to sign a non-compete moving forward. There are some exceptions here, but they largely don't apply to us as physical therapists. The one exception is that you can still be asked to sign a non-compete if you're a C-suite level executive who has ownership stake in the company that you work for and you make more than $151,174 a year. So some of you, depending on where you live, you might make more than that. However, unless you're a C-suite level executive who has ownership stake in the company you work for, then still you are exempt from being asked to sign a non-compete. So where do we think this will go? Well, we're not quite sure. Any party, public or private, has 120 days to challenge this rule. In August, it will become permanent, but we have about four months where private companies could sue and say, this is not allowed, you can't tell us what we can do with our employees. Public organizations such as state governments at the state government level can sue, and then other governmental organizations can sue. Because the Federal Trade Commission is an executive branch of the government, or at least an arm of the executive branch, the president also has the power to shut this down. Congress has the power to change this by passing a law about it. And then any individual organization, public or private, can elevate this to the level of the Supreme Court for the judicial branch to weigh in. So all three branches of government have chances, one way or another, to weigh on this issue. and either cement it, certainly if it's drafted into law by Congress, it becomes a much more solid rule, but if we don't see it challenged, then this will become permanent. And we really like this here at ICE. Again, in our brick-by-brick course teaching people to open their own practices and how to manage their own practice, this is a large concern. Over at Onward Physical Therapy, starting new clinics, starting cash-based physical therapy across the country, it's also an issue of people do not want to leave their current position and start their own business for fear of what might happen to them legally. So this was a great rule and that we hope this stays in effect and that nobody challenges it over the next four months. We'll be watching this issue closely because it's near and dear to our heart.

SUMMARY
As much as we love PT 2.0, we think part of PT 2.0 is also being able to run your practice really well or consider opening your own practice and not being limited by things like non-compete. So we're excited about this here at ICE. We hope you're excited too, especially again, if you're sitting here listening and thinking, oh wow, I have signed one. I've been worried about one. It's cool that it doesn't count anymore. So that's where we stand right now. And then we'll see what happens over the summer, what organizations challenge this, hopefully none, but we'll see how it goes. So non-competes, what's the history of them? Largely used to try to keep a competitive edge in business, but what we see happen is really just obviously very personal negative effects on workers, but also an effect on our economy in general. that they're not really relevant to physical therapists to begin with. They're primarily used as a scare tactic, but the good news leaving today's episode is that as of right now, they're not valid anymore. You can't be asked to sign one. If you had signed one, it's unenforceable and it cannot be legally upheld in court, but we're watching to see what develops over the next couple of months. So, that's PTN Ice for Leadership Thursday. I hope you get a chance to hit that Ignite workout. If you have time over this weekend, grab some friends and go for it. If you're gonna be coming to the Ice Sampler, we're looking forward to seeing you very, very soon. Have a great Thursday, have a great weekend. Bye, everybody.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses helping patients better understand their osteoporosis diagnosis, including learning to read a DEXA scan. Dustin also shares tips on discussing prognosis with patients as well as using the data supporting their osteoporosis diagnosis to inform your treatment choices & plan of care development.

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

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

EPISODE TRANSCRIPTION

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

DUSTIN JONES
What's up team? Dustin Jones here. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Today we're talking about osteoporosis diagnosis, prognosis, and treatment. This is a big topic that so many of the folks, older adults that we work with, they will receive this diagnosis or have this discussed with them. And a lot of times it's not given a lot of context or they don't have full understanding of what this really means for them and what they can do about it. Most importantly, what they can do about it. All right, so let's get into this.

OSTEOPOROSIS: DIAGNOSIS
We'll start with the diagnosis piece, just really defining what is osteoporosis and then spend a little bit more time on the prognosis side of things and the treatment because I feel like that's where we have a lot of opportunity to really serve our folks well. So osteoporosis, we're going to review, go all the way back to your formal training when you learn some of these numbers. that we may have forgotten, all right? So when someone is, when that conversation of bone mineral density starts to come into play, usually it's for postmenopausal women or males over 50 years old, start to look at bone mineral density. And the way that we can measure, objectively measure bone mineral density is through a DEXA scan. You'll see that D-X-A or D-E-X-A, that's Dual Energy X-Ray Absorbed Geometry or DEXA. This is the reason why everyone calls it that. So you're basically looking at bone mineral density. And if for individuals that are over that kind of 65 year range, you're going to get a score. That score is going to be a T score. And so we're taking the measurement of the minerals in the bone in a certain area and comparing that to same sex and race norms for a younger population. So we're comparing it to a younger cohort, and that's where you'll get those T-scores. And so based on those T-scores, you will get maybe something from 0 to negative 1, and that is considered to be normal and healthy. Then that negative 1 to negative 2.5 is that osteopenic range or osteopenia which means the bones are a little bit weaker but not full-blown osteoporosis just yet and then below negative 2.5 and below they will receive that osteoporosis diagnosis. Typically, along with the DEXA scan, a physician is doing a FRAX screen. This measures the 10-year risk of having a fracture. There's some different lifestyle questions and it'll basically spit out a percentage of likelihood that that individual is going to have a fracture within the next 10 years. And so those two pieces of information really formulate the, or someone giving a diagnosis, but then also the treatment that follows. And then based on those T-score readings, as well as the FRAC score, the pathways are typically, there's gonna be some pharmacology involved, right? Whether we're preventing bone resorption or really encouraging more bone formation and remodeling. And then they're typically going to give some blanket generic recommendation of exercise of weight bearing exercise. All right. Now, the tough part about this diagnosis, it can come from a whole host of different providers. So you can see primary care physicians, you know, kind of leading the charge of, you know, looking into bone mineral density. Internists can as well. Orthopedic physicians can as well. And so there will be different doctors that will be kind of looking into bone mineral density. And then they will often refer out to someone like an endocrinologist, for example, for further treatment and so there's a lot of people kind of involved talking about this and what at least I have seen is that this has been a topic that has been brought up and a lot of fear has been revolving around this topic but not a ton of guidance of what it really means day to day to really influence bone mineral density beyond taking that pill and you know quote-unquote weight-bearing activities. I've just worked with so many people that did not understand that diagnosis and what it actually meant. So just understand that. I'm not saying that always happens, but in a lot of the folks that I work with, that is typically the case.

OSTEOPOROSIS: DIAGNOSIS
So they're given this diagnosis and now let's talk about the prognosis. In particular, what I want to speak to is the opportunity to really dive in to the DEXA scan that our patients receive. And I'm not saying it is our place to kind of give a medical prognosis per se. Well, I guess when I'm saying prognosis is what can they expect going forward and to give them context of that diagnosis. So I'm mainly working the context of fitness now at Stronger Life in Lexington, Kentucky, and it's a gym for folks only over 55. And we're about four years old now, and so over the past four years, we've had a lot of members that have had at least a couple DEXA scans at this point. And so I'll put a field out for folks to send me some of their DEXA scans, and this is something that, these are conversations I'll typically have with folks anyway, once they get their DEXA scan. This is something I want you all to do. I want you to ask some of your folks that have osteoporosis on their, you know, their chart, their diagnosis list. Say, Hey, can I see your DEXA scan? Or, you know, if you're in a medical system, look up their DEXA scan, because it's really interesting. And you start to look at a lot of these reports and you'll have some of them that are more kind of narrative based, um, that, you know, are basically just several paragraphs kind of outlining, um, you know, what to expect, what they found, something more along the lines of, a bunch of words if you're not watching I'm just holding up some of these DEXA scans but more narrative but then a lot of them will actually have graphs of T-scores when they had that DEXA scan and where. So the most common areas are going to be the lumbar spine, the neck of both femurs, bilateral femurs, and then they'll kind of zoom out a little bit and look at the total hip as well. And so get those DEXA scans and look at some of those numbers. And when you start to look, what you're often going to find is variation amongst the different sites. So you can have individuals that may have that negative below negative 2.5, negative 2.5 or below, let's say at the neck of the left femur, for example. And then the neck of the right femur may be negative 1.7, osteopenic. The lumbar spine may be negative 1.5, for example, osteopenic. And so technically that person has osteoporosis on the left, on the left side, right? The right and the lumbar spine does not have osteoporosis, osteopenic, still a concern, right? But not as bad as that left side. That message is often missed by many of our patients. Now, I believe they're getting that message, you know, when they are getting these reports and having conversations with some of the physicians, but they're probably getting all kinds of recommendations. They're getting that diagnosed and all kinds of things that, you know, we only may only hear half of what is actually being said. But a lot of folks I work with, they will receive that diagnosis of osteoporosis that in reality is only in their lumbar spine, for example. and they will take that and own it as if every single bone in their body is brittle and about to combust under any type of pressure or load. They embrace that diagnosis as it's this global systemic osteoporosis. Every single bone I have is tremendously weak without acknowledging that there's some variability in different areas of the body. That piece of information for folks can be really eye-opening and very empowering. Oh my gosh, are you saying that I only really have this in this particular area of my body and not everywhere else? That's a sense of relief for a lot of folks. A lot of folks will take this diagnosis and view it as almost like a death sentence. everything. I am so weak. I'm so fragile. I need to be very careful. I'm going to break something, any bone I need to be very, very concerned about. Right. And that's not necessarily what's happening. It's usually in kind of one, maybe two areas that are a concern, particularly folks that are initially receiving these DEXA scans. And the cool thing about where I'm at now, working with folks for over four years, this individual, she's had a DEXA scan every two years. She was on a negative slope, negative three in 2017, negative 3.1 in 2019, negative 3.4 in 2022, and her most recent scan a couple months ago was negative 2.8. This is at her lumbar spine. and when you are able to give context to the diagnosis but then also be able to see over time you'll be able to spot trends and then hopefully be able to potentially reverse trends or slow down trends and we're seeing this at Stronger Life and I know many of y'all don't have the luxury of working with folks consistently you know three times a week over the course of several years but man if we can apply some of the interventions I'm going to talk about here in a second over the course of years you can have a significant influence in a lot of these DEXA scan readings and we're definitely seeing that and you can too. But I think that conversation, the prognosis, them understanding the diagnosis, where in particular that may be, that they understand every single bone in my body is not going to combust under pressure. This particular area may be more concerned, but I'm doing okay in these other areas. It's really good for them to hear that and that can be a more empowering message.

OSTEOPOROSIS: TREATMENT
Now the most important thing I think is that we take the information from this DEXA scan and then we use it in our plans of care. And so if I have someone that has maybe normal osteopenic in terms of the DEXA scan in their bilateral femurs, neck of their femurs, but then they're kind of borderline osteoporosis in their lumbar spine, for example, as a physical therapist, That gives me something that I can focus on, that I can give targeted interventions to give specific forces and stressors to that area in a very progressive manner, keep in mind, to stimulate a change in that bone mineral density or increase the odds that we can see change in their bone mineral density. So we take that information, use it for our plan of care. Some folks, you may be focused, all right, this left hip, let's load up this left hip a little bit more, do some unilateral stuff, staggered stance type things, not neglecting the other side per se, but if there's a big difference, we may want to give preference to one side or the other. If it's a spine, lots of loaded carries, deadlifts, those types of things where we're getting that axial compression, getting those forces through the spine. We can give target interventions. that's gonna encourage those bones to remodel, to get stronger, or potentially slow down, decline. So we take that information and take it into our intervention piece. Now for the intervention piece, you know, this is a 15, 20 minute podcast. We have a whole week on this in our NYA Level 2 course. But what you need to know is there are three things that are really, really important if osteoporosis is on board. One is balance training. This doesn't directly impact bone mineral density, but if we're able to improve people's balance capacity, I would even go as far to say their fall capacity as well. Do they know how to land? Do they have the balance capacity to even prevent the fall? That whole conversation of falls prevention and falls preparedness that we speak to, particularly in our live course, is really helpful for these individuals. Because if we can prevent a fall or even teach people how to fall in a more efficient or safer manner, you can potentially prevent an injurious fall or an osteoporotic-related fracture. So that's the first thing. Second thing is progressive resistance training. Bones really like progressive resistance training, where we're working up to relatively higher percentages of a one rep max, 70, 80, 85%. We're not going to come out the gate hitting that, but it'll take some time. But there's some really promising studies showing that, man, if people are able to regularly train at those higher intensities, they get really strong. They improve in a lot of the functional outcome measures that we care a lot about, but also their bone mineral density as well. Lyftmore trial is a great example of one group that's been able to show that. And then probably one of the more neglected things that we can definitely implement that can be intimidating for a lot of folks, but I found a lot very empowering for patients once they're able to do these things, and that is impact training. Weight-bearing as well. Loading the bones, but really thinking about the rate of loading. Progressive resistance training puts a ton of force, a bunch of load through that skeletal system that gets really good results. But bone can also respond really well to rapid loading. So think like plyometrics, stomping, heel stomps. step-ups, maybe a plyometric push-up, for example, or a quick bearing of weight through the upper extremities, something along those lines, where we're getting those increased ground reaction forces, we're getting those impact that can give the bones a signal to remodel. You take balance training, you take falls preparedness, sprinkle in some progressive resistance training, and then sprinkle in some of that impact training, and you stretch that out over years, And I will put my money that you're going to see some solid results when your patient comes back and says, Oh my gosh, Alan, look at my DEXA scan I just got. Remember the previous year, about a couple of years ago is like right when we started working together. And then man, I just had this DEXA scan and I've reversed my osteoporosis. We've seen that. Not to say it's going to happen every time, but people have the capacity to change and we often don't perceive that with this particular diagnosis. It is not a death sentence. There's a lot we can do. So understand the diagnosis, but then also understand that prognosis and give your patients context. Get that DEXA scan, look at it, analyze it. It's going to give you a lot of helpful information that they may not have comprehended and it can ease their mind of a lot of concern and worry, but it can also give them, something that they know they can do. And we can take that information and give a targeted intervention to a particular area that may be more troublesome than others. But man, if we combine that balance training, falls preparedness, progressive resistance training, and impact training with folks over a long duration of time, we can see some really significant results. All right, y'all. I appreciate y'all taking the time to listen. Let me know if you have any thoughts, questions, or your experiences working with folks. I do want to make sure I'm not saying everyone's going to get better. Everyone's going to improve their bone metal density. That is not the case. But man, if we can try without causing more harm, I think that's a good thing to pursue. And oftentimes, we can see some improvement.

SUMMARY
Before I go, I do want to mention our MMOA courses. I already mentioned that level 2 where we talk a lot about osteoporosis. Our online level 1 course is starting May 15th. Our level 2 course is starting May 16th. These are both 8 weeks long, about 2 hours a week, so you'll get 16 CEUs for PT, OT. and we equip you all to be the go-to clinician to best serve older adults in your community. It's likely gonna make you a very, very busy clinician serving these folks. And then our live course, we're gonna be in Bismarck, North Dakota, in Richmond, Virginia on May 18th and 19th. I'm gonna be in Scottsdale, Arizona, the beginning of June 1st and 2nd, and then we'll be in Spring, Texas, June 8th and 9th. We'd love to see y'all on the road or see y'all online. Y'all have a lovely rest of your Wednesday and go check out those Texas games. See y'all!

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

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses details surrounding velocity changes and fatigue in both metabolic and cardiovascular systems when loading the spine.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Thanks for watching! Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code ICEPT1MO at the time of sign up for a one month free grace period on your new Jane account.

BRIAN MELROSE
All right, good morning, PT on Ice Daily Show. My name is Brian Melrose, teaching both cervical and lumbar courses in the spine division, and just here to kind of round out another clinical Tuesday, talking about loading the lumbar spine in a comprehensive program. Today, the aspects that I want to talk about is kind of loading the spine at different speeds and different fatigue levels. If you can do those two last things, I think you've really built a comprehensive loading program for either your patients or your athletes that you're working with. So a couple of weeks ago, you know, we've talked about all things at this point, barbell isometrics. Last time we were talking about leveraging different planes of motion. And not just sticking in the sagittal plane, loading into kind of side bend into rotation. And so if you miss those episodes, check those out, because all those rules still apply. But the last thing that we need to talk about is different speeds and fatigue levels. And so where this thought process really comes from, is kind of, you know, again, I was sitting at extremity, and I was thinking about loading the rotator cuff. And again, we can't just sit down here, we got to get in different positions, we have to load with variable resistances at different speeds. And I thought to myself, why would the spine be any different. And so that's really where I started messing with some of these things in the clinic. And so If we want to start leveraging some of those concepts for the back, we have to take something like the deadlift, and then start loading folks at different variable speeds, as well as fatigue levels. So just like last time, I made a partnered post here, it should be on our Instagram, it'll be in the reels. Again, that kind of outlines everything that I'm going to talk about for the next couple minutes. There's gonna be a lot of exercises I mentioned. And so again, there's visuals there if you want to check those out after listening to the podcast.

WHY SPEED?
And so when it comes to speed, the first question is, is like, why? Like, why would it matter? And that really comes down to something as simple as different muscle fiber types. We have type one and type two fibers, and those do different things. And so if you're only doing something like power lifting and lifting heavier loads, at lower speeds, you're going to really leverage type two type fibers. If you're moving lighter speeds quickly, again, you're going to be more oxidative, you're going to challenge different energy systems, and you're going to utilize a different kind of muscle fiber type. So if we want our comprehensive loading program to include both of those, you got to have lighter loads, you also got to have heavy loads to train both of those systems and move those kind of weights at different speeds. And so when I think about loading the lumbar spine on a spectrum, there's really a lot of different speeds that we can mess with. The first one you would have to kind of really begin with would be the barbell isometric where the barbell or the weight really isn't moving at all. And so we talked about some of the nuances of that weeks ago, but you can get that barbell underneath those J cups and have a very consistent pull with max effort without any movement. And so the first speed would be no speed. And you can set that at different kind of heights for something like the deadlift. Things really begin there and they can then swing the direction of normal movement. So looking at something like the deadlift, you could do something like a touch and go rep where the barbell is touching the ground and then you're almost using that momentum of hitting the ground and that reaction to pull the barbell back up. And so it's a faster movement and therefore typically a lighter load. We can compare that to something like a heavier deadlift where you're maybe again slowly getting that barbell all the way to the top of the rep. And a lot of athletes use different things to look at speed as a parameter. And so a lot of the powerlifting athletes that I end up working with use a barbell accelerometer. It's a thing that kind of sits on the ground, it's got a cord, it attaches right to the barbell. And as it's lifted from the ground, the device allows you to kind of record how fast you actually pulled it. And this can be a great way to use an objective measure to look at someone's kind of difficulty level. Are you programming it properly? Are they working in the right range? We love using things like reps in reserve, RIR, or RPE, Raiders Perceived Exertion. And we know that those subjective measures are actually pretty good at helping us vary load for our patients. But something objective can also help as well. And so those barbell accelerometers, I'm sure they have a bunch of cute apps that do it too, can really be a helpful thing in the clinic to kind of dial in your speed when you're working with those different athletes. The only other concepts I want to kind of throw out there would be leveraging different speeds with the concentric and eccentric portions of a lift. And so for the deadlift, again, as you're pulling that concentrically from the ground, you could do a fast pull up, and then a nice, slow, controlled lowering. You could also change that. You could do a slow, gradual pull up, and then a fast drop towards the ground, where either you come to a rested point right before the barbell hits the ground, or actually contact the ground. And so that's leveraging speeds within the lift to, again, challenge different muscle groups in different systems at those different speeds. The last thing is kind of what I call a reactive speed drill. And so, again, in my post, if you check that out, it'll have a band just looped around the barbell that's gonna accelerate the barbell down towards the ground each time I pull it. And so that can, again, really change your ability to slowly, eccentrically control a lift. A really cool way to, again, just leverage speed in a different position. Now, if you have access to chains, that's another thing you can put on the barbell. As those chains come off the ground, it increases the weight. So again, typically in the easier part of the lift, you're getting a little bit more load. As that barbell comes back to the ground and those chains kind of pile up, that load is removed. And so both banded or chain work would fall into kind of this reactive speed zone. And I think that's the last speed parameter that we need to kind of consider when we're thinking about challenging someone's system. So that's speed for something like the deadlift.

TRAINING THE SPINE UNDER FATIGUE
The other thing that I really want to talk about today is fatigue levels. And there's really two big buckets that that falls into. The first kind of fatigue bucket that you would want to consider is looking at somebody's kind of movement and taking something like the deadlift, which is primarily a sagittal plane movement, a hinging movement. And you wanted to really tax that entire muscular system, those same synergistic muscles that are doing that movement, and you just want to bury them, you're going to give them two or three exercises that are kind of varying the speed, the load, but they're all taxing that same muscle group. And so kind of the metabolic failure that I'm describing in this bucket, is one that's a little bit more energy specific. I mean, I want you thinking about how can I tax out that creatine phosphate system that's going to be the primary one used for the first 30 to 60 seconds of an exercise. And then it kind of switch it over to like Krebs glycolytic. all the way on up to oxidative. And so for leveraging different barbell speeds and loads, you can also again, give them that same stimulus to tax that muscular system. And so you could take something like the deadlift, have them rep some of those out, Then have them go to, again, a hinging pattern with a medicine ball slam. So same muscle groups working, again, different speed. And then last, put them on something like the reverse hyper, where, again, they're going to kind of tax the same muscle groups. They're all different exercises, but you are bringing that muscular system, that energy system, to complete an absolute failure. And so that would kind of be a position-specific failure scenario. The other big failure kind of bucket that we can push our folks into, and really I think we need to push all of our folks into, would be a little bit more of cardiovascular fatigue. And this can be something, again, that's nuanced all the way down to you're doing it with Doris or Betty, where maybe they're pumping some reps out on the new step, doing a reverse Tabata, and then going and lifting the kettlebell off an elevated step, on up to our higher end athletes, where they might be crushing something on the rower for a period of time, jacking their heart rate up, and then kind of transferring to the barbell. In either one of those scenarios, we want to tax the cardiovascular system. And so now I'm talking about fatiguing that, really the heart and the lungs. Can you keep up and continue to lift when you're absolutely gassed cardiovascularly? And so for more of a lifting athlete, this would look like, again, the last kind of swipe on that reel that I posted would be starting with something like the deadlift, And then maybe having them do something like a kettlebell swing, where they're jacking their heart rate up and moving a little bit more quickly, still a familiar hinging movement. But again, with a little bit more speed, a little bit more cardiovascular demand on board, and then having them for a third exercise, pump a bunch of reps out on the rower. So I like jacking the resistance up to like eight to 10, having them do about 30 seconds to 60 seconds, and then cycling those exercises. And really by round three or four, they are going to be absolutely smoked from that cardiovascular demand, those faster movements with the kettlebell, and it's not just going to be a simple deadlifting, hinging routine anymore. And so those would be the final concepts that I think we really need to consider when we're building somebody a robust strengthening program for the spine. You're nuancing these all the way down for some of our lower level folks, and then really challenging some of our higher level folks that might already be deadlifting, squatting, doing some of these movements a couple times a week. Now you got some different lenses to kind of either add or alter the lift, looking at different speeds, isometric, concentric, eccentric, touch and goes, heavier stuff where you're looking at a barbell accelerometer, all the way up to reactive things with a band or chains. That speed also fatiguing a particular muscle group, a specific position, a certain synergy of muscles, or the cardiovascular system. you can hit all of these different parameters and give your folks a nice robust back program to keep with. Again, I think the chances of them having future injury or issues significantly decreases. So just some food for thought. I hope this was helpful. I hope you guys have an awesome Tuesday.

SUMMARY
I just want to touch briefly on a couple courses we have coming up. There's only a couple spots left. May 18th and 19th. I'll be in Casper, Wyoming teaching cervical So if you want to learn how to twist some necks, we'll be doing that on Casper The next cervical course we have on the books is in Kent Washington on June 29th and 30th again You'll be stuck with me for that one for lumbar. We got two coming up here. We got Zach out in Chandler, North Carolina and on May 18th and 19th, and then we got Jordan up in Victory, New York on that same weekend. Those will both be lumbar courses. Again, if you guys are looking to get out to any of those, we go over everything comprehensively, the whole process, and then give you some manual therapy techniques on the weekend. So, hope to see some of you guys at those courses. I hope this information was helpful. Have a great Tuesday. I will see you guys next time.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses ideas for further treatment for an individual experiencing vaginismus.

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

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

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

EPISODE TRANSCRIPTION

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

APRIL DOMINICK
Good morning, everyone, and welcome to Pelvic Monday on the PT on Ice Daily Show. My name is April Dominick. I'm here to talk to you today about pain in the vag, a case study. This case study was brought to us by some of our students in our level one pelvic cohort, and they just had some questions about a case on vaginismus and where to go since they were feeling a little bit stuck. So I wanted to hop on here and provide some in-depth guidance on how to continue with what they have already started for their treatment. Particularly, they are interested in how to improve their patient's pelvic floor hypertonicity, as that's where they're feeling a little stuck. So here are some details of the case that the treating therapists have already shared with us. The subject is a 19-year-old female who's diagnosed with vaginismus. Her aggravating factors are history of difficulty and pelvic pain with insertion of a tampon. She more recently was on her menstrual cycle, got a chance to try putting the tampon in. and had another failed attempt. She also has reported pain at her inner thighs after horseback riding, and she is an avid horseback rider. Easing factors so far, the therapist had provided the patient with adductor stretching, strengthening, foam rolling, and that seems to have eased the adductor pain, not necessarily helped with her pelvic floor situation just yet. And from a physical activity standpoint, I don't know much, but again, she is an avid horseback rider. And she also reported history of sexual trauma from a horse camp instructor who is now in jail. And thankfully she is currently working with a trauma therapist as well. In terms of objective findings, again, they found some tightness and pain with adductor palpation. as well as when attempting the internal pelvic floor exam, they were limited by the patient reporting pain. Current treatment, they have done some dilator work that has improved since the start of PT. So a few weeks ago, the dilator itself was shooting out upon insertion, and now the patient is able to maintain a dilator inside the vaginal canal for a few minutes. And if you all are unfamiliar with what a dilator is, it is essentially a phallic-like structure, that can be inserted into the vaginal canal. I like to call it a space holder for the vagina. And there are different variations of it. And some of them have a longer length while others are wider. And so it allows someone to be able to progressively overload the vaginal space or the vaginal canal. And after horseback riding, the general adductor exercises that the therapist provided have helped, again, reduced the patient's adductor discomfort. So their biggest question, again, is how do we address the pelvic floor hypertendency? It doesn't seem to be that we are making progress with this. So initial thoughts. First off, the therapists are doing just wonderfully with the direction of treatment. I love that they zoomed out from that pelvic space and addressed structures that indirectly impact the pelvic floor. And I love that they did attempt an internal exam, but again, didn't find that to be helpful given that the pain was present and the patient needed to stop the exam. I also appreciate that they talked about any previous trauma, as that is extremely important in this case in particular, and that they asked about, hey, are you getting help for this? And yes, the patient is again seeing a trauma therapist. So I'll discuss some of the considerations that I am thinking about, and I wanna talk about some things like working from the outside in, with external manual therapy of the pelvic floor, of the hips, as well as mobility and active strengthening that I would suggest as well, and some thoughts on, hey, what is going on with her nervous system and working together with the trauma therapist. So let's start with the internal external pelvic floor work first. Given that pain was a limiting factor in the internal pelvic floor muscle exam, That's a sign to me that the patient is not currently ready for or would benefit from continued internal exam attempts at this time. As she works with her trauma therapist from the inside out, she can simultaneously work with her physical therapist to treat the outside in. And what do I mean by that? External work on the pelvic floor, that can be simply a visual exam. And the vulva, no palpation, just guiding the individual on how to relax the pelvic floor. This is your pelvic floor. Using mirror feedback or even imagery work, like imagining that she, the patient, is inserting something into the vaginal canal and see if she responds better just from that imagery versus any sort of palpation. And then gentle, moving on towards a gentle external pelvic floor soft tissue mobilization. So techniques like sustained pressure or contract relax on the superficial pelvic floor muscles, like the bulbospongiosis, ischiocavernosis, and near the outer labia, as well as near the perineum. And also tackling the obturator internus, given that it is a hip rotator. So the hip, the obturator internus shares some fascia with the levator ani, and if we can work on the obturator internus externally, then it's very possible that we can just help decrease some of that upregulation in the pelvic floor, no matter where we are tackling the pelvic floor. Another piece is working on hey, can I do some cupping in that posterior pelvic floor region? I've been known to cup that area. And for some of my clients who have just a lot of tension and pain in that pelvic floor region, I will again offload the backside of the pelvic floor. in hopes to also decrease some of that hypertonicity in the anterior side or near that vaginal opening. So I pair the cupping with some child's pose or some quadruped rocking just to get some gentle movement, active movement in as well. And then if there is some progress with those techniques, but then we're running into a roadblock again, and maybe we're still not ready for any sort of internal work, then considering some dry needling plus electrical stimulation, maybe with some neuromodulation to the pelvic floor, and that's gonna directly tap into the cortex, create a nice chemical pump to the pelvic floor, and really help downregulate. Now, if this will work the best, if the patient has really responded well to dry needling in the past and is game to have it done in that region, it can be extremely beneficial. And then after doing all those manual therapy interventions, what are some things that she can do herself? She can do some self palpation externally with diaphragmatic breathing and some pelvic drops or pelvic lengthening to release some of that tension. I want to suggest that she try using her own digit, her own finger, to do some external self palpation. while she gradually moves towards internal insertion of her own digit into the vaginal canal. As this can be often more approachable and less painful for someone who has a history of trauma, for them to do it themselves, rather than inserting something external like a tampon or a dilator, or having someone else do the insertion. This way, if she's using her own finger, then she's remaining in control. Then having the client follow up on self-palpation with the dilator practice. It sounds like this person was already doing some dilator practice. So having her try it in varied positions of comfort, coupled with the diaphragmatic breathing. And then in terms of when someone is ready to trial vaginal insertion, I generally prefer them to be able to insert an object that's the same size or larger to what they're wanting to insert. In this case, having the individual aim for comfortably tolerating a dilator that is the same size or larger than a tampon is a great rule of thumb for test-retest with that tampon insertion. Traditionally, many individuals insert a tampon seated or maybe in a mini squat over the toilet. While this client is building up her confidence in getting those positions and doing this in public, I believe that she can try some more comfortable positions for tampon insertion like semi-reclined, maybe having her legs supported by walls or a pillow in her own home. Again, not traditional, but a great place to start.So attacking the hip from the joint side of things. We can do some manual therapy in the sense of doing some joint mobility. The therapist can do some joint mobilizations. And then that can be followed up by the client getting in some active hip mobility exercises. Gotta love the seated hip 90-90s. or seated banded hip IR and ER, banded hip capsule mobilizations, and I really love the long axis distraction just to get some nice general chemical pumping blood flow to that area to address chemically induced stiffness. Then we have hip mobility via muscle. Given that the adductor's origin is the ischiocubic ramus, I like to say the adductors are the long driveway to the pelvic floor. Dry needling plus e-stem for the adductors to reduce tone and increase blood flow is a beautiful option. Only always follow whatever kind of manual therapy to the adductors with standing banded and loaded lateral lunge sliders, sumo deadlifts or Copenhagen variations. We love the holds for 45 seconds. times five rounds for those Copenhagans, just to really tap into the analgesics from an isometric hold perspective. Also of note, if we're continuing the house analogy, and the adductors are the driveway, I like to think about the abdominals as the chimney. So the abdominals, if they are showing signs of hypertonicity and gripping, then we wanna do some of those same techniques, soft tissue manual therapy, to the abdominals followed by stretching and loading of that area. And then the nervous system, given that the individual has that history of trauma, we have to treat her from a holistic standpoint. Addressing that elevated centrally sensitized nervous system by ramping up the parasympathetic side. So doing vagus nerve stimulation exercises to increase calm, What are those examples of? Having her chew her food at least 10 times. This taps right into the vagus nerve. Humming, gargling, having her do one to three physiologic sighs. And that is two inhales followed by one long exhale. It sounds like this. So making sure that first inhale is longer than the second. or having her create a mantra like, I'm in control of my body right here, right now. Doing any of those vagus nerve stimulation exercises before and during her attempts to insert a finger, a dilator or a tampon in. This is going to really help address that tenacity. And then a time expectation. How long have you been working together? If it's only been a few sessions or if the client has dealt with vaginosis for a long time, rest assured it can take time for that physical side to catch up with the emotional or vice versa. especially given that trauma link and reminding her, hey, progress may not be linear, but here's what you've already improved on and showing her what she's made some progress with in terms of a couple of weeks ago, you weren't even able to have that dilator remain in the vaginal canal. And then I love that she's seeing a trauma therapist. This is so vital in this scenario and asking the patient, hey, can you tell me what you all talk about in your sessions? Or are you okay with me contacting your therapist so that we can do some integrative work? So I can bring in maybe some things that you all are talking about and we can practice that from the physical space. So given I don't have all the details, I'd also be curious of, hey, has she been able to insert a tampon in pain-free previously? And if so, we can lean on those positive instances that she does have the capacity to do so. And then I'd also be curious about some of the previous hip, low back, abdominal surgeries or injuries that she's had. Does she have any associated bowel, bladder? issues, urinary urgency, difficulty completely emptying, as these may be conditions that contribute to that pelvic floor holding tension. And then if she's sexually active, understanding what that means and what that experience is like for her. So hopefully those tips help y'all with the case or if you're someone who has someone like this on your caseload. To summarize, when we're treating someone with vaginismus, we really wanna lean into treating from the outside in, with external pelvic or abdominal or hip manual therapy, whether that's soft tissue, joint mobilization, cupping, dry needling, plus stem, all followed by some active mobility and stretching as well. And know with some of these patients, you may never get to the internal exam, and that is totally okay. The internal pelvic floor exam. Remember, the adductors are the driveway to the pelvic floor. The abdominals are the chimneys, so down-regulating those structures and then eventually loading that is going to be helpful. And then tapping into the nervous system via the vagus nerve just before and during insertion attempts in positions of comfort. Timing can have a huge impact on healing trajectory, and working side-by-side with their mental health or trauma-informed provider to reiterate concepts of the mind and body connection. Okay, so if you all want to learn more about some of those external techniques I was discussing, like the external pelvic floor exam, or if you do want to learn more about the internal exam, our next live courses are Kearney, Missouri, May 18th and 19th, and we have a double hitter of a weekend, June 1st and 2nd, with one course going down in Anchorage, Alaska, and the other in Highland, Michigan. So definitely sign up for those courses, or if you're interested in our online courses, we have two available. Head over to btonice.com and hop in. Thank y'all so much for listening, and I'll see you next time.

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

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses utilizing hill running as a gait drill for injured runners, explaining the changes in running mechanics between running flat, uphill, and downhill. Megan also explains when and why to recommend uphill or downhill running

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

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

EPISODE TRANSCRIPTION

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

MEGAN PEACH
I think both YouTube and Instagram are both live. Miracles. Good morning. Happy Friday. This is your PT on ICE Daily Show, and I'll be your host today. My name is Megan Peach, along with the Institute of Clinical Excellence, bring you this topic today of incorporating hills into your gait retraining toolbox. I am one of the lead faculty for our endurance division here at Institute of Clinical Excellence. and I teach both the live and the online versions of Rehab of the Injured Runner. So I'm super excited about this topic today. Let's get into it. So we have a lot of different tools in our gait retraining toolbox that we might use to keep injured runners running or return injured runners to a running program if they've had to take some time off.

CHANGES IN RUNNING MECHANICS WITH UPHILL RUNNING
One of the tools that we don't often use or that maybe we don't often think about as much of the others like cadence training or forward trunk flexion or maybe quiet running is incorporating hills into their current running program as a gait training tool to keep that injured runner running. And before we talk about specific injuries, I want to talk a little bit about the differences between running mechanics when we're running either uphill or downhill as compared to running over a level surface or a level ground. So when we're running uphill, a couple of things happen in terms of the sagittal plane gait mechanics that are different from running over ground on a level surface. One of those things is that our stride length So the distance from where the foot strikes the ground to a vertical line straight down from the center of mass, that's our stride length, that often will decrease when we are running uphill. And what goes along with that is also an increase in knee flexion at initial contact. So when we're running uphill, our knee flexion tends to be more than when we are running over a level surface. and it tends to be a little bit less in comparison. Also, another change that we typically see is a decrease in the angle of inclination from the foot to the ground when we're running uphill. And so what that means is that, or what that looks like, is that a runner running on a level surface who has a rear foot or a heel strike might look like they have less of a rear foot or a heel strike when they're running uphill. So maybe they look like they have a midfoot strike or they may even have a forefoot strike. It's going to be very, very dependent on the runner and that certainly doesn't happen in every single runner. We don't necessarily see a strike pattern change in every runner when they start to run uphill, but certainly that can happen and it does in many, many runners when we go from running on a level surface to uphill. So that's the third change. And then the other change that we commonly see in that sagittal plane is an increase in forward trunk flexion. So from going from a level surface to running uphill, we will often see that runner shift their trunk forward. And what that does is take a little bit of work off of the knee and transfer it to the hip. And so the glutes end up doing a little bit more work. The quads end up doing a little bit less work when we're running uphill. That has some advantages. but potentially some disadvantages as well, depending on the runner. So then when we talk about running downhill, all of those biomechanics changes that we saw, or that I talked about running uphill, are the opposite when we're running downhill.

CHANGES IN RUNNING MECHANICS WITH DOWNHILL RUNNING
So going from a level surface to running downhill, we often see that stride length increase. And so a runner will go from maybe landing with a little bit of knee flexion to nearly a straight knee at contact when they go from running on a level surface to running downhill. So we also see the knee flexion decrease or the knee extension increase depending on how you want to describe and look at that. What we'll also see is an increase in angle of initial angle of inclination at initial contact at the foot and ankle in relation to the ground. And so somebody who was a midfoot or a heel striker or a rear foot striker running on level surface is just going to shift that impact a little bit more posteriorly toward the heel. And it's going to be relative to how they hit the ground when they are on a level surface. So a midfoot striker may look more like a heel striker, or a rear foot striker may look more like a heel striker, depending on how they started out. Again, not in every single runner, but certainly there is that trend. The other thing we see with running downhill is a change in trunk position. And what we see when they're running downhill is more of an upright trunk posture. And even occasionally, we can see that runner almost lean backwards. And this happens for a couple of reasons. One, they're just trying to maintain their balance. It's a different body position running downhill versus running either uphill or over level ground, and so they're just trying to maintain their balance. And another, they're trying to control their speed. So often when a runner leans forward when they're running downhill, that can almost feel like they're gaining speed and it's a little bit uncontrolled, especially if that runner is more of a novice runner or just not used to running downhill. And so they'll lean back in an effort to just control their position and control their speed when running downhill. that has some obvious disadvantages, as it will increase the load on the knee and the lower extremity and decrease the load on the hip musculature.

UTILIZING UPHILL OR DOWNHILL RUNNING FOR THE INJURED RUNNER
So, in talking about specific injuries and running mechanics in an uphill or downhill, we want to take into consideration where those specific injuries are and what types of tissue we want to offload. So starting with patellofemoral pain, super common running related injury. It's one that a runner can typically continue running through, at least in some capacity, as long as there are some shifts and adjustments in their training program. They may not be able to do the same amount of mileage, but they certainly can, in most cases, continue running. So when we consider offloading the patellofemoral joint, We typically use gait retraining drills like cadence retraining or increasing the step frequency. So we reduce the stride length, increase the knee flexion angle at initial contact. We might also use something like a forward trunk flexion drill to shift that load from the knee more approximately to more of the hip. And those tend to work very, very well for people with patella femoral pain. I personally treat a lot of trail runners and so they're generally not running on a level surface and they're generally running uphill or downhill and that's just the terrain that they're running on. And so often when we're using other drills like cadence or like trunk control, then we're expecting that they're going to run on a level surface. And so if we have a drill like running uphill, they're very, very much appreciative of being able to incorporate their normal terrain into their current running training program while they rehab that injury. And so with runners with patella femoral pain, we will often incorporate running uphill. Now I know it sounds a little bit crazy and runners always give me a little bit of a weird look, but because of the biomechanics that go into running uphill, namely the reduction in stride length, the increase in knee flexion angle at initial contact, and the forward trunk flexion, all take a little bit of that load off of the patellofemoral joint and shift it up the chain, so it shifts to the hip, and they're often able to tolerate running uphill quite well, even in comparison to running over a level surface. It is important that you remind them that they need to walk downhill, and that's really important so that we don't actually increase the load on that patellofemoral joint. Now, when I talk about incorporating uphill running to an injured runners training program, I am not talking about incorporating this giant steep slope that I expect them to run up. I'm talking about a very low grade, like a three percent grade, which is generally what's cited in the literature as something that the authors or the researchers are looking into as does this create biomechanical changes. And even a low grade like 3% is enough to create some of those favorable biomechanic changes that are going to make a difference in that runner's ability to tolerate that running load. And a 3% grade is enough to reduce that patellofemoral joint stress by about 25%, and that's per step. And so when we think about that cumulatively over many, many, potentially thousands of steps, that's a lot of load reduction on a single joint that is going to allow that runner to continue running as they rehab that injured tissue. So moving down the chain and thinking about Achilles tendinopathy, very different injury, obviously, different types of structures, different types of tissue injured. And we think about the biomechanics of hill training. And when we think about biomechanics of running uphill, like I mentioned, we have that reduction in angle of inclination as one hits the ground or as one impacts going uphill. that reduction of angle of inclination or the shift toward landing on a midfoot or a forefoot is going to also result in an increase in load or stress on that posterior lower leg musculature. So the gastroc soleus complex, as well as the Achilles tendon and some of the forefoot structures. And so with an injured runner, with Achilles tendinopathy, they're actually going to accumulate more stress while running uphill than they would running on a level surface or downhill. So much so, in fact, it's about a 25% increase in stress on the Achilles tendon while running uphill as compared to that level ground. And so with a runner with Achilles tendinopathy, we actually want to discourage them from running uphill. We do not want them running uphill. obviously while they're still symptomatic later on in the program. That might be something that we incorporate as they're able to tolerate more and more load, but certainly not while they're still symptomatic. And so when an injured runner with Achilles tendinopathy, we actually want to encourage running downhill because of some of those biomechanical changes, those runners are going to tolerate downhill running much, much better than maybe even overground running. And often in those, Runners with Achilles tendinopathy, they've stopped running for a period of time in an effort to rest the injured tissue and resolve the symptoms, they're not always sure how to get back to running. And so downhill running can be a good start with less load on that injured tissue than overground or level running or uphill running. Certainly we want to incorporate those later on as they tolerate more and more load. Okay, so the last one I want to talk about and It's been 12 minutes already and I haven't talked about bone stress injuries, so it's probably, it's a little unusual, probably a record. I do want to talk about tibial bone stress injuries. And so with bone stress, it's a little different than other types of soft tissue stress because with bone stress, we get stress from a couple of different inputs. One is an external input, meaning the ground reaction forces. Two are the internal inputs, which comes from the muscles that are attached to that specific bone. So in this case of the tibia, the gastroxilia is complex. And both of those external and internal inputs are going to have an effect on the amount of stress that that bone is accumulating. The internal load or the internal stress being much, much more of a contributing factor to bone stress than the external ground reaction forces. Although it does contribute a little, so it still needs to be considered. Okay, so when we run uphill, we know that there is going to be an increased load on that gastrocnemius complex. And so therefore, there's going to be a significantly increased load as well on the tibia because of that internal load from the gastrocnemius complex. When we run downhill, then we see an increase in ground reaction forces, which is also going to increase the load on the tibia. So we can talk about uphill or downhill, but they're both essentially going to increase the load on the tibia specifically. And so while somebody, although they will likely have some time off of running after they've had a diagnosis of a bone stress injury, while they are returning to running, we want them to run on level ground. We do not want them to incorporate any hills up or down early on in their program until we are absolutely sure they are tolerating level ground running without any symptoms or exacerbation of symptoms. And then we can start to incorporate the downhills, which are going to be less problematic and less provocative than the uphills because that internal load with the uphills and the gastroc soleus is going to contribute much more stress and load to that tibial bone than the downhills with the increased ground reaction forces. Okay, so a couple of other things to add. One is that if you are working with novice runners, hills often have to be trained. So they're not intuitive in terms of how we can most efficiently run downhills, uphills a little bit more so, but certainly not downhills. And because of some of those maladaptive mechanics that I talked about with running downhill, specifically like the upright trunk posture and the increase in the stride length or the over striding, those we tend to just do when running downhill if we're not trained how to run downhill. So if it's in your toolbox and you know how to kind of instruct or coach a runner to have better mechanics running downhill, meaning lean into the hill just a little bit. You don't have to have so much forward trunk flexion that it's making you uncomfortable, but lean into it just a little bit, or to maybe just be conscious of not extending the trunk posture or having a very rigid upright trunk posture. And then maintaining the stride length. So trying not to reach out as one goes down can really help to reduce some of that stress on the patella femoral joint, and the lower extremity as well. And so training or coaching a runner to be able to run downhill can also have really positive benefits in their ability to tolerate some of those hills, especially if they either currently are injured or have that running related history, especially if it's something like a patella femoral pain. And then the other thing to mention with using uphill and downhill as gait retraining tools is that The biomechanical changes are not independent of changes in stride frequency or our cadence or changes in speed. And so just like any other gateway training drill that we might use, so cadence for example, it's really, really important that we maintain some of the other variables that go into running. So speed for example if somebody's running on a treadmill and we manipulate their cadence we're really really sure to maintain that speed otherwise we may be changing too much at one time or we may not be getting the desired effect that we want from that gait retraining tool if we are changing more than one variable. So if you are recommending like an uphill run for example try to maintain some of those other variables specifically like stride frequency or cadence and speed. So obviously easier said than done, much easier on a treadmill than it is outdoors like on a trail, but just something to be aware of. Okay, so to recap, running uphill or downhill can be a really effective tool for runners with specific injuries, such as patella femoral pain or Achilles tendinopathy, that we can definitely put into our running gait retraining toolbox. As long as we keep some of those biomechanics in mind, and as long as we understand how uphill or downhill running can shift some of that load from one structure to another, And then also taking into consideration that there are instances when we do want runners to run on a flat surface, for example, in tibial bone stress injuries, when they are returning to run, it's really important to keep them on that flat surface so that they are not inducing excessive stress on that injured or healing tissue.

SUMMARY
All right. So before I let you go today, I do want to mention a couple of upcoming courses. We have, let's see, Rehab of the Injured Runner Online. We are just about to start a new cohort. It is in May, the very beginning of May, so you've got a couple of weeks to sign up, but it's filling up. Sign up now. We have just revamped Rehab of the Injured Runner Online for 2024 and so far it's been really, really fun. We've had a lot of great engagement from current participants and previous participants. in our courses this year. Great questions. It's been really fun so far. So make sure you get into that if that's something you've been meaning to do. We also have Rehab of the Injured Runner live. We have June in Wisconsin and then we have September in Maryland and then Certainly the bike fit course is part of our endurance division and so we have a course this weekend in North Carolina. We've got one in May, mid-May in Minnesota and then up with our friends in Bellingham, Washington in June. All right, so that's it for me today. Hopefully you can add in hill training, uphills and downhills into your toolbox for rehabbing injured runners and just hit the ground running with that and use it right away. That's my goal for you for today. Feel free to ask any questions and hope you have a great Friday. All right, have a great weekend as well.

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

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

In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses eating disorders & obesity, the relationship between mood & disordered eating, binge eating as the most common form of disordered eating, and the role of the physical therapist in eating disorders.

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

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

EPISODE TRANSCRIPTION

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

ELLEN CSEPE
Good morning everybody and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a teaching assistant with the modern management of the older adult division coming to you live from Littleton, Colorado. I'm an outpatient physical therapist who practices with the same question in mind every day. Why aren't physical therapists more involved in managing one of the most pressing health crises in the world today. Obesity. On today's Leadership Thursday, we're going to discuss eating disorders in those with obesity. To feel complete in our treatment of those with obesity, we have an obligation to understand the link between eating disorders and obesity. This is a very nuanced topic with a lot of viewpoints and a lot of new research, but I want to be respectful of your morning and keep this discussion succinct and have this framework for today. First, we're going to open about how mood disorders and obesity are related. Then we'll talk about the most common eating disorder that affects people with and without obesity. Then we'll talk about our number one job as clinicians to avoid provoking disordered eating and then what we can do pragmatically if we suspect our patient is struggling with an eating disorder. So to open us up, for those of us who have never struggled with an eating disorder or obesity, having an issue with your weight can just seem like a physics equation gone wrong. Too many calories in, not enough calories out equals obesity. But for those who are struggling with their weight, this oversimplified physics equation really overlooks the emotional and mental language that can come with struggling with your weight or your perception of your weight. We see obesity as a complex biopsychosocial chronic disease with this framework in mind that it is anything but simple. And thinking that there's a simple solution and a simple fix can often make this problem worse in treating our patients.

MOOD & OBESITY ARE RELATED
So to start, obesity and mood disorders are related. Obesity and depression frequently occur together and actually there's a bi-directional relationship between mood disorders like depression and obesity. In fact, depression can be a risk factor for obesity and obesity can be a risk factor for depression. This risk and this association is the strongest in women. eating disorders are mental health disorders. The DSM-5 identifies eating disorders as mental illnesses that are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning. And in fact, eating disorders can be life-threatening and have the highest mortality rate of any mental illness. Eating disorders have their own diagnostic criteria in the DSM-5, and those eating disorders with diagnostic criteria include pica, rumination disorder, ARFID or avoidant restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. Anecdotally, many clinicians feel apprehensive discussing weight, exercise, and eating habits in part because they're aware that executing these conversations poorly can have adverse impacts on their patients and their mental health. But as clinicians, we have to know the basics of diabetes, cancer, Graves' disease, ALS, MS. And if we feel confident making dietary recommendations to our patients, For things like protein intake, calorie deficits, and reducing added sugar in our diet, we want to at least be aware of the most common eating disorder that will likely impact our patients. So we understand that there's a correlation between mood disorders and obesity.

BINGE EATING AS THE MOST COMMON EATING DISORDER
Now let's talk about the most common eating disorder that we're gonna see in our practice. So binge eating disorder is the most commonly recognized eating disorder among people with and without obesity. So it doesn't matter if you have obesity or not, this is likely going to be the most common eating disorder that a patient will suffer from. So eating disorder, let's understand this a little bit more so that we can really clearly understand what this looks like in our practice. So binge eating disorder is characterized by eating a large amount of food in a short period of time, all while feeling the loss of control during this episode and immense shame and guilt afterwards. So you might be thinking, well, do I have binge eating disorder? I chowed last weekend. There's a difference. Having unhealthy eating habits or chowing or going crazy now and again is not the same thing as an eating disorder. An eating disorder is not a choice. A diet is a choice. You can choose to not be a vegan anymore. You cannot choose to not have an eating disorder. And that's the best way to summarize the differences between diets and eating disorder. But binge eating disorder has some specific characteristics. Eating a large period of food over a short period of time without the feeling of control. Eating faster than normal. Eating until uncomfortably full. Eating large amount of food even when not physically hungry. Eating alone because of embarrassment with how much one is eating. and feeling disgusted with oneself, depressed, or very guilty afterwards. So this is a very common diagnosis that we'll see in the clinic. Other unhealthy weight control behaviors that would be reflective of disordered eating could include vomiting, skipping meals, fasting, laxative or diuretic use, smoking to manage appetite, and consuming stimulants to reduce appetite. So these behaviors aren't the same thing as having an eating disorder, but we should know that these behaviors are rarely successful in managing weight and, more importantly, can lead to depressive symptoms and eating disorders in the future. So we summarized the most common eating disorder that we'll likely see as clinicians. Now let's talk about our number one job.

THE ROLE OF PT: PROVIDE AN ENVIRONMENT FREE OF STIGMA ABOUT WEIGHT
So our number one job as clinicians is to provide an environment for our patients free of weight stigma. For us to be psychologically informed clinicians who want to help those with obesity, We have to be aware of how impactful weight stigma can be on disordered eating. Weight stigma implies that people who struggle with their weight are lazy, less adherent, less motivated, less deserving of empathy, sloppy, mean, have decreased willpower, are unsuccessful, or are otherwise unpleasant. And unfortunately, it's very common among healthcare providers. A recent survey of nurses suggested that 24% of nurses would see people with obesity as repulsive. and that 12% of nurses surveyed didn't want to touch those with obesity. These feelings are not only unhelpful, but they're really hard to hide. If you're repulsed by your patients, it's probably going to show on your face. And actually, a recent 2023 systematic review it'll be in the comments below on this Instagram post, looked at how weight stigma impacted disordered eating. So studies that looked at relationships between disordered eating and internalized weight stigma showed that weight stigma is helpful, unhelpful across the board in managing weight and can actually really commonly provoke disordered eating habits. So the studies reviewed looked at actual experienced weight stigma anticipated weight stigma, so for example, the fear of being judged by others, like if you're going to go out in a bathing suit, having that apprehension that you're going to be judged, and then internalized weight stigma, so the personal belief that you are lazy, unmotivated, have less self-control because of your body habitus. And the systematic review suggested that across the board, experiencing weight stigma made outcomes worse. And in several studies would suggest that experiencing weight stigma from a medical provider immediately caused a binge eating event afterwards. So not only are those weight stigma beliefs that we hold as providers unhelpful, they can make the problem much, much worse and can even cause a binge event for those with binge eating disorder. So I challenge you today to reconsider how you face obesity. If you have biases against those with obesity, I really challenge you to recognize with empathy how hard it is to lose weight and to manage your weight. Recognize that when we lose weight, our bodies fight to get that weight back by changing our hormone levels, our ghrelin levels go up, increasing our hunger, our leptin goes down, decreasing our satiety, and our bodies perpetually try and return to that weight that we lost. It's hard. Our world and our food landscape have changed significantly in the past 50 years. You don't have to grow an Oreo. You could go and buy them from the grocery store, and those are quick, low-nutrient calories that you can access without having to do any physical labor. It is extremely difficult to maintain weight, and those with obesity need our help and support in their journey to manage their health for the long term without judgment or weight stigma from providers. I recognize that obesity is a huge problem that our culture and our entire world face. I know that you likely agree if you're listening to this podcast. Weight issues are hard to manage and where we should start is with empathy and dignity and respect and compassion with those with obesity.

SUMMARY
So we talked about how mood disorders and obesity are related. We talked about the most common eating disorder, binge eating disorder, that affects people with and without obesity. We talked about our number one job as clinicians to make sure that we provide an environment free of weight stigma for our patients. And last, if you suspect that your patient is struggling with an eating disorder like binge eating disorder, we have some options. You can ask, have you ever struggled with an eating disorder? Or do you know if you have an eating disorder? Just as easily as we can acknowledge depression or anxiety on a past medical history form, we can identify eating disorder or disordered eating habits. Within the past 24 hours, a previous patient of mine shared that he had an eating disorder, but is only now getting treatment after years of struggling because nobody asked. So our job as clinicians, if we suspect somebody has an eating disorder, it's totally within our scope to ask. And if they say yes, you can refer them to the National Eating Disorder Association. The link will be below in the comments. Or this is a completely, this is not an ad, but there's an online virtual service called Equip Health that takes major medical insurances and provides mental health therapists, dietician, and medical provider support, as well as mentors who have overcome eating disorders and are there to help your patients. So we have lots of resources. To summarize, mood disorders and obesity are linked and we have to understand that as clinicians. Binge eating disorder is the most common eating disorder that we'll see for those with and without obesity. Our number one job as clinicians is to provide an environment free of weight stigma for our patients. And if you suspect that your patient has an eating disorder, ask and offer pragmatic support with a referral to another dietician or mental health therapist or an online program. Thank you so much guys. I know that we recognize that obesity is a growing problem in our world and you being a part of this podcast and a part of this team really reflects your genuine empathy and caring for those who are struggling. Thank you so much for being here and I hope you have a wonderful rest of your day.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how to incorporate geriatric treatment principles into practice to address pelvic floor concerns with older adults.

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

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

EPISODE TRANSCRIPTION

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

CHRISTINA PREVETT
Hello everybody and welcome to the PT on ICE Daily show. My name is Christina Prevett. You saw me on Monday. I am one of your division leads for both the geriatric and the pelvic health division and you guys got stuck with me twice. If you saw the episode on Monday, you can definitely see that my voice is better. So I don't have the same sickness. So hopefully my voice will be a little bit more tolerable for today's podcast. Today we're gonna be talking about how fitness-forward geriatric clinicians do pelvic well. And one of the things that I often will get asked about is, Christina, it seems really weird that you're in both the geriatric space and the pelvic health space speaking to pregnancy and postpartum. How the heck are these two things connected? And they are a lot more similar than you think, especially when it comes to the quality of our care. What I mean by that is that we are not as fitness forward as we need to be in both the geriatric and in the pelvic health spaces. And there is a significant amount of under dosage that happens in both places. And in our older adult course, we talk a lot about this fitness forward mindset and we try and do the ultimate reframe, right? We worry about the cost or risk of loading people and our thoughts are, what is the risk if we don't? And What is the risk if our person gets a little bit weaker or they have an exacerbation of congestive heart failure and now they're five pounds heavier and they were barely getting up from a chair or using their hands when they didn't have that five pounds? We ask, you know, if they have low bone mineral density and we don't give them the resiliency to reactive step when they have a perturbation, what is the risk when they fall of having a fracture versus somebody else? And that reframe is potent, right? Because it eliminates a lot of the fear and it gets us having a sense, or at least it does for me, a sense of urgency with respect to getting individuals moving. When I see individuals in pelvic health, a big part of my clinical practice right now is postmenopausal females. who are struggling with incontinence or other type of pelvic health conditions, and have underlying muscular weakness or muscular reserve issues. And when I step back and I zoom out and I see that the geriatric space, we tend to underdose. In the pelvic health space, we tend to underdose. My goodness, when you slam those two things together, we see that the bias is to keep people on the table doing Kegels, or we don't even offer them pelvic health services because we assume that leaking and incontinence is a part of aging. and it's something that they have to deal with and it's part of being postmenopausal and have had babies 50 years ago and therefore we're not going to address it. Today I want to talk to some of the literature that says that we actually need to prioritize that fitness more. When we look at aging physiology of the reproductive system, we see that as men and women transition through menopause or andropause, right? Menopause blunting of female sex hormones, andro blunting, but not removal of the male sex hormones, AKA testosterone, that we see a rise in pelvic floor dysfunction. For females, there are one in four individuals are struggling with pelvic floor dysfunction that increases with age. For males, significant increases in pelvic floor dysfunction happen because many of our younger or middle-aged men, not all, but the rates of pelvic floor dysfunction are much lower and they start to increase with age, right? So pelvic floor dysfunction is talked about a lot more in the female space because it's more common. It is definitely more common as we get older. And when we are thinking about incontinence, we are thinking about different types, right? We have stress incontinence, that is more of a mechanical issue where inner abdominal pressure in the belly is exceeding the ceiling pressure of our pelvic floor to be able to close our holes, our urethra and our anal sphincter. And if we don't have enough of that capacity to close those sphincters off, then we pee or poop or pass wind when we don't mean to. Urge incontinence is that we get the urge to go to the bathroom and then we don't have the capacity or we have a very sudden behavioral intervention where I have to go to the bathroom and I have to go right now. I get the urge, I can't defer that urge, I have to go right now. That's very largely outside of any pathology in the kidney or the urethra that it's largely we're seeing behavioral issues. The other camp that we need to really speak to in the geriatric space is functional incontinence. So functional incontinence is that individuals are getting the urge to go to the bathroom or when they have to toilet, there is either a functional capacity issue where they physically cannot make it to the bathroom, or there's a cognitive issue where they get the urge, but because of some changes to cognition, They either do not act on that urge or they lack insight to have that toileting behavior. When you are working in acute care, we see a lot of this functional incontinence happen in combination with the burdens on our healthcare system, right? We see that individuals have to go to the bathroom, they're waiting a really long time because of our staff shortages, and then we're giving individuals periwicks or external catheters or internal indwelling catheters to prevent any incontinence issues from happening that are a consequence of them being sick. Okay, so when I think about stress incontinence and functional incontinence with aging, super common, a lot of times this is an issue of muscular reserve. If your body is one rep max living, where the demands of your day are at or exceeding your one rep max, your pelvic floor is a set of muscles that is acting no differently, right? If your entire body is experiencing weakness, then your pelvic floor is experiencing weakness too. And what that means is that yes, we want to be very focused in the pelvic floor. We have excellent evidence for pelvic floor muscle training across the age continuum, including older age. And we have to recognize that by increasing the functional capacity of the system, we are going to improve a person's pelvic floor symptoms, which means that you do not have to be a specialist in pelvic health in order to make a significant contribution to a person's incontinence. And this to me lights my soul on fire because incontinence is one of the leading causes of institutionalization in our older adults. It is one of the main reasons. Urinary incontinence, cognition, mobility disability, right? Those are the top three reasons why individuals can no longer be independent in their home. And when I think about the role of PT and OT, the PT OT dream team and rehab in general, we target two out of three of those issues, right? And every single person can target the urinary incontinence piece. And so the first huge message that I want to have with this podcast is that one, every clinician is a geriatric clinician because we are not going to ignore a group of muscles and just say that this is not our scope and we don't know how to handle it because we know how to work with muscles. Two, if you have a person with frailty or sarcopenia on your caseload, we need to screen for pelvic floor dysfunctions because if we are seeing outputs of weakness in the musculoskeletal system in the person that we are working with, we have a higher likelihood that we are going to see something happen with incontinence. And this is extremely important considering that incontinence is a main reason or a big driver for individuals needing institutionalized care or increased help in the home. decreased likelihood that they can age in place. And then let's talk about how we put this fitness forward pelvic approach in, whether you are a pelvic health clinician or not. Okay, when we look at the evidence of pelvic floor dysfunction in an aging population, there's a couple of things that we see. One is that individuals with higher amounts of sedentary behavior are at increased risk for pelvic floor dysfunction at age match. So when you compare a cohort of individuals at the age of 70 or 75, those that are more sedentary are more likely to have incontinence than those that are not. So by getting individuals moving around more, you are going to reduce their risk for urinary incontinence. That is number one. Number two is that individuals who are physically active have reduced rates of significant pelvic floor dysfunction compared to those that don't. And so individuals over the age of 65 who are more active are less likely to have pelvic floor dysfunction. Speaking to the musculoskeletal reserve component of pelvic floor dysfunction and aging. Number three is that for individuals with pelvic organ prolapse, those that are weaker or more sedentary, have higher amounts of sarcopenia and frailty, are more likely to experience subjective symptoms of prolapse. So subjective symptoms of prolapse are feelings like your bladder is coming out, that you feel like there is a ball in the opening of your vagina, or that there are symptoms of bother as if there is a heaviness or a dragging sensation around your pelvis. And this is one that I wanna kind of focus on. So when it comes to pelvic organ prolapse, the combination of an increase in objective range of motion of the vaginal walls in combination with a subjective complaint of bother is the way that we create the diagnosis for pelvic organ prolapse. Objective range of motion changes to the vagina are a sign of aging, right? So we are going to see an increase in vaginal range of motion. We have wrinkles on our skin. We have wrinkles in our pelvis. That is one of our wrinkles. The subjective signs of bother, though, have a discordance between the amount of range of motion that people see and the subjective reports of symptom thresholds in that person. This is true across the lifespan where some people can have a high amount of range of motion and not experience bother or any symptoms at all can be completely asymptomatic and other individuals can have a little bit of range of motion change and experience a high symptom burden. So that range of motion change is like a disc bulge on an MRI, right? We cannot just hold onto that objective range. We have to do that with subjective complaints. What we are seeing is that those with more weakness have higher rates of bother. And this is where I really want to hit on the fitness forward approach. Because if you are a person who is one rep max living, imagine the strain on your pelvis when you are doing a one rep max lift versus you are doing something that is 10 to 15% effort, right? What are you more likely to do when you're one rep maxing? You're more likely to hold your breath, your inner abdominal pressure in your belly comes out. We see a lot more people who are bearing down or straining when it comes to that activity and that repetitive straining can be a risk factor for subjective complaints of prolapse. So if I have an older adult who is 100 max living, then they are straining with activities of daily living, right? They are straining every time they need to exert themselves around their house, which means that they are more likely to experience some of those subjective complaints of something falling out, right? That is a barrier to us being able to load people. So what the heck do we do about it? First, we acknowledge that that straining can be contributing to how a person is feeling within their body, feeling within their pelvis as they go about their day, okay? That's the first thing. The second thing is that we can acknowledge what our body is supposed to do under strain. A lot of our older adults don't realize that they are pushing down into their pelvis when they are doing strainful tasks. Is that even a word? I don't even know. Straining tasks, I guess, is a better way of saying that, across their day. So the way that I will reduce that strain on their pelvis, if they are experiencing these symptoms, is one, I will get them to acknowledge or understand that the pelvic floor should be contracting, not bearing down on effortful tasks. That might mean that I'm gonna ask them to do a tiny Kegel before they stand up. That means that I may ask them to exhale as they are standing up while we are working on getting them stronger so that we reduce the strain on their system and reduce their bothersome symptoms. And the third thing is that I focus on getting them stronger so that they do not strain their pelvis throughout the day. So if I think about how taxing it is on my body when I'm straining, for a person who has had pelvic floor dysfunction, I have had two vaginal births, I understand what that means, but also a person that has a good musculoskeletal reserve, my older adults are edging into that straining a lot faster. than my individuals without that reduction in deficits. So if you are a person who's working in home health, if you are a person who's working in hospital, if you're a person who's working in long-term care or skilled nursing, they are going to oftentimes be straining down, right? And that's why individuals are farting when they get up from a chair. That is your sign that they are bearing down as they are getting up, which means that they are straining on their pelvis, and that may be a risk factor for their symptoms. add in constipation, which is much more common with our individuals in their 70s and 80s because of a combination of decreased drive for hydration, decreases in gut motility, side effects of their medications, and potentially dietary changes, that constipation that straining, that reduction in musculoskeletal reserve is kind of like this trifecta of risk factors for that pelvic burden. That pelvic burden is a huge barrier to our physical activity, right? 50% of individuals with pelvic floor dysfunction reported as a barrier or a reason to stop being physically active. And so if you are having a person who is resistant, maybe let's ask and really deep dive into why, right? So when we are thinking about our fitness forward geriatric clinicians, where I want to finish off this podcast is know that you are already doing pelvic well. Because if you are getting a person to be less sedentary, get them doing movement snacks throughout the day, if you are encouraging physical activity and exercise in your people, and you are teaching proper movement mechanics, including and avoiding of bearing down, when individuals are doing activities of daily living, you know how to teach the brace, which we get you to do in our MMA live with our plank lab, right? That's the foundations of bracing. You are doing pelvic health well, right? Because we see so many of our older adults are struggling with pelvic floor dysfunction and their musculoskeletal reserve is contributing to that risk. If you are stuck with me for MMA Live, you know I end up on a soapbox about pelvic health because it's so, so important that a deconditioned person is a deconditioned pelvic floor and our older adults do not get the care that they need in conservative management of a muscle group that is absolutely within our wheelhouse. And that is also why if you are in MMA level two, we do an entire week on conservative management for the non-internal pelvic floor physical therapist on pelvic floor dysfunction, because it is a huge part and it is not just do Kegels. It is so much more than that. And everybody who is listening to this can get on board and be positively contributing to some of the improvement of those symptoms. And when I think last kind of point to make with saying that you are all doing pelvic well, is that by adding in the screens, increasing the muscular reserve of the system, and speaking a little bit to straining and breathing, I clear up so much pelvic floor dysfunction almost immediately in my practice. It's like my geriatric PT magic trick, right? If I have a person who is having wind or anal incontinence every time they sit up from a chair because their abs are too weak and they're bearing down and holding their breath every time they sit up from a reclined position, then When I teach them to breathe out as they do that, tell them not to bear down and get their abs a little bit stronger, it clears it up almost every time. And it's embarrassing for people, right? They don't want to engage in certain activities because they're afraid, or they pretend that it doesn't happen because it happens to them so often that they just don't acknowledge it anymore, even if they feel it. Oh my gosh, 20 minutes in. Gosh, sorry, Alan. So if you wanna learn and get the rants on the reproductive system, make sure to jump into MMA Live. We are this weekend up in Hendersonville, Tennessee. Julie's up there in Hendersonville and Dustin is in Aspinwall, Pennsylvania. We are going to have incredible groups. They're looking pretty good. The next courses for MMA, because we have sampler, and we have a long weekend. I am up in Bismarck, North Dakota, the 18th, 19th of May, and Jeff Musgrave is in Richmond, Virginia, same weekend. So you either have the chance this weekend to get into MMOA Live or middle of May is your next opportunities. And if you really want to hear me rant and rave about pelvic floor dysfunction, you guys have made it to the end of this podcast. Our level two is starting middle of May, but today's April, I'm losing track of time. And the level one is our prerequisite for that. We are going all the way to the ICE app for all of our MMA courses, starting our next cohort. We are super excited about that. And let me know if you guys have any other questions, because I love blending the Jerry and pelvic worlds together. Thank you so much, Andrea. All right, have a great day, everyone, and we will talk to you all soon.

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey reviews the anatomy of the latissimus dorsi muscle, its relevance to overhead movement, and discusses two ways to begin to improve long-term functional mobility. Lindsey also provides a rehabilitation every minute on the minute (rEMOM) program to begin to use for an HEP for patients who need to improve their own lat mobility.

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

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

EPISODE TRANSCRIPTION

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

LINDSEY HUGHEY
PT on Ice daily show. How are you? I am Dr. Lindsay Hughey from our extremity division, here with you today on a clinical Tuesday to share some pearls of how we'll get after our LAT mobility. So I first wanna just briefly unpack the function of the LAT, so a little anatomy review, and then I wanna discuss two ways to really get after mobility access, demo those two ways, and then suggest them in a rehab EMOM sequence for you all, so you can directly use it yourselves, or use it with your patients in the clinic. A lot of our overhead athletes, our weightlifters, our crossfitters, maybe even just our stiff shoulders need more access to lat mobility.

REVIEW OF THE LATS
So let's first just review what is the lat and where is it? Well, the latissimus dorsi is responsible for internal rotation of the arm, arm adduction, arm extension, and it even assists in respiration. in both inhalation and exhalation. It spans quite a big area of our extrinsic superficial back muscles. So we have a vertebral part that goes from our spinous processes and converges into the thoracolumbar fascia, goes all the way down to our iliac crest. There are even connections into that inferior angle of the scapula, and then even 9 through 12 ribs. So it spans quite a bit of area. The reason we review all of those areas is when you're doing your mobility work, you really want to make sure you hit all of those and make sure to challenge them.

TWO WAYS TO ADDRESS LAT MOBILITY
So I'm going to show you how we can do two versions, a way where we fix the arms overhead and move the body away to traction the lats from below. And then I'm going to review how you can fix from below and then move lats from above. What we won't do this morning, though, is just a static hold stretch. So before I review these two with you, I want you to know that purposely these two moves are so effective because in the first we're going to use a hold relax technique. So we're going to actually use isometric contraction, hold, and then lengthen tissue longer. And what we see with our ISOs, as long as you hold it at least six to seven seconds, I'm gonna make you all push to 10, but we see this increase in neural drive and we get those Golgi tendon organs to chill out and make that agonist, the deltoid relax so that we can actually gain more lat access. The second exercise, we're gonna actually go after eccentric training. So the reason we choose eccentrics as we see constant and ongoing research links to improve strength and length and even greater cortical excitability when we train in eccentric fashion versus just like a static hold or even doing concentric work for our lats. So without further ado, let me show you these two exercises. So number one, we're going to fix from above by putting our elbows on a surface. I'm going to show you on a bench here today, but it could be a bar. It could be a foam roller, whatever feels good for your body. It could even be the counter or a wall surface. So we're going to put our elbows in like a goalpost position, and then we're going to fix our arms here. And we're going to lean our hips back, but we're going to actively contract our arms down for a hold of 10 seconds, then relax and push our hips away. So we get this tractional effect from below. So it'll look like this. So elbows down, and we're going to push into the object while we push our head down. And we're going to push down for 10 seconds. and then access greater length. So you'll notice that I push my hips back and away as I gain access to new length, but that key piece is activate for 10 seconds into the surface, pushing down, and then move away. To fully maximize this particular movement, we're also going to tie our breath work, because remember I said function of lats is helpful in inhalation and exhalation, And then we have links directly to those ribs. So we're going to pair our breath with this. So we'll do it one more time, but this time we're going to link that isometric hold with an inhalation. And then on our exhalation, we're going to move away. So it looks like so we're going to go hold for 10 seconds, pushing down and then exhale and push the body away. And then we would do another rep pushing down 10 seconds. Inhale. And then exhale. For those that are just listening to this this morning, I do suggest watching the video so you get the visual. But we would repeat that for at least five to six reps. I'm going to show you how we'll do that in a rehab EMOM. But we really want to get at least a six to seven second hold of that isometric where we're pushing down before we lengthen. The key parts here being tie breathwork with it. And then don't forget to access more length and maintain it. So that next isometric hold where you're pushing down in the hold relax sequence should be in that newer length. The second exercise we are going to review today is eccentric training. So we are going, I'm going to lay in either hook lying position or you can put your legs up to put further tension on the thoracolumbar fascia. My palms are going to face toward the ceiling and I'm going to slowly lower a bar. Right now I just have a PVC pipe with a plate on it and I'm going to slowly lower eccentrically. I want the slowly lower to be three to four seconds and then a hold for three seconds at the bottom. And you'll repeat this with a goal of eight to 20 reps or what in extremity management we would call our rehab dose. Keys being that eccentric slowly lowering on the way down and the hold at the bottom. So we want about three to four seconds in each of those parts. Don't care as much about that concentric raising portion. Appreciate this eccentric could be done with dumbbells as well or kettlebells. I love starting with a PVC pipe and just a five pound change plate for those that are new to lat access. So we have two things that we've reviewed so far. We are going to do Number one, our ISO hold, where we get into a position where our lats are on tension and you push and drive the elbows down for 10 seconds. And then after that 10 seconds of inhalation and pushing down, you'll exhale and lengthen those lats into a new mobility access area. The second one is that eccentric overhead with the either Dow or PVC pipe and weight. Just these two things done.

MAKE MOBILITY EFFICIENT: THE rEMOM
So if you do each of these for a minute and you do three rounds, you have yourself a very efficient six minute rehab EMOM to attack lap mobility access. Nothing gets more bang for the buck when you combine both of these and you'll get relaxation. Start subbing your static hold stretches that either you're doing or that you're doing for your patients and really get the neuromuscular system on board to see change more rapidly. From a frequency perspective, at least two to three days a week is something I would recommend for my patients to get after and even using it as like a precursor before they do some overhead work because we know what will solidify this even more is then to actually load it and do some functional meaningful thing.

SUMMARY
If you want to learn more about how to even test if your patient has lat mobility tightness, if you want to dive a little bit more into dosage and the rationale behind eccentrics and why we don't use static stretches in our course at extremity management, Mark, Cody, and I and our extremity team would love to see you on the road. Um, and literally we have courses all throughout this year, almost every month in May, May 18th, 19th, I'll be in Bellingham, Washington, and our director of marketing say will be with me. So if you want to join us, that is sure to be a blast. And then June 1st and 2nd, we have two offerings, one in Wisconsin and then one in Texas. So check us out on ptlnice.com. if you want to learn more about how we think and treat the lats. Thanks for tuning in with me today. And if you're listening, be sure to watch the video later. Take care, everybody.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the role of physical therapy in the male fertility space.

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

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code ICEPT1MO at the time of sign up for a one month free grace period on your new Jane account.

CHRISTINA PREVETT
Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in both our pelvic health and our older adult division. I'm going to apologize in advance if I sound a little hoarse. I am not feeling well, but that doesn't mean that we aren't going to be able to have an incredible episode here on the podcast. So today I wanted to dive in a little bit on male fertility. So last podcast episode that I did several weeks ago, I was talking about our role as physical therapists or individuals in the rehab space in fertility. That conversation circled very much around female fertility and around ethical considerations for fertility. We're gonna continue that conversation. We are gonna launch off of that conversation into our male fertility and male fertility related factors. So I feel like when we are talking about individuals who are struggling with fertility related concerns, a lot of our conversation centers around the female pelvis. And that makes a lot of sense because individuals who are struggling with fertility, it's oftentimes, we are hearing about assisted reproductive technologies like IVF and IUI that are largely interventions that are done for females. And so if couples are dealing with infertility, the female is oftentimes doing different interventions to allow for more successful rates of conception or implantation in the uterus based on a variety of factors. What I think is important for us to recognize, though, is that 30 to 50% of couples who are going through infertility have male-related infertility factors. Let me repeat, between 30 and 50% of couples seeking help for fertility-related concerns have a male-related factor in their journey. And I think this is really relevant for us to be starting to have conversations about because so much of our education has focused on the female pelvis and our males really don't know a lot of things that relate to their fertility. So there was a cross-sectional survey that was published asking males of reproductive age about their fertility. 55% of them, 54% could not identify factors that positively influenced male fertility. So we have a role to play sometimes when we are working with individuals. This is probably not an area of practice where individuals are going to be all of the time marketing their services in male fertility, but I think it's important that we talk about the male aspect of infertility as well. When we are talking about male related concerns, we have sexual response concerns and then we have sperm related concerns. When it comes to the sexual response related concern is that in order for conception to happen, an erection has to be able to be developed and maintained in order for that erection to lead to ejaculation in order for sperm to meet the egg. That sexual response needs to happen. If you are struggling with erectile dysfunction, if you are struggling with pain with ejaculation or testicular pain with sexual activity, those are going to be big barriers to a person being able to successfully have penetrative intercourse. We have a huge role to play in helping with erectile dysfunction and with individuals who are experiencing pain. And in our level two course, we go into a lot of these pain syndromes that focus around the male pelvis. And so the first thing is clearing some of those conditions. Secondly is we talk a lot about the sexual response being not just a mechanical property where you want to have sex, you get that sex response, and ejaculation occurs. There are a lot of bio-psychosocial factors that go into a person's sexual desire, their libido, and issues related to their want for that type of intimacy. We have a book called Come As You Are that is focused on the female pelvis and the female sexual response, but we don't have as many of the same type of resources for males who are struggling with the same thing, right? Like if you are really stressed out, if you are not sleeping well, new parents who are like in the thick of postpartum, that doesn't just affect are females, that can affect our males as well. If they are struggling with mood disorders like depression or anxiety, that can have huge side effects on their libido and their desire for sexual activity. If they are on certain medications, it can have influences on their sexual desire. And so having conversations about the biopsychosocial factors of the sexual response are also important. So when we are thinking about the bucket of sexual response for males, our role comes into helping individuals with erectile dysfunction, if that's something that we have cleared that may be in our wheelhouse around hypertonicities or different type of pelvic pain issues that are leading to that response. A lot of erectile dysfunction is a vascular response and individuals with erectile dysfunction are at higher risk for cardiovascular disease. So there's a health promotion component there. And then we're also going to have a lot of education around libido. If it is the physical act of penetrative intercourse that is a stumbling block for a couple who is dealing with infertility. We see this all the time in our female pelvis with those with vestibulodynia or other dyspareunias or pelvic pain syndromes. This can also be true for our male pelvis, which can create a barrier for individuals being able to have sex at the right time. Okay, so that's kind of our male response piece. The second is on the sperm itself. And so when we are thinking about the male sperm meeting in the fallopian tube and being able to successfully have a conception moment that happens, we have to think that there has to be enough sperm and the sperm has to have good motility or movement, which is related to its shape in order for it to make the long road to the fallopian tube. I mentioned in my female fertility podcast that it's interesting with some of our health promotion because female pelvises have all of the eggs that they are going to have in their entire life by the time they are born. They do not develop more eggs. Eggs mature across cycles. That is not true for the male side of the physiology. For females, that means that health promotion is related to their entire lifespan. For males, that is 74 days. So the maturation cycle of the sperm is 74 days. What that means is the acts that you take, the health promotion incidences that you take when you are trying to conceive, what is really important is those 74 days are approximately three months prior to conception. So if you are a couple who is trying to conceive, your health promotion factors for the male in the three months prior to trying to conceive matter, okay? They matter. So when it comes to our sperm volume and motility, what we are seeing is that there is a large influence on motility for reactive oxygen species and low-grade inflammation. And you all are probably thinking, well, that's good news because that means that our health promotion factors are going to be very relevant in male fertility. And you would be correct. OK, so when we're looking at the magnitude of improvement in fertility for those that start taking on more lifestyle related factors, health promoting factors, it is significantly more beneficial for men who are trying to get pregnant or get their partner pregnant than it is for females because females it's the accumulated reactive oxygen species of their entire life up to this point where it's still going to be beneficial but the magnitude is not going to be the same as the 74 day cycle of the male sperm. What that means is that we have several modifiable risk factors that we can be educating on when it comes to our fertility. So heat stress, use of a sauna, is one modifiable factor that seems to degrade sperm quality. Another one is alcohol use. Alcohol use can negatively impact sperm and sperm-related factors, and it should be avoided or minimized for individuals, for the male partner, for the female partner too, but specific to the male when we are trying to conceive. Steroid use and use of testosterone replacement therapy is a big cause of male-related infertility. It is not everybody who is on TRT, but in our male pelvis, right, the exogenous hormones shut down some of our spermogenesis type of physiological pathways and our body or the male body isn't producing sperm because there is an exogenous hormone that is coming in that says we're good. Okay, we're good. So individuals who are on exogenous steroids, so this is kind of our athletes. Pardon me, sorry. They're on TRT. We're seeing a lot of individuals who are topping up their T to be on the higher end of physiological normal. That may be a big contributing factor for them for their infertility. So asking about any supplements or any medical interventions that individuals are doing to top up their testosterone is a big factor. Smoking is another male related factor that can influence fertility. Smoking creates an increase in reactive oxygen species. creates chronic low-grade inflammation, this makes a lot of sense. The other one is obesity. Adipose tissue is low-grade inflammation tissue and can contribute to the burden of low-grade inflammation on the body. So a lot of these like heat stress saunas, alcohol use, TRT, smoking, and obesity are things that we can counsel on. Another very big influencing factor is a person's exercise. So sedentary behavior is linked to lower fertility rates and those who are physically active in the three months leading up to their fertility journey, starting, trying to conceive, have a higher rate of fertility. So the influence here though is a little bit nuanced from what we're seeing in the literature. So individuals who are active going into their conception journey. It doesn't seem for those who are not struggling with infertility to influence how fast a person gets pregnant, but it influences if there is going to be a male factor fertility issue. That makes a lot of sense because it's two people, right? We're going to only be able to optimize the person that we are working with. being physically active, going into your conception is a good thing to do. Especially most of our evidence, you guys are not surprised based on where my research is, like a lot of this is in aerobics, so we're trying to build up some of our resistance training literature. So being physically active, being less sedentary is good. The only flip side of that is for individuals who are really active. Okay, so for our highly, highly active, especially endurance, especially cyclists. Okay, so when we are working with individuals who are very highly active, especially our endurance trained individuals, we are seeing an influence on sperm motility for those who are cycling for more than five hours. And what that is, is the closeness of the testicles to the body when you're on a bike that is putting the seat close to the body, because the heat can influence the sperm and sperm quality. It's also some of the impact, mechanical impacts of the bike seat. We see that there are higher rates of erectile dysfunction and pudendal neuralgia, which can influence sexual response in our high-level cyclists. And we are recognizing that individuals who are in the endurance space, our male endurance athletes, are at risk for RITS, relative energy deficiency in sport. Our female athletes are much more sensitive to underfueling and that low fuel and energy availability and its impact on their physiology, but our males are not immune. And our endurance male athletes, in particular, appear to have a higher incidence of underfueling than we are recognizing. And so Exercise in general is very good for fertility. For those who are on the very high volume side of the spectrum, we may be counseling on type of exercise, fueling, and volume, and clearing for any types of sexual dysfunctions that may influence a person's conception.

SUMMARY
All right, I hope you found that helpful. I found this literature to be so fascinating. When I think about fertility and the male cycle, I just kept thinking, this really feels like a vital sign for health for our males, right? Like when I'm thinking about the sperm quality, reactive oxygen species load, like it almost feels like an HPA1C for health of the entire body. We use HbA1c to get a good idea of blood sugar responses over the last three months. We can get almost like an inflammatory load response for males in the previous 74 days with sperm analysis. Now, we're not going to go and get pupils to have a sperm analysis every couple of months to take a look at their health, but I think it is fascinating to see how sperm-related parameters can really give us some insights into the overall health of the male that we're working with. All right, if you are interested in learning all things about fertility, we dive into fertility management in our level two course across a variety of weeks. So we talk about fertility and influences for fertility. We talk about fertility related conditions that lead to infertility, and we talk about assisted reproductive technologies and the influence of different fitness forward modalities on ART technology. So if you are interested, our next level two, you have had to have taken our level one online course to get into that is in August. I have just been in Texas last weekend. It was so fun. You guys were so great. I'm so thankful for you all. Around learning about all things pelvic this weekend if you were looking to get into our live course Our next course is May 18th 19th in Kearney, Missouri Then I'm gonna be in Highland, Michigan June 1st and 2nd Alexis is gonna be up in Anchorage, Alaska and then June 8th 9th. I have a back-to-back I'm in Mineola, New York. So I'm at Garden City CrossFit close to New York City and I would love to hang out with you guys. We had so much fun at dinner. We were talking all things Pelvic health and we just had a great time. So if you're interested in any of those courses

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses incidence of knee injury in functional fitness, common types of knee injuries seen in this space, and how to begin to treat knee pain for the fitness athlete.

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

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

EPISODE TRANSCRIPTION

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

ALAN FREDENDALL
All right. Good morning, everybody. Good morning, Instagram. Good morning, YouTube. Good morning to those of you on the podcast. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. My name is Alan. Happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and our division leader in the fitness athlete division and practice management divisions. It is Fitness Athlete Friday. We would say that means it's the best darn day of the week. And here on Fitness Athlete Friday, we talk all things for folks who are recreationally active. So those patients and athletes active in CrossFit, functional fitness, running, endurance sports, whatever, that person who is getting up every day and getting in their daily movement, we're here to help you help them. So today we're going to be talking about knee pain in the fitness athlete. And in the context of today, we're going to be talking about specifically those folks who are probably squatting on a regular basis. So CrossFit and functional fitness athletes, folks who are maybe squatting, squatting heavier, higher volume on a more frequent basis than maybe some of our endurance athletes.

INCIDENCE & TYPES OF KNEE INJURIES IN FUNCTIONAL FITNESS
So I want to talk about what types of injuries do we see in the knee in this space, describe a little bit about those injuries, and then discuss the beginning stage of how to begin to treat some of those conditions. So first things first, What do we see with knee pain in the fitness athlete population in general? The great news is over the past decade or so, we have got a lot of great high-quality research out of the CrossFit and functional fitness space about what regions of the body are injured most frequently, and then kind of what conditions follow those injury diagnoses. So we should know that in the fitness athlete, we primarily see shoulder as the most injured region. About 45% of injuries are from the shoulder. Really close behind that is the low back about 35% and then really musculoskeletal injury kind of falls off after shoulder and low back. Specifically today talking about the knee we see about 15% of injuries are related to the knee. Beyond that we have elbow, wrist and hand, ankle and foot, that sort of thing. So primarily shoulder and low back and then a real sprinkle of the knee. With those knee injuries, we're not seeing really major traumatic injuries. It's very rare, probably never in your gym, anecdotally, have you seen somebody fracture their leg, fracture their patella, tear their ACL, get hit by a vehicle, fall off a thing. That usually doesn't happen in the space of the gym. Primarily what we see in the fitness athlete population, folks who are doing a lot of impact, a lot of squatting, is that we see a lot of patellar tendinopathy and we see a lot of what we maybe would describe as a meniscus issue but really something that we could just generalize as medial knee pain. So now breaking down those two major conditions patellar tendinopathy and meniscus or medial knee pain first things first I would tell you if you haven't yet taken our extremity management course with Lindsay Huey, Mark Gallant or Cody Gingrich I would recommend you get to that course as soon as possible. That course is a really great complement to our fitness athlete courses as far as being able to recognize and diagnose and stage a tendinopathy, diagnose an extremity condition, but also treat it and learn a lot of progressions and regressions to treat those injuries. Specifically, they spend a lot of time the entire afternoon on Saturday addressing the knee in a lot of detail. So make sure you're really comfortable with these conditions. if you hear words like patellar tendinopathy or meniscal care and you think, quad sets? I don't know.

PATELLAR TENDINOPATHY & MENISCAL CONDITIONS
So talking about patellar tendinopathy, what do we know in overuse condition? who is that person in the gym that we maybe need to be aware of, or questions in our subjective exam with that person that would let us know this person may be in that bucket. Somebody brand new to squatting, think of somebody in their 40s or 50s, sedentary, maybe their entire life, that's not out of the realm of possibility these days, who is now jumping into CrossFit, jumping into Orange Theory, jumping into F45, being expected to squat at higher volume and higher loads than obviously they ever have in their life. Folks who maybe are not new to this space but are maybe incurring and encountering a higher level of squatting volume than normal may also fall into this bucket. There are also movement patterns that tend to show up in these folks. I like to stage these as two different movement patterns. The first is what I'll call the close enough squat depth pattern, right? That person who is getting to maybe just above or just at parallel. what do we know about that range of motion in the squat we actually know that's when force on the knee is at its highest that above that point at about 45 to 60 degrees or less of knee flexion and then below 90 degrees of knee flexion we know we have a deloading effect at the knee so those folks who are trying to squat to full depth but are in just that close enough bucket are putting a lot of mechanical force on their knee that they could get rid of if they either squatted more shallow, which is not ideal, or ideally squatted a little bit deeper. The second group of movement pattern folks who fall into overloading their knee is that back and down squat pattern person. So that person who does not break at the hips and knees at the same time. So as we instruct the squat, we like to tell people, imagine there's a rope around your hips and your knees and they're pulling in opposite directions at the same time. That means your hips should flex and your knees should flex. And ideally with a relatively vertical torso, you sit down, sit straight down into that squat pattern. The down and back folks tend to initiate their squat with a hinge, and then to get to depth at the last moment, bottom out that squat and drive all of that force into the anterior knee to hit depth. This is kind of how powerlifters tend to squat, especially with a low bar back squat. But folks who just have not grooved out the motor pattern of the squat yet, when they hinge back and then sit down to finish the depth, the knee again is taking up a lot of force that really we could clean up with some coaching and cueing, right? Maybe we could elevate that person's heels, give them a corrective to hold a plate in front of them, but otherwise encourage a more vertical torso and a more sit straight down squat pattern that distributes force equally between the hips, knees and ankles in their squat pattern instead of at the moment of truth, putting all the force in the knee as they try to hit depth. So that's the patellar tendinopathy bucket. What about the meniscus, the medial knee pain bucket? These are folks who are encountering a lot of impact in rotation. So we do see this a lot in the functional fitness space, right? We do running. We might not go run marathons, but we do a lot of workouts with 200, 400, 800 meter runs. We do a lot of box jumping to train triple extension. We do a lot of double unders for model structural cardio work. And we have begun to introduce shuttle runs, at least in the CrossFit space, to be able to run indoors during the winter in a competition environment where maybe we don't have access to run outside or we don't have the treadmills to be able to run inside on a machine. With shuttle runs comes not only the impact of running, but now a turning rotation moment. not too dissimilar from catching a box jump in the bottom of your squat with your double unders or with running in general. Also in this group are folks who might be new to squatting full depth or otherwise increasing their squat volume, right? No different than the patellar tendinopathy bucket that they are now encountering extra volume. So understanding who that person is is really important and that's where knowing that this person is a functional fitness athlete knowing if they are new to this or not, if they're returning after a break, if they've never done something like this in their life. Uncovering all of that in the subjective history is really important because it's going to give you a better idea of where your treatment might take you.

TREATING KNEE PAIN IN THE FITNESS ATHLETE
So let's talk about that treatment. What should be our priorities in treatment? With our functional fitness athletes, we're demanding full range of motion at every joint whenever possible. That means one of our primary goals should be if we find an asymmetry, a lack of range of motion, particularly in knee extension and knee flexion, we need to restore that as soon as possible. Again, I'll point you towards our extremity management course. I'll point you towards our fitness athlete live course to learn techniques to self-mobilize to load to restore that full range of motion. But as we're restoring that full range of motion, respecting the irritability of the patient, we need to begin to strengthen in whatever available range of motion we have. These folks do not need more volume, right? They're coming to you with an overuse, a repetitive use injury already. Giving them a 20-minute AMRAP or a 30-minute AMRAP and having them do hundreds of squats or lunges in the scope of their PT session is just adding insult to injury, especially if we are thinking that this is a patellar tendinopathy case, for example. These folks need strength, they need capacity and resilience in those structures, so that they can continue to not only stay in the gym, but perform in the gym, ideally, beyond the point at which they got injured, right? We don't wanna just return somebody to the exact moment at which they got injured. Ideally, once we clear them fully, hey, you don't need to do your PT exercises anymore, they are a stronger person than when they first began rehab with us. So we need to strengthen that full range of motion of the whole knee. Now PT school has closely associated in our brains that the knee means quadriceps and that's it, right? It's all over the research. It's all over knee extension machines and really, really focused on making sure that we have really, really strong quads, which is not a bad place to start, especially if that person is missing some knee extension, right? Some, some traction banded straight leg raises can do a lot to both begin to restrengthen quadriceps, but also restore knee extension. but we can't just stop at the quadriceps. We need to strengthen the whole knee, right? All four muscle groups of the leg that attach to the knee. So we also need to make sure we're targeting our hip abductors, our hip AD ductors. We need to target, yes, the quadriceps, but we also, especially if we're thinking this is a rotational-based injury, if we are thinking this is medial knee pain, call it meniscus, call it whatever, we really need to focus on the hamstrings because why hamstrings flexed and rotate the knee. They are pulling the knee into medial or lateral rotation in a movement like running. Ideally, hopefully, they're firing pretty much in sync so that we don't have a lot of rotation in our knee. We're primarily going through flexion extension, but our knee does have the capacity to rotate, obviously, and it's primarily driven by our hamstrings pulling the knee into flexion and in rotation. What is the problem with hamstring strengthening? The problem with hamstring strengthening is that in most functional fitness environments, we don't primarily isolate and train the hamstring. We certainly do a lot of deadlifts, we do a lot of kettlebell swings, that sort of thing, but if you think about the range of motion from the knee and the hip in motions like deadlift, kettlebell swing, it is not full range of motion of the hip and or knee, which means we're not strengthening the hamstring through its full range of motion. Yes, you'll feel a little maybe glute, high hamstring burn on high volume deadlifts or kettlebell swings, but you are not getting that deep behind the knee stimulus that you are with things like Nordic curls or even just isolated knee flexion on a knee flexion machine or banded knee flexion or anything like that. So understanding that the hamstrings flex and rotate the knee is really important to kind of finishing the drill on a really comprehensive knee strengthening program. Understanding that biceps femoris is responsible for knee flexion, but also yes, lateral knee rotation, and that semimembranosus and tendinosis are responsible for flexion and medial knee rotation. So particularly with those medial knee pain bucket folks, we wanna get into semimembranosus, semitendinosus, maybe with our hands, with needles, with cups, whatever, try to restore both that flexion and rotary component of the knee, and then get out in the gym and really strengthen those hamstrings on top of, yes, the quadriceps, the hip abductors, and the hip adductors.

TIME UNDER TENSION IS KEY
The key with strengthening the knee, again, is time under tension. The folks you're working with are already doing higher volume, higher repetition, relatively moderate to higher load training for the knee in a Metcon style workout. So adding in more air squats at high volume or light wall balls or thrusters or goblet squats is really just doing the same thing that they're already doing in the gym, which led them to be sitting on your table in the first place. So just giving them more of that isn't necessarily a prescription. When we have students at Health HQ, they're so excited to have people out in the gym moving, folks who are interested in taking care of their health and fitness, and they love to jump up to that whiteboard and write out, Remom 24, Amrap 30. We have to go, wait, stop, stop. That's not appropriate for this patient, right? This patient is already dealing with the consequences of too much volume. We need to back their volume down, especially in physical therapy, and focus on time and attention. So be careful that we're not actually exacerbating or at least prolonging the healing time of that patient's condition because our volume in PT, our volume for our home program is too high. Slow it down, less reps, less sets, more time under tension. Depending on the patient's irritability will let you determine how much tension you can apply both in the clinic, in the gym, and for homework. When someone's really irritable, I'm thinking maybe isometrics, and I'm thinking something like a reverse Tabata. 8 rounds, 10 seconds of work, 20 seconds of rest. There are apps out there. I personally like GymNext. It is a timer. It has a Tabata built in, EMOM, AMRAP for time built in. It can connect to a Bluetooth clock that the company sells, but you can also just use it as a standalone app and play it through a Bluetooth speaker or just through your phone speaker for your patient to hear. So reverse Tabata, eight rounds, 10 seconds of work, 20 seconds of rest, that gets us 80 seconds time under tension. That's a pretty good start, especially if we're doing it isometrically and the patient is really, really, really irritable. Now, as symptoms calm down, as function begins to improve, as tolerance to loading begins to improve, we want to increase that time under tension dose, especially if we're convinced that this is a tendinopathy based condition. So I like to move next to 10 sets of 10 seconds of work. I'll usually do 10 seconds on, 20 to 30 seconds off for 10 sets. That bumps the needle about 20%. That gets me 100 seconds time under tension. Then, when that patient appears ready, we'll probably progress to a Tabata. That's 160 seconds, right? It's the opposite of a reverse Tabata, a full Tabata. 8 rounds, 20 seconds of work. 10 seconds of rest. So the inverse of a reverse that gives us 160 seconds. So now we're close to pushing three minutes time under tension through that structure. At this point, you're probably away from isometric exercise, but if you're not great, keep rocking the isometric exercise for more attention. And then really for me, kind of the hallmark that someone is getting close to the end of their plan of care is when we can do isotonic movement, we can do five sets of five, and we can do some really gnarly tempo right think about a slant board goblet squat right so he was really elevated a lot of focus on tension through that anterior knee and that medial knee structure three seconds down hold the bottom and as deep of a squat as you can show me three seconds and then three seconds standing concentrically out of that squat. That's nine seconds per rep, five reps per set, five sets. That gives us 45 seconds time under tension per set. That gives us 225 seconds across the five sets. That is what the tendinopathy research tells us we need to be hitting as a benchmark for our time under tension. So understanding, depending on that patient's irritability, depending on how long this condition has been going on, that person may not be able to walk into the clinic and do a slant board, heels elevated, goblet squat, five sets of five at 3-3-3-1 tempo. That might be a lot, right? Certainly probably going to make them sore, but it might aggravate their condition. So understand how we can regress and progress, time and retention is needed. And then make sure as well that we're doing that for every structure of the knee. Again, that we're hitting the medial knee, the lateral knee, the anterior knee and the posterior knee, particularly doing things for the hamstrings like Nordic curls, curls on the rower, furniture slide curls, anything to really target the hamstrings as they insert at the knee as they flex and rotate the knee. and not just strengthening mid-range of the hamstrings and mid-range of the quadriceps.

SUMMARY
So knee pain in the fitness athlete. How frequent? About 15% of all injuries, so relatively low compared to all the other injuries that this population encounters. Primarily, folks, patellar tendinopathy, meniscus, medial knee. Why? Overuse, either a sudden spike in volume from a more competitive athlete or a new athlete, or someone who is maybe doing extra stuff outside of the gym, extra running, extra squatting, whatever. Folks to watch squat when they're with you, are they the close enough depth person? Do maybe they need some help in their ankles or hips to hit better depth and take load off the knee? Are they the back and down squat person? Do they primarily squat with a hinge and then bottom out through the knee to hit depth? That is a person that can benefit from sequencing their squat pattern a little bit better, especially if they do have a goal to be a functional fitness athlete. They need to be able to show a relatively vertical torso squat, a high bar back squat, a front squat, a thruster, a clean, that sort of thing. With our treatment, make sure that we're working as soon as possible to restore full range of motion of both extension and flexion. We need full knee flexion to squat. We want full knee extension for impact. We want to strengthen the whole knee, not just the quadriceps. Hit the hip abductors, hit the AD ductors, and particularly full range of motion hamstring work, not just things like deadlifts and kettlebell swings. They're already doing partial range of motion hamstring strengthening in the gym. And then remember, it's not about volume. It's not about coming into PT and doing 500 air squats. They can definitely do that. It's probably going to exacerbate their symptoms. What we're focused on with our strengthening with their home program is time under tension. Start with the reverse Tabata. 10 seconds on, 20 seconds off, eight rounds. 80 seconds time under tension. Move to 10 sets of 10 on, 20 to 30 off. That's 100 seconds. Move through a full Tabata. Now 160 seconds, 8 rounds, 20 on, 10 off. And then the gold standard is can we do 5 sets of 5 of a movement at 3 seconds eccentric, 3 seconds isometric, 3 seconds concentric. Can we get to that 225 second time under tension benchmark? So I hope this was helpful. I'd love to hear questions you all have, throw them here on Instagram, shoot us an email, shoot us a message over on the ice physio app. Some courses coming your way from the fitness athlete real quick before I let you go. Our next cohort of fitness athlete level one online starts April 29th. That course is already almost sold out and it does not start for three more weeks. So if you've been looking to get into that class, that class has sold out every cohort since 2017. This next class will not be the exception, I promise you. So if you've been on the fence, get off the fence. If you've already taken that course, your chance at level two online to work towards your certification in the clinical management fitness athlete begins September 2nd. And then some live courses coming your way. Mitch Babcock will be down in Oklahoma City this weekend, April 13th and 14th, if you want to join him. He'll be back on the road again, May 18th and 19th out in Bozeman, Montana. And in that same weekend, Joe Hanesko will be up in Proctor, Minnesota, which is in the Duluth, Minnesota area. That will also be the weekend of May 18th and 19th. So hope this was helpful. Hope you all have a wonderful Friday. Have a fantastic weekend. Bye everybody.

OUTRO
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