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The faculty of the Institute of Clinical Excellence deliver their specialized content every weekday morning. Topic areas include: Population health, fitness athlete management, evidence based spine and extremity care, older adults, community outreach, self development, and much more! Learn more about our team at www.PTonICE.com
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Now displaying: Page 6
Aug 30, 2023

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses how healthcare providers can learn to assess patients' readiness to change when becoming more active, barriers they perceive to exercise and confidence in implementing a regular exercise program. Alex challenges providers to become a "guide to self-efficacy" with patients to increase their regular physical activity.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:33 ALEX GERMANO

Good morning, Instagram. Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today's segment of Jerry on ICE. My name is Alex Germano. I'm a member within the older adult division. We are going to talk about a recent article that came out talking about how to address inadequate physical activity in our patients, especially older adults. The older adult division continues to charge across the country this fall with courses in Charlotte, North Carolina, Fort Collins, Colorado. That's happening this weekend. You can catch us in Oklahoma City, Bellevue, Washington and Falls Church, Virginia to round out September. Head to the PT on ICE.com website to learn more about our current course offerings. It does not seem like we're slowing down coming into the end of this year.

02:31 INCREASING PATIENT'S PHYSICAL ACTIVITY

I know it seems a little lame to come on the podcast and talk about increasing our patients' physical activity clinically. I mean, I say this is a little lame because I think it's something like we're like, duh, we all know. We need to get our patients more physically active. And so it doesn't seem like the coolest thing we can talk about if it's a problem we all know about. But I thought this article added a lot of value to this conversation. Clinically I've really gotten to this point as a therapist where I believe that most of my patients' ailments, their balance concerns, the unsteadiness they have, the lack of endurance they have, the lack of strength could all really be fixed by joining a gym or performing some type of meaningful fitness in their lives. I have really begun to embrace and step into this role of being a guide to their land of fitness for my patients. And I do care about the reason I'm there and trying to work through that with them. But really the ultimate goal in the back of my mind the whole time is how can I lead this person to meaningful fitness for longer durations? Because I know that my physical interventions are not going to stick around too long if the only thing that they're doing for physical activity is physical therapy or occupational therapy. Now because this is the way I approach my patient care and sometimes I'm all by myself out there in the world doing home visit, I really thought that every physical therapist out there was trying to increase their patient's physical activity. And I think I'm a little blinded by the community that I'm a part of, ICE, and that we're probably all trying to do this. So I just thought every physical therapist is out there really trying to do this thing and everyone's going to be super bored by this conversation until I saw the statistic in this paper that despite 91% of older adults over the age of 65 not performing recommended activity guidelines, 91%, which is costing the world $53.8 billion a year, 50 to 75% of healthcare providers are not assessing and addressing inadequate physical activity in their patients. 50 to 75% are not addressing physical inactivity. And I thought to myself, oh well let me look at the studies that they're citing for these statistics because clearly physical therapists or occupational therapists are definitely addressing this. They probably lump together all these healthcare providers. No, most of the studies they cited for the statistic were involving physical therapists or other rehab providers. Yikes, mind blown. This is significant. And I think a lot of us are trying. We're probably trying. We are making some of these light suggestions for home exercise program. We tell people to break up sedentary behavior and sedentary time. But how often is that really working? How often does that patient go off to join a gym? How often do they start seeing the personal trainer? Do they start telling you every time you come, I am doing all of my home exercise? Honestly, not very often. So it's not maybe our lack of trying, but rather the way we're trying to approach this conversation is what's off about how we're trying to solve this problem. So this article that I am referencing, which will be in the links on this Instagram page, suggests that we might not be advocating for physical activity well due to a few factors. It could be our lack of knowledge or confidence on how to assess and address inadequate physical activity. It could be an uncertainty on how to use behavioral change techniques in clinical practice.

04:05 LACK OF PHYSICAL ACTIVITY AWARENESS

So the first part, how do we get more comfortable and confident in assessing and giving our patients physical activity recommendations? At the Institute of Clinical Excellence, you've heard it a million times. We do it ourselves. We walk the walk. We be about it. We can't say this enough, right? By having a solid foundation of our own exercise program, you're going to be much more convincing, much more inspirational to your patient whom you're trying to get to the land of fitness. Now I will admit sometimes though, I'm going to be and not worry about this. I don't think that this is, I think this is important that we're this way, but it's also important that we remember what it was like to not be fitness forward at all because having this strong personal practice and exercise can be detrimental. I am on vacation and I, when I'm on vacation, I love to exercise. Like love it. I got out there for a run this morning because we're coming up to our marathon and I wanted to get out there, got a good run in. I love to work out because on vacation I have extra time. I'm not in a rush to be in the gym early and get out of there early. So I love it.

07:21 EXERCISE AS A CORNERSTONE

A lot of my patients though report that exercising on a vacation is like absolutely not going to happen, right? It's like, it's so easy they're not going to be able to do it. And like I was thinking about like, why do I exercise on vacations? Because it means so much to me and I really know and appreciate exercise in my life, right? This is the curse of knowledge that I have. I know how good exercise is going to make me feel for the rest of my days. My patients do not feel that way. Dustin Jones talked about this actually a number of years ago talking about the curse of knowledge. I know how good it feels, how easy I can fit it into my life even in exceptionally busy times. We don't remember what it's like to be that newbie. And it's a huge excuse I see for my patients and I almost want to laugh when I make patients tell me they don't have enough time to exercise, especially knowing they're retired. They're not really having much to do around the house. Like most of their chores are kind of outsourced to other people and like as a new, like a newer mom, right? Like I have a one and a half year old and I've worked multiple jobs. Like sometimes I feel like I'm barely hanging on. Exercise remains a staple in my life. I could sit on my high horse and tell them I'm so busy and I still can fit in five days of exercise during the week. How many hours of TV a day are you watching? Don't you think you could sub in one of those hours for exercise instead? That conversation has never worked in clinical practice to elicit change in my patients. Okay? When I hear my patients don't have time, that really tells me something more. It tells me a lot about their readiness to change their lifestyle. And this might be really the missing piece around some of our education surrounding physical activity. So after you ask your patients about their current activity levels and compare these to the traditional guidelines set out by the ACSM, those ACSM guidelines, you can start to assess their stage of change. I think that's the most important thing we answer first. How ready is my patient to change? How ready are they to change? So an important question could be, do you intend to change your physical activity in the next month or in the next six months? I'm trying to determine a timeline. Now you can decide based on the answer if they kind of fall into these different categories. Are they in the pre-contemplation phase? Meaning they're not interested in really changing their physical activity at all. Or are they in the contemplation phase? Do they intend to increase their physical activity in the next month or the next six months? And do they have a plan in place to make that change? Most of my patients really land in the pre-contemplative phase where they're not considering changing really anything. They're not coming to me for an exercise program. They just have a problem they want me to fix. Now if there's some, you might even meet somebody who's in a preparation phase, who's actually made a plan to change some of their physical activity. They've reached out to a local gym, something like that. And if they're in that preparation phase, you're going to want to follow up on what's their action plan to increase their physical activity levels. If someone is in the pre-contemplative stage of change, we want to validate their current perspective. We don't want to convince them to switch sides. Not yet. It's our turn to show them what physical activity can do in their lives and wait for them to be interested in doing more. This is a call to action to make sure our patients really see the value of rehab that we provide. They should see a super clear connection between their goals and the exercises we select. If our patients are in that contemplative phase without a plan, so they're thinking about it in the next six months, they don't really have a plan to get there, it's our job to develop specific goals for them and an action plan while assessing their confidence to committing the plan. I think that's what we miss is that confidence piece. We usually miss it and we only kind of set out a goal or action saying you're going to do this exercise five days a week, sounds good, I'll check back in on that later.

11:20 ASSESSING CONFIDENCE WITH EXERCISE

The confidence assessment is key. You can ask your patient how confident they feel on executing a plan. Ask them on a zero to 10 scale, how confident are you that you're going to be able to do this exercise program five days a week? If the patient says anything less than a seven out of 10, we need to reevaluate the goals and the action plan. We probably should drop that down. Do you think you're going to be able to get three days of exercise in a week? Assess confidence, super important. Now if the patient already has a plan going, it's worth it to stop and talk about barriers. The article mentions using the 27 item inventory of physical activity barriers, which works through a patient through eight domains of barriers that could impact physical activity. That is a super thorough assessment. 27 items is a lot. So this could be appropriate for some, maybe not for all. The simpler one would be the self-efficacy for exercise scale. That's a bit simpler. It's a far fewer items. I'm sorry, I don't remember the exact number, but it's far fewer items than 27. But if you're really interested in figuring out what's going to cause your patient to stop being physically active, these are assessments you definitely want to do. Now as your patient begins to execute their plan, it is our job to constantly check in. In the article they say, recognizing success is essential because it increases self-efficacy. And I couldn't agree more. I am all about and in the business of improving my patient's self-efficacy. Honestly, I wonder if that is the job of the physical therapist for the older adult at this point. Bringing our patients back in control of their lives and giving them this feeling and sensation of self-efficacy. So I'm a guide to that land of self-efficacy. Now how do we do that is we check in constantly with our patients about their program, their physical activity program. And we cheerlead and recognize and give kudos to every little step that our patient makes towards these goals and especially when they work around barriers to completing the activity. So make sure if you have physical activity goals for your patient that these are things you're asking about every session. We're not giving them the plan and then not checking back in. It's really our job to continue to check back in. It's why we are different than medical doctors who see our patients once every six months and you know six months to a year. At that six months to year visit our MDs are usually telling people, hey you have to be more active and that's all they're doing. No, we get to do the hard work and really check in with our patients how this plan is going.

14:00 AGE-FRIENDLY HEALTHCARE

Now this article also describes age-friendly healthcare which helps to foster a person-centered care. So for older adults in particular you kind of have to determine what matters. They call this the four M's but what matters, M matters, knowing what our patient's mentation state is which I love, taking this consideration towards dementia and delirium that we need to understand before giving these guidelines. Talking about mobility optimization that making sure our patients maintain high levels of mobility and safety is critically important to the population and optimizing medication. So there's a lot that goes inside of this, there's a lot that goes into this conversation rather of physical activity and addressing inadequate physical activity in older adults. This article was really lovely, I really recommend a look because in the back of the article there's a resource guide of all the different physical activity related measures that you can compare and contrast to see if you can find some that are appropriate for your patient population. It's at the very end of the article. So I'll link it in the Instagram page but just remember first and foremost we are in the business of addressing physical activity, absolutely. We have to recognize that we have a bias towards exercise that our patients do not have so we need to come back to that newbie state of mind and really address physical activity from that place and not from our high horse of exercise. By doing this we have to first assess my patient's readiness to change. How often are they thinking about implementing a physical activity program in their day to day life? Think about those things first before you start giving recommendations because if they're in the pre-contemplative phase of behavior change they are not ready to hear from us that they need to be doing a physical activity program. Not yet. Think about the barriers that our patients are going to encounter and potentially use some scales like the physical activity barrier scale or the self-efficacy for exercise scale to address these barriers that are going to inevitably pop up when we start engaging in a physical activity program. Think about some older adult specific techniques such as thinking about mentation, thinking about medication in order to optimize our recommendations. Alright, so you guys are in the business of increasing physical activity for older adults. It's actually probably one of the bigger parts of our job. 91% of older adults are not meeting physical activity guidelines so get out there, let's start attacking these numbers. Have a good Wednesday.

16:29 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.

Aug 29, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses how encouragement and support are crucial factors in helping patients overcome challenges and develop resilience. This episode emphasizes the significance of being there for patients and showing them that a healthier and stronger version of themselves is achievable, despite the short-term suffering they may experience. Lindsey acknowledges that this aspect of patient care cannot be measured on standardized scales or assessments, but it plays a vital role in the patient's journey towards better health.

Additionally, the episode highlights the importance of providing encouragement to patients when they face setbacks or failures. It is essential to support them and let them know that it is okay to struggle. By reframing these setbacks as part of the process and emphasizing that it is better than not taking any action at all, healthcare providers can help patients maintain their motivation and continue working towards their goals.

Furthermore, the episode emphasizes that patients should not be defined by their diagnosis or label. It is crucial to help patients understand that they have the power to make choices that can improve their well-being. Healthcare providers should assist patients in reframing their experiences and show them a different way to approach suffering. This involves forging connections, offering hope, and helping patients gain a new perspective on their situation.

In addition to encouragement and support, the episode also mentions the importance of accountability. Patients may need someone to hold them accountable for their actions and help them stay on track with their goals. This can be achieved through forming new connections, such as involving family members or enlisting the support of a healthcare provider. By creating a sense of accountability, patients can stay motivated and make positive changes in their lives.

Overall, the episode emphasizes that encouragement, support, and accountability are essential components of helping patients overcome challenges and build resilience. By providing these elements of care, healthcare providers can help patients navigate their journey towards better health and well-being. Lindsey emphasizes that simply modulating pain symptoms is not enough. They want to open up opportunities for patients to maximize their fitness, both physically and psychologically.

Take a listen or check out the episode transcription below.

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

00:00 LINDSEY HUGHEY

Good morning, PT on ICE Daily Show. How's it going? I am Dr. Lindsay Hughey, one of our lead faculty for extremity management, along with Dr. Mark Gallant and Cody Gingrich. It's nice to see you all this morning. I am coming to you from Manitou Springs, Colorado. There are some mountains peeking in the background. This Clinical Tuesday, I am going to be chatting with you all about the stimulus of suffering and how in our folks in particular with knee and HIPAA can transform their current suffering to a strength. But I'll tell you it's not by giving up suffering, it's by transforming it. So we will take on this challenging subject today and consider how the suffering stimulus produces growth and satisfaction. But before we do, I would love to tell you about some upcoming courses that Mark and Cody and I have in the extremity division because there's only a handful of courses to catch us in 2023. So coming up is we are in Amarillo, Texas, September 9th and 10th. Mark will be there, so there are still spots left. Join him. And then September 16th, 17th, we'll also be in Cincinnati, Ohio. Moving into the fall, in October, October 7th and 8th, Cody will be in Rochester, Minnesota. So that'll be his first lead course. Join him. He is going to crush that. He has been on the extremity management team and ice team for so long. He brings such a wealth of knowledge. So that is going to be a blast of a course if you are nearby. And then Ridgefield, Connecticut, I added that course about three to four months ago. I'll be there with Melissa Reed. It's a really rad CrossFit gym, CrossFit 203. Lots of spots there, so join us. And then just a couple more opportunities in November and December. So check us out on ptlonice.com. But to the topic at hand. So I've come on here the last few months really chatting a lot about Hip OA and Knee OA and kind of that underlying systemic struggle that they have. And so in particular, we're going to talk about the mental physical struggle that they go through. So those folks with Hip OA and Knee OA, they often start to really identify with that bone on bone label, right? Osteoarthritis becomes who they are. It's how they plan their day. They plan their outings, their weekends, their shopping trips. It's all planned around how long a distance to walk, their energy level, the amount of steps that might be on board, wherever they're headed, how much pain they might be in, how much medicine they might have to take to get through that, or how much they'll pay for it later. So they are considering all of these factors. And it all comes back to like that label that diagnosis of, Oh, I have osteoarthritis. And this starts to really dictate their whole life. And it starts to creating quite a bit of disability limiting their interaction socially. It monopolizes their mental and emotional capacity a bit. And they're struggling. They are suffering. And this is on top of their pain, right in their knee or hip joints and in other areas in their body, because they're walking with the intelligent gait patterns. It's not just the physical impairments, right? Range of motion and strength. They are suffering physically and psychosocially. And we have to recognize this if we want to make an impact. And what's strange is that this suffering becomes a sort of comfort for them, because it's familiar, right? This is now their identity.

04:42 WHEN SUFFERING BECOMES COMFORT

We often associate comfort in our society with happiness and well-being. But there's really this intriguing paradox that you start to become comfortable in your current suffering because it is familiar. And this happens to our folks with hip and knee OA in particular, their suffering becomes their comfort. It's what they rely on to dictate their life. Their whole identity is around the suffering. So the reason they don't go to the grocery store anymore, that they have their cousin do their shopping for them, the reason they ride the motorized car and don't walk through the store, the reason they don't take that flight to see their daughter because they can't help bear the thought of walking to that plane and the pain that will cause, or maybe the embarrassment of being pushed in a wheelchair, they're missing their bingo nights, birthday parties of family members, their church Bible studies. They're not able to mow the lawn anymore. They need their nephew or their grandson to do it. They're not doing their exercises because they hurt. They don't want to do them. They'd rather watch their shows. They're not going outside and enjoying the weather. This is suffering and it becomes this holding pattern of inactivity and excuse, which leads to what? It leads to more suffering. The familiarity of that routine to stay home, to not exercise, to eat out, maybe because it's convenient, because they no longer can stand to make a whole meal. This becomes comfortable. Folks are suffering though in another way with these choices, right? They're missing out on socializing. Their joints become more immobile the less they move. They become more painful with less activity and then plus that sequelae of untangible systemic inflammatory changes that are happening when you stop moving, right? Physically and then we can't even put a, you know, a tangible thing on the mental emotional changes that are happening internally and possibly affecting their ecosystems. They will not only stay in these patterns, think about your patients with HIP and NEOA or really anyone really suffering in any diagnosis. Folks tend to find solace in it. We are creatures of habit humans, right? And we stay in these holding patterns of suffering. Our job, we need to create a novel suffering stimulus for these folks. We have to help them see there's this opportunity challenge before them and guess what? They're going to continue to suffer, right? But in a different more productive way, right? And what I mean by that, it's doing your exercises regularly, getting 30 to 60 minutes of physical activity regularly, these things, planning a meal so you don't eat out or having someone come over, help you prepare that meal, things that are outside of comfort zone. Our job is we have to show them the dividends of adapting and learning and evolving lifestyle behaviors. They can change their activity level little by little. They can change their diet and nutrition, their fueling. They can change their hydration. This will all be hard. It will cause some suffering shifts, right? Because of the planning and the change associated with changing those behaviors, like waking up early to do exercises, right? If there's someone that works full time and they just say, I don't have any time to do my exercises for my hip and knee. It might be helping them develop a routine to take their vitamins or hydrate. It might just be asking for help, right? To have an exercise buddy in the morning to walk with. But these all take effort and it takes getting out of that comfortable routine of sitting, right? And doing less. It will definitely take failing, right? Patients, it's hard when you make lifestyle changes. Think about yourself, right? It's hard to make diet and lifestyle changes and nutrition, like eating more protein, drinking half your body weight in ounces. But if you're there, encouraging them, they'll continue to go back at it despite these failures. All of this causes some amount of suffering, right? This change out of normal routine to shift to more healthy lifestyle behaviors. It's one that involves sacrifice, but they have to be novel. It has to be something different, not their comfortable suffering.

09:17 PATIENT AUTONOMY & RESILIENCE

We have to try to challenge and force adaption and learning and evolution surrounding their ecosystem, not just in their home program. And this ultimately leads to the patient's autonomy, right? Showing them that a healthier, stronger version of themselves is more resilient despite some short-term suffering. If you can be there to encourage them, right? When they do fail, this helps produce fortitude and resilience. And this can't be measured on an MPRS or KOS. I can't tell you an MCID of encouraging someone and the dividends associated with this. But if we can be there, right, to help them get back up on the saddle, maybe they take off doing their, they're doing great for a week with their physical activity and then they hit three days in a row where they don't, and they just don't feel like it. We have to be there to encourage them. When you fail, right, patients, this causes mental suffering. So as they shift behaviors, lifestyle behaviors, and maybe fail at them, we have to let them know that that's okay and that that's normal and that you're going to be with them. But this is better than sitting on the couch, not going out with your friends, planning your life around your osteoarthritis diagnosis. Our patients are not their diagnosis. They are not their label and they have to believe that. We have to help reframe that and I've talked about that in previous episodes you can check out. But the patients, they are, the some are their choices and we have to let them know that. We have to make them make better suffering choices. It is not okay if they miss doing their exercises, right, those three days. I'm not going to tell Nancy or Marilyn, it's okay. I'm going to say we need to get back at it, Marilyn. We need to get back up on that saddle. They need someone to tell them it's not okay. Along the way to the suffering and accountability, there's healthy byproducts, right, like forming new connection as your PT, right, as their healthcare provider. Maybe it's a family member that they're eliciting to help them be accountable to eat a little bit healthier diet or to drink that extra glass of water. We all need help and accountability to get through hard things and so help them realize that this is also an opportunity for connection to change their outlook and how they even connect with others around them.

12:21 THE SUFFERING STIMULUS

The suffering stimulus creates change. Your values of the patient priority start to shift. I keep saying suffering stimulus and that's because in our course we talk a lot about dosage stimulus. In particular, we talk about it in the physical realm, right, like when we talk about strength, we say this is for functional confidence and competence or performance dominance. We work at this at five reps, five sets, greater than 80% one rep max intensity. We're working some sets, greater than 80% one rep max intensity. We're working so hard we need a three-minute rest break. We are doing this three to four days a week. In the rehab dose, it's eight to 20 reps, three to four sets, 30 to 80% intensity. This is for dysfunctional tissue issue, local issues, right, we might rest 60 to 90 seconds and then powers three reps, 10 sets, right, requiring a three-minute rest break because we're taxing the CNS to use strength quickly, right, power is force times velocity, right, these all have standard definitions and reps and set schemes and frequency. The suffering stimulus is a little bit different, right, this is an intangible dose but this is a dose that pushes a human outside of their mental and emotional comfort zone. It shifts their values and their priorities in their time choices, their nutrition choices, their exercise choices, lifestyle choices, even your friend choices. Some friends have to go, right, if they're the ones you're drinking with on the regular and that tell you to eat that extra piece of cake and those cheese fries, right, we might need to change our circle and that might even involve some family ties, right, our activity choices will change and there is a certain amount of suffering associated with that. The suffering stimulus frequency, it's a daily commitment, it's reps and sets, they are boundless but this yields in unmeasurable dividends of hope, resilience, confidence, and maybe a dash of fun if we do our job well to elicit and show them the power of doing exercise and how that changes life and how lifestyle behaviors enhances that even more. The suffering stimulus, it's a life-altering dose that we don't talk about enough. It's our job to show our patient that they can do this and support them in this journey and we do have to be honest that some folks are not going to really lean in to suffering, right, they find finding comfort in suffering. It really is a deeply personal journey, right. I want you to know this isn't about glorifying pain. I hate the saying no pain no gain, we don't say that but this is about recognizing that resilience and growth emerge from life's difficulties, from one's sufferings. We have to reframe that experience for the patient, show them a different way to suffer. It is a delicate balance. We have the privilege of serving humans on the regular, right, in their most vulnerable moments when they're in pain and they're hurting and they are suffering but let's forge connection, hope, and perspective change. Let's help them redirect to control the controllables. Let's help them find their why, paint that picture of what is most important to them, right, playing with grandkids, picking up their kids, running, it's always usually family, right, being able to keep running with their kiddos. Maybe it's running a marathon, maybe it's doing chores without restriction or mowing the lawn again, going to bingo. Let's give them the resources that hold them accountable to achieving these goals like gym access, community classes, connecting them with others with the same struggles. We know this if you've been to an ICE course and you've been part of our tribe for a while but we don't just want to change your hip or knee, shoulder pain, back pain, pelvic pain, right, we want to change your life. We want to modulate your pain symptoms to open the opportunity to maximize fitness but not just physically and not just through fitness-forward lifestyle behavior. We want to build and challenge your psychological fitness. We have to help our humans break their routine suffering for a novel suffering stimulus that challenges them not only physically but mentally to lean into hard-think mindset, lifestyle shifting behavior that yields a more healthy human.

15:47 PRODUCTIVE SUFFERING

I want you to not only think about humoring suffering with hip and knee OA patients but even consider yourself, is there some comfortable suffering that you're currently taking part in that you maybe need to shift in to more productive suffering? Maybe it's tracking your food, maybe it's getting in zone two work more, maybe it's actually taking a rest day if you're a work outaholic, right, and allowing yourself dessert once a week. Consider how you can shift your patient to a suffering stimulus that changes their life and think about in your own life as well. Thank you for joining me this clinical Tuesday and if you feel so inclined share with me some ways that you have helped invoke the suffering stimulus personally or in your patients. The suffering stimulus is always a catalyst for change if you let it be. Happy Tuesday folks.

16:20 OUTRO

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

 

Aug 28, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Rachel Moore discusses reintroducing exercise early to the postpartum athlete, including modified CrossFit workouts, gymnastics, core training, and impact training.

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at sign up to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show.

01:22 RACHEL MOORE

Good morning PT on ICE Daily Show. My name is Dr. Rachel Moore. I am on faculty with the pelvic division here at ICE, and I am coming at you live from a different space than I normally am today. I was in San Antonio this weekend with Christina Prevot at a pelvic course, and it was a blast. It was so much fun. We met so many amazing people. We always love our weekends out on the road. So if you are interested in jumping into one of our upcoming live cohorts, we've got Scottsdale, Arizona coming up September 23rd and 24th. That is our live course. It'll be myself and Alexis Morgan. And then September 30th and October 1st, we actually have a course in Canada. Christina Prevot will be leading that one. So if you are north of the border and you're interested in jumping into one of our live pelvic courses, great opportunity to do that coming up. We also have our pregnancy and postpartum newsletter. If you're interested in learning about all things pelvic, staying up to date on everything pelvic, it's a great way to get resources sent directly to your inbox. And you can find that link on the website. So you might hear my baby screaming in the background because he's eating. My mother-in-law is feeding him, so just ignore the baby.

02:46 MODIFYING CROSSFIT WORKOUTS

I'm here to talk to you guys this morning about modifying workouts for the postpartum athlete, particularly in that early stage. So what I wanted to do is kind of break down one workout and talk about how somebody at four weeks, eight weeks or 12 weeks for the same athlete, maybe we would modify that workout. Modifying workouts can be confusing because there's no set standard of at this point you do this, at this point you do this. So kind of across the board, it's going to be very individualized depending on the athlete in front of you. This is something we dive into a ton in our online cohort and we have an entire assignment where we break down different types or the programming and talk about ways to modify it for a particular athlete. But just to kind of give you a little glimpse of what that looks like and just chit chat about it this morning, there are a few factors that we're going to really heavily consider when we're trying to decide what we want to do for a postpartum athlete. And before we dive into those, I want to talk about why.

04:09 GETTING ATHLETES BACK INTO THE GYM

Why do we care about getting an athlete back in the gym, maybe at that three to four week mark rather than waiting until six weeks or even later? Why are we really emphasizing and why do we promote here at ICE getting our athletes back? For a lot of women, the gym is their community and it is their mental health support system. And so postpartum in and of itself can be an incredibly lonely time, especially if you don't have a village around you and especially if you feel like you're isolated from a village that you maybe have. So if we can find ways to get these women into their boxes back at the gym, maybe bringing baby along in their car seat or stroller or if there's child care, great. But bringing baby along, finding ways to modify the stimulus appropriate for somebody that's at that three, four week postpartum mark, we feel that that is incredibly advantageous for mom from both a physical health standpoint. So what are the factors we're going to look at when we're deciding what workouts need to be modified and how to modify them? For one, we want to know what mom did before she was postpartum. So did she work out in pregnancy? What did she do prior to getting pregnant? Had she been a CrossFitter for years when she found out she was pregnant? What was her previous level of strength and did that maintain throughout pregnancy or did she take a long time off and see this big deconditioning response? Method of delivery is another thing that matters really heavily. Some issues with their anterior core wall, but we typically expect to see that somebody who's had a vaginal delivery is going to have potentially more struggles with pelvic floor dysfunction with things like heavy lifting and running and that are going to challenge that anterior core wall. Again, that's not a hard and fast rule. That's not saying it's the only way. We see that overlap, but that's kind of the things that we can expect to see based on the type of delivery. We also need to know about the type of delivery that we expect to see. Especially if they're breastfeeding, we need to make sure we're having the discussion with them about making sure that they're getting enough calories in to support their body and help that not only postpartum healing that is occurring naturally, but also that recovery from being in the gym. We also really want to think about mirroring the stimulus of the workout. So we're not going to do the same things that somebody who is not postpartum, four weeks postpartum is doing, but we want to think about what the intended stimulus of that workout is and try to find ways that we can match that intended stimulus, whether that's muscle groups that are being hit, whether it's cardiovascular versus more muscular strength or what kind of factors we're shooting for and prioritizing in that workout. We want to preserve that with our modifications. So let's break down an athlete and a workout and let's talk about how we would how I would scale this athlete at four weeks postpartum, eight weeks postpartum and 12 weeks postpartum. So our athlete, we're going to call her Suzy. Suzy is a CrossFitter. She's been doing CrossFit for seven years. She just had her first baby. She exercised during her pregnancy until 38 weeks and then she just kind of felt like she wanted to rush. She was feeling like, meh, I'm not really wanting to push fitness right now. I'm just going to kind of take it easy. Her previous lifts, her one rep max back squat was 215 pounds pre-pregnancy. Her one rep max deadlift was 275 pounds pre-pregnancy. Her strict press pre-pregnancy was 95 pounds. And from a gymnastics standpoint, she was able to do kipping pull-ups, bar muscle-ups, chest to bars, and she was able to do double-enders and workouts. So an athlete that has pretty decent experience in CrossFit. It isn't brand new to this and continued to exercise during her pregnancy, had a vaginal delivery. How would we modify a workout for her at four weeks? So we're going to take a workout. It's going to be the same throughout just for the sake of not being confusing. And it's hard to kind of conceptualize and listen. So our workout, the RX version of this workout is five rounds for time, 40 double-enders, three wall walks, 15 toes to bar, and 20 double kettlebell deadlifts. At four weeks postpartum, how are we going to modify for Suzy? So we're going to maybe keep that same stimulus of five rounds. We could also decrease that, but for this exercise, we'll keep that same stimulus of five rounds for time. Instead of 40 double-enders, four weeks postpartum is pretty dang early to start doing that impact. So instead of just doing something like calf raises that would work her calves, but maybe not tax her cardiovascular system, I'm going to have Suzy do a 30 second either bike, row or ski, whatever feels the most comfortable at a comfortable pace. So she's not going breakneck. She's not going to like an eight, nine out of 10 RPE. She's just moving and getting her heart rate up for 30 seconds. Instead of wall walks, we're going to do a 30 second, 30 second, 30 second workout. So swapping the three wall walks out for 12 elevated plank shoulder taps, really focusing on that core connection piece. So focusing on that hollow body, maintaining that core brace, making sure that she's not pushing down into the basement and doing plank shoulder taps to an elevated surface that is challenging for her, but does not feel uncomfortable in any way. Instead of toes to bar, thinking about what the components of that toes to bar are with that lap pressed down and core component piece. I'm going to have her hook a band up to the rig and face away from it. She's going to hold a isometric lap pressed down. So she's going to engage her lats. If you're watching, you can see, but facing away from the rig, hands are in the van, pressing down, standing in that hollow body position, focusing on maintaining that core brace. Focusing on maintaining that core engagement. And I'm going to have her do knee marches. So we're going to swap out those 15 toes to bar for 15 standing knee marches with isometric lap pressed down to mimic that pressing with the knee raise. We could also, if we're thinking about flipping this, preserving grip or reintroducing grip, have her hold an active hang for 30 seconds as well. Those are two options for the same athlete. And you could also alternate from round to round. So maybe one round, we're doing that lap pressed down knee raise. And then that second round, we're doing that active hang and we're alternating between those two. And then finally, instead of the 20 double kettlebell deadlifts, we can even just take bodyweight good mornings. These get sneaky on you if you haven't worked your hammies in a while. So putting hands behind the neck, nice flat neutral spine, hinging forward and coming back up. So her workout again, five rounds for time, 30 seconds on a cardio machine bike rower ski, 12 elevated plank shoulder taps focusing on maintaining that core engagement, either 15 standing marches with isometric lap press downs or 30 seconds of an active hang or whatever amount of time she was able to maintain. And then 20 bodyweight good mornings. That would be the workout for somebody who is four weeks postpartum. She's showing up to the gym. She's hitting a similar intended stimulus. She's moving. She's in class with her friends and she's getting a workout in. Let's take this same athlete, same workout and pretend we have fast forwarded for whatever reason she's now eight weeks postpartum. At eight weeks post, five rounds for time, 40 toe taps or line hops. So we are introducing impact at this point. We can absolutely have maybe began this earlier at about that six week point. So introducing that impact 45 times is a high volume. So if this was something where we wanted to work on single unders, we could maybe cut that rep scheme to 15 or 20 and then still have her do those five rounds focusing on that less volume as we're introducing impact. So two options there from that impact standpoint instead of three full wall walks, maybe we're having her do three modified wall walks. So if you've done the crossfit open and you did a scale division with the wall walk, you start out on the floor, press up on your hands, feet go on the wall and you go hand behind, hand behind, hand forward, hand forward, come all the way back down. The chest hits the floor again. to start working on that core engagement, that active shoulder and getting up on the wall. Alternatively, she can work on a wall walk as high as she can go. So two options there as well. Instead of toes to bar, we're going to say that she's been working on her hangs, she's building that grip strength, she's got that hip swing down. We're going to swap that out for hanging knee raises and maybe 15 is too high volume so we can do 10 hanging knee raises, working on that good kip swing, pressing down as she brings her knees up and really pulling through the bar to get into that arch position. And then finally for the double kettlebell deadlift, we're going to let her send that and she's just going to choose a weight that she's able to hang on to that is an appropriate stimulus for her that she's not feeling any heaviness, pain or leakage. So for this athlete at eight weeks postpartum, five rounds for time, either 40 toe taps or line hops or decreasing that rep scheme and adding in single unders to work on that impact with the rope swing. Three modified wall walks or walking up as high as she can. Ten hanging knee raises and 20 double kettlebell deadlifts at a lighter weight. Let's take this athlete, hit the fast forward button and now we're 12 weeks postpartum. Same workout, same athlete. Five rounds for time. We're going to let her play with double unders.

12:27 INTRODUCING IMPACT

So these 12 weeks postpartum, let's say we've been working on impact. Eight weeks we did some single unders or some line hops. That's four weeks of time to have built up the stimulus of maintaining or responding to that impact. So instead of setting a set number for her, I'm going to give her a time domain. I want you to spend about 30 seconds of effort working on your double under. Doesn't mean it has to be breakneck speed. Maybe she's getting two to three, getting into that pelvic recovery position, resting and then picking the rope back up. This is giving her time within that workout to work on the skills that we are hoping to get back to while progressing along in that impact. We're going to swap out wall walks. Maybe not three wall walks, maybe just two. She may be able to do three, but if not, then we are going to drop that number down to two. We can always scale volume with movements. Same thing for toes to bar. So maybe she's back to toes to bar. She's able to hang on to four or five and then she starts feeling some fatigue, hops down from the bar, jumps back up for that second set. Again, this is five rounds, so that cumulative volume does add up. So instead of 15 toes to bar, maybe we're dropping her down to eight toes to bar instead. And then finally, that double kettlebell deadlift, we're going to let her send it and we're going to think, okay, at eight weeks she may have done a certain weight. She's probably at a little bit heavier weight at this point. Maintaining able to breathe, not having leakage, not having heaviness, not having pain, but choosing a weight that feels great for her. Double kettlebell deadlifts are an incredibly functional thing if you're a mom, constantly picking up diaper bags and car seats and kiddos and all the things. So one workout, one person, three different timelines. There are options even within each timeline for this athlete. There is no one right answer when it comes to modifying a workout for an athlete. We need to consider the stimulus of the workout. We need to consider this athlete's history. We need to consider this athlete's recovery and we need to consider the athlete's goals. So when we take all of these things into account, this is kind of a day by day process starting out, but eventually we want to get to the point where our athletes understand how to make these modifications themselves and they feel comfortable. Okay, I can press the gas on this or maybe I need to take a step back on this. At the end of the day, our job is to help them figure this out as we are actively working towards getting back to doing all the things that it is that they want to do. I hope that makes sense. I know it's kind of hard without like, I'm a whiteboard person. So I hope you guys learned something this morning. This is an area that we cover in our online cohort. So if you are looking to learn more about modifying workouts for the postpartum athletes from a programming standpoint especially, hop into our online cohorts, come hang out with us live on the road. We've got tons of courses coming up between September to December and hopefully we'll see you guys soon. Bye!

18:02 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.

Aug 25, 2023

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses using curved, self-powered treadmills for running & gait analysis, including the differences between metabolic output on overground running, motorized treadmills, and curved treadmills. In addition, she talks about pros & cons of using curved treadmills for gait analysis. 

Take a listen to the episode or read the episode transcription below.

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

00:00 INTRO

Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money-saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show.

01:26 RACHEL SELINA

Alright, good morning everyone. Welcome to the PT on ICE Daily Show. My name is Rachel Selina and I am with our Endurance Athlete Division, so both our rehabilitation of the injured runner live and online. So first, sorry that this is a little bit later. I'm in Southeast Michigan and we had some crazy storms come through last night, so I have no power, I have no internet. So I am currently at my sister's house, so a little bit of a travel today to do this, but I'm glad to be here. So today we're going to dive into using curved treadmills for gait analysis. It's a question that comes up a lot in our live and online courses, which if you're hoping to get into the live course this year, we have only one more course for 2023. So the next or the last chance for this year to do rehabilitation of the injured runner live would be in Knoxville, Tennessee, November 4th and 5th. Like I said, that's our last course for the year. And then we have another online cohort coming up as well. That one is September 12th. It starts so you can jump into either one of those or both of those at PTonice.com.

02:38 CURVED TREADMILLS FOR GAIT ANALYSIS

So like I said, we get asked this question a lot as to whether or not you can use a curved treadmill for gait analysis. And so by curved we mean like the non-motorized curved treadmills, which are common now in a lot of CrossFit gyms. So they're self-propelled. Probably the most common one is the Woodway Curve, and that's the one that's become more common in CrossFit too. There's a Rogue branded one. That's kind of the official treadmill of CrossFit and CrossFit Games. And then there's also like the Assault Fitness brand has a Assault runner. In true form is one that has another or another brand that has the same like type of treadmill. So there's some different ones out there, but they're all essentially the same. Like it's not motorized, so it's powered by the athlete. And it has that kind of curved surface instead of the flat belt that we would be used to seeing on a treadmill. So the claim by kind of manufacturers about these treadmills is that they better reflect over ground running, mostly in terms of the self pacing. So when you're outside and you're running, you can just kind of spontaneously decide, hey, I'm going to speed up and start speeding up or kind of not consciously. Decide to do that and you speed up or slow down. So you can do that on the curved treadmills because they're not motorized or you don't have to like push a button to tell it to speed up or slow down. You can just kind of naturally do what your body would do. So they're marketed as being more reflective of over ground running. They're also purported to decrease impact and therefore reduce your risk of injury. Right. Claim that they promote good running form, good running technique, and then also that they cause more posterior chain muscle activation during running. So that's kind of all like if you were to jump on any one of those websites for those brands of treadmills and kind of read about what they say the purpose of this treadmill is, that's what you would find. When we take it to the research, though, one, there's not that much yet of just good solid research as far as like how running on this type of treadmill actually does change your running form or how it causes muscles to activate or definitely not yet. Like, does it reduce risk of injuries? We don't have that yet.

05:16 GREATER METABOLIC DEMAND ON CURBED TREADMILLS

What we do see kind of consistently in the research is that there is a greater metabolic demand from using these treadmills. So like for the same, you know, if you were to do a 5K and you did that outside, you did it on a standard treadmill, like with a motor and a flat belt, or you did it on a curved treadmill, it would it would be harder in terms of there'd be more oxygen uptake. You'd have a higher heart rate and higher RPE for like the same pace on the curved treadmill versus the other ones. And so that's consistent. Like that has maybe not great quality evidence, but there is that evidence out there from the research. We also see on the curved treadmills that we do get a little bit of a reduced ground contact time. So that's the like the amount of time your foot is actually in contact supporting your body on the treadmill. And we tend to see a shift or just like a, I don't know, not not in everybody, but we see that trend to take pressure off of the rear foot, especially when we're striking and go to a more mid foot or forefoot strike when we're using a curved treadmill. So that's really all like, and not even super conclusively, but that's all that consistently we see in the research about using a treadmill like that. Inconsistently is the muscle activation piece. Like there's there's not solid research to support that you have more posterior chain activation. One of the studies that looked at that was actually not using a curved treadmill. It was just using a flat treadmill that was self powered. So in that one, they saw like a little bit more soleus activation and a little bit more rectus femoris activation. But like I said, we can't necessarily apply that to the curved treadmill because it wasn't on a curved treadmill. Like that just might be something about being self powered, but can't say for sure. It also happens when we're on that curve. So some inconsistent stuff like maybe they don't quite do what we what we think they do, but we're not just not quite sure on that yet. In terms of how we use them in the clinic or in the gym, right, like if you want to do a running analysis, is this a viable option to do so? Can you use this treadmill and still get good data? So I'd say you can get good data. We just kind of have to take it in stride with what else we know is going on. So just like on a normal treadmill, we want someone to have a period of being able to adapt to that treadmill if they're not already comfortable running on a treadmill. So what we mean by that is if someone's coming in for a gait analysis, we want them to at least have had exposure to running on a treadmill before we assess the mechanics on a treadmill. Otherwise, you're going to get a lot of inconsistencies because they're just not comfortable running on that surface. So the same thing applies here. We definitely would want someone to have exposure to running on this curve type of treadmill if that's where we're going to then assess the mechanics. Otherwise, we're just not going to see a gait pattern that really is consistent with how they would typically run. So you could use it to make sure they have that period to be able to adapt. So usually that's like three sessions on the treadmill. It doesn't have to be full like you run for five miles three times. It can just be like 15 minutes, three separate times of getting used to that treadmill before you try to do the analysis. The other thing is that we have research for motorized treadmills.

09:45 RUNNING MECHANICS & TREADMILLS

We have that research showing that someone's gait on a motorized treadmill, a standard one, is consistent with what their pattern would be over ground. So we can take what we see on that treadmill and assume that that's what we also would see if they're running outside. And we just don't have that yet for these curved treadmills. So we can't 100% assume that the pattern that someone would be showing us on that curved treadmill would be what they would go out and run like over ground. The claim, and I wasn't really able to find where this was coming from, but the claim is that running on that curved treadmill is actually more similar to running uphill. So the one kind of caveat there would be if someone runs uphill a lot, like they're doing a ton of maybe trail or just like big ascents, then it might be more accurate because you can't really on a standard run. You could run on an incline, but that's the one case where it might be more similar to their over ground running if they're running uphill. But that's not like the majority of our people, especially kind of in that more traditional gym or clinic setting. So we have to kind of take it with a grain of salt. What we're seeing on the treadmill might not be 100% reflective of what we would see over ground. The other thing though would be if someone, say you're in that gym setting, if someone is only going to really be running on this type of treadmill, by all means then assess their gait on that treadmill because that's how they're going to be running. So if someone only runs during CrossFit classes when running is programmed and that's where they'll do their run is on that treadmill, then that's fine because that's the type of running that they're going to be doing. Otherwise, if you're going to use that curved type of treadmill for someone that's just kind of running on a treadmill, then that's fine because that's the type of running that they're going to be doing. Otherwise, if you're going to use that curved type of treadmill for someone that's just kind of normal, maybe recreational runner, I don't think it's pointless. I think we can get some good data. We'll probably be able to pick up on big, just like big faults going on. We'll still be able to see from that coronal plane if they're, you know, from Dellenberg, how their knee separation is, all of that we still could see. We just need to keep in the back of our mind that this type of treadmill might reduce their tendency to overstride, like to have their foot land far in front of their center of mass. It might reduce that, and it might also make them run a little bit more biased towards their forefoot or midfoot, which we might not really see, like they might overground be more of a heel striker. So I think we just have to kind of keep those in mind. The one other kind of big, big picture thing to keep in mind is if we're going to use that type of treadmill for gait retraining, like we want to start changing someone's mechanics, there's going to be a few gait retraining drills. There's going to be a few gait retraining drills that are really challenging to do on that type of treadmill. So the main one would be retraining cadence. When we're retraining cadence, it's really important initially that the runner keep a consistent pace. So usually that's why like a standard treadmill is super useful because we can set their pace, right, say we're going to set it, their comfortable running pace is a 10 minute mile. So we can set that treadmill to 6.0 and we know the belt's going to stay at the same speed. So if we're encouraging them to increase their cadence, right, to listen to that metronome, to turn over their feet faster, we know that they can do that without speeding up. Because otherwise the tendency, if you just increase cadence without being able to control that belt speed, is just to go faster. All right, so if we're trying to retrain cadence on a curved treadmill, you can see the speed, but you would have to consciously like work to keep that speed the same while you're also trying to consciously pay attention to a cadence. So it would just be a really challenging setup to kind of internalize that cadence and learn that really well.

14:04 CURVED TREADMILLS & OVERSTRIDING

For some of the other tools, though, like the curved treadmill might actually be a good way to help someone who does over stride to start to learn what it feels like to keep their foot closer. So the curved treadmill would almost force them to not over stride because they keep over striding, right, that they're going to be landing higher up on that curve. They're going to just make the belt go faster, which is why that treadmill causes you to kind of keep your foot closer. So it could be a good tool for someone who does over stride to get on that type of curved treadmill and start to feel, OK, this is what it's like to keep my foot closer to kind of find that that more centered spot. But we would also need to make sure as they learn that that we make sure that transitions for them back to over ground running. And I think that's just the big thing, right? Like, I'm excited to see more research that comes out on these treadmills to kind of show us, hopefully, where where the usefulness of them is and how it actually does really change our mechanics. So we know best how to use that. But I think as long as we keep in mind that, you know, some of the things we see might not be 100 percent reflective of over ground. If we can also get a little bit of an over ground sense of what this runner is doing, we can use both of those together to make this still a really good tool for assessing and for retraining. So that's it. I'd love to hear your thoughts. If you typically use this type of treadmill, whether from like you personally run on it a lot or you do a lot of assessment on it. I'd be curious your thoughts. So definitely put those in the comments. And then, like I said, if you are hoping to catch one of our live courses, our last one is coming up in November. So feel free to jump into that. We'd love to see you there. All right. Perfect. Have a great weekend, everyone, and thanks for being here!

15:43 OUTRO

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

Aug 24, 2023

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses being wrong about dogmatic approaches to physical therapy, the harmful influence of technology on daily life, and long-term changes to the American healthcare system.

Take a listen to the podcast episode or read the full transcription below.

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

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a fantastic start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at the Institute of Clinical Excellence and a faculty member in our fitness athlete division. We're here on Leadership Thursday. We talk all things practice management, small business ownership. Leadership Thursday means it is Gut Check Thursday as well. This week's Gut Check Thursday is a little test, Cooper's test in fact. This was a test created way back in 1968 by an Air Force Lieutenant Colonel Kenneth Cooper. He was a doctor in the Air Force and he wanted to figure out how to start to objectively assess the aerobic fitness of our military personnel, the Army and the Air Force, way back in 1968. This test is great. It has been studied a lot. It has a lot of normative data behind it. Very kind of similar to the six minute walk test that we use in the clinic with a lot of our patients to assess aerobic capacity. This is a 12 minute max distance run. Basically how far can you run in 12 minutes? So set a timer. The idea behind this test is that you would run it on a track or you would otherwise just basically run 12 minutes in a straight line. You don't want to end up running maybe in the CrossFit parking lot or the neighborhood where you have to turn and stop a lot. You really want to be able to pick up speed and stay at speed as long as possible. So make sure you're on a track. Make sure you're doing maybe six minutes out, six minutes back, or maybe 12 minutes straight out and then come on back with a walk. And then if you're on a treadmill, make sure you have the grade at 1% to imitate kind of the uneven nature of outdoor pavement. And then that's it. Figure out how far you ran in either meters or miles. There's some equations in the Instagram post to calculate, predict your VO2 max based on how far you ran. And then we've posted some normative tables as well. So this is a great test for ourselves. This is a great test for our athletes or patients as well to see how we stack up. So figure out Cooper's test. Yes, you can row it. You can bike it. Just be mindful that those are unloaded assessments of aerobic fitness so they don't quite translate directly to running. But as long as you retest under the same parameters, have at it with a biker row as well. Courses coming your way related directly to Leadership Thursday. Brick by brick, our practice management startup course starts again September 12th. That course just has one seat left. That's taught by yours truly. We cover everything you'll need to know about starting your physical therapy practice literally from step one of all the legal paperwork you'll need to figure out and file to get started. And then we get a little bit more into what it actually looks like to open and begin your practice. So that starts September 12th, one seat left. And then live courses I want to focus today on total spine thrust manipulation taught by our instructors Justin Dunaway, Jesse Witherington and Britt Lotteman. We have a couple courses coming your way through the end of the year. September 9th and 10th you can join Jesse down in Clearwater, Florida. September 16th and 17th you can join Britt out in Chicago. September 23rd and 24th Jesse again will be on the road this time in St. Mary's, Georgia kind of down in the southeast corner of Georgia by Savannah. October 7th and 8th, two chances to catch total spine thrust either in Columbia, South Carolina with Jesse or in Hendersonville, Tennessee right outside of Nashville with Justin Dunaway. November 4th and 5th Jesse will be out on the west coast, Simi Valley, California. And then two chances again in November before the end of the year November 18th and 19th. Britt will be on the road in Santa Rosa, California this time Northern California and Jesse will be in Albuquerque, New Mexico. So total spine thrusts coming your way. Today let's talk about this topic. So I do have some research to share with you regarding this topic but I really want to talk about the top three things I think I've been wrong about so far in my career. So we're going to talk about what it looks like to treat a comprehensive plan of care with a patient. We're going to talk about technology and we're going to talk about long-term changes to the health care system.

04:08 BEING WRONG ABOUT DOGMATIC APPROACHES TO PATIENT CARE

So I want to start with talking about the kind of back and forth dogmatic guru battles that we see all day long on social media of manual therapy sucks, it doesn't do anything, you shouldn't do any manual therapy, if you do manual therapy you're committing malpractice. And then the far other side of that same continuum of if that's exercise only then the belief that manual therapy is the only thing we do that matters that we can somehow cure or fix patients with our hands, with our dry needling, our cupping, our spinal manipulation, whatever stuff we do with our hands. So two different kind of camps fighting and barking at each other on social media and then talking about the research supporting one side or the other or both or neither. So what I've realized and keep in mind I'm coming from a point where I have sat in both of these camps at different points in my career of coming into school as a background as an exercise physiologist, of having no way and no knowledge of how to put my hands on people because I was an exercise physiologist so my intervention, the only intervention allowed to me was exercise. So coming into grad school with a belief that exercise is medicine as taught by the American College of Sports Medicine and that exercise is the way that creates the long-term fix and that manual therapy has no value. So I certainly sat in that camp in the beginning of my PT school career and then I've sat in the other side of the campus while getting into PT school learning more about manual therapy residencies and fellowships and diving really deep into the weeds especially behind spinal manipulation and dry needling and going to the other side of manual therapy is one of the most robust tools we can offer and a little bit of exercise maybe at the end for the patient to keep up their progress in between but being very heavily in the manual therapy camp and holding the the previous belief that maybe folks who are in the exercise only camp are there just because they're not that good at manual therapy so I certainly held that belief for a while. Now I would say I'm in in neither camp and maybe not even in the middle of coming to the belief of the unfortunate belief that we just can't talk or exercise patients into better lifestyle choices no matter how much we have the answer of some sort of combination of both maybe one more than the other is needed for our patients depending on who they are and where they're at in kind of their health and fitness journey and this can be maybe I think the most frustrating part of being a physical therapist and being a health care provider in general of knowing the answer right of knowing that exercise and a solid nutrition plan go a very long way into helping you become and stay a healthy fit individual but that from time to time some hands-on treatment is needed so knowing knowing the answer walking the path but really unfortunately not being able to just give that to another person especially maybe a patient that at the beginning of their plan of care has no formal relationship with us yet. I myself have an unshakable belief that I will continue to probably encounter some minor musculoskeletal injuries within lines of statistical norms due to the impossible ability to balance a lot of different things essentially balancing workload versus recovery of there's going to be days where I don't sleep enough there's going to be days where I don't eat enough there's going to be days where maybe my training volume is higher than I wanted to be my overall life volume is going to be higher than I wanted to and otherwise I put myself at a greater risk for an injury and sometimes we'll actually encounter an injury so I believe that is just part of the journey of health and fitness. I also have an equally unshakable belief that the current meat suit that my brain sits in has been evolving and adapting to stress for over two million years and that it's a naturally resilient structure that's capable of healing itself from most injuries maybe not a car accident or getting hit by a bus but certainly encountering some shoulder pain or knee pain in the gym or out on the run or something like that so that's what I believe but it is hard to transfer that to another person that my third unshakable belief is that it does not matter how much I trust my own body how much I believe that the body can heal itself I can't just take that belief from my brain and put it into somebody else's brain no matter how much I want that to happen no matter how much I talk to that patient in front of me we just can't talk people better we can't talk people into better lifestyle choices we kind of have to show them and that can come from a couple of different angles that can come from having them do some manual therapy techniques maybe even self-manual therapy techniques that helps alleviate your own symptoms to help connect that stress recovery adaptation cycle maybe some exercises or maybe both but otherwise we we do need to show people that this this thing that I've been wrong about is that seeing is believing and 99 percent of people can't be talked better the interesting thing is we have more and more research supporting this now we have some fantastic articles coming out of the pain neuroscience education space that support this that we cannot just talk people better we cannot talk people out of pain we cannot talk people into being healthier we have to show them both by our own example but also by them seeing the success as well and part of that comes from showing them some sort of change manual therapy exercise based doesn't matter whatever you think the patient needs so they begin to buy in to I'm not broken I'm resilient my body can fix itself I don't need surgery I don't need an MRI I don't need pills but that we can't just talk that person better really fantastic article if you have not read it yet by shala and colleagues 2021 the journal of manual and manipulative therapy saying that same thing literally the title of the paper is can we talk patients better and the conclusion is no we can't that we need to combine these things and that the most successful interventions for pain are multimodal they involve yes education discussion of sleep and diet but they do also involve manual therapy and they do also involve exercise it's everything together it's and not or most physical therapy studies if you read the methodology if you read the inclusion and exclusion criteria and if you read and find out in these papers why they initially studied a thousand people but only 760 people completed the study what happened to those other people well yes people get busy yes people get injured or whatever else they drop out of the study but in a lot of these studies folks drop out because they're not getting better they are maybe even going to get care somewhere else outside of the research study which you can imagine creates a lot of confounding variables that makes us need to exclude that person's data from the study there's a lot of really cool research now looking at that of that if we do not offer hands-on care there seems to be a sub-population of people who will leave our care and go get it somewhere else that if you try to talk somebody better and you say i am not going to do anything hands-on because i'm going to make you addicted to manual therapy there are people who will leave your clinic and immediately go get a massage or go see a chiropractor or maybe go see another physical therapist they will go get the care they think they need somewhere else sometimes immediately after your appointment and we need to to be cognizant of that likewise there are people who believe that if there's nothing hands-on as far as doing exercise of them being hands-on that the therapy has less value and likewise they will leave your clinic and go get extra care somewhere else so we need to be cognizant of that as well i think often of i get my hair cut every three weeks on thursday afternoon i see the same stylist i've seen her for years now she has had what i believe to be a pretty gnarly case of achilles tendonopathy from overdoing it increasing run volume i see her i've seen her progression of having a soft brace on to having a walking boot to now having a full cast on of chasing down what she thinks is going to help her in the health care system even though she talks to me for about an hour every three weeks and i try to talk about anything i can to get her to try literally anything else except pills and casting and surgery and imaging and she still won't come down to my clinic to see me even though i've offered to treat her for free of i cannot take the beliefs in my mind and put them in somebody else's mind they have to come unfortunately to that conclusion on their own so being wrong about being able to talk people better about being able to exercise people better and more understanding and recognition as my career has gone on that i need to recognize that every single person who comes into the clinic is different they have different beliefs and i need to recognize what those are and address them accordingly some people may need to start with a bunch of front-loaded physical therapy some people may not like to be touched at all they don't want to do any manual therapy they only want to do exercise and maybe some sort of blend for folks in between.

04:08 THE DANGERS OF TOO MUCH TECHNOLOGY

The second thing I've been wrong about is technology if you know me you probably have the belief in your mind that i am the biggest nerd you've ever met and i'm okay with that i grew up playing world of warcraft you can find me in my limited spare time probably trying to sneak in a video game or two every now and again so i'm certainly a giant fan of technology but as my career has gone on as i've gotten older i now have the belief that i think technology creates more problems than it solves the previous point was a great example of we would probably not have these dogmatic arguments and be so fervent in these different camps if we did not have technology to use to yell at each other from across the planet that the computer the internet the mobile device the whatever you're using has revolutionized humanity maybe for the better but i think nowadays more bad than good that having access to all the combined knowledge of our species is amazing but also being a button push or click away from constant contact with friends family frenemies work whatever can be really bad for us especially our mental health of you maybe you're this person maybe you are the spouse of this person or a friend of this person of that person who says did you see what so and so just posted this person is is my wife in our relationship of getting really upset at what other people put on social media and kind of letting it ruin your day and i think that happens a lot in modern society i think back to a question that i was asked very very early on and again i used to have the belief that more technology was better that we could talk other practitioners into better practice habits if we just argued with them on social media if we yelled at them on twitter and about nine years ago jeff moore saw me in an argument on twitter and just sent me a simple message that said hey do you think this is the best use of your time to advance the profession of physical therapy and obviously probably most things in our our life if we ask ourselves that question is this the best use of my time the answer is probably no but definitely to that question the answer was no definitely not and so i often ask myself that question a lot and what i've found over the years is that question and that answer that question takes me further and further away from engaging a lot on social media if you follow my social media now you see pictures of my son in my workouts and that's pretty much it right if far by far and large disengaged from physical therapy social media as a whole i don't listen to any podcasts anymore i listen to the news in the car and music when i work out and that's pretty much it so i've pushed technology away as i've gone through my career as i've gone through my life and i think i'm the better for it and i think having access to all of the gadgets that come along with technology is really doing us a disservice as well of i used to be a big proponent of whoop if you've listened to us here before if you've come to our fitness athlete classes you've heard us talk about whoop and other devices like that and likewise i think those cause more harm and good that having a constant stream of data letting us know you're not moving enough hey you need to move you need to exercise you're not eating enough you're not eating right you're not eating enough you're not sleeping enough you're drinking too much you're overeating this specific type of food i think those constant technological inputs into our life really set us up for a lot of unhappiness of folks who look at a whoop and think what if my resting heart rate is high because i had a beer last night what if it's low because i underate what if my respiratory rate is high because i'm sick what if i have coven 19 what if i have cove 23 what if i put strawberries up my butt would my fart smell better like we can what if this stuff to death and we i think we are doing that with our technology that i do think there is a sub-population of people who have to see that data that have to see whoop say hey every time you report drinking two or more beers you have an 18 reduction in your sleep quality i do think there is a group of people who need to be smacked in the face with that realization of again they can't be told that by somebody else a friend or a family member they have to be showing that objective empirical data but i also think there's an equal sub-population of people who will go completely insane festering about that stuff of worrying themselves to death about what does this data mean i shouldn't exercise today uh maybe i ate so wrong my resting heart rate my hrv is messed up i'm just gonna fast today or i'm not gonna work out for a week and they literally what if themselves to death about this stuff until probably the end result is that most of those people just ditch the gadgets i no longer wear a whoop i haven't wore one for many many years i have a pretty neat cassio g-shock this is a solar powered watch its only thing it does is tell time and then i have a fitbit which tracks my steps i try to hit 25 000 steps a day and that's it right i have no access to any sort of heart rate data or sleep data and i think i'm all the better for it so i think technology is really doing a disservice and i think the more we can intentionally disconnect from some of these data streams and communication streams we will find that we're a lot happier for doing so.

20:07 LONG-TERM CHANGES TO THE AMERICAN HEALTHCARE SYSTEM

My third belief is maybe a little bit pessimistic that i think unless something considerable changes with the american health care system i think the way that our health care system currently works is not going to alter significantly at least in our lifetimes that when we step back and zoom out and look at how a lot of stuff in our life is run they're run by for-profit companies the power company is a for-profit company the internet company is a for-profit company the health care clinic company is a for-profit company the insurance company is a for-profit company so we need to ask ourselves are we just victims of people trying to maximize profit and that's why we can't really seem to get ahead in a lot of big system changes and i think the answer that question is yes that's 70 percent of all americans still get their health insurance through their employer so they receive health insurance insurance from a for-profit employer that's run by a for-profit agency the insurance company that uses that insurance at a for-profit health care company so it's no wonder that we are trying to keep margins really narrow high profit low expense and at the end result the person that suffers is usually the health care provider and the patient while the overarching organizations post record profit after record profit year after year after year that both the input and output sides of the system have a vested interest in minimizing costs and maximizing profit and at some point we need to acknowledge and recognize that we also need to recognize acknowledge that with some exception health care providers are really uninvolved or minimally involved with the ownership and management usually of the business that they work for insurance companies are led by led by corporate executives and large health care systems are also led by corporate executives and if we look who sits in the leadership positions of a lot of these companies they're not health care providers they are investment bankers venture capitalists that sort of thing they're interested in profit it really starts to explain and i hope that this doesn't come off as a conspiracy theorist of why our outcomes are so poor despite how expensive our health care system is and that we really need to see big system changes if we're really going to make a dent in the issues that we have which is 90 of humans are sedentary 70 of of americans have chronic pain and we seem to be going backwards despite how hard we get up and go to work ourselves individually every day what do those changes need to look like i don't know i'm not i'm not a big picture person i'm kind of a logistics person but i think that's kind of the frustration that we all experience day to day of yes our individual patients are getting better but why are we still seeing people who got a knee replacement two days after going to see a provider about knee pain why have they not tried physical therapy first why have they not tried literally anything else first except getting booked right into surgery we feel those frustrations we wonder where those are coming from and it's no surprise i think it comes from our giant for-profit health care system as a whole so three things i've been wrong about been wrong about being on one side of the fence or the other the belief that we can talk or fix somebody with our hands or just help them with exercise only that we can take the beliefs in our mind about our bodies and the proper plan of care at least in our mind and put that into somebody else's brain been wrong about leveraging maybe too much technology especially both in personal and professional life and been wrong about the belief of really creating long-term systemic change in the health care system so i'd love to hear what you've been wrong about i'd love to hear questions comments discussion about this topic as well i hope you all have a fantastic thursday have fun with with cooper's tests if you're going to be at a live course this weekend enjoy yourself other than that have a great thursday bye everybody.

21:41 OUTRO

Hey, thanks for tuning into the pt on ice daily show if you enjoyed this content head on over to itunes and leave us a review and be sure to check us out on facebook and instagram at the institute of clinical excellence if you're interested in getting plugged into more ice content on a weekly basis while earning cus from home check out our virtual ice online mentorship program at pt on ice.com while you're there sign up for our hump day hustling newsletter for a free email every wednesday morning with our top five research articles and social media posts that we think are worth reading head over to pt on ice.com and scroll to the bottom of the page to sign up

Aug 23, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult Division Leader Dustin Jones discusses recent changes to the Modern Management of the Older Adult Division and its mission to help clinicians provide the best possible care to older adults in their community as the provider of choice.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

 

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

01:33 DUSTIN JONES

We are live on Instagram. We are live on YouTube. Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the faculty members within the older adult division. This is Older Adult Wednesday. Today we are going to be talking about what is MMOA? What is this division? What are we about and what are we trying to achieve? We are going to spend some time diving into this because we have so many new folks that are new to the ICE community. We want to make sure that you're crystal clear on what MMOA is about and if you'd want to join forces with us. Before we go into the goods, I want to mention a few courses we have. We have a few live courses coming up in the next couple of weeks. We're going to be in Southern California this upcoming weekend with Alex Germano. I'm going to be in Windsor, Colorado outside of Fort Collins on the 9th, so the weekend after Labor Day. I believe Julie Brower is going to be down in Fort Mill, South Carolina, so you can catch MMOA live on the road the next couple of weeks.

02:43 MODERN MANAGEMENT OF THE OLDER ADULT

What is MMOA? Modern Management of the Older Adult. Our division, we just went through our big live revamp, so our MMOA live course is all new material and we're spending a lot of time reflecting on what we are about as a division. What are our goals? What is our mission? How can we get to that mission and what traits do we want our MMOA team to really demonstrate? I want to share this publicly just so you all are very clear of what we're about, so our goals and where we're headed and to propose that you join forces with us to achieve that mission of really changing the game for physical therapists, occupational therapists, fitness professionals that are working with older adults. So MMOA, Modern Management of the Older Adult, it really grew out of a big problem that we still see that we're still fighting. That older adults by and large in our society are underserved in so many areas, but in the context of rehabilitation, in the context of fitness as well, that most individuals, most professionals that are working with older adults will look at a date of birth. They'll look at medical diagnoses. They'll look at the medications that they're on and make assumptions about what that person is able to do. And when those assumptions don't line up with reality, we have a very, very unfortunate situation where people are not being served appropriately. They're being underdosed. They're being handled with kid gloves and we're not getting the results with these folks, the life changing results with these folks that we can get. That is a huge issue that pains every single MMOA faculty to see and we are on mission to try and solve that problem. How do we solve that problem? It is you. It is you that is watching this on Instagram, on YouTube, that is listening to this on the podcast. It is you, the rehab or fitness professional that has, we believe, has the most qualified skills to influence this population compared to any other healthcare provider. And we mean that. When we look at the research of how we can really influence older adults, it continually points back to that fitness forward approach. That exercise, that movement is such a big lever that we can pull to change these people's And you all watching and listening to this are the best professionals in the context of healthcare to administer this to this population that we love so dearly. Another big problem that we see that we're trying to solve is we have so many clinicians, so many fitness professionals, especially coming up in their training that they think, man, I want to work with the athletes. I want to work with the sports teams. I want to do the fun, sexy outpatient ortho clinic. And we go through our training and our training talks about a lot of things, but by and large, not a lot about older adults and how to best serve these individuals. And then we get out into the real world and what happens? You wanted to work with the sports team. You wanted to work with athletes, you know, from 8 a.m. to 5 p.m. or whatever. And who are you working with? By and large, on average, over half of your all's caseload, everybody watching this or listening to this, over half of your caseload is likely someone that is on Medicare, someone that is over 65 years old. And are you equipped to serve that person? And what happens when you're not equipped and yet you have these folks as the majority of your caseload, there becomes a big mismatch, right? It can be frustrating. It can be challenging and could lead to a lack of fulfillment and enjoyment in your work. And we're trying to absolutely crush that, to show you, the clinician, the fitness professional, of the life-changing impact you can have on these folks. When you use your skill set and you embrace that old-not-weak mindset, that you give interventions that actually meet that person where they're at to drive change, that it can be some of the most fulfilling work that you can do in the context of rehab and fitness, that you can change someone's life in a matter of weeks in certain situations with this population. And that has really driven a lot of the MMOA faculty. And we just want to spread that and share that just far and wide, as much as we can through many different means. So those are the big problems. The solution that we are trying to provide is we're trying to create an army. We're trying to create a community of like-minded clinicians that are locking shields to really fight ageism, to fight the under-dosage in our profession, and to show people what is possible when we serve these folks with an evidence-informed, fitness-forward approach. We do that through many different avenues. We'll do that through this podcast that you're watching or listening to, the PT on Ice Daily Show. We also have an MMOA podcast that's specifically older adult material. We have a Facebook group of about 5,000 clinicians from across the world that serves as a resource for so many individuals in terms of certain research cases. So much good conversation is going on in that group. We have our MMOA Digest. It's a bi-weekly email where we're sending out all the relevant information related to geriatrics. And then we have our courses, our certification.

07:49 CERT-MMOA

Cert MMOA. This is the certification that is our promise to clinicians. That if you go through our certifications, three courses, MMOA Live, our two online courses, Essential Foundations and Advanced Concepts, that you will confidently be able to serve that person, that older adult that walks through your door, or you walk into their home, or you walk into their hospital room. It's also a promise that when you see those letters behind someone's name, you can trust them. Our goal is that cert MMOA means I am 100% confident that my mother, that my father, that my grandmother could go to you and you are going to deliver an evidence informed and a fitness forward approach to my family member. That is what we're trying to do, selfishly trying to do to ensure that that cert MMOA holds some weight and you've got the goods. And so there's a group of 10 individuals from across the country that are working towards trying to solve these problems and providing the solution through those different means. We absolutely love what we do and it is such an honor to serve you all and to interact with all the students when we're out on the weekends and live courses and the online courses as well. And this team, this team of 10 all-stars of folks that really embrace that old not weak mindset that have been through our curriculum are spreading this information far and wide to try and equip you, the rehab and fitness professional, to better serve your older adult patients or clients. And each member is going to demonstrate three main traits. We call this our DNA. And what we're going to do over the course of the next couple of weeks on our MMOA channel or Instagram account, we're going to go live and really dive into what these DNA traits are and the specifics of them and how we may see that play out whenever you come to a live course, whenever you interact with us online as well in essential foundations or advanced concepts. These three DNA traits that we're all going to embody is that we're all leaders. Regardless of your role on the team, we're all leading someone and there are certain characteristics and traits of leaders that we embody. We're also teachers. We understand this material, but we're also methodical in how we relay that information to our students so you can use that come Monday. And then last but not least, we're performers. We are performing. We're trying to entertain you so to continue to engage and learn. And whenever we're having fun and you're having fun, we know learning goes up across the board. You will never come to an MMOA course and see someone read off of a PowerPoint presentation for three straight hours while you're sitting in your butt getting a pressure ulcer. That ain't happening, right? We're going to have fun. We're going to get the music cranking. We're going to be moving. It's going to be an absolute blast. So over the next couple of weeks, we're going to dive in. What does it mean to be a leader? What does it mean to be a teacher? What does it mean to be a performer? And how are you going to see that within the MMOA division? So tune in there. We'll be posting over there, but I just want to take this opportunity just with all the folks on here now, I just want to say a big thank you. We've had a lot of change as a division, a lot of growth as well. We're interacting with so many of you all in person on Instagram, you know, in our courses as well. And it is an absolute honor to get to do this, to get to share our passion with you all through these means. And you all just really fill our cup up. When you share, when you execute, you know, that particular tip or intervention, or you just share, man, I got to use this on Monday after this course, that makes it all worth it for us. So we're just incredibly grateful for you. All right. If you have any thoughts on that, or if you've experienced some of this in our course, we'd love to hear in the comments, but just wanted to share this, put it out into the world, and we're going to continue to break down our DNA leaders, teachers, performers over on the MMOA account. We're grateful for y'all. You have a lovely rest of your Wednesday. Talk to you soon.

11:46 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.

Aug 22, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant debunks common myths surrounding the IT band. Mark emphasizes the importance of exercise in enhancing function. He mentions two types of exercises: local tissue exercises and functional activities. Local tissue exercises are designed to respect the irritability and stress levels of the tissues. These exercises may include variations of hinge movements, knee bends, or squats that are unloaded enough for the individual to handle. They provide a healthy stimulus to the tissues and help build strength and capacity.

Functional activities, such as step downs, squats, and deadlifts, are also incorporated into the treatment plan. Mark explains that coaching these functional movements is crucial in helping the individual return to their normal activities. By gradually increasing the training volume and appropriately dosing the force, they can both manage symptoms and provide a beneficial stimulus to the tissues.

Take a listen or check out the episode transcription below.

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

00:00 INTRODUCTION

Alright, what is up PT on ice crew? Hope you're doing well on this Tuesday morning. I'm Dr. Mark Gallant coming at you here on clinical Tuesday. Lead faculty of the extremity management division alongside Lindsey Huey and Eric Chaconis. Want to talk to you today about IT band syndrome and some common myths. Before we get into that, we've got a few upcoming courses. So I'll be in Amarillo, Texas, September 9th and 10th. So a lot of tickets flying off the shelves for that one. So make sure if you're in Texas and want to check us out on for extremity management, that you get some seats to that. And then the following weekend, I'll be in Cincinnati, Ohio at Onward Cincinnati. So love to see you out there for that one as well. Again, for any of the ice courses, if you have not already signed up for the ice course that you want for the fall of 2023, the courses that are on the website are the only courses that are going to be added for this year. So make sure make sure you hop on there and sign up as soon as you can.

02:38 COMMON ITB BANDS

So IT band myth. So IT band syndrome is one of those syndromes that we had a lot of ideas that came out of research from the 70s, 60s, even early 80s that for whatever reason or another have stood the test of time and stayed in our profession for over 50 years. And that's influenced a lot of the way that we treat a lot of the common manual therapy we see, the interventions we see. And we've got a lot better research that's come out in the last 10, 15 years to direct us how to treat these these IT band patients. And so we want to look at that. This is not to bash the researchers that have come before us. So Renee and Ober and those folks that did a lot of the research in the 1970s. We owe everything we know now to them. And I sincerely hope in five years, six years, a lot of you are looking back at these podcasts and go, man, like all all the stuff that Mark was saying or his colleagues at ICE, it seems kind of silly now. That's what we want to happen. We want you all to take everything we're we're looking at now and make it way better over the next five or six years. So so thanks to Ober. Thanks for Renee. And now we can stand on their shoulders and really move forward. So what were some of the common myths that came out of that research in the 70s? Well, the first one is that the IT band, the iliotibial band track starts at the proximal hip with the TFL and glute. And then it has a very simple unidimensional insertion point at Gertie's tubercle. So one single insertional point for that big, massive iliotibial band structure. What we now know is that the the iliotibial band insertion point is actually quite more complex than that. It attaches at the tibia. It attaches at the lateral femoral condyle. It attaches to the patella. And not only does it attach at multiple sites, these attachments are firm. So so that that distal IT band is not really moving very much at all. The second myth is that the IT band is tight. That that iliotibial band is going to get tight and it's going to limit that person's hip adduction. What we now know is that the structures that are most commonly going to limit someone's adduction are the glute medius, the glute men and the joint capsule. So the IT band is rarely going to be the primary driver of limited adduction. And the TFL, the glute max, the structures that it attaches to are also not typically going to be the primary driver of adduction. What we then see is the third big myth that that iliotibial band syndrome is a pain dominant syndrome being caused by a friction of that iliotibial band rubbing along the lateral structures of the knee because it has a unit dimensional insertion point. Because that thing is tight that it's starting to rub. And that makes a lot of sense going after those those old ideas. Right. If you've got a certain kind of problem, you can go to the doctor's office and you can get a prescription. If you've got a single insertion point and there's extra force causing that that to be tight and it starts to rub, certainly we can see tissues being irritated because we now know that it's got a complex insertion that's really firm, that the IT band is rarely tight. What we now know is that the typical pain presentation is often being caused by repeated force due to an increase in volume change in that person's activity and the lack of frontal plane control. So the most common thing you're going to see is someone really picks up their volume of running. They've got they've got poor control over the hip, knee and ankle. And that knee starts to ping in when you get that at a really, really high volume, the opportunity for the lateral structures structures of the knee to become sensitized gets significantly increased. Another one we see it in is as folks who do a lot of downhill running, they increase their trail running their downhill running by by high volume. So you're getting a ton more load into those those structures and you're getting that lack of frontal plane control and those tissues are going to get irritated. So what are we going to do about that tissue irritation? So so like any other pathology that we're going to treat, our first step is to calm things down. We want to put out that fire initially.

05:30 CALMING DOWN TISSUE IRRITATION

So with IT band syndrome, the primary thing that you're going to do to put out their fire is you're going to you're going to get control of their volume. All right, Chris, you were running 10 miles a day, five days a week. We're going to cut that down to five miles a day for three days and see if we can calm that tissue down. So it's rarely full on abstinence. Where we like to start is can we find that sweet spot where your symptoms are starting to calm down and we're still keeping you involved in your functional activity? So whether it's running Olympic lifting, whatever the activity may be, can we control the amount of load, the volume of force that's going into that system and get those symptoms to calm down? In addition, using using our manual therapy techniques to modulate pain. So you're dry needling, your myofascial decompression, your soft tissue mobilization. You're going to base these off irritability. If that person's high on their irritability, then we're often going to needle massage and cup tissues that are a little more distal to where the pain is at that lateral knee. So looking a lot at the glutes, maybe lower down on the ankle. And then as symptoms calm down, we can get at the tissues more more close to that knee, that tibialis anterior, the distal vastus lateralis, the short head of the biceps and really try to modulate people's our patient symptoms and and get those tissues a little healthier. From there at the same time, so we're not waiting until the pain modulation comes down, we're going to start doing some therapeutic exercise to get those tissues to tolerate load better. So we've got to strike that balance of we're trying to lower their symptoms and we want some healthy, good force to go into their tissues. So oftentimes that can be open chain exercises. So they're going to have typically a little less load on the tissue because you're not dealing with so many structures. You're not dealing with ground reaction forces. So keeping that that low to improve the overall tissue health and then progressing them into more closed chain exercises that are going to stimulate those tissues in a little bit closer environment to their typical activity. So things like hip hikes, closed chain clamshells, your side steps, all those sort of things. Then we want to get into some functional exercise. Can we get compound movements that are going to be close to the activity that that person is typically doing with those compound movements for IT band? We're looking at things like step downs, single leg squats, all of those type of activities. Kickstand deadlifts are another good one.

08:25 PT 1.0 & MOVING FORWARD

Now we're PT 1.0. A thing that we did in our profession that we would like to move on from now is we said, OK, we're going to do our local tissue stuff. And when you get good enough at the local tissue stuff, then we're going to graduate you into doing these functional components. What we what we know now is we want to get all of this involved as early as possible so that we can influence the nervous system better and make that person less fearful of doing these these more challenging activities. So you're going to hit your local tissue exercises, respecting their irritability, respecting the amount of stress that that tissue can handle. And you're going to start doing variations of functional activities that they can tolerate again with their pain level, their irritability and their stress. So finding a hinge variation that's unloaded enough that the person can perform, finding a knee bend variation or squat variation, single leg squat variation that's unloaded enough that that individual can handle. So that's two components, local tissue with three components, pain modulation with our manual therapy, local tissue exercises to get some healthy stimulus into those tissues. Looking at a functional activity, squats, deadlifts, all those sort of things. All these are happening relatively at the same time. And then the fourth piece is looking at the activity that caused the problem. Was it running? Can we get them on the treadmill and do do a run a run gate analysis? Shout out to Jason, Megan and Rachel in the in the injured runner division. Can we look at their their Olympic lifting? Are they getting IT band syndrome because they started doing split jerks all the time and that position of their knees a little bit irritating? You know, the whole CMFA crew, can you really look at and coach well through a video analysis what that person is doing on their their Olympic lifting and start moving them forward there? So we're going to modulate the pain by controlling their volume. We're going to modulate the pain by using some manual therapy to influence the central nervous system to calm those tissues down. We're going to start exercising, getting good healthy stimulus while respecting irritability into the tissues through open chain and closed chain local tissue exercises. We're going to get a big functional movement, step down, squat, deadlift to start building robustness and capacity overall. And we're going to coach them on the functional activity that may have been the aggravating, whether that's running, downhill running or or their Olympic weightlifting. Now, what this does that's really cool is it positions you as a wildly unique provider to this individual. We are the only profession or one of few professions that are able to control that entire experience for that person. We've got the education where we can control their training volume. We can say, hey, look, I looked at your programming. Looks like you had a huge jump here and all of a sudden you're doing like three times the volume. Let's see if we can cut that back a bit. You can poke them with some needles. You can do massage. You can do myofascial decompression. You can do joint manipulation to calm that lateral knee down. You're the expert in local tissue exercise. You know, if I put this amount of force into this tissue and dose it appropriately, we can both keep symptoms calm down and give a good healthy stimulus to that tissue. You got to know how to coach the step down, the squat, the deadlift to get them back to their functional movements. And we've got to start getting better at being able to do those run gate analysis, video analysis for the big lifts, the Olympic lift, the squat, all those that we can really coach those well. And that will uniquely put you in a position to take that person through a whole plan of care and get them back to the things they love. That will really position you as the best possible guide. So again, to recap, IT band syndrome, we no longer believe that this is a friction based component because we now know that the IT band is firmly anchored to that lateral knee at the tibia, the femur and the patella. We know it's more of a volume increase and a lack of frontal plane control that's really irritating the system. If we can get that frontal plane control by getting a better step down, a better squat, better functional movement, use our local exercise to get better healthy stimulus into that lateral knee so those tissues can tolerate increased stress and improving our efficiency with the movements that we want to do, our running, our Olympic lifting, those sort of movements. Hope this helps. Love to discuss this more in the chat bar. Can't wait to see you all on the road in a few weeks. Hope you have a great rest of your Tuesday.

13:01 OUTRO

Hey, thanks for tuning in to the P.T. 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 P.T. on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to P.T. on Ice dot com and scroll to the bottom of the page to sign up.

Aug 21, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Christina Prevett breaks down two recent studies, one that is VERY new to challenge beliefs on prolapse, the pelvic floor and strength training.

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back, with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show.

01:22 CHRISTINA PREVETT

Hello everybody and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the team within our pelvic health division. If you are interested in learning more about our pelvic health division, we have a online newsletter that goes out every two weeks that focuses on the research, which I'm going to talk about today, in pelvic health. One of the things that is so exciting, but maybe a little bit overwhelming about being in public health and being in this area of exercise and rehab in the pelvic health space is that it is constantly changing. The research is coming out at a very fast pace, fast being relative because research is very slow, but we try and focus in on getting that research to your inboxes every two weeks. You can go to PTonICE.com slash resources and sign up for that newsletter. I am writing it this week and it goes out on Thursday. Also all of our online content, our next online cohort, and all of our upcoming live courses, our two-day live course is in that email newsletter. I hope that you all sign up to get all that research straight to your inbox.

02:48 ACUTE EFFECTS OF RESISTANCE TRAINING

Today I'm going to be talking about a new study that came out of Carrie Bowes' lab, talking about the acute effects of resistance training on the pelvic floor. And so before I do that, I kind of want to set the stage for you all around some of the thoughts in pelvic health around heavy strength training. Where we have started this journey was that one of the risk factors for pelvic organ prolapse or descent of one or more of the vaginal walls towards the vaginal opening is that occupational heavy lifting. So individuals who lift heavy weights for their job, consistently lifting heavy weights, were shown to be at risk for more objective descent of one or more of those walls compared to those that didn't. And that because we didn't have any research on resistance training was extrapolated and said, well, maybe we shouldn't do any strenuous heavy lifting as females in order to mitigate or prevent the risk of pelvic organ prolapse from occurring. That was kind of the thought. Since then, we have really pushed back against that narrative and said, well, that doesn't really make a lot of sense because it's very different to go in for eight hours a day doing lifting versus, you know, the 30 to 90 minutes that individuals are doing. In your job, you can't control if you're feeling bad or feeling weak and just take a rest day or modify the way that you're doing your exercise. So again, there isn't really that comparison.

04:24 ACUTE CHANGES TO THE PELVIC FLOOR

And now we're starting to get more and more research come out that's talking about kind of this acute change to the pelvic floor that we're seeing with different amounts of strength training or different types of strength training. So Carrie Bo came out with a study and what she was doing was she was taking individuals who were resistance trained. So on average, these were individuals who had never had kids. They were Nellie Parris. And so I never had a delivery and were trained resistance trained athletes. So they had on average about two years of experience. They were then put into a crossover design. So what that means was they took half the individuals and got them to strength train first and then took half the individuals and got them to rest first and then kind of compared. So what they were trying to look at was after a high load resistance training session, what was the impact on the pelvic floor? The thoughts were one of two camps. There's two camps in this space. One is that individuals who strenuously lift are going to have bigger pelvic floor muscles, stronger pelvic floor muscles. And the other is that it may actually create damage over time that they're going to see a big change in symptoms or change in vaginal descent. So you kind of have individuals in both of these camps and we're trying to figure out which hypothesis is correct. And so they took, they did a one rep max or a perceived or rate of perceived exertion that was very high in the squat and the deadlift on one day. And then they got them to come back the next day. So after that one rep max test, they kind of flushed out, let the body recover, came back in. Half the group started with a rest window. So took pelvic floor muscle strength measures at the beginning pre, then half of them rested and did a post and then half of them did a four by four strength training session between 75 and 85% of their one rep max on the squat and the deadlift with reps in reserve between one and three and then did a post assessment and then they flipped, they flipped them. So what they saw was that there was no big differences, no statistically significant differences between the rest pre post, but then also the resistance training pre post. And I think that's really interesting because one of the things that we kind of explain around our, our thoughts around heaviness or prolapse are things like that it's a fatigue issue or so maybe it isn't fatigue or maybe it is, but doing a supine assessment, which is our traditional way of conceptualizing pelvic floor muscle strengthening, isn't sufficient to look at this type of, of fatigue, like to really evaluate this type of fatigue in individuals who are experiencing these symptoms. So that was really interesting. The other thing was that, you know, they did see some individuals who complained of urinary incontinence in this sample around 28%, I believe. And so those individuals, the study wasn't powered enough to be able to subgroup those that experienced incontinence versus those that didn't, but there, what it was not just on individuals who were symptom free. I think that's a pro to this study because we can say, well, of course there isn't any fatigue or any downstream effects of individuals who've never experienced pelvic floor dysfunction, but that's not the case in this study. There was a significant cohort of these individuals who did experience leaking with lifting and the study just wasn't powered enough to subgroup this out. So the first step was to kind of take a full circle approach and say, was there any differences? And then the next step is going to say, is there any differences for individuals who do experience pelvic floor dysfunction versus those that don't? And then the next step is those that are multiparous or multiparous, like multiparous, we kind of, tomato, tomato, those who have had vaginal deliveries before or have given birth before vaginally versus those that haven't. And so this is kind of setting up this conversation around the way that we message things. So another study was done in 2016 and I just found it because it was in the discussion section of this paper around vaginal descent. So Carrie said the Bowe study was looking at pelvic floor muscle strengthening, pelvic floor muscle strength and assessment.

09:23 VAGINAL DESCENT AND EXERCISE

The next question is around vaginal descent and are you more likely to experience symptoms of prolapse or heaviness post resistance training? And so this study was done in 2016, I believe it was published out of Janet Shaw and Ingrid lab that was looking at CrossFit athletes, those who experience, sorry, those who participate in strenuous exercise. So they got CrossFitters and they got them to do pre-post on the pop cue versus those that participate in non-strenuous exercise. So let's kind of break this study down too, because I think it's important. So in this second, this, I guess it was the first study, what the group from Nygaard and Shaw's lab did was they took individuals who were CrossFitters, got to check their pelvic floor muscle strength and the pop cues. The pop cue is an objective assessment of prolapse that has good reliability that looks at the different segments of the different walls of the vagina. And then as they do a strain maneuver, they see what the range of motion or the amount of each segment of each component of the wall are, and then create a grade based on the most amount of movement in whichever section of the vaginal wall that may be. So they took individuals who were CrossFitters and then they took individuals who participated in non-strenuous, non-high impact exercise and got them to come into the lab. And then the strenuous group was, they did a pelvic floor muscle strength exam and then the pop cue and then in the non-strenuous group, they did the same thing. And then they got the CrossFit group, the strenuous group to do a 20 minute AMRAP of sit-ups, heavy deadlifts. There was an impact movement in there and kind of went for 20 minutes. And then they got the non-strenuous group to do 20 minutes of an exercise of their choice at a self-selected pace. And then they did the pop cue again. Here's something that's really interesting. So the strenuous group was participating in CrossFit for over two years. They had an extensive history of strenuous exercise versus the non-strenuous group. And they kind of conceptualized this based on looking at what they did for exercise and the amount of loading in their bones to try and get some sort of measure of impact, which I thought was kind of brilliant. And they compared them. Strenuous group had done a lot more loading of their bones and musculature and therefore loading of their pelvic floor compared to the other group. And what they saw was that before their pre-exercise, descent in pelvic floor muscle strength was not different. Was not different. So this created preliminary research that the strength, individuals who are participating in strength training for several years, so it was like on average 22 months plus or minus, and they had to have at least, I think, a year of doing CrossFit regularly, three to four times per week to be able to get into the study in the first place, that there was no difference in vaginal descent. They had, there was no differences between the two. So that kind of goes against this argument that resistance training is going to cause a prolapse, resistance training in general for individuals who haven't had a vaginal birth yet. So I think that's interesting. And then post-partum, or post-exercise rather, they did see differences in descent in both groups. So both groups saw a difference in descent immediately post-exercise, which again, I think is really interesting because this does not support that resistance training and high impact is going to lead to prolapse down the line. Now again, we have a lot of work to do within this space. This was one study. I'm not going to just start shouting from the rooftops that all of a sudden, you know, we know all of the things that we need to know. I'm not saying that, but the fear focused language that is coming into this space around resistance training and avoiding Valsalva and all these types of things isn't founded objectively. So the other interesting thing was that there was only one individual, even though there was a change in descent, right? There was some changes pre-post-exercise and they didn't re, they didn't kind of follow them further and further forward. I would have loved to see them do multiple time points to see how long it took before that changed or kind of returned to baseline. There wasn't anything that, that was looking at what, what that change of symptoms were.

12:57 RESISTANCE TRAINING & PROLAPSE

And there was only one person with subjective symptoms of prolapse. So again, we're, we're seeing this disconnect between objective signs and subjective experiences, which I think again is really interesting because we are focusing a lot on the grade, like what grade do you have? What grade do you have? And the evidence isn't really supporting that we, that should be our focus. If you are thinking surgical routes, if it is coming past the level of the Hymen, absolutely, because then we're going to say, is this impacting your quality of life? Is there sufficient imaging data to see that a surgery, for example, would be warranted? For individuals in the conservative space, again, we're, we're, we're questioning, does the objective signs matter? And, you know, we can't answer that question, but it is an interesting thought experiment and we're starting to have more evidence accumulate that, you know, there is a big disconnect. And yes, our body is going to change and show signs of fatigue with things like impact, but what's the cost benefit? What is the risk of telling people that they shouldn't be getting strong for their 60-year-old self, for their 70-year-old self, for their 85-year-old self, when we know that strength is such a huge, huge component of independence in later life? So it is so exciting, kind of going through Carrie Bowes where she didn't see any change in pelvic floor muscle strength to some of the research coming out of the Nygaard and Shaw lab that are talking about changes in pelvic organ support with heavy lifting and long-term heavy lifting. I think we're starting to get more and more data that the fear-focused messages aren't warranted, that we're going to start treating the symptoms and that we can expect changes to the pelvic floor when the pelvic floor gets a workout. Again, I don't think for anybody in the ice fitness forward community that that is necessarily a surprising finding, but it is definitely pushing some of the narratives in pelvic health and I think pushing them in a really necessary direction to try and change this narrative around the fear-focused language of resistance training in the pelvic floor. If you are interested in those studies, I'll post their DOIs below in the comment section. I am so excited to be talking about this research. Again, if you are a research nerd like me and you want to see the new studies that are coming out in this space, which these two studies are going to be in our newsletter this next week, I encourage you to go to ptonice.com slash resources to look for the pelvic newsletter. I am really excited to see some of the changes happening within our course and I just can't wait to continue connecting with you all about research in the pelvic health space. All right. Have a great day, everyone, and I will talk to you soon. 

16:40 OUTRO

Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at 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.

Aug 18, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses three postpartum physical scars that are often invisible to rehab providers. She explores how these scars can impact exercise prescription for clients in the early postpartum period.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:27 APRIL DOMINICK

 

Welcome to the PT on ICE Daily Show. Dr. April Dominic here. I am your host representing the ICE Pelvic Division. Today we'll focus on three postpartum physical scars that are often invisible to the rehab provider. We'll talk about how these scars can affect exercise prescription when it comes to working with a client who is early postpartum. But before we dive into that, let's chat about all things, updates and course offerings for the ICE Pelvic Division. If you're looking for a virtual option to learn all things fitness, athlete, pregnancy Our next Level 1 online cohorts starts September 5th. Otherwise, you can catch us on the road. We've got tons of courses coming up for this fall. And our next one is September 23rd and 24th in Scottsdale, Arizona. This is going to be with the lovely Dr. Alexis Morgan and Dr. Rachel Moore. This course is chock full of literature outlining the ins and outs of pelvic floor basics, pelvic floor dysfunction, the assessment for the pregnant or postpartum fitness athlete that includes an external exam or an internal exam option. We also have a lot of super fun labs that are going to cover core and c-section management. We also have tons of labs on reintroducing or continuing to use the barbell, do rig work and endurance exercise. Please go hop on PTONICE.com. Get yourself in one of our courses. We would love to see you there virtually or in person.

03:23 PHYSICAL SCARS POSTPARTUM

Today I wanted to hop on and shed some light on physical scars that a postpartum body endures early on. These scars aren't always visible or front of mind for the rehab provider. So think about it like this. You may have someone who is coming in very early postpartum due to some sort of orthopedic injury like for their hip, their shoulder, maybe their back, or they may be coming in for core and pelvic floor work. So it's important for all of us to be aware of these scars as they heal and the role that they play early postpartum with movement and exercise prescription. So when someone is pregnant, there is usually some sort of baby bump or something that is a visible reminder to others of their condition that they are pregnant. Enter the postpartum period. For many postpartum folks, those visible reminders of pregnancy fade and the physical impact the labor and delivery on the body are invisible to others. When someone is postpartum, there's no physical sign that they and their body have gone through this incredibly challenging feat. There's no cast for like when we have for a broken bone. There's no crutches for that ankle sprain. There's no sling to support the wounds. Unless maybe they have their newborn with them, there's really no obvious physical sign that someone is recovering postpartum. So three invisible scars that we'll chat about today are the uterine scar, the perineal scar, and the lower abdominal scar from a cesarean section. Let's circle back to wound care from school. Remember for our healing stages, our tissue healing goes through four major stages. Starting with the first couple, the hemostasis and inflammatory stages. This is going to be a period of local swelling. Next, the proliferative stage. And that's going to be the stage focusing on covering and filling the wound. And then the remodeling stage is characterized by scar tissue formation, which this can last for a year or two, if not. So let's unpack those three major postpartum scars. The first, the uterine scar. I feel like this is the most invisible. It's as the name indicates, a wound on the uterus. And in terms of time to heal, the uterus typically involutes or returns back to its pre-pregnancy size that's smaller by six weeks. And muscles that may be impacted by this scar, by this wound on the uterus, would be indirectly the pelvic floor and the abdominals. In terms of considerations to return to movement when we're thinking about uterine healing, if someone does some physical activity and there is an increase in vaginal bleeding, then that is going to be a sign for regression that the uterus and body may not be ready for that specific intensity level of physical activity or the duration of physical activity.

07:33 PERINEAL SCARRING

Our second scar is the perineal scar. In terms of where it is, it is on the perineum. And the perineum is the tissue that's between the vaginal opening and the anal opening. A perineal scar or injury may occur due to a large stretch on the tissue at the vaginal canal as the baby exits through that vaginal canal. In terms of time to heal, a majority of the stitches are dissolved by about two to four weeks. So there are two ways to tear the perineum. And that's either naturally or via an episiotomy. And that's going to be when the provider actually makes a cut in that perineal tissue. In terms of levels of severity of the perineal tear, there are four. The first degree is the licevier. It's small, skin deep. The second degree is going to involve the muscles of the perineum. The third degree is going to be a tear of the external anal sphincter. And that is what we use to keep poo in or keep poop out, like allow for defecation. And then the fourth degree tear is going to be the most severe. And that's going to be a tear that likely involves the internal anal sphincter, the external anal sphincter, and the rectal mucosa. One time I was talking to a group of OBs and one of them said, you know, we were talking about perineal tears. And one of them said, you know, the vagina is just simply remarkable. It gets to heal in real quick and nobody F's with that vaginal tissue. So that is the one good thing about perineal tears is that the vagina takes care of business. So muscles that are impacted by the perineal tear, the pelvic floor. And then when we're thinking about return to movement with someone with a perineal scar, movements that are wide-legged, like maybe a sumo squat or lateral lunge or really deep squat, there may be some discomfort at that perineum due to that stretch on the tissue in those wide positions.

09:01 C-SECTION SCARRING

And then we have our C-section scar. So where is it? I'll talk about the most common cut that is done is called the bikini cut. And then it's about four to five inches long and it's stretched across the lower abdominals. In terms of time to heal, that's going to depend on various factors. But some scars start to close at the skin level as early as two weeks. And then we know by six weeks, generally speaking, the scar is fully healed if there are no complications. And that's about the same timeline that someone is likely returning back to their provider. Some complications with scarring may be hypertrophic scarring or keloid scarring. And the keloid scar is going to be when the body over heals and the scar tissue extends beyond the original boundaries of the wound. So we want to make sure that we are referring them back to their provider if that is the case, if we happen to see that scar on the client. We know that around six weeks, abdominal tissue has only regained about 50 percent of its tensile strength. And by six to seven months, it's approximately in the 75 percent range of its tensile strength pre-incision. And muscles that are impacted by this scar, the C-section scar, are going to be our abdominal group. So the rectus abdominis, internal-external obliques, and the transverse abdominis.

14:01 CORE-CENTRIC MOVEMENTS & EXERCISE

In terms of considerations for return back to exercise specifically for a C-section scar, we're thinking we got to watch for that core heavy work, any sort of rig or gymnastics-based movements, or any lifting that may involve some sort of contact at the lower abdomen. So those are the scars. Now let's talk about two movement categories more in depth that may be affected by those scars. We have the return to exercise and then return to intimacy, which we'll dive into. So in terms of movement early postpartum, when dosed appropriately, it can assist in so many areas of recovery. We're talking reduction in postpartum depression risk or reduction in risk of blood clot, promoting tissue healing, promoting getting better sleep. That's just to name a few of why movement is important early postpartum. But when it comes to exercise, variables such as sleep and fuel not only influence the risk of injury and recovery, but they also directly relate to the energy status needed to participate in exercise. So sleep, we should be getting nosy and ask about sleep status. Be realistic and recognize that you're talking to a person with a newborn. So their sleep is going to look a little different given the newborn schedule. But we do want to make sure that the client in front of us is optimizing their sleep. Are they creating the best environment? Is it a cool environment? Can they make everything dark? Can they talk with our partner and be like, hey, I need this chunk of time for sleeping. Can you handle the baby while I do this? And then maybe they switch. In terms of fueling, are they able to nourish themselves with nutrient dense packed meals that are full of protein, packed with plants, reduced processed sugars that have sufficient calories, especially caloric intake is important, especially if someone is breastfeeding. They'll need about 400 to 500 extra calories. Okay, let's talk about return to exercise. Generally speaking, when we're talking about return to exercise for someone who's early postpartum, it's a great idea to start somewhere close to where they left off at the end of pregnancy and then build tolerance from there. Early postpartum, that's a time to determine the body's capacity for tolerating exercise. As a provider, it's helpful to have a conversation with our clients about ways we can manipulate exercise dosage to meet their current needs of their current physical status. These modifications are temporary. This is something that we want to communicate with them. We want to educate them on signs for regression with, hey, they did a certain workout or did certain exercise and then, hey, they experienced some leakage of urine or fecal matter. They had some pain or increased abdominal discomfort or vaginal heaviness. So we want them to communicate this to us so that we can then show them how we can alter a workout if needed through load, through adding rest intervals, maybe modifying the intensity or changing the volume and duration. That way they can still continue exercise without symptoms. So now let's talk about scar types and different types of exercise such as core, impact, or lifting. So during the early days and weeks postpartum, walking, reconnection with the core, the pelvic floor, and breathing is a really great place to start. This is going to be when we are starting to add in a little bit more after the first early days or a couple weeks. So with core-centric movements, as we move towards adding more intensity or load, we want to ensure that that abdominal incision is healed to avoid dehiscence. We can begin to experiment with its tolerance, with the anterior abdominal core walls tolerance to stretch in all planes, specifically going into extension, flexion, side bending both ways, rotation, a combination of all those movements. We want to be mindful of tolerance to pressure on the scar, whether that's pressure from simply just the workout clothes, or maybe they are baby wearing while they work out and they have some irritation there at the abdomen. Or maybe it's increased pressure at the abdomen from a set of dumbbells when they're doing a hip thruster, or when they slam down onto the floor with a burpee, or the rig or barbell making contact with the abdomen during gymnastics movements or lifts. With return to impact exercise, such as walking, running, or jumping, we want to be mindful that someone with a vaginal delivery and significant perineal tearing could experience an increase in their pelvic floor symptoms. Remember symptoms reported may be heaviness, vaginal bleeding from the uterine scar, or irritation of their perineum. And someone with a C-section could also experience these as well, but we're thinking that it may be more common with someone with a vaginal delivery or more likely to happen. So with return to impact, we're going to find their guidepost in terms of how much impact their body can tolerate, whether it's starting with a walk around the block, then adding a few more blocks each day, or if it is explosive calf raises, single unders, or step ups. And then for return to lifting, maybe we start with a PVC pipe, or a light kettlebell, or a barbell only movement. This is going to allow the client to re-familiarize themselves with the movement pattern, say of a clean or any sort of overhead press, and then they will be simultaneously building tolerance and in ranges of motion and load at their perineum and abdomen, where some of their scars may be. So return to any exercise will be person dependent, but knowing their history, mode of delivery, current symptoms, and scar status can help you guide them. And bonus, maybe this is a time that they slow down and dial in on foundational pieces of complex lifts or impact training.

18:07 PAIN WITH INTERCOURSE

Besides return to exercise, we also have a different return to movement, and that is return to intimacy, specifically penetrative intercourse. Once cleared by their providers, return to penetrative intercourse, the postpartum person may run into difficulty tolerating that vaginal penetration. This could be from a finger, a toy, or a partner student, Natalia. So it's estimated that 43% of women report pain with intercourse in that first six months early postpartum. And this is something major that we should be thinking about when someone is maybe sharing with us things that are going on with penetrative intercourse for them. A C-section or perineal tear can contribute to painful intercourse. There's a greater risk associated with pain with intercourse with an episiotomy versus a natural perineal tear. Just as we would practice scar desensitization in any other part of the body, we're going to do the same here at the vagina. And a pelvic PT is going to be really great in assisting and making recommendations for internal massage, stretching, or using a dilator set. So let's recap. Today we talked about three main scars that a postpartum person may have. A uterine scar, a perineal scar, or an abdominal scar from a C-section. Remember to respect these healing timelines. They will be unique to each person. The next time you have a client who's early postpartum on your schedule, encourage them to start small. Go slow for returning to exercise and intimacy. Educate them on progressive overload and how that may not be a straight line for them. Maybe a series of peaks and valleys that are impacted by external factors such as sleep, fuel their body's current physical capacity. Communicate with them. Get curious about their invisible physical scars as they may not feel comfortable telling you and offering you that information that, Oh, they have pain at their vagina at the bottom of a deep squat or their abdominal incision site is really bothering them when they're doing a hollow hold or hanging from the bar. So they will no doubt be thankful if their provider considers these scars, asks about them, and because they're not often discussed. So thanks for tuning in, everyone. I hope you gain some awareness of these physical invisible scars that a postpartum person may be dealing with. Next episode, I'll be discussing the emotional invisible scars in the postpartum period. Cheers y'all.

20:28 OUTRO

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

Aug 18, 2023

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Mitch Babcock discusses that consistency in the gym, combined with attention to lifestyle factors, can lead to significant rewards in terms of fitness and overall health. By being present and dedicated to regular training, individuals can see improvements in strength, conditioning, and cognitive function. Additionally, by addressing lifestyle habits such as sleep, nutrition, and alcohol consumption, individuals can further enhance their fitness journey and ultimately live longer, healthier lives.

Take a listen to the episode or read the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show.

01:26 MITCH BABCOCK

Hey, welcome everybody. Welcome to the PT on ICE Daily Show. Welcome to Friday. Welcome to Fitness Athlete Friday. I'll be your host today. Mitch Babcock, lead faculty in the fitness athlete division, all things online and live course. And it's been a minute since I've been on the podcast. So I'm excited to be back joining all of you this morning. So thank you. First of all, if you're downloading us, listening to us on your way to work, if you're on live with us on Instagram or YouTube, thanks so much for making this part of your morning or your evening, whatever it is for you. And thanks for downloading wherever you download your podcast from. We always appreciate it. Don't forget we're the only daily physical therapy show on the market. So thank you for subscribing and liking and signing up for those automatic downloads. It really means a lot to the whole team here at ICE. Before we jump into today's topic, which is post CrossFit Games for the rest of us. Okay, I want to talk a little bit about some of the courses that we have coming up for the live division. We have a very busy September in October and even leading into November and a couple courses in December. So looking at Q3, Q4, we've got quite a bit on the books. The fitness athlete team as a whole was a little quiet through the summer. As our team, many of us on the lead faculty, not us, but others on the lead faculty, welcomed some new additions to their family or kind of spending some time at home. So the summer months were a little quiet and we're excited to ramp up on the road here in Q3 and Q4. So you can find us all over. Zach's going to be out in the Bay Area here in September. The end of September you can find him out in California. I'm going to be out in Seattle, just north of Seattle in Linwood with Joe as well. We got a course in British Columbia coming up, Alabama, San Antonio, Florida, New Orleans, Colorado Springs. We're hitting some big cities and covering a large part of the map this fall. So if I just named off any cities, your cities or near you, please check those out on the PTA On Ice website. We'd love to see you at one of the live courses.

02:16 POST CROSSFIT GAMES

All right, let's get into today's show, shall we? If you didn't tune in last week to Kelly Benfey's episode on her post CrossFit Games Reflections, you should definitely do that. CrossFit fan or not, whether you train this stuff or not, you need to understand the level at which Kelly is at in humbly speaking herself. She's not going to give as much credit as she deserves. Making it to the CrossFit Games is a feat 99.9% of people that participate in CrossFit will never achieve. You can be pretty good at CrossFit. You know, you could be pretty good at pickup basketball, but you're not going to make the squad and play with the Lakers. You know, like that's kind of the comparison of which we're dealing with now in the CrossFit sector. And so for us to have someone like Kelly, who's went there, who's done that, who's trained at the highest level, who's rubbed elbows with the best of the best in the game and to get some reflections from her, it's worth the 10 or 15 minutes about what it's like behind the scenes. So great episode, Kelly. But today I want to talk about after the games, what about the rest of us that just train this stuff because we like it? We want to stay healthy and fit. We enjoy getting stronger, but we also have nine to five jobs. We also have families, husbands, wives, kids. We got to shuttle kids off to soccer practice. Maybe I coach the soccer team, right? What is what does it look like setting and reframing goals after the CrossFit Games for the rest of us? Because we still want to be motivated. We still want to be inspired. We watch the games and we see what's out there and we see what people are capable of and and all of that is fun and it's all a great part of the sport. But when it's our time to take the floor, it's important to reframe those goals and context and the things that matter to us and are achievable to what we can set our sights for over the next six, nine or 12 months. And that's really what I want to focus today on.

04:35 SETTING & REFRAMING GOALS

What can you reasonably achieve in the next six to nine months or even set your sights on before the next open rolls around? Because we know we're going to throw the hat in the ring and do the open. You know, what are some realistic goals, realistic goals that are going to turn into real change in your health and fitness and overall well-being? And that's ultimately what we're doing this for. We're not most of us aren't going to make the games. Hat tip to Kelly for putting in a ton of work over the last five to 10 years, probably to get to that point where she was able to make the games. But for the rest of us, we're looking to check that box. We're looking to do it safely and effectively and making sure that when we come out the other end, we come out unharmed and we come out healthier and a better person after doing the training than when we started. So here's some goals that I have for you today for post CrossFit Games goals for the rest of us. What part of your training really behooves you to spend time training?

06:30 INVESTING IN FOUNDATIONAL STRENGTH

And what I mean by that is strength and monostructural conditioning work. It's really going to benefit you long term to invest hours weekly daily into getting stronger. So I want you to set a goal to try to put 30 pounds on your deadlift over the next year, to try to put 20 pounds on your back squat and to try to put five to 10 pounds on your strict overhead press. Those are realistic goals that are going to require you to train those movements consistently. And because you're training the foundational strength movements, the squat, the deadlift, all of your other movements will then reap a reward from having done so. Your clean and jerk, your front squat are going to benefit from your back squat being trained regularly. All your Olympic lifts and all your other movements are going to benefit from you training your deadlift frequently. Your shoulders are going to be healthier from having done more strict press. So set some realistic goals. I'm going to put 30 pounds on my deadlift, 20 on my back squat, 10 on my overhead press And that's going to require me to make sure that I'm hitting those boxes week in and week out over the next handful of weeks, months, and the better part of the next year. So it really is helpful that you spend time working on the foundational strength. The other thing that's going to benefit you for your gymnastics movements. So spend time benefiting or getting increased reps or getting your first rep of a strict pull up. Many of you in the CrossFit space are still gung ho about your kipping pull ups, your toes to bar technique, all these other things. I want to bar muscle up, but you haven't laid the foundation with the strict pull up yet. You need to stay there. Over the next six or nine months, can you add one or two reps on your max strict pull up? Can you get your first strict pull up by going through a beginning strict pull up progression and over the next six months, get your first strict pull up. Those are going to be big rewards for your long term health in fitness training. The same thing with your push ups. We in the CrossFit space, those of us that coach a bunch, boy, we're used to seeing a lot of crappy push ups, right? Poor midline stability, we can't hold a good plank position, we don't have a strong shoulder position to be able to press out of the end range of extension, and we have athletes wanting to bang out a lot of reps and not even one of them looks solid. So spend time mastering your strict pull up and your strict push up. You're going to be a better athlete and your fitness will reflect that if you do. Master a skill over the next six to nine months. Get better at double unders. Figure out how to climb a rope, right? Finally take some coaching advice from your team at your gym and figure out how to put down a new skill. There's a lot of reward that goes into the neural motor, the coordination, all of the things that come together to allow you to build and develop a new skill. And if there's one that you've been putting off, because let's face it, your ego is kind of getting in the way, you don't like to look like you can't do the thing so you just scale out of it a lot, spend time over the next six months and learn that skill. Just one, pick one. I want to get better at double unders, I want to be able to do 20 unbroken double unders. Cool. Over the next six months you're going to attack that and that's going to be a goal that's going to elevate your fitness long term. You're going to have that skill for a long time and you're going to be able to use that skill in a lot of workouts coming up. So spend a couple of weeks, a couple of months and develop a new skill. And then your model structural work.

10:06 LONG DURATION ZONE TWO WORK

Add in one day a week where you're adding in some longer duration zone two, you know, longer duration stuff on the bike or the rower going out for a long paced run. Like we don't do enough of that. And every single expert in the space says from a longevity standpoint, it is so key from a health standpoint, from a fitness standpoint, it is so key that we get more long duration zone two work in. And now some of the research, some of the leading experts are saying 60 to 90 minutes, 120 minutes a week. Look just start easy with one day a week where you stretch it out more than 20 minutes. I mean low hanging fruit one day a week. I need to do a long duration piece that's more than 20 minutes. If we can check that, then we'll start talking about increasing the model structural workload and be able to increase that more. But that's a foundational component to your fitness. That's on the base of the CrossFit hierarchy pyramid that says, hey, we need to be really good at metabolic conditioning. And when we have a better aerobic base, everything else steps up above that. So build that aerobic base. Add in one day a week of model structural work zone two on a bike, on an erg, on a runner and stretch it out more than 20 minutes. So you're prioritizing strength. You're working on a skill. You're getting better at your foundational gymnastics movements and you're adding in some longer aerobic work. 20 minutes one day a week.

13:21 MORE CONSISTENCY IN THE GYM

From a class perspective, I would just say it ain't volume. It's not loading that's going to make the difference for you. You don't need to be lifting heavier weights and metcons. You just need to be present more frequently. Just be more consistent. If you normally make it three days a week, try to make it four. If you normally make it four, can you make it five? Can you just add one more day a week making it to the gym? Can you slide in that little Saturday morning class that you typically skip out on? Because you're going to see big rewards coming by just simply the consistency in the gym. You don't have to do anything heroic. You're just more consistent. You're getting five sessions instead of four. And week after week, that aggregates into a lot more training sessions at the end of the year. So bump it one day a week. If you have other skills that are going to make you a much better athlete six, nine, 12 months from now, set a bedtime and actually stick to it. Get the water intake that you need and try to reduce the alcohol. Can we go 30 days with no alcohol and just see what that does for your overall health? See what it does for your sleep, your concentration, see what it does for your overall training, your fitness in the gym? How much sharper am I cognitively when I'm at work? Measure all those things after 30 days of no alcohol. If you make it 30, can you make it 60 days no alcohol? 60, can I go 90 days no alcohol? And just start aggregating these days of optimizing all the little details that you can. And you're going to see such big rewards on your fitness. They're little challenges. They're hard ones. They're not easy, but they're ones that we can bite off and actually stick to for a month, make one month into two months, make two months into three months. The majority of us don't need a new competitors program. We finished watching the CrossFit Games and everybody's selling their hard work pays off, their Matt Frazier program, the new Mayhem Rich Froning style stuff. And while all those are great programs, for most of us, that's not what we need. We don't need additional loading. We don't need more volume or longer duration workouts. What we really need is more consistency in the gym. We need to get stronger at the things that matter and we need a better conditioning, a better engine to be able to do more things. And then the lifestyle stuff comes along with that. We're going to be one hour in the gym and the 23 hours out of the gym. What are we doing with the 23 hours out of the gym? Can I set a bedtime? Can I get better sleep quality? Can I eat better? Can I reduce my alcohol consumption? All of those little details that will stack up and aggregate over a year or six months or nine months into a much fitter version of yourself. The stronger and healthier you get, the longer you're going to live. And ultimately that needs to be all of our game plan. Why are we doing this? The oldest, not the oldest member, the most tenured member of my gym, we call him the Godfather just for that reason, says all the time, I'm just trying to still be doing CrossFit when I'm 70. Like every decision he makes in the gym day by day, he keeps that greater focus. He's not coming into the gym saying this is the year I make it to the games. He's coming into the gym every day saying, I need to make a decision that's right today so that I can still be doing CrossFit when I'm 70. Because I know that if I'm still doing CrossFit when I'm 70, I can be doing all the things in my retirement that I want to be doing. So keep the long term vision in play. We're looking to be able to do this over a lifespan. Stretch out and increase your lifespan, the number of healthy, good years you're living. That's what ultimately this is all about for us. So here's some small actionable goals that people like you and me can really bite off and really set our sights on over the next six or 12 months. Throw our hat in the ring when the Open comes around next year and say, hey, you know what, because I put that work in starting in August, I'm really a much better version of myself now in February. Comment below if one of these, if you've got a goal that we listed off and you're like, look, I need to jump on that. Drop a comment below whether that's YouTube, whether that's Instagram, whether that's on a podcast format. Let us know. Reach out to us. And then as always, if you need help with any of these things, that's what we're here for. So talking about all things lifestyle related in our live course as well. Excited to see those of you that are going to make it for your first time out at one of those courses. We're hitting the road heavy this fall. So looking to see you guys out there. In the meantime, if you're training today, have a great session. Get some caffeine in you and ramp it up. I will see you guys out on the road very soon. Have a great day, everyone.

15:56 OUTRO

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

Aug 17, 2023

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses average arrival rates in physical therapy, what the research says about how to improve arrival rates, leveraging technology to improve arrival rates, and creating policies & systems that ensure your clinic still gets paid for missed appointments.

Take a listen to the podcast episode or read the full transcription below.

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

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

Good morning, everybody. Welcome to the PT on ICE daily show. Happy Thursday morning. Hope your morning 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 the chief operating officer here at ICE and the faculty member on our fitness athlete division. We're here on Thursdays. We talk all things leadership Thursday, small business ownership, practice management, that sort of thing. Leadership Thursday also means it is gut check Thursday. This week we have a 17 minute AMRAP, as many rounds and reps as possible in 17 minutes of the following 21 plate ground to overhead. Our Rx weight there for guys 45 for ladies 25. So grabbing a bumper plate, hinging down, tapping one side of the plate between your feet and then up and over overhead, almost like a snatch. Moving into 15 cows on the rower for guys 12 for ladies and then finishing with a small dose nine burpees to plate. So looking for somewhere between three to five rounds of that great workout for home, the garage, the basement, the clinic. Just need a rower and a bumper plate. Great to maybe take out to the park as well and sub the row for some running or something like that. So that is gut check Thursday. Course is coming your way. We have so many about to enter a very, very busy season for ICE here as we get into the fall, get away from the summer, school starts back up, that sort of thing. We have a couple hundred courses coming your way between now and the end of the year. So if you're looking for live courses, head on over to p10ice.com, click on our courses and check out our map to see what's coming to your neck of the woods. Some online courses I want to highlight. Pretty much all of our entire catalog of eight week online courses are starting back up after Labor Day. So if you don't know about our online courses, they are eight weeks online. They are synchronous, which means that you meet with us every week. They are not completely self study, a mixture of lecture, of reading, of homework and of live meetups. They're meant to simulate the feeling of a two day live course, but stretched across eight weeks to make it a little bit more accessible, save you a little bit of money on travel. So online courses, pretty much like I said, all of them are starting after Labor Day. We have ICE Pelvic Online. That's our entry level online pregnancy and postpartum course. That's going to start September 4th. We have Fitness Athlete Essential Foundations taught by yours truly Mitch Babcock, Kelly Benfee and Guillermo Contreras. That's going to start September 11th. The very next day, September 12th, Brick by Brick is going to start very relevant course to this day of the week to Thursdays. We talk all things practice, startup and ownership and management in that course. Injured Runner Online also starts September 12th and then Virtual ICE will open back up September 26th for our next quarter of enrollment. So let's get into today's topic. Let's talk about how do we handle, how do we get better at when a patient reschedules, cancels or no shows. I want to talk today about three main topics. I'm going to talk about what are the average no show cancellation rates, what we would call an arrival rate across the country, across physical therapy, what's normal, what's abnormal. I want to talk about how to improve those arrival rates. And then I want to talk about how to get paid when somebody does not show up for those appointments.

05:46 ARRIVAL RATES IN PHYSICAL THERAPY

So let's start at the beginning and let's talk about what is a normal rate. If you have been practicing physical therapy for a while, if you have been practicing in a traditional clinic, you may have heard that the common recommendation for the maximum arrival rate is about 93%. That is to say that 93% of your appointments show up for their appointment that day. That there's some margin of error. We recognize that 100% of people probably won't make it, but pretty typical. 93% is the standard that's set and sometimes enforced by the clinic that you work for. Maybe if you fall below that, maybe you get a warning, maybe you get a talking to, or maybe they actually dock your pay for visits underneath that 93%. What's awesome about this topic is that we actually have a lot of research, surprisingly, supporting the numbers that I'm about to tell you. So we have a great survey back from 2015 of about 7,000 outpatient physical therapists. This is from Bo Kinski and colleagues, sorry if I mispronounced this, of 7,000 outpatient PT's looking at a couple of different things. Looking at finding the average cancellation no-show rate, but also finding what things seem to help fix that. So across the country, we see an average no-show cancellation rate of actually about 10 to 14%. So thinking you may have been told 93% is the gold standard, in reality, somewhere between 85 to 90% is actually probably more realistic. If you had 10 patients scheduled for the day, you could expect maybe eight of them to show up for the appointment. You could expect maybe one to two appointments to be unfilled. I like this survey because it goes a couple levels deeper. It asks why. Now knowing that rate, knowing that 10 to 14% rate, why do people not show up for the appointment? What is the number one cause? The number one reason why patients do not attend their appointment is not that they can't afford it, not that they don't like you, it's that they forgot and that the clinic that they went to physical therapy to had no reminder system. So that's a huge error, that's a very easy fix. When we delineate outpatient physical therapy from hospital-based outpatient physical therapy, so private practice versus hospital-based, we see that hospital-based clinics actually the no-show cancellation rate of a private practice clinic. Why is that? I would imagine it's probably due to having a modern reminder system, but again, that number of 93% isn't the gold standard that we think it is. In private practice, we can expect maybe 85 to 90% arrival rate, a little bit lower in hospital-based, maybe 75 to 80% arrival rate. Now this survey looked at the concept of a multi-method reminder system. What does that mean? That means that the patient received multiple reminders across multiple communication methods. That they usually received some sort of automated phone call reminding them of their appointment. They received probably a text message and then maybe also an email message. So they received two to three different reminders ahead of their appointment across different modalities, basically reminding the patient as much as possible of their upcoming appointment. Now they found that those clinics that used a multi-method reminder system had a significant reduction in no-show cancellation rates, about a 50% reduction. So they cut their no-show cancellation rate in half just by having a reminder system. And we're going to talk about how to set that up at your clinic here in a minute. The second reason that clinics did better with no-show cancellation rate was those clinics who had a 24-hour appointment change policy. That is inside of 24 hours, you will be penalized if you cancel or reschedule or no-show your appointment versus if you give more than a 24-hour notice that you need to reschedule your appointment or otherwise cancel it. So those clinics which had a 24-hour policy and enforced that policy on their patients also had a reduction in their no-show cancellation rate. So that brings us to the question of if 10 to 14% is the mean of the average of no-show cancellation rates across the country, then how realistic is 7%? The answer is not very, right? Even if you are treating one-on-one for an hour and you maybe only have eight patients on your caseload for the day, it's probably unrealistic to expect 100% of those people to show up every day. That we have to recognize at some level that the reason we see so much overbooking in traditional physical therapy clinics is it's just that leadership strategy to limit the impact of those inevitable no-show cancellation rates. That if you see eight patients in a day and 10 to 15% don't make it, you may see five to seven patients. So kind of the aggressive leadership solution here is just to make you see more patients. That if you see twice as many patients and you still have that 10 to 15% no-show cancellation rate, then you'll still see more patients than originally intended and scheduled to and the clinic won't lose as much profit. But that being said, that is an aggressive way. That is a way that puts all of the burden of the work on the therapist and none of it on the ownership, none of it on the leadership and none of it kind of on the backend logistical side of the clinic. Instead of making you see more patients, why don't we just have a 24-hour policy that we enforce? And if we're not using a reminder system, why don't we start using one? Why don't we do some more conservative approaches to reduce that no-show cancellation rate, especially now knowing that we have research that supports, does those actually improve our no-show cancellation rates? So let's talk about that.

08:48 IMPROVING ARRIVAL RATES

Let's talk about aside from having a reminder system, aside from strategies to remind patients to get to the clinic and aside from having a policy, how can we approve improve those arrival rates? You know us here at ICE, if you've been listening to us for a while, Jeff Moore, our CEO says it best. The first thing you can do to make patients show up to physical therapy more is make sure that you're focused on getting good and not getting busy. That when people see results, when they begin to associate value with their physical therapy appointment, they come to their appointment more often. I think this is so overlooked, especially in a higher volume clinic where a therapist may be expected to see multiple patients per hour. By providing lower quality care, patients aren't able to get results or they're not able to get results as fast as maybe they want to. They don't really associate physical therapy as a valuable use of their time and it makes sense that they find better stuff to do and that you get that message at 4.55 p.m. that your 5 p.m. patient is not going to make it in today. So really focus on getting good, not getting busy. We also need to recognize that people are not stupid. When they show up to PT and they see that you are working with three other people at the same time and you have forgotten about them in the corner at the TheraBand station or on the recumbent bike or the pulleys, again, that really begins to lower the value proposition that patients have with physical therapy and it's not surprising again that they begin to find better stuff to do with that hour of their time. The counter argument here is that you can get so good as a physical therapist, I'm good enough that I can see multiple patients at once or patients aren't as fragile as we think. We don't need to give them one-on-one care, but we need to recognize that at some level, patients are paying for it, especially if they're paying cash for a one-on-one visit. They are expecting one-on-one treatment. Even if you are an insurance-based clinic and using a patient's insurance, that insurance is still paying you based on one-on-one care. And not only that, but the patient expectation is that you are going to give them the care that they need. And I often relate this to other professions of you would lose your mind if you had a therapy appointment with a psychologist, a mental therapy appointment, if you showed up and there were three other people getting mental health therapy at the same time as you. No one would put up with that, but for some reason, it's just expected and normalized that that's the kind of care that we give in physical therapy. So then it's no wonder that patients, again, find something better to do with their time for the hour. So really focus on getting good and not getting busy, of taking really quality care of that patient that you have on your schedule for that hour. And you'll be surprised how much they come back to physical therapy when they see their range of motion improving, when they see their balance improving, when they feel stronger, when their pain is getting better, whatever their goals are, as they can see progress towards their goals, it's much more likely that they're going to come back to physical therapy. And I think that is often overlooked. My second point with improving arrival rates is to leverage technology, implement that multi-method reminder system. It's 2023. There is no reason why your clinic does not have automated reminders, text, email, phone, whatever. It's all built in to a modern EMR. If your EMR does not do this, you need to get an EMR that does this. If your front desk person is still calling people by hand to remind them of their appointment, you're a little bit behind the curve, right? to do the work for you so that you can focus on treating your patients while the technology sends out those reminders for you. We need to recognize that people are busy and that the more we can be prominent in front of mind with reminders, the more likely people are to attend their appointments. We have research that supports this, right? We can cut these no-show cancellation rates in half with a multi-method reminder system, but also it gives the patient a chance to reschedule if they know they already can't make it, right? That text reminder, when they get that phone call, when they get that email, it gives them multiple chances to reschedule. And if they don't, it also kind of builds the case for you against them that you gave them plenty of chances to reschedule and they still did not. And that makes it a little bit easier to charge them money, which we'll talk about in a few seconds here. So remember, we can cut that rate in half, that no-show cancellation rate in half with a multi-method reminder system. So if you're still using Google Drive as your EMR, if you're still using paper documentation and scanning it into a computer, consider getting a modern EMR. They're not that expensive. EMRs, we're big fans of Jane here, obviously, at ICE, other EMRs, Prompt, PT Everywhere, pretty much all the modern web-based EMRs are going to offer reminders and more often than not, they're free for you to use. So why not use them, right? It's one more push of a button when you're building out that patient chart for them to get reminders. In addition to reminders, leverage technology to create an online booking and waitlist system so that when you do send that reminder, it should come with a link where it says, hey, if you can't keep this appointment, please click here, right? So that your appointment comes off my schedule and that you get a little link to rebook at a time that works better for you. So we still keep that visit on the schedule, but we also open up that visit to maybe somebody else who can use it so that we don't have a missed slot on our schedule. Pretty much just like reminders, modern EMRs are very good at having automation with waitlists of where when a patient reschedules and a slot opens up, usually automatically or with the push of a button, you can pull people in from your waitlist and make sure that that slot stays filled without having that patient get charged for cancellation or no-show because they were able to go in on their own and reschedule their own appointment. So make sure we're leveraging technology whenever possible to do this work for us. My last point here on improving arrival rates is probably something that we don't consider very often of making sure in that initial evaluation that the patient actually has the time and or money to come to their physical therapy appointments. I feel like a lot of time patients feel beholden to maybe a referral they had from a doctor or what you tell them of some sort of verbal contract of the doctor said I have to come here three times a week for six weeks or maybe that's what you wrote on your documentation is the physical therapist and they feel like they have to come no matter what, even if they know they do not have the time or money. I feel like this is something that should be discussed as we're wrapping up our initial evaluations that just doesn't get done. As we're building the bike for that patient, we're explaining our findings, we're demonstrating that we can help that person reach their goals by showing them some improvement in that first visit and as we begin to discuss what that plan of care might look like, also making sure that the patient is on board, right, including the patient that conversation of hey, Diane, this seems to be a pretty irritable tendinopathy. You know, I think I would like to see you here in the clinic twice a week, probably for at least the next four weeks. And instead of stopping there, take it one step further. How do you feel about that? Right? What do you think about my plan for your care? And we don't necessarily have to ask, hey, can you afford this? Or do you have the time for this? But that's what we're hinting at of how do you feel about coming here twice a week for four weeks? How do you feel about coming here once a week for the next four weeks and getting the patient's input because that's a great time for them to say, that's going to be tough with my schedule. You know, I have 17 kids or I work 30 jobs. I won't be able to do that, right? That's a great time to make sure that person does not get put on your schedule for a bunch of visits that they're not going to attend. And then making sure we're following the law, right? No surprises act that was passed last year that were very transparent with how long we think the plan of care is going to take and what that's going to cost that patient. Whether you're charging cash, whether you're billing insurance, you need to provide that information upfront to the patient. I would argue you should be doing it even if it's not the law, just so you don't have people on your schedule who are not going to show up. But being very forthright and how long you think it's going to take and what's that going to cost and get that patient's input on it before we talk about scheduling out for their visits.

19:05 GETTING PAID FOR MISSED APPOINTMENTS

My last point here of talking about what average arrival rates are, what improves arrival rates is how do we get paid when somebody does not show up to the clinic? This is another area where I think physical therapists are very uncomfortable with asking people for money to come to rather not come to their appointment. And it's an area where again, when we look at the research, what improves arrival rates, multi-method reminder system and having a rescheduled cancellation policy that is enforced. If you don't enforce it, you can't get paid for these missed visits. And if you try to enforce it like halfway through the plan of care, the patient is probably going to be upset versus if you're straightforward from the start in your intake paperwork and with your expectations before they begin physical therapy, it's not as jarring to that patient when you charge them for that canceled or rescheduled appointment. So remember, combination of a reminder system and a clearly stated 24-hour rescheduling policy that's enforced are the keys to reducing your no-show cancellation rate by as much as 50%. So first things first, create a policy. What do you want your policy to be? Make sure that policy is very clear, very transparent and that patients see it before they actually come to the clinic. So for us here at Health HQ, this is the first thing that patients see when they go through their intake paperwork. They see our cancellation no-show policy. They see our rates. They know what they're going to be charged. They know the maximum they can be expected to pay out of pocket if they do have insurance and they're going to see what they can be expected to be charged if they cancel or reschedule appointment within 24 hours. So ensure you have a policy, make sure it's actually written out, make sure that it gets in front of patients before they commit to a plan of care and then decide on what you want to charge that person. Decide on what your rate will be. I would argue it should be what you would want to get paid for that hour even if the patient had come. A lot of clinics will have what I would call a dinky, kind of a really lackluster enforcement policy where maybe if you don't show up to your appointment, you're charged $10 or $15. That's really not enough for people to have skin in the game. Being charged $10 or $15, especially if you don't actually enforce it, is really not going to set the expectations for your patients the way you want it. For us, we want to be sure the patient, sorry, the therapist gets paid as if they had seen that patient even if the patient no shows or cancels. So we charge $75 and we enforce it. Right? How do we enforce it? Well, you should probably start obtaining payment methods before the plan of care begins. So again, somewhere in your intake, transparent, clear, laid out should be what you charge for cancellation, a no show, a reschedule, the amount, and that you should take a payment method and have that payment method on file even before the initial evaluation happens so that even if they don't show up to the evaluation, your therapists are able to get paid for that hour. And then actually enforce it. You have to enforce it. You have to rip the bandaid off and actually do it. If you don't do it until somebody has done this to you 19 times, it's going to be difficult to actually start enforcing it because you've let them get away with it so many times. Maybe your personal policy in your mind is that everybody gets one freebie. Whatever that is, stick to that and then start actually enforcing it. What you'll find is that when you enforce it, guess what? The first time that patient gets charged that money, guess what they never miss again? Physical therapy. Or they reschedule so that they don't leave an empty spot on your calendar book. So recognize that we have to enforce this. Yes, it's uncomfortable, but the more you do it, the sooner you do it in the plan of care, the more you'll find patients will either adhere to it or they might decide therapy with you is not for them and that's okay too because the end result is we want people on our schedule who are actually going to come to physical therapy. We need to recognize that this is not unusual. Oftentimes we said, well, this isn't something physical therapists do. They don't charge people for not coming to appointments. Literally every other industry on the planet does this. When you make an appointment to get your haircut or whatever personal beauty grooming thing you do, they have a reschedule cancel no show policy where if you don't show up to your appointment for whatever reason, you're probably going to get charged a little bit of money. Massage therapists do this. Lawyers do this a lot. You have to pay money upfront to even talk to a lawyer, right? You have to have that retainer money on file. Dentists do this. Other healthcare providers do this. This is very, very common across a wide range of industries except for physical therapy. People often ask me, why do you think that is? I think it's because we spend a lot of time with our patients and we begin to almost view some of our patients maybe as friends or at least acquaintances, which makes it that much harder to begin to charge that person for missing a physical therapy appointment. So we need to recognize that yes, it is difficult, but again, every other business does this. Every other industry does this. The sooner and more comfortable you get with enforcing this, the less awkward it's going to feel. And remember, leverage technology to fill those missed appointment slots so that ideally the therapist still gets paid for that person not showing up, but maybe they can also fit another patient into that spot still. I love when I pull up our schedule and I see that somebody has canceled, they've been charged for it, and we've been able to pull another patient from the wait list to fill that same slot. That therapist went to work, came to work here that day thinking, I'm going to see seven people and they actually got paid as if they had seen nine. That's fantastic, right? That's way better than systems where you may be expected to clock out if a patient doesn't show up and not get paid at all for your time, or you may be expected to clean the toilets or something like that in that missed time versus actually getting paid for that time and either being able to use that time for whatever you want or trying to fit another patient into that slot. So remember, it's really important here. This is all an end, not or situation that there are different components to this that we need to implement. It's not just we need to charge people for not showing up. It's not just we need to have a reminder system that we need to understand that at some level, having 100% arrival rate is unlikely. People not showing up is unavoidable, whether kids, family emergencies, that sort of thing. But there are things that can be done to reduce those rates. They're not unavoidable that we can deliver great outcomes to patients so that they do not find other reasons and other things to do instead of coming to physical therapy. We absolutely have to get with the program and begin to leverage technology, begin to send these reminders out if we're not doing it already, begin to use technology to have a waitlist system so that we can fill empty slots quickly, create and actually enforce a policy, get credit cards on file, begin to actually charge people for not coming to those appointments, hold them accountable, hold their feet to the fire, but also recognize and have that conversation early on of what is realistic for that patient. Do they actually have the time and money to come to therapy two or three times a week? Or do we need to look at maybe, hey, I can see you once every other week, but you're going to have to be really judicious at home with your homework because you're not coming here as much. So having those conversations early and often in the plan of care so they don't come back to bite us later on and then utilize technology to get paid for those visits and fill those empty slots. So reschedules, cancels, no shows, not to the end of the world, things we can do better to get better at them, I should say. Leverage technology, enforce a policy. So I hope this was helpful. I hope you all have a fantastic Thursday. Have fun with Gut Check Thursday. If you're going to be on a live course this weekend, have a wonderful weekend with our faculty on the road. We'll see you all next time. Bye everybody.

24:17 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.

Aug 16, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult Division Leader Christina Prevett discusses the need for falls prevention initiatives to shift their focus towards early identification of individuals at risk for falls. By doing so, healthcare professionals can implement targeted interventions and reduce the occurrence of falls before they happen.

Christina emphasizes that outcome measures should be used to guide interventions. She mentions the Mini-BEST as a specific outcome measure that assesses various aspects of balance and mobility. By administering this measure at the beginning of a session, the clinician can immediately identify areas of deficit and tailor their intervention accordingly. For example, if the person shows deficits in dynamic gait and reactive posture control, the clinician can focus on exercises and strategies to improve these specific areas.

Overall, the episode highlights the importance of outcome measures in falls prevention and emphasizes that they should not be conducted for the sake of it. Instead, outcome measures should provide meaningful and actionable information that guides clinical reasoning and informs interventions.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:33 CHRISTINA PREVETT

Hello, everybody, and welcome to the PT on ICE Daily show. My name is Christina Prevett. I am one of the lead faculty within our modern management of the older adult division, part of our geriatrics team. Everyone, we are flying high this week because we got everybody from our MMOA division to descend on Lexington, Kentucky at Jeff and Dustin's Stronger Life facility, which was beautiful. And we got to show the world some of what we have been working on, which is some revamped material. So we got to really focus on dialing in live to be about lab. We were moving all weekend. It was so fun and so amazing. If you were thinking about joining MMOA live, we have a couple of opportunities coming up in the remainder of this month. So this weekend, Dustin and Jeff are going to be in Bedford, Texas, and Julie and Ellen are going to be in, oh my gosh, I'm blanking on where they are. They're in Minnesota. And then there I was like, I know this. And then the next weekend, Alex is going to be in California. And so if you are looking for where MMOA is going to be, we have a ton of courses into the end of 2023. We are not adding any more locations for MMOA live in 2023. So if you're kind of waiting for one to come closer to you for the end of this year, that isn't going to happen if it's not there now because we're kind of locked in. We have lots of offerings that's going to come up for 2024. So if you're looking to see that live material, that is where to go.

03:29 A FRAMEWORK FOR BALANCE INTERVENTION

OK, so today I wanted to talk a little bit about a framework for balance intervention. When it comes to balance, I think it's a bit tougher for us to put this marker of effort or intensity on, maybe more so than other styles of fitness. What I mean by that is when we think about aerobic training, it's easy for us to conceptualize effort because we're seeing that perspiration, we're seeing that heart rate response. And that's correlating to our rates of perceived exertion. When it comes to resistance training, right, the amount of effort is either going to fatigue kind of in those higher rep ranges or our personal preference is getting to fatigue and effort through higher load. And again, it corresponds to changes in rates of perceived exertion. When we're trying to conceptualize intensity and then we're really trying to dial in our balance interventions, it's a bit tougher, right? We don't really have the same magnitude or the same outcome measures with respect to gauging intensity well. And so within MMOA, we really try and create this framework for individuals to help guide them through this kind of thought process and then create a kind of stepwise framework within our mind for how we implement this in clinical practice. The way that we do this is by first looking at the mechanism at which individuals are falling or where they are having near falls. This is important, right?

05:00 FALLS PREVENTION INITIATIVES

Our falls prevention initiatives are only preventative if we are identifying individuals early rather than waiting for them to get hurt and then working in secondary tertiary prevention. We want to be able to identify those who are at risk for falls before that fall has happened, which unfortunately is not as common in our health care system as it stands right now. So we want to figure out the mechanism. We want to identify risk factors that are intrinsic to the individual and extrinsic around their environment. And then in order for us to put objective data on those things, we need to take that information from our subjective and use the appropriate outcome measure in order for us to have a good data point or multiple data points in order to guide our interventions. And then we want to make sure that those outcome measures that we are selecting are giving us tangible information, right? We don't want to be doing outcome measures for the sake of doing outcome measures. We want to do our outcome measures so that they can guide our clinical reasoning. And so let's kind of go through this very briefly and speak to the different aspects of this framework. So the first thing is mechanism, right? When we are asking about our person subjective, many times they're kind of cursory with their storytelling. A lot of individuals are when they're speaking about falls. Oh, well, I stubbed my toe and I fell over. What were you doing when you stepped your toe? What was your frame of mind? Were you really rushing to get from point A to point B? Were you really tired because it was late at night? Were you holding something in your hand when you tripped and that created an other barrier or other cognitive load in your mind that created more of a predisposition to not be able to keep your center of mass over your base of support and respond to that perturbation? Was it that there is a visual issue going on and you were having trouble with depth perception? We need to kind of dig really deep into some of these stories because that's really going to triage this risk factor profile in our brain. But you're probably thinking, well, Christina, a lot of my clients just can't do that or they don't remember or they are not able to give us some of that really tangible information. And I hear you. And so when we don't have that information, the next step is for us to go to the literature and look at what are common scenarios that lead to falls in different settings. Right. And how much do those mechanisms and that group of individuals that are being conceptualized in this research study relate to the people that are in front of you? An example is if you're an outpatient orthopedic therapist looking at some of the acute care mechanisms of falls may be relevant, but probably is less relevant to you. So you're going to be wanting to know, well, what is happening for our community dwelling older adults? What is their profile look like? What age group are individuals looking at in this study? And then how does this relate to my current caseload or people that I have that I am seeing right now? And so there is a recent study that came out in 2023 that was doing a prospective. So following older adults forward in Boston that was looking, for example, at mechanisms of falls in community dwelling older adults. So what they did was every month they sent older adults in this study. So they consented to this study. They were in their 70s or older. They sent a postcard to them and asked some questions. Did you have a fall in the last month? If yes, what was the mechanism? What were you doing at the time of the fall? And what was the cause of that fall with what you were doing? And I think this is interesting because they are two different things, right?

09:26 SLIP & TRIP TRAINING

So the cause of the fall in our community dwelling older adults over 70, for example, more than half was a slip or a trip. The activity when they were having that slip or trip was walking forward. That gives us a lot of information in terms of where we start with our older adults. We're not going to start standing on one leg. We're going to start with slip and trip training. We're going to look at reactive stepping, volitional step training. Maybe we'll do that in standing first to see where a person's control is, but we want to see what happens when they start having perturbations. And so if that slip or trip is happening going forward, it also tells us that that perturbation is often backwards or lateral. People aren't falling forwards, right? It's that they're slipping and coming to the side or they're slipping and coming back. And that's a really important piece of information for us. And then it's going to guide where we go. So the next thing is now we're going to look at a person's risk factors, right? So extrinsic risk factors when individuals are having slips and trips was, was this in the wintertime and they're slipping on ice? Was this a step? Was this a rug that we know we're never going to get rid of, but we may ask about trying to tape down? These are things that we may be considering when we are looking at these mechanisms or are asking these questions. And so that's extrinsic. So we're taking this mechanism. We're looking at some extrinsic factors. And then the intrinsic people are going to be telling us in their narrative that they may feel like their balance isn't really great, or they're having trouble holding on to objects and navigating around their home or navigating outside. Or they recognize that the pain in their knee is making them not feel as strong or confident in their gait. And it's going to create them to have a hesitation to react when a perturbation happens because they've had times where their leg has given out. Or they they don't feel like they're strong enough to move their feet, right? They're they're telling us these things in their subjective. And so when we take that information, now it's going to guide us into our outcome measures. So if individuals are saying that they're having falls because of a strength deficit or a weakness issue in their lower extremity, we may want to make sure that we have a general mobility or a strength focused measure in our assessment to get a good idea of where our triage list is going to be. So we may use a five times it to stand or a 30 seconds to stand test, or we may go a bit more general and go to the short physical performance battery because the mechanism of their fall is showing us that potentially that being that capacity to move their feet is coming from a weakness issue.

11:54 REACTIVE POSTURAL CONTROL

We are also going to want to in this example, look at their reactive postural control. We heavily leverage the mini best because there is a subsection of the mini best that looks at reactive postural control in each direction. So we're going to look at a person's capacity to react to a forward perturbation, backward perturbation and lateral perturbation. Right. If a person is having pain in the lower extremity, they're worried about it and we do a lateral perturbation, they may not move their feet out. They may want to cross because they're worried that that painful knee on that left hand side is not going to support their weight. So their reaction may be a step out to the right and a crossover to the right because of that painful knee. So now we've learned two things, right? We know that their pain is a contributing factor to their falls mechanism. It's an intrinsic risk factor that's creating troubles with clearance. It's impacting their gait, whether it's causing deviations in their gait or it's making them not lift their foot enough and now slips and trips are more common. And we recognize that their lateral posturing, the way that they are moving to the side is impaired. So now we've really dialed in our assessment, right? We've gotten a good idea about what's going on and we've picked the outcome measures that are going to give us that information. Because if we just focused, for example, on a burg. Because that is our go to balance assessment, not only are community dwelling older adults more likely to sealing that out, but it's not really getting to the two really big issues that they spoke to in their subjective assessment, right? They are probably going to be able to stand up once and do a pivot transfer. But that five time or 30 seconds to stand that's requiring a repeated chair stand is going to hit into maybe their pain thresholds that they're going to start having some compensatory mechanisms. And they're talking about having perturbations in a forward movement pattern. So the burg is in capturing backwards and lateral perturbations. So we have to be using those mechanisms and risk factors that they're discussing with us in their subjective and then leveraging the outcome measures that have strong reliability, validity, responsiveness, interpretability in order for us to have a good idea of what the next step is. But we're not going to do outcome measures for the sake of doing outcome measures. The next step is that we need to use those and leverage them in our interventions. One of the reasons why we also love the mini best is that oftentimes the way that we implement this is not day one. It's a little bit more of a longer intervention or sorry, it's a longer outcome measure. But we use it at the beginning of a session because it drives us into our intervention immediately. So if we have, for example, there's the anticipatory sub scales, sensory orientation, dynamic gate and reactive posture control. If we think that dynamic gate and reactive posture control are the two areas that based on a person's objective, they may struggle with more. We may use those, see where they're starting to have these deficits. It may be obstacle navigation, for example, with that still going with this example of having slips and trips because of a painful knee and seeing gate deviations where they're not clearing obstacles as readily as they used to when pain was a bit more managed. And they may have issues with reactive postural control backward and laterally. And we're going to see that it's coming to the left because it's their left knee that's painful. So now we have a lot of good information. We have a lot of good data. We use those outcome measures and we're directly going into intervention, right? Like I may use a clock yourself app and block out the forward stepping and I'm going to be focusing on reacting backwards. Or I may take out the right hand side of the clock and I want them to react to the left. And that is going to do at different cadences and then see, you know, what does the threshold look like? What does the step length look like? Does pain start to increase? What is that pain threshold like? How long does that pain take to come back down? And we're also intervening. We can also take, you know, some of these obstacle courses and put them into our interventions that day. Throw all of them together and put them into a round for time or an AMRAP where they're going back and forth between reactive stepping and obstacle courses. And now you're working on some strength because they're doing bigger clearances. We may put a step up in that obstacle course and then we're working on reactive control to the side that they're experiencing difficulties. So when we kind of take a step back, when we slot in what we see into this framework, it can be really helpful. So to bring this full circle, we want to think about balance intensity just like anything else. It's just like aerobic training. It's just like resistance training, but we cannot get good outcomes with bad data. So how do we do this? Our subjective, we need to dial in on mechanisms and risk factors. We need to be asking questions. If we do not have the answers to those questions, we're going to rely on the evidence of where older adults in different settings tend to fall. Then we're going to use outcome measures and we're going to select the outcome measures, if we can, based on our setting, that are going to give us the information we need to see where those thresholds are. From there, we're going to drive ourselves right into intervention based on where those deficits lie. And we're going to get to an intensity where individuals are either weary, we're pushing into potentially some low-grade pain, or they are self-reporting high amounts of fatigue or nervousness.

17:31 PROGRESSIVE OVERLOAD & FEAR

So we may be doing some graded exposure into fear. And that is a form of progressive overload, especially in the geriatric space where fear of falling is a big risk vector for future falls. So kind of bringing this full circle, here is the framework for you when you have a person coming in who is having falls or is worried about their balance. And it'll allow you to really dial in your interventions. Let me know if you have any other questions. What are your thoughts on this? I would love to have a dialogue. If you are interested in learning more about some of this research, we just put that 2023 paper into MMOA Digest. So every two weeks there is a research email that we send out that allows you to stay up to date with the evidence. We put all of our new courses on there, so definitely go to ptnice.com slash resources and sign up for Digest. If you are not on Hump Day Hustling, please make sure you do that too. That is all different types of research from all of our divisions. Have a wonderful Wednesday. Bye everyone.

18:34 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 are interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE Online Mentorship Program at ptonice.com. While you are there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top 5 research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 11, 2023

Dr. Kelly Benfey // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Kelly Benfey discusses her experience competing at the 2023 CrossFit Games, the role of rehabilitation providers in competitive sport, and the capacity of the human body for exercise as it ages.

Take a listen to the episode or read the episode transcription below.

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EPISODE TRANSCRIPTION

00:00 INTRO

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

01:33 KELLY BENFEY

Good morning and welcome to the PT on ICE Daily Show. It's Fitness Athlete Friday and my name is Kelly Benfey. I just wrapped up an amazing CrossFit season where I got to compete at the CrossFit Games. And so what we're going to get to talk about this Fitness Athlete Friday is going to be a couple takeaways from the CrossFit Games that I think are relevant in the rehab space. Before we jump into that, though, within our Fitness Athlete crew, we have a couple of online courses coming up that I just want to bring to your attention. So we just wrapped up an awesome cohort with our clinical management of the Fitness Athlete Essential Foundations course online. And so our next course is going to be kicking off in a few weeks on September 11th. That course always fills up. So if you're thinking about it, please jump in with us, grab your spot right now. And then if you've already taken that and you're looking to continue developing your skill set, our Advanced Concepts course that's only offered two times a year is also starting September 17th. So rarer opportunity to hop in on that one. So if you've been looking to take this course, that's going to get started quite soon. And then we have a handful of live courses for the remainder of the year. So all of that information is going to be on PTice.com, PTonice.com. So we hope to catch you live on the road. I'd love to see you all. So we'll be getting back on the road for the remainder of this year to finish strong. So let's get into our topic. Of course, I could talk about this stuff all day if you know me. So we're talking CrossFit Games takeaways. A couple of things that I experienced and found were relevant in the rehab space. This is Fitness Athlete Friday, so we get to geek out on all things, CrossFit Games, CrossFit competition, all that good stuff. So number one, I have five different things that we'll kind of work through.

03:35 HUMAN CAPABILITY

So number one, I always leave the CrossFit Games feeling absolutely motivated and inspired by what the human is actually capable of doing. So I really it was it was just such an honor to be on the same field as some of these amazing, amazing athletes, be behind the scenes and all that good stuff. So a couple highlights that I saw now just to I competed in the team division. So it actually didn't allow me to watch as much as the individual competition. I'm still working through catching up on that all the live the live coverage that they had. But I got to be within the team division. So one of the athletes in the team division, she clean and jerked 250 pounds and then a couple hours later ran a 5K, 4.5 ish K, 5K in under 20 minutes. So it just always impresses me that people can excel in things that I also excel in the strength events, yet also push their aerobic capacity and monostructural skills to an insane level as well. So it was just absolutely mind blowing to see athletes also just I know how hard we worked on my team and just having other athletes really push the boundaries. I find to be super inspiring as a competitive athlete. And then moving moving towards almost even debatably more inspiring.

04:11 OLDER ADULTS PUSHING BOUNDARIES 

The age group divisions are always just such a blast to watch. I wish they had a little bit more coverage because arguably that's more these are more the athletes that are relatable and even more inspiring. For example, the 60 plus division, I believe the 60 60 to 64 division, both men and women had bar muscle ups in their last event. So these are our older adults crushing it, doing high skill level at a very high competitive level. Just absolutely amazing. And like I had the opportunity, my mom came and watch. She's going to watch me and have a blast, obviously, but she's not necessarily going to see like watch me and think, oh, wow, that's something I can do. She's going to see something in her age division and then become inspired of, hey, maybe I'm going to start my barbell class in my gym, for example. So I just think the human capabilities, even in our older adult divisions, is just as important as what the individual and team athletes are doing. The professional athletes, if you will. And then we also have the adaptive visions that are starting to grow and the upper extremity adaptive athletes were performing rope climbs. Rope climbs are hard enough when you have two upper extremities to grip onto the rope with. They were doing it with one and we're also sealing our lower adaptive lower extremity adaptive divisions, doing things like box jumps and maxing out their clean and jerk and snatch and really just taking no opportunity to have an excuse to not push their fitness forward and continue to be athletic and competitive in their sport. So I absolutely love seeing those. I wish I got to see a little bit more of it. I wish we got to view a little bit more of it on the broadcast, so hopefully we'll be able to continue pushing that forward. I just saw a couple posts of highlighting those athletes, so keep keep those in the forefront of your mind. That's what's really inspiring to more people, I think, in this world, in our country. OK, so the next three points that I want to kind of work through all kind of build off of each other.

09:20 INJURY RATES & PROGRAMMING

So one thing that I thought was really relevant this year at the Games was the programming. And like I said, I have paid attention a lot to a lot more detail of our team division programming, but I just wanted to bring your attention as a rehab professional, as a movement specialist that's working with athletes all the time. I think it was important to note this. So just a couple examples. So in our competition, we had four days of competition. On day one, we had overhead squats at 135 pounds and 95 pounds. Then day two, we had a one rep, one rep max snatch. And then on day three, we had more snatches at 185 pounds and 135 pounds with running. So that's back to back days that we're seeing a barbell shoulder stability type exercise that is very demanding on the shoulders. In general programming, we would probably look to spread the frequency out of when we're doing things like overhead squat and snatching. Being able to do those back to back days can challenge the shoulder and challenges your ability to recover and perform repeatedly. Another thing that I noticed as on our day two, we had a strict ring muscle up to a front support hold. So going through that pole to deep press and hold at the top of the unstable rings is really challenging for the shoulders. And then right into day three, we had 30 synchro ring muscle ups on the long straps, which are tough. And then 63 more parallet bar dips. So that's a lot of vertical pressing for the shoulder to get through back to back days. And so I've personally experienced issues with pressing with shoulder pain. I've worked with a handful of athletes that recently have been that's a common theme in our clinic that I'm working with. So that is I remember if I was in the middle of having a flare up of that shoulder pain presentation, it would be really hard to be able to do that back to back days because you can always push through one workout. Adrenaline is a really strong drug, I would say that helps you get through it. But the next day when you wake up and things are a little bit inflamed, it's really hard to be able to repeat those motions. So that was just one thing I noticed that was not necessarily what I would have expected in programming, just how frequently the same movement is tested. And it's one thing to test the fitness of it, but it's also one thing to test the tissue capacity. So those are things that the my rehab mind was kind of evaluating while I was going through it, which brings me kind of into that next point I want to bring up was injury rates this year. I'm not sure if I just noticed more injuries and pain happening. A lot of KT tape being thrown on our limbs because I was in the background. But there did seem to be a lot of withdrawals from individual and team, excuse me, team athletes this year. We know the injury rates in CrossFit, the highest injury rates that we're seeing are in the shoulder joint. And based on that programming, it kind of makes sense. It makes sense that we're seeing a lot of shoulder issues. And so just from an athlete's perspective, it's absolutely devastating. It's so upsetting to have to withdraw from an injury, whether it's yourself, whether it's a teammate. We put so much time, money, effort and dedication to an entire long season. This started in February. So working day in and day out, making decisions based on that this specific weekend. It's just an absolute shame to see an athlete have to pull out of competition because of shoulder pain or whatever issue they may have. So I know I got to talk to a couple of the teams that had to withdraw. And the common theme that they were telling me was like, oh, yeah, I had this lingering issue for a while. I just retweaked it about two weeks ago. So they weren't necessarily the Roman Krenikov situation where they just, unfortunately, came down and rolled an ankle and had a new injury. This was a couple of these things were like lingering elbow issues that are really tested in the moment of competition with all the stress on board. Exposing to really deep positions of that dip position. If we have lingering shoulder stuff going on when you're pushing to 150 percent of your capacity, it's not likely that you're going to come out OK sometimes. So as soon as some of the workouts were announced, these athletes were like, well, I'm not feeling too great about this. So I take it's just such a shame because I think as rehab professionals, we need to have the skill set to be able to address these issues that our competitive athletes are experiencing and make sure that we're not just getting them back to be able to do a ring muscle up and take an ibuprofen. That's a whole other issue. We don't want our athletes to be doing that, obviously, but we want to be able to get them back to baseline and then beyond baseline because that originally that shoulder with that skill set got injured. So it's definitely up to us to be able to have the resources and provide rehab for these athletes that they find valuable. Not every single one of these athletes has a team of physical therapists that are top notch, that are traveling with them, that are on like on them 100 percent of the time. And so it is very likely that you may come across a CrossFit Games team athlete that's going to need to go through four days of competition with repetitively dips and butterfly pull ups and pulling, pulling whatever it may be. All these really challenging things for our shoulder girl to be able to tolerate. So that just I walked away being thankful that I came out unscathed, essentially, because if you followed any of my CrossFit career, I've had issues with my shoulder before. And strength always is super protective against injury. And I feel really lucky, essentially, to have all the knowledge that I have to put myself in the best scenario. Even within my teammates, we had a shoulder issue that we had to train around a little bit where we couldn't our best choice wasn't to continuing to do 30 muscle ups the week before, for example. But we rehab the crap out of it and put ourselves in the best situation possible to be able to come away without withdrawing by any means and putting up a pretty good performance over the course of the weekend. So that just brings me to want to plug our courses just one more time. So I mentioned the beginning, we have a couple of online courses coming up. I would say 75% of the clinical decision, clinical decisions I'm making on a daily basis are all things that I learned from these courses. The other 25% is probably all the other stuff I learned from my ice courses. So I know I'm biased, but I promise I'm not lying. If you at any point would feel nervous, nervous if I came into your clinic saying I can't do ring muscle ups, help. Please hop in one of our courses. It's really a fun, fun way to spend your eight weeks online. And so the last point I wanted to make kind of along the same theme was the importance of stress and recovery. So if you are an ice in the ice world, I'm sure you have heard us talk about the importance of stress and stress that the body takes on and how it helps us or doesn't help us recover well.

11:04 COMPETITIVE ATHLETES & REHAB

And competing in the CrossFit Games this past weekend really made this become like full picture for me. I prioritize sleep, I prioritize what I'm putting in my body, and I prioritize managing stress as well as I can with all of the training that we were doing. But at the CrossFit Games, I will say I was probably at a peak stress level in my life. I don't live there on a daily basis, but the couple of weeks leading up to it, highly stressed and enduring also highly stressed. For example, day one, the volume wasn't really high. We were coming off of two sessions a day, up to two hours per session. So training heaps, I would say. And day one, all I did was three leg assault climbs, 30 overhead squats and then four laps on the bike track, which was aerobically really challenging, but not high impact. And the next day when I woke up, my fitness tracker is showing me my heart, HRV is plummeting. I felt like I did probably triple that amount of volume at minimum. And I was really surprised because volume wise wasn't crazy, wasn't out of my realm. But I felt the I think what I was feeling was the high level of stress that competition brought on. So and just to circle back a little bit, if you're having lingering shoulder pain, it's probably not going to get better with how much we're ramping up as far as volume in the eight weeks leading up to the CrossFit Games.

15:10 HIGH STRESS IN COMPETITION

And then in the high, high stress environment, it's also going to be asking a lot to be able to recover and repeat these highly demanding movements like snatching, overhead squatting into ring muscle ups, to fatigue into dips where we're highly fatigued and moving at 150 percent of our capacity, essentially. So it just really is that's another way that I think bringing like stress and managing our recovery is just too important to ignore as the physical therapist, because we all know that person that's chronically stressed, chronically in that sympathetic state that maybe they are going into the gym and adding more weight. More stress onto their body. It's I absolutely can understand how they probably don't feel well at the end of the day, day in and day out. And so you have the ability as their rehab pro to help change their foundation of what they feel on a daily basis, too. So don't forget those things when you're dealing with any type of person that comes into your clinic. Stress management can really hit hard on so many levels and prevent maybe just set them up to rehab even better with all the good rehab skills you're doing with them in the clinic. And then lastly, I just wanted to share a couple of highlights because I feel like I had so many so much amazing support from our ice community. So just a quick couple personal highlights. Having been a spectator of the CrossFit Games for the five or six years or so has been in Madison. It was just such a cool opportunity to be able to push the Bob to do ring muscle ups with the long, long straps on the Zeus rig to use that four person axle bar for the deadlift. Those are things that you just never would see in a norm or any other CrossFit competition that's really only going to be at the CrossFit Games. So I remember pushing the Bob to the finish line and just reflecting on North Park, like, how cool is this? I've always wondered how it felt. So that was a really cool personal highlight that was really motivating throughout the weekend. Another personal highlight was our one rep max snatch. I have had some issues with shoulder pain and snatching and tweaked my elbow before from kind of poor movement patterns. So all season I was in a bit of a snatch funk. I'm sure you can relate if you are an athlete that tries to snatch frequently. It's sometimes good, it's sometimes not good. And so just about two or three weeks before the CrossFit Games, everything kind of clicked and I was able to hit a PR and perform really well on stage. So as an athlete, it just felt really special to be able to showcase the hard work that I put into that movement all season. And then lastly, I just had the best time with so many friends and family that were there to support at the CrossFit Games. I had my gym community from Milwaukee, my gym community from Chicago when I lived there, my ice community was there, our onward community. We had such a large cheering section, essentially. And trust me, that helped us get through that whole weekend. So thank you so much for everybody that was there, that sent messages, that supported us. It was such an honor to be able to represent this crew and we had a blast doing it. So thank you, thank you, thank you. So those are my takeaways from the CrossFit Games. I would like, like I said, this is stuff I can talk about all day, every day. So if you have any thoughts on programming, injury rates, anything you noticed from your spectating view, I would love to chat about it. So feel free to comment and tag me on this post, send me a message. Other than that, have a wonderful weekend and we will see you next or on Monday with our PT on Ice Daily Show. Have a great weekend.

19:06 OUTRO

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

Aug 10, 2023

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


In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore challenges the common belief that vacations and time off are necessary to decrease stress levels. He argues that the expectations around time off may not align with reality, often leading to discontentment. Jeff suggests reconceptualizing the idea of time off and vacations to have better trajectories and lower stress levels.

Jeff then discusses what creates low stress levels and a healthy ecosystem. He addresses the issue of returning from vacations to a chronically disorganized routine. Jeff explains that when our day-to-day lives lack discipline and organization, we often find ourselves in a cycle of feeling like we need a vacation, being disappointed by its inability to meet our expectations, and feeling worse off as a result. Jeff emphasizes the importance of taking ownership of our day-to-day routines and reorganizing them to break free from this cycle.

Take a listen to the podcast episode or read the full transcription below.

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

EPISODE TRANSCRIPTION

00:00 JEFF MOORE

Alright team, what is up? Welcome to the PT on ICE Daily Show. Welcome to Leadership Thursday. I am Dr. Jeff Moore, currently serving as the CEO of Ice. Thrilled to have you here live via Instagram or YouTube. Thrilled to have you on the recording if that's the way you're taking in the show. It is Gut Check Thursday. Let's get right down to business. What is the workout that all of the Ice Train folks are going to be taking on this week? It is as follows. 35, 25, 15, 5. So we have 4 rounds descending in volume. They are going to be double dumbbell push press but not real heavy, 35 and 20. And then ab mat sit ups are going to be paired with that. Okay, so you've got your 35 dumbbell push press drop down. You get your 35 ab mat sit ups. In between each round, you're going to run 200 meters and the rounds are going to be 35, 25, 15, 5. Okay so you should be able to keep a pretty high intensity up because the volume on those rounds are dropping. Make sure you get a snippet of that. Put it on Instagram. Let us know what's up. Hashtag Ice Train. We love seeing everybody throwing down on those Gut Check Thursday workouts. Real quick, courses coming up. I want to highlight cervical spine. If you want to be out there solving neck pain, radiculopathy, headaches, all the things that come with that upper quarter region, get to this class. We've got 3 options coming up. August 26, 7. It's going to be at Onward Charlotte. September 9, 10. It's going to be at Onward Atlanta. In October 14, 15. Going to be at Onward Greenville. So going to be in North Carolina, going to be in Georgia, going to be in South Carolina. So belt there and hit that course. Learn those skills. Serve those patients well. Okay, welcome back to Leadership Thursday.

02:01 VACATON & WORK-LIFE BALANCE

We are going to have a conversation about why I think we've gotten vacations wrong. And I want to talk a little bit about the origin of this episode. So the other day I posted on Instagram some of the best advice I've ever received. It was from a friend. It was many, many years ago. And he said to me, if you play between the ages of 25 and 35, you will work hard for the rest of your life. If you work hard between the ages of 25 and 35, you will play for the rest of your life. And as I've watched now coming up on wrapping up the second decade of my career, I've seen a lot of people finish off their careers, seen a lot of people start them, myself going through my own. A lot of observation and the amount of truth embedded in that quote has been nothing short of shocking. When you get in the right lane early, and you get to you get with the right people early, you wind up doing what you love and excelling at it. And of course, just like investing, the earlier you do that, the more it compounds. And it really creates a scenario where the back two thirds of your career not only are more of what you love, but really decompress the stress. On the other hand, if you kind of get yourself into a financial hole and you're not in the right lane, and you're nearing the halfway point of your career, it really becomes a tough thing to dig out of. And it just sets you up for a bit more of a grind on the back end. Now we could have a whole episode about that quote alone, but that quote got a lot of feedback. And anytime you talk about working hard, you tend to get a lot of DMs and messages about the need for people to avoid burnout. And specifically that people need vacations and time off to decrease their stress levels.

03:46 EXPECTATIONS AROUND TIME OFF

That's what I want to zone in on because I think that our expectations around time off are really, really aired, if you will. And the problem with your expectations not being aligned with reality is that discontent is the inevitable result of that. So let's see if we can't reconceptualize this a bit and wind up with better trajectories. So think about what creates low stress levels. So if we're going to talk about stress levels, what creates low stress levels? What creates a healthy ecosystem? The answer is the following. Now we could put nine bullets here, but let's go with the really, really big rocks. That when you have them dialed in, your stress levels tend to be low, your nervous system tends to be really under wraps, you tend to feel really dialed. Probably the biggest one we'd all agree on is sleep quality. The consistency of it we know is the primary driver. But the other small things, having it cold in the room, having it dark when you're eating food, not having those late meals, sleep consistency is probably, or sleep quality, driven primarily by consistency, is one of the biggest drivers to day to day having low stress, having more energy. Number two is a regular fitness routine. You're getting to the gym at the same time that you're engaging in quality fitness. Number three is nutrition, that you're eating a quality, clean, well-balanced diet. Sufficient in protein, void, hopefully, of a lot of nonsense and processed foods, that you're eating quality nutrition. When you're doing these things that we preach about all the time, your ecosystem tends to be optimal, your stress levels tend to be low, you tend to feel your best when those variables are dialed in. Now think about how those variables fare when you're on vacation. And I think we would all agree the answer is poorly. You're sleeping in a totally foreign environment, your consistency of your sleep is all over the map, you're trying to get some fitness in but it's random, it's not nearly as structured as usual, and your nutrition, let's be honest, leaves a lot to be desired. It's usually very fun food, you're usually trying a lot of new things, but you tend to be eating late at night, it affects your sleep quality, all of the primary metrics that create that really well-defined healthy, low-stress human are significantly disrupted, specifically when you're on vacation. Now does this mean, right, and I think it's worth saying that if that's not the case, if those things, if your sleep quality, your gym routine, your nutrition, if those things are better when you're on vacation, your day-to-day routine needs a serious second look. So if you don't have those things dialed in better on your day-to-day and your usual environment compared to when you are out in some random state or country where you've got no control of the other variables, if you do better on those things out there, you need a serious look at your level of discipline and organization on your day-to-day life. But I think for the vast majority, as we would agree, those things are pretty dialed when we're at home and they are very erratic when we're on vacation. Now does this mean that we shouldn't take vacations? And the answer to that is of course not, right? A lot of the coolest memories in your life, right? The things that you're going to do that you're going to look back on and say, gosh, that was crazy or do you remember that? And the stories that fill your life, a lot of those things are going to be formed when you're on vacation. Your perspective will expand, right? You're going to be in new environments. You're going to be seeing new people. You're going to be looking at things differently because you're outside of your usual routine. Your relationships with those that you go on will often deepen, whether it's your partner or your family or your friends, right? You rarely spend that kind of concentrated time and it creates incredible opportunity for those relationships to deepen. All of these incredible things are going to happen when you're on vacation. What will not happen though is usually that your stress level will drop because the things that drive that are generally disrupted. So then what's the secret sauce?

08:18 DEVELOPING A ROUTINE FOR VACATION

The secret sauce is developing a routine that allows you to look forward to, but never need a vacation. That's the most important thing, right? You can't wait to do it. It's going to be a blast. You know those memories are going to be formed, but you don't need it because your routine day to day is so dialed that you feel outstanding, even under the presence of high workload because you've dialed in those metrics. So developing a routine that allows you to look forward to it, but not be desperate for it, not require it. And number two enables you to bounce back upon your return because if you do vacations right, a lot of that stuff is probably disrupted and you're probably coming home, hopefully thinking the classic quote, I can't wait to get back into my routine. That is a very healthy thing to be thinking, right? Like, hey, we went out there, we collected incredible memories, we got new perspective, we deepened relationships, we did all of the enriching things that vacation can bring. But now I'm pumped to get back into my dialed in routine because that's what's going to drop back down my stress level. That's what's going to allow me to perform optimally. So hopefully you're coming back to a routine that's dialed that not only did you not even need the vacation in the first place, you're bouncing back in two to three days, as opposed to having that post vacation hangover for weeks on end where you can't get your act together, which only increases your stress, which makes you need to step away again. And now you're in this vicious cycle of trying to survive when you're there and always wanting to be gone. The exact opposite should be true. You should love when you're gone and be taking a ton from that, but you should be strengthening while you're home to be able to enable that. Not weakening while you're home, hoping that it can do something that it can't when you step away. That's the challenge. The bottom line is people need more disciplined lives to decrease their stress levels. And people need vacations to enrich their existence. Unfortunately, a lack of discipline in our day to day lives requires a need and a desire for vacations chronically and a hope that they can do something that they usually won't. Simply because the organization of them doesn't tend to organize our nervous system. It tends to disrupt it, which in the right amount, when you've already got it balanced, is an amazing stimulus to get you to think differently, to get you to freshen up, if you will.

11:14 TAKING OWNERSHIP OF ROUTINE

But if you are coming back to a routine that's chronically disorganized, you're going to be in that vicious cycle of, I feel like I need a vacation. The vacation didn't do what I wanted it to do. Now I'm a little bit worse off. And we go back and forth and back and forth. And there's really no getting out of that wheel until we reorganize and take ownership of what we're doing on the day to day. Then we can enjoy the vacations and be strengthened by our routine. So just want to put that out there because so often people are saying that people need vacations to decrease stress. I think we can live in a way that we don't need that at all. And yet we do get great things from those breaks and can certainly take them as opportunity allows. Hope that makes some sense. Had some great conversations this week. Feel free to continue those in the comments. Everybody have a wonderful Thursday. Thanks for being here on Leadership Thursday.

Aug 9, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult faculty member Jeff Musgrave discusses a randomized control trial that investigates the impact of inflammation and different intensities of strength training on global inflammatory load and immune response. The study involved 81 participants, aged 65 to 75, who underwent a 12-week strength training program at varying intensities. Thigh muscle volume was measured using computed tomography, and blood tests were conducted to assess inflammation markers.

The results of the study revealed that moderate and high intensity strength training yielded superior improvements compared to moderate and low intensity training. Participants in the moderate and high intensity group experienced a 15% increase in thigh muscle volume, while those in the moderate and low intensity group only saw a 9% increase. Furthermore, the moderate and high intensity group exhibited reduced thigh fat volume, decreased pro-inflammatory cytokines, increased anti-inflammatory cytokines, and elevated free floating leukocytes.

Jeff underscores the significance of incorporating moderate to high intensity strength training for older adults, particularly those in the 65 to 75 age range. He highlights the sedentary and overweight state of many older adults in the US, emphasizing the need to address frailty in this population. Jeff also discusses the risks associated with not implementing moderate to high intensity strength training, including increased inflammation, decreased muscle volume, and heightened body fat.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:43 JEFF MUSGRAVE

Welcome to the PT on ICE Daily Show. It is Wednesday, so that means it is all things geriatrics. We like to call this Geri on ICE. So can't wait to get into a deep dive of this randomized control trial that just dropped last month in July, talking about inflammation, various intensities of strength training, how that impacts our global inflammatory load, as well as things like our immune response. And then we're going to deep dive after the article into what happens if you don't follow the results of this study and if you do, what the opportunity is for your patients. But before we get into that, we've got lots of opportunities. If you want to continue the learning process, if you want to sharpen the sword when it comes to working with older adults, we have got just a handful of seats left in Essential Foundation. So if you want to jump in, you need to do that quick. There are only a few seats left. We can still get you on boarded. You're not going to miss a thing. If you want to hop in for advanced concepts, you've already had Essential Foundations. The next cohort is going to be October 10th. And then if you want to see us live on the road, the revamp is releasing this weekend. I cannot wait. All of the faculty of the older adult division are descending on Lexington, Kentucky. We're coming to the bluegrass to show show out with this new content. It's going to be super fun. If you miss getting your seat for that this weekend, next weekend, we're going to be both in Bedford, Texas, as well as in Minneapolis, Minnesota.


06:20 IMPACT= OF MODERATE AND HIGH INTENSITY STRENGTH TRAINING FOR OLDER ADULTS

So as promised, the study, Intensity Effects of Strengthening Exercise on Thigh Muscle Volume, Pro and Anti-Inflammatory Cytokines, Immunocytes in the Elderly, a randomized control trial. So this trial had 81 participants. We've got adults 65 to 75 years old. 39 of those were male. 41 of those were female. And they were taken through a 12 week strength training program at various intensities. Baseline measures were thigh muscle volume via a computed tomography and blood test. They also did their due diligence. We know how important nutrition is to get an idea, at least of their caloric intake. Now, did not go into detail of how much protein, how much fat, how many carbs. Didn't look at macros, but they did identify that all the adults in the study were consuming about the same calories on average. So the control group spent 10 to 15 minutes doing meditation and stretching. Not things that are awful, but definitely the control group when we're talking about effects of strength training. The experimental group did 50 minutes of exercise three days a week. They had squatting, they did pressing movements, spine flexion and extension on Mondays and Fridays. On Wednesdays, they hit those knee flexors, extensors. They did ankle planar flexion, chest flies and rows. All of this was primarily done on machines, machine based exercises. And then when they broke down the different intensities, what they did is they recalculated each month and they worked them off different repetition maxes. So the low intensity strength training group worked off of a 10 rep max, a 9 rep max and then an 8 rep max. If you're looking consecutively across those three months as it was a 12 week study. The moderate intensity group hit 10 rep max, 9 and 8 rep maxes and recalculated their strength each month. And then the high intensity group worked off an 8 rep max, a 7 rep max and a 6 rep max. So I thought that was pretty cool that they recalculated their strength and then they used the same measure there of course to calculate their intensity for their strength training. So, after 12 weeks of strength training, the moderate and high intensity strength training group had superior improvements in their thigh muscle volume. Their thigh muscles got larger at a percentage of about 15% versus 9% on the moderate and low side of things. They showed reduced thigh fat volume, reduced pro-inflammatory cytokines, increased anti-inflammatory cytokines as well as increased their free floating leukocytes. Lots of $10 terms in there, but the reality is when we're looking at the impact of moderate or low intensity versus moderate and high intensity. It was statistically significant that moderate and high intensity strength training for older adults superior. Whether you're talking about adding muscle, reducing fat, reducing inflammation and even bolstering the immune system, which really I thought was super cool. So that's the basics of the study. If you've been hanging around the Institute of Clinical Excellence in this community, you're not going to be surprised to hear the results of the study. But what I want you to do is I want us to go a level deeper.

09:30 AGING & STRENGTH TRAINING INTERVENTIONS

I want you to think about your patients on your caseload that are 65 to 75 years old. The state of the union on older adults, especially in the US more so than other places in the world, is we are inactive. We are overweight. We are not hitting ACSM guidelines. Most older adults in that 65 plus category are on somewhere on the continuum of frailty. They have low physical reserve. They have low physical resiliency. They are vulnerable to injury and decline, losing their independence. So most of our clients are on this very rapid downward trajectory. And we have got at our hands the tools, rehab clinicians. We are able to intervene with strength training intervention. If we will go moderate to high intensity, we know we can increase their muscle mass. We can reduce reduce their body fat. We can reduce inflammation. And let's think about some of the conditions that are on board outside of low reserve, low resiliency. We like to think about a thing called one repetition max living. They are very near their 100 percent capacity to get out of a chair. Think about your client who cannot stand from their normal chair without using their arms. Their one repetition max squat is less than body weight. And think about how many times they have to stand up and sit down throughout the day, giving a near one repetition max effort. Crazy! How exhausting is life for those people that are barely able to do their activities of daily living? I want you to also think about some of these global inflammatory conditions. These inflammatory markers increase the risk of progressions in arthritis, cardiovascular disease, metabolic syndromes like diabetes. Think about how many of our patients are sitting in this very vulnerable situation. So we've got this picture of our older adults on the decline, probably on the frailty spectrum. If they're on our caseload, probably have arthritis, probably have inflammatory conditions. Then we think about the opportunity that we have if we just add high intensity strength training intervention. Think about the change that you can make for them. How you can bolster their strength, their function. Get them away from that line of independence where they can just not barely get through their activities, but start building some sizeable reserve. Think about how much we can do if we hit moderate to high intensity. If they don't have inflammatory conditions yet, think about isolating them from that risk. And then not even covered in the study because these were not primary measures they were tracking, but just knowing the literature for older adults.

12:06 FRAILITY & AGING INTERVENTIONS

Think about the benefit of heavier loads that's not even discussed in this study. Think about their bone density. Think about their confidence. If they know they can lift way more than they have to in daily life, is that going to impact their confidence? Is having more confidence going to help them lift with better mechanics more confidently? Is it going to help them balance in unusual scenarios more confidently? Absolutely. Confidence in that psychological impact. Don't count that out. So just think about all the opportunities with heavier load. And then what I want you to think about is maybe you're still on the fence with this stuff and you're like, I don't know if that's safe. I'm a little concerned. Maybe you don't feel quite equipped or you've not seen that modeled before and you're a little bit nervous. But I want you to think about this. I want you to think about the risk and what happens to these older adults in a very vulnerable situation if you don't. If you don't hit them with moderate to high intensity, I want to outline some of the results of the control group. During just that 12 week period where they did not perform moderate to high intensity or any strength training whatsoever, their resting inflammation went up. Their muscle volume went down. Their body fat went up. Their leukocytes went down. They became way more vulnerable in a 12 week period, just 12 weeks of not doing what they should be on the strength training train. Think about what happened to markers that were not tested. Think about their bone density. Think about their ability to get through their day with enough reserve and enough strength to really make it through the day. Just think about all the missed opportunities. I'm going to recap real quick. I know I'm super pumped about this. This is what it's all about, team. But I want you to think about the opportunity with moderate to high strength training interventions. Based on this randomized control trial, we can feel confident that we're going to increase their muscle thigh volume. Thinking about things like sarcopenia, frailty, all those categories. We can reduce their body fat. We can reduce pro-inflammatory markers. We can increase anti-inflammatory markers. We can bolster the immune system. Just based on this study, forget about bone density. Forget about one rep max living. Forget about confidence. We know those things just from this study. Then I want you to think about what you can do for your patients if you start these interventions. Think about how powerful of a tool you have. You have the keys to the castle in your pocket. If we can just go a little bit heavier. Remember, it's relative. It is relative. Yes, I will be sharing the link to this study in the caption. What happens if you don't? If you don't, we know this steady decline of frailty, deconditioning is going to continue. We know based on this study that if we don't intervene here, our older adults are going to become more frail. They're going to lose reserve. They're going to lose more muscle mass, be at higher risk of sarcopenia. We know that they're going to have higher inflammatory markers. They're going to be more at risk for progression in arthritis, metabolic conditions, cardiovascular disease. Just think about what processes you're allowing to hasten on. What's going to happen to your client if you don't get on board? Team, super spicy, super pumped about this. Got a little impassioned about this. I'll be sharing the link to this study in the caption. Super cool. Lots to think about here. Would love to hear your thoughts. Would love to hear if you have any success stories of clients that you've been using, moderate to high intensity strength training, and what the results have been. Otherwise, team, I hope you have a wonderful Wednesday and we will see you soon.

14:10 OUTRO

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

Aug 8, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses recent research evaluating the effects of training programs that prioritize the back squat vs. the barbell hip thrust. 

Take a listen or check out the episode transcription below.

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

00:00 INTRO

What is up PT on Ice Crew, Dr. Mark Gallant here having some trouble with YouTube webcams this morning so we're going to be solely on Instagram and we'll get it downloaded for you on the on the back end for the YouTube. Again, I'm Dr. Mark Gallant, lead faculty with the Ice Extremity Management Division alongside Lindsey Huey, Eric Chaconis. We're going to get into some hip thrusts versus back squats today. Before we do that, if you've been looking to sign up for an ice physio course, the courses that are on the website now are the only courses that are going to be there for the remainder of 2023. So if you've been on the fence thinking about jumping in, those fall courses are the fall courses. So go ahead and get that dialed up and come join us on the road. If you've been looking to join the extremity management faculty on the road, Lindsey is going to be in Rochester Hills, Michigan this weekend. So if you want to it's a beautiful time of year in Michigan. If you want to jump up there, grab a seat. The course with Lindsey that's still available. And then I'll be in Amarillo, Texas September 9th and 10th. So I'd definitely love to see you all out on the road. One of the things that Lindsey and I and Cody and Kristen and all the staff for extremity management, one thing we're always trying to help do is to simplify our exercise selection and dosage so that for any n equals one patient that comes into the clinic, it's a bit easier for us as clinicians to go like, based on these parameters, this will likely be the best choice exercise and the best choice dosage for this individual.

02:39 HIP THRUSTS VS. BACK SQUATS

And we had an article released last month. It's not even published in a journal yet. It came out of Auburn University. That's going to help us do just that. So the lead author on the paper is Daniel Plotkin with Brett Contreras, aka the glute guy, also being an author on the paper. And what they did in this paper is they wanted to compare. If we gave a group of people hip thrusts for nine weeks, and we gave another group of people back squats for nine weeks, of those folks getting those individual programs, who would have the greatest strength gains and who would have the greatest hypertrophy gains to the glute max specifically. So that's what they looked at. They took a group of individuals, about 34 individuals, who were 18 to 30, who had not done any significant training in over five years and were relatively healthy. So BMI under 30. So relatively young, relatively healthy and under trained. At baseline, what they assessed was they assessed three rep max for their back squat. They assessed three rep max for their barbell hip thruster, three rep max for a deadlift, and hip extension against a force plate to see how much output that glute max was doing. They also, which is kind of cool, they threw them through an MRI tube. And that's how they got a measure of how dense and how robust their glute max tissue was. So they threw everyone, day one, through that MRI, got an assessment of how thick their glute max was, how thick that booty was, and then they reassessed that after nine weeks. The final piece they assessed was they took EMG output for both the back squat and the hip thrust. So what did they do for an intervention? So over the course of nine weeks, one group got hip thrusts and one group got barbell back squat. Each group did nine weeks. Week one, they did three sets of eight to 12 reps. Week two, they did four sets of eight to 12 reps. Weeks three through six, they did five sets of eight to 12 reps. And then week seven through nine, they did six sets of eight to 12 reps. So over the course of the program, they were getting a lot more volume as time went on. The way they controlled for the intensity, if a person was able to do more than 12 repetitions at any given set, they bumped the weight up. If they were unable to get to eight reps, they lowered the weight down. So they always wanted to keep it between those eight to 12 reps while making it approaching failure. So getting close to failure for each of those individuals to really challenge those tissues overall. So each group did twice a week, only back squat for the back squat group, two days a week with those loading parameters. Hip thrust, twice a week, only hip thrust for that nine weeks with those loading parameters.

05:12 THE LAW OF SPECIFICITY

What shook out at the end of the nine weeks was pretty cool. We're starting to see some strength and conditioning principles that are becoming clearer for us as better studies come along, as time goes on. The number one thing that we continue to see is the law of specificity. If you want your client to get better at back squats, have them do back squats. If you want your client to get better at hip thrusts, have them do hip thrusts. If you want your client to get better at deadlifts, have them deadlift. You want them to get better at step ups, have them step up, so on and so on. And that's exactly what we saw in this study. The group that did barbell back squat got significantly stronger at their three rep max back squat at the end of that nine weeks with only minimal gains in their barbell hip thrust, in their deadlift, in their force plate. They made gains in those other things. They were not nearly as significant as the gains as they made on the specific exercise they were doing. Same for the barbell hip thrust. The group that did the barbell hip thrust made significant gains in their three rep max on the barbell hip thrust. We did not see the same significance in their back squat, in their deadlift, and in their isometric hip extension against the force plate. Again, they made some gains, not as significant as the specific exercise. So again, we're seeing this article reinforce. If you want to get better at a specific thing, that person will need to do that thing as soon as their tissues can tolerate it, as soon as they're ready. Get them doing the thing that they desire to get better at. The other cool thing about this paper was hypertrophy. What we saw with hypertrophy with this study is both groups hypertrophied their glute max equally. So it didn't matter whether you were in the back squat group, whether you were in the hip thrust group, both groups showed glute gains.

09:58 HYPERTROPHY AND EXERCISE SELECTION

And what we're seeing in a lot of the hypertrophy research is exactly this, where as long as the tissue is being stimulated at a challenging level and enough volume, that's good enough for the tissue to grow. So this study met those two criteria. It had an extreme amount of volume. So getting up to six sets of eight to 12 reps is a ton of time under tension for a tissue. And by controlling that they always wanted those folks to be approaching failure at a challenging range between eight to 12 reps, we got both high volume and high intensity. If those two parameters are on board and the tissue is getting some stimulus, almost always we're going to see some local tissue change or some growth. So again, law of specificity, do the thing that the person wants to do. And if you're looking for local tissue changes, hypertrophy, it seems to not matter as much which specific exercise. As long as the tissue is being challenged at an appropriate volume and at an appropriate intensity. The other interesting thing about this study was the EMG output did not seem to matter. So the barbell hip thrust had a higher EMG output for the glutes and that did not correlate to either strength gains or to more hypertrophy. Again, the strength games came from specificity. The hypertrophy gains came on board because the intensity was appropriated up. Now, looking at any study, we always want to be aware that there's problems with every study or challenges to any study that comes across the board. There are no perfect studies out there. The challenges with this study were it was a relatively low population. So there were 34 individuals, 18 in the hip thrust group, 16 in the squat group. So a fairly small population. They were all young and relatively healthy, which is going to be different than our general physical therapy population. And they were all significantly undertrained. So no one that was accepted in the study had more than one day a week for over five years of weightlifting experience. So appreciate that likely these gains that we saw in strength and these gains that we saw in hypertrophy are somewhat attributed to that. These folks were so significantly undertrained. And we've all seen that the more undertrained the person is, the easier it is for them to adapt early on. Also, with this, nine weeks is a fairly short amount of time to have a strength and conditioning or a hypertrophy program show results. It's likely that because they were undertrained is why we saw results in nine weeks. With our general physical therapy clients, some of whom may have been weightlifting for 15, 20, 30 years, we would expect a bit longer time to get true tissue adaptations and to get true strength adaptations. So again, to recap, study showed hip thrust versus barbell back squat. If you want to get better at the hip thrust, do the hip thrust. If you want to get better at the barbell back squat, you want to get stronger at that, do the barbell back squat. If you want to hypertrophy, whichever exercise you want to choose is great as long as you've got the intensity and the volume. The final cool thing that this study showed was that when someone did the barbell back squat, they had a ton of adductor activation and ton of quad activation and a ton of glute activation versus the hip thrust, which had primarily glute activation with far less hip adductor or quad activation. So if you've got a patient who comes in and they're in a lot of pain and you say, man, they've got some knee pain on board, their adductors seem a bit irritable, those quads are all gummed up. And we want to make sure that that athlete or that client is maintaining powerful hip extension, which is one of the most important movements for all humans. Then let's bias early on to the barbell hip thrust because it's not going to challenge those adductors and those quads. When that patient starts to get better and their adductors and their quads are not as irritable and they're not as gummed up, then let's go straight after that squat. Or on the flip side, you have no tissue irritability on board and that person's daily life requires a lot of squatting. It's going to behoove you to go right after that squat instead of spending time on the hip thrust early on. In reality, we've beaten a dead horse with this saying over the years and not more. For most of our folks, you're going to want to program hip thrust. You're going to want to program some squats. You're going to throw your deadlifts in there to have a nice well-rounded program. Law of specificity. Make sure the intensity is good. Make sure the volume is good. Have a great Tuesday treating clients. Can't wait to see you all on the road. Have a great rest of your day. Always grateful to be speaking on this podcast and hope to see you all soon.

11:37 OUTRO

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

Aug 7, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses considerations for postpartum exercise include the type of birth, birth trauma, sleep deprivation, and nutrition. It is important to take into account the impact of the birth on the postpartum exercise plan, especially if it was traumatic physically or emotionally. Respecting the individual's experience is crucial. Additionally, sleep deprivation and nutrition should be considered. If a mother is struggling to get proper nutrition due to the demands of caring for a newborn, adjustments may need to be made to the exercise plan. It is also important to consider specific goals when designing a postpartum exercise plan.

The episode highlights three recommended exercises to initiate postpartum impact: heel drops, alternating hops, and jump rope exercises. Heel drops involve going up onto your toes and dropping your heels down. Alternating hops are done by moving side to side and can be performed with or without a jump rope. Using a jump rope adds an extra challenge and requires coordination. The third exercise is small hops with both feet. These exercises are ideal for postpartum women who want to regain strength and fitness after giving birth. However, it is crucial to consider the type of birth, any birth trauma, sleep deprivation, and nutrition when starting these exercises. Monitoring for symptoms such as leakage, pressure, pain, and bleeding is also important during the progression into impact exercises. Breastfeeding moms should be advised to wear a supportive bra during exercise for added comfort.

Jess emphasizes the importance of utilizing progressive overload principles when starting with small impact movements and gradually increasing intensity. She stresses the significance of meeting the individual where they are and understanding that progressive overload is a natural part of the process. This means that as the individual progresses and adapts to the small impact movements, they should gradually increase the intensity of their exercises to continue challenging their pelvic floor muscles and promoting strength and function. Jess also highlights the importance of speaking positively about exercise and the pelvic floor, as it encourages individuals to stay active and avoid deconditioning. By incorporating progressive overload principles, individuals can safely and effectively strengthen their pelvic floor muscles while minimizing the risk of injury or negative symptoms.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:25 JESSICA GINGERICH

Good morning PT on Ice podcast. My name is Dr. Jessica Gingrich and I am on faculty with the pelvic division here at ICE. So we just finished up a wonderful weekend of the CrossFit Games. We have a huge congratulations to extend to Dr. Kelly Benfey. She is on faculty with the CMFA division. Her team took 16th place this weekend and boy was that fun to watch her compete. So I was on virtual ice last Tuesday and what I want to do today is talk a little bit about that virtual ice. So I've been on here the last couple times talking about the benefits of certain things early in the early postpartum period. So within that first 12 weeks postpartum. So I wanted to continue that and just what a wonderful time to do it as we did have a mom on the podium this year. So Ariel Loewen took third place. She has a child as she's a mom and she's just out here crushing the fitness space. So before we dive into that we're going to talk about early impact which is going to be really fun. We're going to start to reframe that a little bit but we do have courses coming your way. So hop on the website PT on Ice dot com to check that out. We have two courses here with the pelvic division. We have an eight week online course that bridges everything from gymnastics and barbell lifting to handstand push-ups to everything with the pelvic space with using the internal exam to help get people back to where they need to go. And then we have a two day live course and that one is just really fun. We get moving a lot. So if that is something that's on your list go ahead and head over there to secure your spot.

03:45 THE FOURTH TRIMESTER

So we are going to talk about that early impact in the fourth trimester. So the fourth trimester is the first 12 weeks postpartum. There's a lot of things that matter here but I want to start to reconceptualize the phrase of this or certain things put a lot of pressure on your pelvic floor. So we know that growing a fetus is going to put more demand on the anterior abdominal wall as well as the pelvic floor as well as a lot of other systems in the body. So does a sneeze. Like when we sneeze it puts a lot of pressure on the pelvic floor. When we lift weights it puts a lot of pressure on the pelvic floor. When we lift our child that then wiggles around it's going to put a lot of pressure on the pelvic floor. The phrase this puts a lot of pressure on your pelvic floor we want to maybe refrain from doing that can be a very fearful message. And also one that's just incorrect at this point. We want to do it in a way that is going to allow the pelvic floor to succeed. We don't want to blast through symptoms of leakage or heaviness or pain but we need to start reconceptualizing this especially speaking to our clients. So now before we jump in, no pun intended there, impact, we want to understand the demands placed on the pelvic floor in the day to day. So number one when you have a baby whether it's a c-section or a vaginal delivery we do have a healing process. So with a vaginal birth if there is no tissue trauma, so this is a vaginal birth with no tearing, no episiotomy and episiotomy is where they would cut to allow more room. We know that the tissues stretch approximately three times, 300 times their original length. So right then and there we can put that as tissue trauma, right? That is tissue trauma without any disruption to the sarcomeres or the skin or the connective tissue. Patients will need about four to six weeks for healing but this doesn't mean that we can't do nothing for four to six weeks. Now there's going to be probably a lot of questions that come with this because everyone is different, right? So we need to understand that and set the expectation early can be super helpful. So in educating our patients I love to give a timeline. So I usually say between six and twelve weeks, sometimes six and eight weeks depending on where that person is. And that's kind of nice because then when they get back to doing impact things that's now something where they're like oh I was kind of anticipating twelve weeks instead of now, right? And so that gap is pretty big but at least it allows them to be like okay I have this set date or timeframe if you will where we're going to start working back to that.

04:16 PRESSURE ON THE PELVIC FLOOR

Number two, we need to start talking about toileting. We need to teach people how to poop. We need to teach people how to pee. If we are not asking that question, are you burying down when you go to the bathroom? Are you pushing your pee out? You're going to be missing a big mark here. Your pelvic floor is reflexive. So as pressure gets put down on it, it should be turning on. So if you're going to the bathroom and you're burying down, we're putting a lot of pressure on the organs if you will. However, we're also putting pressure on the pelvic floor that's likely kicking it on and if it's not, it's just pushing it downward. So we need to be asking about that. We need to be encouraging a squatty potty. We need to be encouraging fluid, water intake, fiber intake and really the time spent on the toilet and this goes for males too. So spending a lot of time on the toilet just isn't what you want to do. If they are the person that takes their phone in with them, you could even tell them hey let's try not taking your phone in to see if you get off the toilet sooner.

08:12 BLADDER IRRITANTS

So number three, we do have oral intake. So we talked about water intake just a second ago, but just recognizing that beverages like carbonation, alcohol, artificial sweeteners, they could be bladder irritants. And so I went to the gym this morning and I did one of the CrossFit Games workouts today called Halina, which is a three rounds of 400 meter run, 12 bar muscle ups and then 21 dumbbell snatches. I went at 7.15 so I had coffee and I had to go to the bathroom probably three times before I went and did the workout because that is a bladder irritant for me. So when we talk about bladder irritants, we are not saying stop having these things. It's just saying hey this may be a trigger and so if this is happening to you, that's okay. Just recognize that if you have double unders or running or something, box jumps, that may be we try to have the coffee after the workout or maybe you have one cup instead of two or can we sandwich that coffee with some water to dilute the urine a bit. That's one of the big things is not necessarily taking those things away but just telling them hey this could just be a bladder irritant for you. It looks different for everyone. Number four and probably one of the biggest ones is the symptom threshold. Helping your client find their symptom threshold is going to mean that they're going to be reaching their symptoms. They are going to likely be leaking. They're going to likely be maybe feeling like they're going to leak and that can be a very daunting thing but it's going to give us a lot of feedback, a lot of them feedback and it's going to give them a lot of freedom when they're in the gym. If you reach this threshold, take a second, pause, take a breath. Maybe we do a little bit of jumping and then we back off and we do the bike and get a sprint in. Or we do another option for jumping. I'm going to talk about some options here in a second. Speaking positively about exercise and their pelvic floor is huge. They are not going to ruin their pelvic floor. I would rather, we would rather have someone stay active in the gym or whatever that looks like for them rather than telling them they're going to ruin something so they stop and then fast forward 30 years later and now they're in a skilled nursing home sooner because they're massively deconditioned or they have a massive injury because of being deconditioned. Now that we have some guidance on the return factors that we want to manipulate and play around with, let's start using pressure rather than, or rather forces if you will, to strengthen the pelvic floor. Now there are considerations we need to keep in mind, like the type of birth, we talked about that earlier. Birth trauma, so this could actually be physical as well as emotional. So if you have someone who is identifying that their birth is pretty traumatic, we're going to respect that. Sleep deprivation, nutrition, if your mom is having a hard time getting protein in and carbs in and good fats in because every time she goes to eat her baby starts to cry, that's something to just talk about and maybe we push that back a little bit and that's okay. And then of course specific goals. So our top three exercises to initiate post-part or impact in that time is going to be heel drops. So that's where you'll go up onto your toes and drop your heels down. Alternating hops is just going to be alternating side to side. You can do that without a jump rope or with a jump rope. Doing it with a jump rope is actually very difficult. It takes a lot of coordination. And then small hops. And that is going to just be small hops with two feet. Something to keep in mind in here are breastfeeding moms that can be very uncomfortable. So just talking to them about wearing a very supportive bra when they come to that visit. As always, we are going to ask about symptoms during your progressions into impact. So the symptoms are going to be leakage, pressure, pain, and then also bleeding. So in that early trimester we want to just keep an eye on bleeding. It is normal to have an uptick in bleeding, but we want it to not be like that they're passing clots after they start upping their intensity. Keeping the conversation positive even if they're hitting symptoms early and we're regressing. All we're doing is we're meeting them where they are and understanding that progressive overload is going to happen. And even talking to them about that is a really fun thing. So to recap, pressure doesn't have to be a bad word when talking about the pelvic floor. Understand other factors that may be influencing the pelvic floor, such as toileting, nutrition, type of birth. And essentially linking that to their symptom threshold. Utilizing small impact movements at first and start to initiate those progressive overload principles. So I'll leave you with that. Have a great Monday and we'll see you next time.

13:40 OUTRO

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

 

 

Aug 4, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the efficacy of mobility programs to produce meaningful, function change in range of motion for patients & athletes.

Take a listen to the episode or read the episode transcription below. 

Article referenced

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:32 ALAN FREDENDALL

Good morning everybody, welcome to the PT on ICE Daily Show. Happy Friday morning, I hope your day is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and lead faculty here in our fitness athlete division. It is Fitness Athlete Friday, we would argue it's the best start day of the week. We talk all things CrossFit, functional fitness, powerlifting, Olympic weightlifting, endurance athletes, runners, bikers, swimmers, everything related to the person who's regulationally active here on Fridays. Before we get started with today's topic, we're going to be tackling mobility. We're going to define mobility versus flexibility. We're going to discuss a recently published paper showing the effects of long term stretching on mobility changes and address concerns related to that paper. Before we get started, let's talk about a couple of announcements. It is the CrossFit Games individual and team competitions began yesterday. Age group and adaptive athletes began Tuesday. We have a day competition all week long. You can catch it on ESPN. You can catch it on YouTube. Our very own Kelly Benfee here from the fitness athlete division will be competing with her team. Plus 64 CrossFit Army end game in the team division. So you can check her out. She had a couple of events yesterday and she's got events every day the rest of the weekend. Speaking of fitness festivals, the I Got Your Six Fitness Festival will be June 21st and 23rd down in Charleston, South Carolina with our friends at Warrior WOD. We had the virtual competition this year, but next year it's going to be in person. So it's a ways away, but look forward to that calendar if you want to come down to Charleston and join us for a weekend of approachable fitness courses coming away from us here in the fitness athlete division. Your next chance to catch our live course will be September 9th and 10th. That will be in Bismarck, North Dakota with Mitch Babcock or the end of September, September 30th and October 1st. You can catch Zach Long out on the West Coast. He'll be in Newark, California. That's in the Bay Area. Our online courses, Clinical Management Fitness Athlete Essential Foundations, our eight week entry level online course begins again September 11th and Fitness Athlete Advanced Concepts, our level two online course begins September 17th. So mobility, let's talk about it. How much can we really move the needle? My goal today is to define mobility as it's often talked about in kind of common terms with athletes in the gym, patients in the clinic when they talk about mobility, defining mobility versus defining flexibility. Talking about a paper that was published a couple of weeks ago, looking at the effects of long term stretching specifically at ankle mobility, which is a joint we're always after to improve the range of motion within and then really how to approach mobility from a practical clinical standpoint.

2:01 EFINING MOBILITY VS. FLEXIBILITY

So let's start first with defining mobility versus flexibility because they're often used interchangeably and that's not the correct way to use them. Then when we talk about flexibility, we're talking about the capacity of soft tissues of muscles, tendons, ligaments to be passively stretched, whether me as the therapist stretches you the patient or whether you stretch yourself using your own body, using stretch straps, things like that. The ability to passively stretch muscle tissue at a specific joint. Now mobility is different. Mobility is the ability of a joint to actively move through a range of motion. And of course, we're always chasing a full range of motion. So the ability, for example, of the need to advance across the toes in active closed chain dorsiflexion, the ability of the hip to externally rotate or flex sitting down into a squat, that would be an assessment of mobility, actively moving the joint through the range of motion. And you, the patient or athlete moving yourself through the range of motion, aka how much motion can you actually access? Because we see some folks have a big difference between their flexibility and their mobility. We may be able to passively move their ankle, passively move their leg into a normal or above average range of motion. But when that person stands up, they re-encounter gravity and they try to actively move that joint. We can sometimes see a big difference between mobility and flexibility. And that brings us to a really important point that a lot of what we see in marketing, in programs, in our own home programs for athletes and patients is that we say we're prescribing mobility. But really, what we are giving for the most part is flexibility, that a lot of passive stretching is what is given out, which can improve flexibility. Yes, but may not always result in any sort of functional change in mobility. We see a ton of programs all over social media, especially in the fitness athlete space, that are marketed at improving mobility. But when we actually look at the content of those programs, things like ROMWOD, things like GOWOD, things like whatever WOD, that we actually see a lot of passive stretching, a lot of flexibility. And so it's no wonder that folks come in and have been doing one of these programs for weeks, months, years, and have not seen any sort of beneficial improvements. In their mobility, their ability to actively move joints through a range of motion, because they have not been doing any sort of mobility work, they have been doing a lot of flexibility work. And we know those two things don't always translate. We don't always see a bunch of flexibility work translate into any sort of improvements in actual meaningful functional mobility.

7:32 THE RESEARCH ON STRETCHING

So what does the research say? There's a bunch of research on passive stretching. There's a bunch of research on the benefits specifically of eccentric loading to improve range of motion, to improve active mobility. And we've always kind of wondered the question of what is the dose response relationship with flexibility training, with stretching? We have a great paper that came out last month in the Journal of Strength and Conditioning Research by Wernicke and colleagues. I'll post the link on Instagram and in the show notes on the podcast that sought to answer that question. So this was a study that sought to look at the effects on maximal voluntary muscular contraction, flexibility and muscle thickness of the ankle plantar flexors. Now, the experimental group had a lot of stretching prescribed. Specifically, they stretched six times a day for 10 minutes each session for six weeks. So about 42 total hours of stretching through the calf complex, an hour per day for 42 days. They perform the stretching with a night splint type orthotic of a boot that prepositions the foot into ankle dorsiflexion with the addition of a strap assist to pull their ankle into additional dorsiflexion if able. So essentially stretching the gastric complex 10 minutes, six times a day for six weeks. Now, what did the results show? The results did show an improvement in range of motion of when they remeasured ankle dorsiflexion. There were improvements that reached statistical significance. But really, when we look at the results, when we look at the actual data itself and not the summary of data in the discussion, we look at the raw data. What do we think about the results? We think that the functional improvement here is probably questionable. Then we actually look at the ranges of motion increases experienced by these subjects that most folks experience the change of about 0.25 to 0.5 centimeters or about one tenth to two tenths of an inch of an improvement in ankle dorsiflexion. Now, when we measure functional ankle dorsiflexion in the clinic, we use the closed chain half kneeling knee to wall task to measure the ability of the knee to advance over the toes with a planted heel. We show this assessment in our online essential foundations course, and we show this in our live seminar as well. And what we'd like to see there is that an athlete with the heel flat can advance their knee over their toes about four inches. That ideally they would contact the wall. We know if they can contact the wall, they have about four inches of motion there or possibly more. But that is enough motion, for example, to be able to advance the knees over the toes and sit down into a nice full depth squat. And so when we look at changes of 0.1 inches in a test where we're looking to see four full inches of range of motion, we realize that's not really that much of a functional improvement of yes, the results did reach statistical significance. But the practical application here is very, very, very minimal of that person. If we improve their ankle dorsiflexion and it was, for example, zero inches, somebody like me, somebody with a very stiff ankle, particularly my right ankle that has about zero inches of closed chain dorsiflexion. What good really is 0.1 to 0.2 inches of closed chain dorsiflexion improvement? The answer is not. It's not right. It's not a functional improvement. It's not a meaningful improvement. Yes, it was a statistically significant improvement, but in real life, it would not help that person move any better. It would not improve that person's mobility, even though their flexibility, yes, has technically changed. So we need to be mindful of how to actually interpret results of studies like this. We also need to now talk about what is the practical application of a study like this to practice, because this study came out and a lot of social media posts were made, a lot of podcasts were made that said, look, you're just not stretching enough. If you stretch an hour a day for six weeks, you can see an improvement in joint range of motion. And yes, again, while true, not functional.

10:14 APPLYING RESEARCH TO PRACTICE

We also have to step back and really analyze the methodology of this paper and also analyze things like the inclusion and exclusion criteria of this paper. We're probably unlikely to find an actual real person, a patient or athlete who's going to do six hours a week, an hour per day, seven days a week for many, many weeks of flexibility training, essentially, right? We hear time is the biggest barrier to exercise. We hear time is the biggest barrier to home exercise program compliance. So it doesn't really make sense that if we can't get somebody to perform a 12 minute remom for the home exercise program, what's the likelihood that they're going to do an hour a day of home exercise program on top of maybe also trying to exercise an hour or more per day? The answer is unlikely. Right. We know that if we if we dose that out to somebody, there are very few patients who are going to come back and say, yep, I did. I did six sessions a day, 10 minutes per session, and I did it every day, seven days a week, just like you prescribed, doctor. That's a very unlikely result. So we need to be mindful of that when we're talking about applying this to real actual people. We also really need to dig into the inclusion criteria and look at the baseline assessments in a study like this, because this study would portray that some of these folks were stiff and saw improvements. Some of these folks had OK mobility and saw improvements. But really, when we look at the baseline assessments, the quote unquote stiffest person in the study still had three point four inches of closed chain dorsal flexion, right? More than enough ankle mobility to be able to squat to depth, assuming nothing was wrong mobility wise in that person's hip or knee. That person would have all the dorsal flexion needed to be able to, for example, functionally squat to depth. So we have to ask ourselves, is this actually representative of the populations that we treat? Is it representative of somebody who might come to us and say they need help with their mobility? What's the likelihood that they're actually going to do an hour a day of this type of training? And also, this is not the person that's going to present in our clinic, right? Of the person who can close chain dorsal flex at least three point four inches. You're not even going to consider that their ankle is stiff and maybe even prescribe some mobility stuff for their ankle to them, because they already possess all the range of motion needed to squat. On the high end in these subjects, they were beyond three point four inches, right? There were people with four, five, six, some folks close to seven inches of closed chain dorsal flexion. Way above average mobility. And so we need to recognize and ask the question of why are we studying the effects of flexibility and mobility on people who already have adequate, above average, perfect or excellent mobility, right? We see this a lot in medical research of we study the effects of, for example, resistance training on bone loading in older adults, and we exclude people with osteoporosis and osteopenia and folks who have any sort of issue that might throw an extra variable into the study. And what we find ourselves is studying interventions on people who don't need the intervention, right? And this study is exactly that case of we are studying the effects of flexibility training on the mobility of people who don't need any help with their flexibility or mobility. So again, can we generalize studies like this to the general population? Probably not. And for a lot of reasons, the ones we've already discussed here. And what we need to realize when we look at this data and look at a big picture is when we look at the results of studies like this, when we look at all the data aggregated, yes, but also unaggregated on those data tables, what are we looking at? That we tend to find that folks fall into buckets, that we can classify them. We know that, for example, with low back pain, we can find people who are flexion intolerant, extension intolerant, shear intolerant. We know they may or may not respond to directional preference type exercises, but people tend to fall in classification buckets based on what's going on. And we need to recognize that mobility is no different. Even looking at this study, looking at the baseline measurements of folks, we have folks who appear to have great mobility, who improved with intervention. We have folks who have great mobility, who did not improve with interventions. We had folks with poor mobility, who improved with intervention. And then we had the most unfortunate group of all, folks with poor mobility, who did not seem to improve with intervention. So we need to recognize that the person we're working with in the clinic, in the gym, probably fits into one of those buckets. If they are somebody who is interested in working on the mobility, even if we may not need it, right? We have that person who can hinge all the way to the floor with a perfectly flat back and locked out knees and touch their palms to the floor. A very bendy, flexible individual who is asking you for help on their mobility, right? That person does not need mobility help. They do not need flexibility help. But yet they are maybe seeking some extra mobility programming. We have folks with poor mobility, who need mobility training, who we know will not work on it anyways, especially an hour a day. So we see that our patients and athletes fall into these buckets, and we need to recognize which bucket they may fall into. We may not know early on how they're going to respond to interventions, especially if they haven't tried anything previously, but we'll know very quickly across the plan of care of their physical therapy if they're going to be somebody who responds to interventions like these. So what do we actually do with that person in front of us? Well, I think what we don't do enough is ask people a few simple questions of I see that you have some mobility things you could work on. How much time do you actually have for this? I don't think we ask that question enough. I think we give people what we want to see them do, what we hope they will do, and then we're often disappointed when they don't do it because we haven't asked first of all how much time they're willing to dedicate to it. I appreciate over the years how I've started to ask this question, and people have been very honest of I'm never going to do this at home. I'm only going to do this when I come here to physical therapy. Well, I appreciate that honesty, right? Because I'm not going to waste my time writing out a really detailed program that you're not going to do. So I think starting with that, excuse me, that question is very, very important. And then also recognizing and being really, really thorough and methodical in your reassessments along the way so you know if this person appears to be somebody who's going to respond to mobility type interventions. This study in particular has a lot of issues with the methodology, only including people who already possess a lot of nice functional mobility. It did a lot of long-term passive stretching, and we also need to recognize that primarily due to the way the intervention was done in this study, they primarily stretched the gastroc but assessed mobility and range of motion by the closed chain dorsiflexion test, which really looks at soleus muscle flexibility more so than gastroc. So we're stretching the gastroc, but assessing the ability of the knee to advance over the toes in a kneeling position, which is really looking at the soleus muscle complex. So we need to recognize the limitations of this study, and in our own practice of actually making sure we're giving the right mobility to the right person based on the deficits that we're finding in their assessment. We hear often, what are some great shoulder stretches? Well, it depends on what is limiting your shoulder mobility. If I give you a bunch of lat stretches and you seem to be really limited in external rotation because of maybe something going on in your subscap or your internal rotators not related to your lat, if you pass all of the screens we see for the lat, then giving you a bunch of lat stretching, a bunch of shoulder stretching, it's really not going to benefit and improve the mobility we need to work on. So we need to be sure we're working in the right area and addressing the right area with our exercises as well. So mobility, how much can we move the needle? Well, it really depends. It seems to be maybe a genetic component. It seems to be a combination of how well people respond to this type of training, and we also need to recognize that it appears to take a lot of time, possibly more time than the patient or athlete in front of us actually has. So understand the difference between flexibility and mobility. Flexibility, the ability for us to stretch muscles passively or a patient or athlete to stretch themselves passively versus mobility, the ability of the person to actively move their joints through a range of motion under gravity, functional movements, things like a squat, a lot of close chain type movements. We have research that looks at long-term stretching, but we know the quality of the research is not that great and the practical application of the research itself is not that great. Yes, we can reference the study and say if you're willing to stretch six hours a week, you might see changes in your ankle mobility, but again, we don't know that for sure. In practice, we know that our athletes and patients tend to fall in buckets. We need to be able to recognize those folks where they lie in our assessment. And again, always ask the question of how much do you really want to work on this? How much time do you really have to work on this? Somebody who says I have an extra hour a day before bed at night. Okay, that's a person who maybe could try out an hour of flexibility training before bed. Whether you give them a program, whether they sign up for something like ROM WOD, GO WOD, Mobility WOD, whatever WOD, Stretch WOD, the millions of programs out there. Or somebody who goes I'm not going to do this at all. I know myself, I'm not going to do this at night before bed. I'm not going to do it in the morning. I'm not going to do it before I work out and I'm not going to do it after I work out. Okay, that is a person that we probably should not spend our time on trying to give a bunch of mobility homework already knowing that they're pretty intentional and honest that they're not going to do it. So mobility, can we move the needle? Maybe. Jury's still out. We still need to see more research, of course, more impactful research, more functional research, and more practical research. Research that actually looks at what sort of changes can we expect to make in maybe 12 to 15 minutes a day? The range of time that we're probably prescribing to most of our patients and athletes. So I hope this was helpful. I hope you have a fantastic Friday. Hope you have a great weekend. If you're going to be at a live course, enjoy yourself. Enjoy the CrossFit Games. Watch Kelly Benfee and Ruth Huron. Have a great Friday. Have a great weekend. Bye everybody.

20:32 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. You

Aug 3, 2023

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes the importance of considering individual circumstances and not allowing blanket statements to hinder progress. While the general principle of "do less better" is often advocated for efficiency and clarity, Jeff acknowledges that there are exceptions to this approach.

Jeff encourages listeners to think about situations where a person may come into the clinic with psychological barriers or feeling overwhelmed. In these cases, Jeffg suggests that overwhelming the individual with multiple interventions or exercises may actually be beneficial. By providing a variety of options and allowing the person to choose one or two to focus on, it can help shift their psychology and get them on board with the treatment plan.

Jeff also mentions that this concept applies not only to exercise but also to other aspects of healthcare, such as sleep hygiene and diet. Instead of overwhelming individuals with a long list of changes to make, it is more effective to start with one or two manageable changes. This approach makes it more approachable and minimizes barriers to compliance.

Overall, the episode highlights the importance of considering individual circumstances and being flexible in treatment approaches. While the general principle of "do less better" is valuable, it is essential to recognize that there are times when overwhelming individuals with options or interventions can be beneficial in getting them on board and moving in the right direction.

Take a listen to the podcast episode or read the full transcription below.

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

EPISODE TRANSCRIPTION

00:00 JEFF MOORE
Alright team, what's up? Welcome to the PT on Ice Daily show. I am Dr. Jeff Moore, currently serving as the CEO of Ice and thrilled to be here on a Leadership Thursday. Always wonderful to have you on Instagram, on YouTube if you're live streaming or over on the podcast. Thank you so much for carving out a few minutes for us today. It is Thursday, it means it's Gut Check Thursday, and it is a doozy. So many of you are at the CrossFit Games, you're probably going to be throwing this workout down together. I know it comes from our friends at Mayhem, they're probably going to be doing it as well. But the workout is, and it would be simple if it was just the first part, it is a hundred for time at a relatively manageable weight. Okay, so we've got 75-55 on the bar. Many of you probably remember the 100 clean and jerks for time that we've done I think twice now. The problem is you also have an EMOM of 15 air squats, and that's going to make it a different kind of stimulus, and that includes starting at zero. The first thing you're going to do when the timer goes off or Gut Check Thursday is you're going to bang out 15 air squats, then you're going to grab your bar and start rocking your power snatches. You're going to keep doing this every minute, 15 air squats, as many power snatches as you can until you've accumulated 100 power snatches at 75 or 55 pounds. Can't wait to see some of the post commit, I already saw one this morning, somebody said their low back was on fire, I'm sure that's the case, I can't wait to try it. Probably going to knock that out here on Saturday afternoon. Alright, as far as upcoming courses go, I want to highlight, speaking of power snatches, I want to highlight our Fitness Athlete Live courses because the ones that are coming up, I see those courses swelling. So Mitch is going to be in Bismarck, and that is going to be on 9-9. So that's in four weeks, a little over four weeks. That class is already pushing 30 people, we're about at capacity, so if you want to jump into Bismarck, you're going to need to probably do that in the next week or so. Similar story for Newark, California, Zach is going to be down there on October 7th, and again, I'm seeing that course edge towards capacity, so if you want to jump in Fitness Athlete Live, you're going to want to make that move pretty quick. We do have Linwood, Virginia following that, so it goes Bismarck, 9-9, it goes Newark, 9-30, it goes Linwood, Virginia, 10-7. If you want to jump into one of those courses, try to make it happen in the next week or so to make sure you get your seat. Alright, it is Leadership Thursday, but this one's a little bit more clinical, but I do think that it really revolves around leading people, so I think it's appropriate for this day of the week.

02:56 "DO MORE, BETTER"

I want to talk about doing it more, better sometimes. Now the obvious caveat we have to open with is the fact that we have preached do less better on this show, in this company, for the better part of a decade almost constantly, and there are good reasons for that because the majority of times, doing less better is what makes it work, is what makes for an efficient avail, is what allows you to know which intervention you did actually have the effect. If you're doing a million things with a small dosage, you have no clue what moved the needle. More importantly, your patient doesn't know, so they don't know what to focus on, they don't know what to attach their outcome to. If you're doing a ton of things, it gets messy, it lacks clarity, and it's very hard to get treatment effect. Additionally, it's very hard to give sufficient dose of anything if you're doing everything. Do less better is a hallmark statement and should generally be observed. The challenge I want to make for all of us, including myself this morning, is it always the case though? Is there sometimes, and there should be exceptions to all of this stuff, are there sometimes where overwhelm is exactly what the doctor ordered? Are there times we have to go big? Right now, what's very in vogue, and I generally like this, is things like don't do more than three exercises. There's actually a bit of research showing from a compliance perspective that statement makes sense. If you give somebody a whole laundry list of things to do, they're not going to do any of them. But it's not just exercise. We're hearing these comments around things like sleep hygiene. Don't try to make a bunch of changes, just make one. We hear it around diet. Don't change a ton of things, just start with one or two. I myself preach this all the time. Make it approachable, try to minimize barriers, just choose one or two. But I want us to pause for a second to make sure we don't just make this our default And think about when the opposite might make more sense.

06:30 MANAGING RELUCTANT PATIENTS

I want us to think about that reluctant encounter. What I mean is that person who comes into your clinic and you can tell they are really suspect, they're suspicious about whether or not this is really going to work. And you know this person. This is not the person who gets rehab consistently. It's not the person who's already bought into this being the primary treatment choice. It's the person who's like, I don't know about this. My doctor said come so I'm here, but I just don't know about this. Think about that person who's really reluctant. For some people, for that person in particular, this might be the only time that they're going to be in this stage where they're even considering this route. It's not the route they've used in the past. They're really unsure about it, but they've heard some good things. They were told to be here. It's a small window of opportunity. You might only get one at bat with this patient. You can all picture this person. You've got him on your caseload right now. You can just feel what their energy is. I don't know about this. I don't think this is going to get the job done. You might only get one shot at this person. And I want to make a two-part argument about how we manage this individual, especially at that first encounter, which might be the only encounter if things go wrong. The absolute worst outcome with that person is nothing. The absolute worst outcome is no change because it's kind of what they think is going to happen. This is a waste of my time. This isn't going to work. Getting no change is the worst possible outcome. The second argument I'll make is that while I totally agree, especially this person, won't do a bunch of things for a long period of time, they will not do the long litany of exercises, they won't make a million changes, they won't do those things for a long time, but I think they will do it for four or five days. I think they will make a really aggressive change because they're wondering if their time is being well spent. They almost want to prove it wrong sometimes. Like, see, it didn't work. While I don't think a long list of massive lifestyle or exercise changes is sustainable for that person long term, I do think they'll do it for a few days, especially if we tell them, hey, listen, this is not sustainable for a long period of time. What we're trying to see is if we can move this needle. So let's figure it out once and for all and right out of the gates. What if we go this route where we tell them, you don't have to do this for a long time, we're going to put all the guns on early, we're going to see if anything changes. If nothing changes with a high dose, we can both agree that this isn't going to work. But if something does change, what we can then do is begin to look at what you've got on the board and we can tease that down to the things that were the most manageable for you to alter. And that's the stuff that we can ride out into the sunset. Right. Then we can pare down the program. What I'm saying is, should we be asking a ton upfront, prove that change will happen with the highest dose that they can tolerate and then refine and make it sustainable? Should we be telling them, I'm going to ask you never to continue this, but I want to know if we can make a difference and then we'll choose the things that were the easiest for you to stay with. And that's going to be our long term program. It's not for everyone. It's not even for most.

08:38 SWING FOR THE FENCES

But on those people who are particularly doubtful that PT will work, I think we need to swing for the fences. And I'm bringing this episode to you because I've had numerous conversations recently with people who did the less better thing, right? Small changes that were easy for the patient that didn't do anything. Where the patient was like, I don't really think I felt a difference. That's fine. In someone who's committed to rehab being the solution, that is not fine. In someone who's testing you out to see whether or not they're wasting their time. On that second person, we need to identify them and say, look, they're only going to give us one chance. We don't need to make it sustainable. We need to make it noticeable. I want to say that one more time. In the highly speculative person, we don't need to make it sustainable. We can worry about sustainability later. We need to make it noticeable. We need to tell them what I'm about to ask is you're going to eliminate a bunch of stuff from your diet. You're going to change a bunch of things about your sleep environment. You are not going to have to maintain these long term. This is going to tell both of us if you're in the right spot. Once that person comes back and you've all had the person who's made really drastic diet changes, think about fasting or total sugar elimination. What do they come back and say? They say really drastic things like, my gosh, I feel less swollen all over my body. I had carpal tunnel as well and that feels better. I used to have headaches and now I don't. They tend to see things happen because they made such a drastic change to the ecosystem. In the unsure speculative patient, that is exactly what the doctor ordered because the number one goal with them is psychological. We've got to get them to believe, oh my gosh, this stuff can actually have an effect on my condition. Now the moment they realize that these are the things that I should be tweaking to make a change, now we alter that program to make it sustainable and do less better.

11:29 OVERCOMING PSYCHOLOGICAL BARRIERS

But I am making a call to action on this episode that for the reluctant individual, for the person with the psychological barrier, doing more in the very short term to show them that what won't happen is nothing is the most important thing to get that initial piece of traction that allows you to then refine, pare down and make sustainable a program they now believe in. Give it some thought. Is there a place to go with overdoses, overwhelm, to shift psychology, to get that goal in mind and get that patient on board? I hope it makes sense. In general, I'm always going to believe in do less better but there are always exceptions and let's make sure that we're not letting a blanket statement prevent those people from moving in the right direction. Cheers everybody, PT on ICE.com, you know where the goods live. All of you at the CrossFit Games, good luck. Kelly Benfey, especially good luck. I hope the 64 Army crushes it this weekend. I will certainly be watching from right here. Cheers everybody, take care.

12:20 OUTRO
Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning Check out our virtual ICE online mentorship program at PT on ICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ICE.com and scroll to the bottom of the page to sign up.

Aug 2, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the idea that passion alone is not sufficient for thriving in a career. She mentions that while it is possible to sustain a career solely based on passion, it is not sustainable in the long run. Julie shares personal experiences and acknowledges that many colleagues and friends have also encountered this issue. She emphasizes the importance of considering the entire ecosystem, including supportive management, colleagues with similar philosophies, and a network of supportive friends, family, and partners. Without this support system, Julie warns that burnout is likely to occur and that the initial passion will start to diminish. The episode emphasizes the need for a supportive ecosystem, where managers value and understand the contributions individuals bring to their work. Julie also mentions the importance of growth and opportunities for advancement, as well as being surrounded by like-minded individuals who share a fitness-forward approach.

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

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

EPISODE TRANSCRIPTION

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

01:43 JULIE BRAUER
Good morning, crew. Welcome to the Geri on ICE segment of the PT on ICE Daily Show. I'm brought to you by the Institute of Clinical Excellence. My name is Julie. I am a member of the older adult division. Excited to talk to you all this morning about five things I've changed my mind about in Jerry PT over the past, I think it's like eight-ish years now of my career. So I actually have a list of like eight or nine. It keeps growing as I keep thinking about things, but I'm going to try and keep it to around five. And so my hope is that over the past eight years of all the mistakes I've made and the paths I went down and the things I've learned, I'm hoping that someone out there listening today, if I can inspire and encourage you to think a little bit differently, to do a little bit differently, if I can save you a little bit of heartache that I've experienced, then I will call this a 100% success. Okay, so these aren't necessarily in order of importance except this first one. So number one of five things that changed my mind about in Jerry rehab, changing settings will fix your burnout. Changing settings will fix your burnout. It will not. If you are in a situation where you feel really unhappy, you feel burnt out with the job that you currently have and the setting that you currently are in, please know that the grass is not always green around the other side. I promise it's not.

03:08 "CHANGING SETTINGS WON'T FIX BURNOUT"

It's not necessarily that changing settings is going to fix your burnout. Identifying why you are burned out and doing something about the root of the problem is going to fix your burnout. So I'm not going to get into this too, too deeply because I've done an entire podcast specifically talking about burnout and those of you who are thinking home health will fix that. So if you are interested in that specific podcast, send me a message and I will send you the link. But as an overview, I just want you all to know that you have to identify why first before you jump ship. So the why could be a multitude of different things. Is it truly that you are not passionate about an athletic population and you actually are passionate about a more acute, medically complex population of older adults? Is it that you really want flexibility in your schedule and you can't stand the back to back, the back to back schedule of inpatient rehab? You have to be able to verbalize and write these things down about why you are so burned out in your job.

04:51 BURNOUT IN DIFFERENT THERAPY SETTINGS

I spent many years starting out in acute care, getting burned out, thinking that I was going to love inpatient rehab. I was convinced I'm going to have more time with my patients. I'm going to be able to follow them. I'm going to be able to do higher level therapy with them. It's going to be so much better. I went into inpatient rehab. I absolutely hated it. And then I was like, all right, home health, total flexibility. I'm going to be able to see less patients a day. That's definitely going to be the setting for me. Nope, that wasn't it either. What I was doing is thinking that changing up setting was just what I needed to do. And in reality, for me, I came to the conclusion that full time clinical care is what was burning me out. It did not matter what the setting was. And I wish that I would have realized that very, very early on in this process. Now, I learned a lot and I'm really happy that I have experience in all of these settings. However, I could have been much further along in really dialing in what I want to spend my time and effort towards. If I would have thought of that earlier. So those of you that are really burned out, you're thinking about jumping ship. Don't do it. Start to really evaluate those things. Okay, next, you can give a really high quality session and a really efficient session without timing yourself. This is simple. No, you can't know. You absolutely cannot give a really high quality session that is also efficient unless you have yourself on a clock. For the entire session and truly throughout your entire day of doing your job. I think it's really hard because we go from PT school where all we have to do in a day is study, right? Like if our eyes are open, we are like, well, I have to learn the brachial plexus today. And that's all I have to do. So all I'm going to do is sit here for hours upon hours upon hours and study and memorize things from a book. And then we get into clinical and then we get into the real world where we have this thing called productivity. We have to meet while we are also trying to maintain our sanity. And all of a sudden, it is very overwhelming to try and bring quality at the same time as being efficient. So my call to action to you all is put a clock on yourself for your entire day. When you are with your patients, when you are not with your patients, it will change your life. I promise you when I started doing this in home health and you start this just like you start anything, like if you are starting to train for a race, for example, and you know you have to hit certain macros, you need to just start by tracking. What do you normally eat? How many calories are you actually bringing in? So you don't change anything at first. You just track. So you time yourself all of your breaks, your bathroom breaks, your snack breaks, your chatting with colleague breaks, the amount of time it takes you if you are in home health to drive to patient to patient, the amount of time that you are sitting in acute care at the desk and documenting. You time everything. In addition to how long you are actually spending with your patient and how long you are actually doing those subtitles of your session like education or neuromuscular read or gate training, whatever it is, you time everything. You will realize all of your inefficiencies. You will realize, wow, my hourly rate is actually crap. So when I timed myself when I was in home health, I timed everything. And I realized that if I was spending 60 minutes with the patient and I was actually hustling to get everything else done, calling doctors, etc, etc. I was making $40 an hour. Not ideal. Once I started timing myself and figuring out where I could cut, I went from $40 an hour to over $60 an hour. I have an entire podcast just on how to improve efficiency in home health. Again, if you were interested in that, message me and I'll send you the link. So again, my call to action for you all is use your phone. Your lap timer on your stopwatch is really helpful. Wear your Apple watch time every single thing. Start there, track it for a week, and then start chipping away at where you can cut places where you're really inefficient. Not only will you be able to give time back to yourself, which is what we want at the end of the day because taking care of humans all day is exhausting, but your patient sessions, you will get them so much more fit in so much less time. That's a win-win. So start timing yourself.

10:53 PT's DON'T NEED TO TAKE PATIENTS TO THE BATHROOM

All right, next. PTs don't need to take patients to the bathroom. PTs don't need to take patients to the bathroom. That is an OT's job. That is a nurse's job. That is a tech's job. Man, this is one thing that I may be like the most sorry about. What I feel so guilty about for years in my career is that I'm with the patients and I'm wrapping things up, right? I know that I want to get out that door so I can get to my next patient. I'm done. I've done my PT thing and they ask me to take them to the bathroom. It's that moment you're like, I really need to get out this door. And what would I say many times? You know what? OT is coming to see you later this afternoon. They will take you to the bathroom and work on toileting. Then for right now, I'm going to press that button and your nurse is going to come and take you to the bathroom. So many of you have been there. I know you are. I know you've done this. But guys, what do we know happens or not happens? We press that button. Nobody comes. Our patient is sitting there uncomfortable. They may not actually get to the bathroom for a very, very long time. What we know from the literature why we have to change our mind about this and start doing this differently is that many falls in acute care. A very high percentage of them happen in the bathroom. This is avoidable because what is happening? Our patients ring the bell. Nobody comes. And then they have the choice of urinating on themselves or continuing to, and sitting there and waiting or breaking the rules and trying to rush to the bathroom where maybe they're on pain meds, their balance is off, they slip, et cetera, et cetera. We need to realize that is our job. We are not above any freaking job when we are with those patients in acute care. They need their butt wiped. We wipe their freaking butt. That is our job. It is patient care. We are all in this together to get that patient out of this DM hospital and back to their life wiping their butt, taking it in the bathroom. That's included. The very basics of giving this dignity back to this human. It is not a particular person's job. And think about it, even from a self-serving perspective, how much information you learn from taking a patient to the bathroom. You are watching them transfer. It gives them motivation to get out of bed versus like, let's get out of bed and go on a walk and lift these weights, right? You get to see how their ambulatory capacity, right? You get to see their balance. You get to see their problem solving, their stand pivot, how they have e-central control getting down to that toilet. Are they able to problem solve how to sequence those steps? Can they grab the toilet paper? Do they know how to use it? You get so much valuable information. And maybe watching someone toilet and saying, I know that looks off. It seems like they don't know how to sequence this, but I don't know the language to put to it. And I don't, this isn't really something that I understand how to treat, right? Yes, your OT partners are going to be able to take that baton that you hand them after you give them an information. And they're going to be able to do a much better job in that specific task, right? It's collaboration. We need to be setting our patients up for success. Never, ever, ever, ever from today forward, please PTAs ever tell your patient, that is someone else's job, someone else's job. I'll go tell the nurse when I leave. It is your job. You should start planning for this in your sessions. Just give some time before you absolutely have to get out that door. Give five, six minutes to a lot for this patient needing to use the bathroom. It is your job. We are part of a team and you can prevent something drastic happening like falls or someone losing their dignity by literally having to urinate on themselves.

18:21 ALTERNATIVE HOME EXERCISE OPTIONS

Next, weights are the best pieces of equipment to initiate loading with older adults. Weights are the best pieces of equipment to initiate loading with older adults. Look, I love being able to get my older adults, especially those who are pretty medically complex and deconditioned, lifting weights, right? All of you all, this ice crew, your fitness forward, you are incredibly enthusiastic about this. However, if we focus too much on that, I think we can be actually increasing the barrier to loading versus decreasing it, which is our job. We need to realize that the best equipment older adults are using to introduce loading are not necessarily weights. The best equipment are the objects, the animals, the people, the boxes, whatever the odd things are that are in someone's life, an older adult's life, that they will lift, push, carry, pull, hinge. Those are the best pieces of equipment to introduce loading for an older adult. That may not be a weight ever, ever. If it is, amazing. I love it. Bonus points. The best equipment is the one that our patient is actually going to use. I love how enthusiastic we are. And if we can get our older adults lifting weights, wonderful. But ask yourself, like, is this sustainable? Is this only going to be something that they do with me? What am I doing to allow sustainability and longevity of loading with this older adult that they will continue to do after I am no longer caring for them? When our plan of care is over, have I decreased the entry point to loading so much that they have a technique that they can use on their own? Are they going to buy those weights off of Amazon that you've told them? Are they going to have a family member go and buy the dumbbells from Walmart? If they're not, then you better have another option. You better have something that they can use around their home that's less intimidating, that's cheaper, whatever it is. And not over here. Try to introduce the weights, but also give them something that's incredibly, incredibly convenient, right? Where you're decreasing the barrier of making the right choice, which is introducing loading, and we need to make it convenient. So I would argue that while I would bring weights in my backpack, walking around the hospital, I will bring weights in my trunk when I go to see my patients in home health. A resistance band, not a TheraBand, a rogue resistance band, many times was the best piece of equipment to introduce loading to an older adult. It's not intimidating. It's versatile. Not only can you use it to introduce loading and resistance, but I love to use those resistance bands for balance reactions. You can do a lot of perturbations with them. You can put them on the floor and use them as like an agility ladder. They are incredibly versatile. They're light. They're easy to carry around with you. Many older adults are not intimidated by them. Many times, a resistance band is the way to go. Many patients, I am not getting weights into their homes for these really sick folks in home health. It's just not going to happen. They're not going to make it there. So you need to make sure that you have something that is going to be practical for them and it's going to be sustainable. For me, it has been a resistance band. Give that some thought. Maybe go onto Amazon today when you're ordering your other stuff and getting your cart ready for Prime. Add a rogue or some other brand. It doesn't have to be rogue, but a actual resistance band to your cart. Okay. Last one here before we go.

23:53 SUPPORTIVE ECOSYSTEMS IN YOUR CAREER

Last one, most unpopular opinion. You can thrive in your career on passion alone. You can thrive in your career on passion alone. I don't think this is true. I have experienced, and I know many of you have experienced this, many of my dear friends and colleagues have experienced this, that you can survive in your career on passion alone, but it's not sustainable. You have to think of your entire ecosystem. If the only thing that is able to get you up and get you out of bed and get you going to your clinic, your hospital, your patient's home is that you love treating older adults. You love the relationships you build. You were so called to better serve this population. If that's it, if you do not have supportive management, if you do not have colleagues that think in the same way that you do and share your same philosophy, if you don't have supportive friends, family, partners, you are going to really start to burn out. That passion is going, that fire is going to start to diminish. It may not go out completely, but damn, it's going to be a lot harder to keep that going. It is absolutely critical that you are in a supportive ecosystem, that your managers value you. They understand the value that you're bringing. They offer you opportunities to grow and advance and to really stretch your skills that you are surrounded by other people who feel the same way, who want to charge forward with a fitness forward approach. You need to have friends and family and people that you're maintaining your relationships with, and they need to be supportive of what you're going after. You need to create that ecosystem. When you don't have that, I think so many, and I believe this for a long time, as much as I care about this mission, this thing, this job, older adults, as much as I care about it, it will be tempered. That fire will not burn as bright if we do not have the support from all those different parts of our ecosystem. It just gets to a point where maybe you're just running on fumes. Start to think about who your ecosystem is within your job, your managers, your colleagues. Do you have growth? Are you challenged? Are you very passionately connected to your team, to the mission, and about your personal relationships? How are they supporting you? How many individuals have you built up around you that are there to support you? Really start thinking about that. Okay, that's it. I think that was five. Just to review, five things I've changed, or maybe six, five things I've changed my mind about in Jerry Rehab. Changing settings will fix your burnout. You can be efficient and give a high quality session without timing yourself. PTs don't need to take patients to the bathroom. Weights are the best pieces of equipment to use to introduce loading to older adults. You can thrive in your career on passion alone. Five things I've had a massive, massive thought switch as I've gone through my career. Hopefully you all found some of those things to be really helpful. It gave you some things to think about. Please, if any of that spoke to you, do one thing today to change how you think or change what you do. To close this out, I will let you guys know what we have coming up in the older adult division. We have tons of courses. We are going to be in Lexington next weekend. That's our MMOA summit. The entire crew is going to be there. We get to check out Stronger Life with Jeff and Dustin. They're spot there. We absolutely can't wait. We are in Texas, Minnesota, and California for the rest of August. Then MMOA Central Foundations starts next Wednesday. One week from today, our online cohort starts. That cohort is filling up rather quickly. We took a little bit of a break in June and July. If you're interested in that course, I would not wait. I would get your ticket ASAP. All right, guys. Have a wonderful rest of your Wednesday.

25:49 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 1, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses the significance of addressing the underlying ecosystem challenge to achieve better outcomes for patients. She specifically highlights the prevalence of poor diet and obesity as contributing factors to this challenge. Lindsey points out that there is evidence suggesting a link between these factors and knee pain, as overweight and obesity are often observed in individuals experiencing knee pain.

Lindsey emphasizes that focusing solely on physical therapy interventions, such as knee range of motion and strength exercises, is insufficient. Instead, she argues that healthcare professionals, including physical therapists, need to consider the broader ecosystem in which patients exist. This includes addressing mindset, mindfulness, exercise, diet, and sleep.

To guide patients along this path, Lindsey  suggests that physical therapists can play a role by providing support and education. She compares physical therapists to shepherds, who can assist patients in navigating and making positive changes in their overall lifestyle. By addressing the underlying ecosystem challenge, Lindsey believes that better outcomes can be achieved for patients.

Take a listen or check out the episode transcription below.

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

00:00 LINDSEY HUGHEY
Good morning, PT on Ice Daily Show. How's it going? Welcome to Clinical Tuesday. I'm Dr. Lindsay Hughey coming to you live from Edgerton, Wisconsin. So good to see you all today. I am going to chat with you about playing offensive medicine in our folks with degenerative meniscal injury. Before I dive in to what that looks like, I'd love to share with you a little bit about courses Mark and I have coming up in extremity management. So we have a couple options in August and actually one of them, well we did have a couple options, we only have one now because all the tickets in Fremont, Nebraska August 19th and 20th are actually sold out. So our last ticket went I think yesterday. So the only option in August to check us out and learn all things best dosage and tendinopathy care of the upper and lower quarter is Rochester Hills. So August 12th and 13th I will be teaching there and so join me if you can. And then in September Mark has two options for you on September 9th and 10th out of Amarillo, Texas and then September 16th, 17th out of Ohio. So Cincinnati will be coming your way. And then some fall and winter courses but again opportunities are dwindling. We hope if we don't see you this summer to see you in the fall or winter.


01:48 STOP THE SCOPE

But let's chat about how do we play offense for degenerative meniscal injury because today is really a call, another call to stop the scope. I've hopped on here before over a year ago, I'm kind of charging us with those folks that have that gradual onset of symptoms of pain in their knee, maybe a little bit of swelling but have no specific injury or twisting event that happened that's more related to a degenerative process or like or I would like to refer to as a living life process. They don't need arthroscopic meniscectomy. And so we had more literature just come out this year to really bolster that argument of why physical therapy is really the number one choice, exercise medicine is the way to go. But I would like to first highlight that new literature that came out in January of why it's not appropriate to have surgery for these folks and then to also take a moment to reflect on why are we still seeing the arthroscopic partial meniscectomies being done if we keep finding literature that says let's not do this. And then also reflect on how can we do better as a profession to stop this continued over medicalization. So I first just want to briefly review in January 2023 we had a systematic review and meta-analysis come out from the Osteoarthritis and Cartilage Journal and we actually did share that on hump day hustling a while back. But this systematic review and meta-analysis again let us know that degenerative meniscal injury, the scope is not the way. And so let me unpack a little bit about this study because it was pretty inclusive this systematic review and meta-analysis. They looked at tons of RCTs so that the pool data of all patients was 605 patients. The study populations in each of the RCTs ranged somewhere between 44 and 319 so decent size overall in each study. The mean age of these folks was about 55 with the standard deviation of 7.5 so kind of that middle age and then majority were female about 52.4 percent. So you also see an even distribution almost of males and females in this study and then mean BMI was 26.5 standard deviation 3.7 you know below or above that. And what they investigated was the effectiveness of using arthroscopic partial manisectomy and they compared that via non-surgical so either sham which was exercise treatment or some form of exercise program so every RCT they looked at had to have the comparator of exercise. And degenerative meniscal findings were confirmed on MRI in all of the studies. The primary outcomes were knee pain, overall knee function, and then health-related quality of life and they looked at outcomes for up to two years so we see again a long-term follow-up in these RCTs this collection of RCTs that they looked at. And so the conclusions January 2023 so we're you know over six months out over half a year through and the conclusion was for insidious onset of knee pain so non-traumatic with MRI confirming degenerative meniscal tear in adults arthroscopic partial manisectomy is not the answer.

05:15 "NO CLINICALLY RELEVANT EFFECTS OF PARTIAL ARTHOSCOPIC MENISECTOMY"

Literally if I'm going to quote verbatim no clinically relevant effect of arthroscopic partial meniscectomy was detected for overall knee function health-related quality of life or mental health. They did find one small marginal difference in pain levels a couple points but there was no evidence that there was superiority in having surgery. In fact they even took a look to see are there subgroups of patients right that might have a greater benefit from APM that were just not recognizing and when they looked and compared again the non-surgical to sham exercise therapy they did not see a subgroup that existed. They made other conclusions to say most degenerative meniscal tears are going to improve over time without the need for that arthroscopic partial menisectomy. Other findings that I think are really important to point out before we kind of reflect on why if we have this evidence do we keep seeing surgeries being done is that when they looked at the individuals in the studies those with BMI over 30 so obese individuals compared to the healthy BMIs less than 25 they had a 4.7 fold increased risk of progressing to knee osteoarthritis whether they had surgery or not. It was really a call to action when they found this in this pool data of all these folks is that body weight reduction strategies need to be on board for pain and function effects.

07:28 "...NO SIGNIFICANT ADVANTAGE OVER NON-SURGICAL TREATMENT"

So just to send it home about this study and what they said one of the final things that they wrote in their conclusion was and I'm going to read it verbatim we recommend that physicians minimize the use of arthroscopic partial mastectomy to treat patients with degenerative meniscal tears because there is no significant advantage over non-surgical treatment. This is the osteoarthritis journal right this is a pretty high tier journal osteoarthritis and cartilage journal making this statement. So why are we still seeing a ton of them? Why does this keep happening where we see patients I have one of my caseload right now right why is this happening? Well we're obviously not reading the literature as a health care team and as physicians right because patients still think this is a primary defense. I'd love to reflect on that even 10 years ago in 2013 we had a study from Yim et al where they compared meniscectomy versus non-operative strength care and this was in 103 patients them and the same exact message was there there are no significant difference between arthroscopic meniscectomy and non-operative management with strengthening exercises again when we look at knee pain function and satisfaction at the two-year mark. So even 10 years ago we had this evidence but yet it's not translating to practice that's a lot of surgeries a lot of over-medicalization so I we need to really step it up here in our not only in ingesting this information but advocating that this is not a new message. In this article they point out that in 2017 so the systematic review and meta-analysis that we just reviewed that in 2017 an expert panel that regarding the degenerative meniscal injury said that the use of arthroscopic partial meniscectomy in nearly all patients with degenerative knee disease that several guidelines do not support this procedure. They've literally made clear statements against it again yet we're still seeing it so we can do better here and that probably takes some building relationships with surgeons right and chatting with them and letting them know like PT first get them to us right but really advocating that message in the community because we know that's not always going to work talking to the health care team. I think this message needs to be broadcasted widely more widely than it is currently. The other reason I think we keep seeing it besides like poor translation from what we're reading to the general public is there's this image mismatch so we see this a lot in the extremities and if you've been to our extremity of course you know we have a lot of conversations around this in different areas of the body shoulder hip knee but you see degeneration on the MRI right but there is no clear link that that's the cause of their pain symptoms it's an incidental finding but yet patients think oh you know my knee is really banged up right they leave hearing this message of harm rather than hearing you know I'm glad this is a normal age-related change so there's the image is linked inaccurately to pain and so again another opportunity to educate in this space and then the other reason I think that we keep seeing a ton of them being done regardless of what we know in the literature regardless of what we know that imaging doesn't tell the whole story is that there's this message put out about the fear of progression right if you do not get this meniscectomy you will go on to having knee OA or early onset knee OA which will lead to a knee replacement.

11:12 "IT'S DOING MORE HARM THAN GOOD"

Let's stop allowing this message to be passed on it is harmful right it's doing more harmful than good and we don't actually know that right any fear-based messaging is not the way and so that message that is a thought virus and if our patients are coming into us or even like people in our community right our family or friends um we have to really um call BS on that right because we don't know that for sure and we're not seeing that link so finally kind of the background of the that we just had in January 2023 tell us that having surgery is not the way we've kind of reflected on why do we keep seeing this so what do we actually finally do about it well promote PT first faster right when someone's knee is starting to ache right stop ignoring it get into PT stop going to a medical provider even primary care orthopedic first come to physical therapy first so we can help you um with your hip and your knee pain and your um any associated muscle weakness or swelling so that we can get these healthy messages into our folks and into the community these folks get lost in the system letting them know that it is very common what they're experiencing and a plan for success that's our job that's our wheelhouse we need to manage expectation too so folks right some of our patients are going to want to do the surgery anyway right despite any of the things we can tell them about the evidence right they're set on it their belief and expectation it's going to help well i need you to manage those expectations as well because surgery after surgery i don't know about you all but all the ones i see doesn't actually take away their pain and swelling in fact the surgeons have actually told my patients you can expect swelling for up to six months which is literally the reason they came in there they want to feel better and they want the swelling to go away well guess what at least for six months it's not going to happen folks so letting them know that in a kinder less passionate way probably so while these folks might return to work or sport they're going to have ongoing symptoms and that's swelling so letting them know that that even if they opt for that it's still going to be a challenge they're still going to need pt so i tend to want to say why not play offensive time along those six months where you don't have to um respect healing time frames after surgery where we can really get after strength around that that knee and that hip the other thing we need to reflect on and how we can do better is that it's not just promote pt faster it's not just managing expectation but we have to understand the underlying ecosystem challenge that is present in a lot of these folks we see and especially in the systematic review and analysis that came out in january 2023 we see an underlying poor diet and we the reason we can know that it's related somehow to diet is it's we see overweight and obesity being precedent being present excuse me and so we have to understand that we have to intervene in these folks not just on knee range of motion and knee and hip strength and proprioception but we actually have to consider there's that underlying ecosystem piece and here's where pts can help too right we can help with mindset mindfulness exercise diet sleep and really guide them along that path as a shepherd we can help so we need to know that we can help right so some of us maybe don't even realize that our own you know 2018 cpg guidelines at the josp t let us know that exercise is medicine and whether patients do opt for surgery not that guideline really points out that supervised exercise so how many folks you see after arthroscopic partial metastatic go on they have the surgery and then the docs just give them a standard h.e.p. right so they go on having swelling quad like because they don't have an individualized program with progressive resistance exercise let those folks know too you need to be a part of their care in our own clinical practice guidelines say that it's not good enough to just do a an h.e.p. that's not tailored to the individual and then what that cpg highlights is we're always going to do a mix of hip and knee strengthening we will have manual therapy on board we will do proprioceptive activity and neuro re-ed for those joining this morning thank you to summarize where we are at when thinking about our degenerative meniscal care we need to advocate against surgery with that insidious onset of knee pain we need to share this evidence far and wide that it is not recommended as frontline defense we need to stop the fear messaging as a health care profession and let folks know that degenerative changes found on images are normal signs of living their life and that pain does not equate to imaging findings we need to dose hope and let folks know that at that two-year mark we can see just as great of improvements in pain function satisfaction of care with just p.t. right and i don't take the just p.t. lightly we don't need that overmedicalization p.t. first is the way i'd rather see a patient taking control of their ecosystem and knee health for two years rather than that wait and see approach will surgery help stop the scope folks have a happy tuesday and thank you for joining me

16:35 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 pt on ice dot com while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to www.ptonice.com and scroll to the bottom of the page to sign up

Jul 31, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Alexis Morgan discusses how virtual pelvic floor care can prove beneficial for physical therapists in both virtual and in-person settings. Alexis shares that engaging in virtual pelvic floor care has significantly improved her overall abilities as a physical therapist, particularly in asking questions and gathering necessary information. She also notes that virtual care seamlessly integrates into both virtual and in-person worlds. Alexis highly recommends physical therapists to explore virtual pelvic floor care as it can be incredibly helpful. Furthermore, she mentions that a future podcast episode will delve into objective exams for pelvic floor virtual PT, indicating the importance of further exploring virtual care.

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

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

EPISODE TRANSCRIPTION

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

01:27 ALEXIS MORGAN
Good morning, Instagram. Good morning, PT on ICE Daily Show. My name is Dr. Alexis Morgan. I am one of the faculty with the Ice Pelvic Division. Really happy to have you all here joining me this Monday morning. My voice is a little raw from the weekend. We were just in Denver, Colorado, right outside of Denver at Onward Denver in Parker. This whole weekend, April and I spent with an awesome, awesome group of individuals and we were going through all of our material in our live course. We did our internal exams, supine and standing, and dove into all issues of pelvic floor dysfunction. We of course didn't stop there. We progressed through everything that our athletes are doing at the gym. So talking about how pelvic floor dysfunction fits into weightlifting and Valsalva and using a weightlifting belt and jumping and running and doing gymnastics. We had an absolute blast with this last weekend and we hope that you all will join us in the future for not only our live course but also our online course. I want to talk with you all today about virtual pelvic floor PT. We get a lot of questions asked over Instagram and on our Ice Students Facebook page. Sometimes we answer you all directly with some help. A lot of times we like to use your questions to teach everyone else about the topic that you asked.

03:10 VIRTUAL PELVIC FLOOR PT
This particular topic actually came from an Ice student who was wanting to know some more information about how to really apply what we talk about in our live and online courses into the virtual setting. And so that's exactly what I want to dive into today. Kind of similar to what we talk about really in all of our courses is that our subjective exam should be very detailed. It should be specific and we should be taking a while to do our subjective exams. I will say that when it comes to doing an assessment virtually, the subjective becomes huge. Not everything but a vast majority of especially that initial assessment. I'll talk through some ways that we do some objective exams but I want to before we even get there really emphasize to you all the importance of that subjective exam particularly in the virtual setting. So when I say be specific, there's a couple of things I mean with this. Depending on the issue that they may be coming to you for, whether that's leaking urine, whether that's pelvic organ prolapse or feelings of heaviness or vaginal bulge, that might be leaking bowels, whether that's anal incontinence with stool or potentially with flatulence. Maybe it's constipation. Whatever that may be, we want to get very specific on their problem. Again, this is true in person and in virtual but it really does become extremely important in this setting because all you've got to track changes are your words. By you having conversations and by asking questions, that's how you track the person's change. So it's not in session, which sometimes we can gather on that first virtual, but definitely between sessions. It's really, really important. So maybe you use the patient specific functional scale where they fill this out ahead of time or maybe you help them out and ask them further questions when they tell you they leak with double unders.

06:26 LEAKING WITH DOUBLE UNDERS
When I hear I'm leaking with double unders, that is not enough information for me to help you just yet. I've got a lot more questions and you should too because depending on how they answer, it could really change how you're going to treat them for that leaking. Not all leaking with jump rope is treated in the same way. And we've talked about this so much yesterday in our live course as we were going through jumping rope. But what we need to do is ask questions. So when does the leaking occur? When in that workout? And tell me what jumping rope looks like to you. Is it single unders? Is it double unders? If it's double unders, is it always doubles? Did you just gain that skill or is that an old skill for you? At what point during the workout? If it's early on, that's going to be different than if it's later on, right? I'm starting to think fatigue plays a role in their leaking. If it's later on in a workout, does it matter about which exact workout it is? What is the volume with that? That's going to be different, right? If it's 50 double unders versus 500 double unders, that's going to be different. And so we need to figure that out and we need to ask those questions. So you can use the patient specific functional scale and make that work for you. You can also use the PFDI, a specific to pelvic floor questionnaire. Now that is not an open box. That is marking, marking symptoms on a questionnaire. But what we've got to do is we've got to get information about their specific number one problem that they have. And moving forward, we need to understand what is their entire pelvic floor environment like. So we're going to ask questions and see if they have issues in other pelvic floor realms. Realizing we understand the number one reason why you came to me and I promise you I'm going to help you with that. But sometimes some of these other issues kind of play into your main leaking problem. Or as we're addressing your leaking, we can also address these other issues and together everything within your pelvic floor is going to function better. So a couple of those questions, again, depending on what they're coming in for, whether that's vaginal or bowel issues, you're going to ask, are you experiencing any leaking with maybe coughing or laughing, sneezing? And even with that, sometimes people are like, no, I don't leak with sneezing, but I do have to cross my legs together aggressively in order not to pee. OK, that's a problem, right? We're going to add that to our list. Do you feel like you can fully void? How frequently are you peeing? This one's a hard question for people to answer, but I generally want to know like, is it every 5, 10, 15 minutes or is it more like every hour or two? If it's very frequent, like every 15 minutes, that's going to be something that we note down and address early on. If it's every hour or two, we're going to lower that on our list. We may get to that if it's every hour and bothersome, we may not get to that. If there is high frequency, we're going to send them with a bladder diary and that's going to be one of our first trial treatments that we do with them.

12:00 STRAINING TO POOP
We want to actually pull up the Bristol stool chart. I always laugh when I pull this up. I'm like, OK, listen, I'm going to ask you a weird question. I promise it's relevant. And then I pull up the Bristol stool chart and I say, give me a range like where do your poops normally fall within this Bristol stool chart? Looking at that to see, we want to see around that three or four that are relatively normal. But if it's above or below that, we're thinking, what does diet and hydration look like? And that may lead us into more questions. How frequently are we having a bowel movement? Is it every one to three days? Because that's normal. Or is it six times a day or every six days? Those are not normal. And so we can dive into that. Do you feel like you have to strain really hard in order to have your bowel movement? We have evidence and plenty of it on straining to poop. And we need to be teaching people not to do that for their pelvic floor health. It's a very simple and effective intervention. Do you use a squatty potty or do you use something under your feet to bring your knees up higher than your hips? For most cases, that's going to dramatically improve the ability to go have a bowel movement. And that's really, really helpful. And again, is there any leaking, any anal incontinence that is, again, flatulence or potentially stool? All of these, again, are good questions to ask, even if they're not coming in with bowel problems for you to resolve. We want to go through this with them. And then vaginally, we're going to ask some questions as well. Do you have any pain with insertion? So that insertion could be anything from a tampon to a penis, sex toy, or speculum exams. Do you have any pain with that insertion? And asking, do you have any loss of air, especially with our active individuals who might be going upside down, whether that's in yoga, Pilates, CrossFit? Sometimes people can have loss of air or queefing. And we want to know about that because all of these things really paint a picture for us. Now, usually, this takes up quite a bit of time. I mean, I've been talking about what questions to ask for the last 10 minutes with absolutely no answers behind them. So this typically is a really good starting point and often is the vast majority of my first virtual pelvic floor assessment. However, I like to leave time for a few more questions and then getting into education as my trial treatment. So the few other questions that we always want to know is what is exercise or movement look like, how is sleep, and what do you do for stress management? Some of these questions you can ask in your intake paperwork. You may want to go over that with them as well. But looking at them as a whole person and looking at their pelvic floor issues as a whole. And then from here, we do trial treatments as education. So depending on how they answer any of these questions, typically, and it's beyond the scope of this podcast to really talk about various education pieces for each of those questions, but I'm going to educate and I'm going to intervene. So maybe that is let's start hydrating. Get yourself a favorite water bottle and I actually want you to hydrate. Or potentially it's the opposite if they're over hydrating. Maybe it's can we decrease that intake throughout the day or right before bed? Maybe it's get a squatty potty or get your toddler's stool that's right in front of the sink and slide that under your feet for when you need to have bowel movement. Going back to our initial example of the leaking with double unders, perhaps it is I want you to video yourself doing double unders from the side view and the front view and send it back to me. But between now and then, I want you to make sure that we are videoing it at the end of you're having that leaking. And after we get that, I'm going to have you take more rest breaks if that's what they need. Or maybe it's go into your single unders since double unders are always causing leaking and throughout our plan of care, we are going to dive into that. I try to find some piece of education and something that we know will help them resolve a little bit of their issue and get us rolling with this. We talk about it in our live course, but we have good evidence for education actually improving pelvic floor symptoms. And I think there's no better place to really feel that as a practitioner to feel the difference in the amount of education that you can provide and the amount of change that can occur. There's no better place than in this virtual care where truly we are guides. I can do nothing with my hands. I can do nothing with my body to change how that individual is functioning. I purely have to use my voice and teach and ask questions. If you have not done virtual pelvic floor care, I would highly recommend it. It has made me a much better physical therapist altogether, much better at asking these questions and getting the information that I need. And it blends into both worlds, both virtual and in person. So if you haven't done it, I highly recommend getting some patients in that virtual care because it can be really helpful. That needs to be all for today. I have a lot more that I could say, especially if we dive into the objective exam and how to do that. But I think that's going to need to be a podcast part two for virtual care. So I will do that the next time I hop on to the daily show and talk with you all about how we do objective exams for pelvic floor virtual PT. Thank you all so much for joining me and listening in this Monday morning. Or if you're listening later on the podcast, thank you for listening. One quick note, it is CrossFit Games Week and we are so, so excited to be cheering on our very own Kelly Bimpy at the Games with her team this year. So tune in to the Games. If you're going to be there, let us know. There's several of us ICE faculty that are going to be at the Games. We would love to see you and say hello. And I don't know, maybe we can snag a workout in or something. But we are so excited. It is Games Week. Have an awesome week. Hopefully we'll see you up north. If not, catch you later. Have a good one.

19:26 OUTRO
Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

 

 

Jul 28, 2023

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 how manipulating reps within a set can alter the intended stimulus of the set to bias towards power, strength, hypertrophy, or endurance gains. Guillermo discusses new research highlighting that depending on population, some individuals may still experience strength gains at lower loads & higher rep counts and that most individuals will improve hypertrophy regardless of rep dosage.  

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

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

EPISODE TRANSCRIPTION

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

01:32 GUILLERMO CONTRERAS
Good morning, crew. Welcome to the PT on ICE Daily Show. Welcome to one of the best days of the week, if not the best day of the week, Fitness Athlete Friday. I am with you. My name is Guillermo Contreras, part of the teaching team with the fitness athlete crew of the Institute of Clinical Excellence, talking all things delightful and super interesting, such as the rep continuum. So I'm going to leave you a little bit guessing as to what that means and dive into some fun stuff as in where are we going to be over the next couple of months? Where can you catch us on the road before the year ends? For our live courses, we have more than a handful coming up here in the next several months, starting in September on the weekend of September 9th and 10th. We'll be in Bismarck, North Dakota. In October, we will be technically September, October, September 30th and October 1st. We are going to head out to the West Coast to Newark, California. A couple weeks later, October, a week later, October 7th and 8th, we're going to stay in the West Coast. We'll be in Linwood, Washington. Moving into November, we'll be double, double teaming for, I guess, I don't know if that's the right phrase, but two different locations on November 4th and 5th, San Antonio, Texas and Hoover, Alabama. So moving from the West Coast down to the South. November 18th and 19th, we will be in Holmes Beach, Holmes Beach, Florida. I'm not sure where that is, but Florida. And then lastly, in December, we are going to be in Metair, Louisiana, as well as Colorado Springs on the weekend of December 9th and 10th. So there you go. If you've been looking to take a live course with the Central Foundation, or with fitness athlete courses, one, two, three, four, five, six, seven, eight opportunities for you between now and the end of the year to catch us on the road and be able to take that course and join us. And hopefully we get to meet you out there. If you are looking to do the online courses, Essential Foundations currently is going on their seventh week of this current cohort. So we're finishing up in about a week and a half. That take about a month off. And then we're going to kick off the next Essential Foundations cohort on September 11th. So if you've been looking to get started with the fitness athlete coursework, try to get an idea of what you would do when you work with fitness athletes, get more comfortable with the barbell movements, the squat, the deadlift, the press, what CrossFit is in general, some introduction to programming as well as the gymnastics movements, such as the pull-up. Would love to have you join us on September 11th as we kick off the new Essential Foundations cohort. These courses do tend to sell out online. So signing up sooner rather than later behooves you if you're interested in it and you want to get it in before the end of the year. Advanced Concepts as well. I think that only has two cohorts a year. So only twice a year that you can actually sign up and take Advanced Concepts. That second time right now is going to be on September 17th. Advanced Concepts does always sell out. It's a more high level course. You're going to learn a much deeper dive into programming, into modifications, into the high level gymnastics movements, such as handstand push-ups, muscle ups, high level Olympic weightlifting, breakdown and progressions. A lot of really deep dive stuff. A lot of brain work and physical work you'll be doing for this course. So that one starts up on September 17th. So please be sure to sign up again sooner rather than later for that one because that one does absolutely sell out early. Sometimes a couple months early. So sign up now if you're looking to complete your coursework to get your fitness athlete certification or if it's just something that's been on your bucket list you've been dying to take but you have not and you want to get it in before the end of the year. Fantastic. So that's what we have on the docket for fitness athlete. This morning the topic at hand is the rep continuum or the repetition continuum. For those who are not sure what that entirely means, what we're looking at with the rep continuum is, I just realized my camera is really blurry over here but that's okay. Is what we commonly know as the strength endurance continuum which for the majority of us or anyone who's been in like the strength and conditioning realm what that means is okay what are the optimal rep ranges and loads that you want to use when you're trying to train strength, when you're trying to train hypertrophy and when you're trying to train more like localized muscular endurance. And for the longest time we have had the accepted theory that it is one to five reps at 80 to 100 rep 100 percent run at max. Hypertrophy is going to be eight to 12 reps at 60 to 80 percent one rep max and endurance is going to be 15 or more reps at anything below 60 percent of your one rep max. That's what's been commonly known and so in 2021 Bradshon building company down at the NSCA right they decided to do a lit review look at everything they could out there and got a better understanding of is it truly that is that the only way or are those the only things we know or are there actually other ways to gain strength gain hypertrophy gain gain endurance in our muscles and is that truly the most optimal way that we can do these things or is there other ways that we can kind of build it up can we use lighter loads can we use moderate loads can we use heavy loads and play around and dive into these different realms. So again they did a very very significantly large lit review and their purpose of the paper was to critically scrutinize the research on the repetition continuum highlight gaps in literature and draw practical conclusions for exercise prescription. Based on the evidence they proposed a new paradigm whereby muscular rotation can be obtained and in some cases optimized across a wide spectrum of loading zones. So that is that kind of the basis for the paper and it's a long one it's probably like 11 pages and you have like a bunch of pages of exactly the the the protocols that they use in all these different studies that they reviewed and I'm just going to try and do my very best to summarize what they kind of found in each section and then at the end if you don't want to like listen to this whole thing you're listening later on just jump to the last maybe like minute or so and I'm going to try and kind of concisely conclude everything there. When it came to strength strength as we know it is supposed to be ideally that one to five rep range 80 to 100 percent one rep max heavy heavy loads is how we're going to build strength and what they found in this here is that trained individuals people have been doing it for a while tended to show improvement in strength even with light loads so people who have been doing it for a while people who who already lift heavy and such when they use lighter loads in different variations there actually is an increase in overall strength albeit they they mentioned in a caveat that it is to a lesser extent than the use of heavy loads. Um they also mentioned that typically what they see is as you reach that genetic ceiling like where your where your strength is kind of at its highest or going to be pretty high the greatest benefit is going to be in heavy loads with specific movements that you're trying to get stronger and again that should be something that all of us are probably saying like no duh right that's that's the set principle right you learn that in undergrad kinesiology right specific adaptations to impose demands when you get someone that's a higher level at the very highest level and you're trying to get them stronger the way to get them stronger is to apply specific stressors to elicit a specific progressive improvement in strength that's what they saw there so what we see is with heavy loads or when we want to build strength you can do it with low loads there are ways you're going to build low loads and that practical application the clinical application is that all the studies i guess the majority of studies that found that low loads improved strength their way of testing strength was using isometric dynamometry therefore the isokinetic or isotonic leg extension leg curl hip extension you name it they used single joint mechanisms to test that single joint single movement strength from a practical application that can very easily mean for us in the rehab realm if we are trying to get someone's quad stronger if you're trying to improve specifically quad strength hamstring strength whatever it may be there is a point where we can use lower loads to high intensities right all across the board effort was dependent on improvement maximal or hard efforts with low loads showed improvement when individuals cut off before maximal effort before fatigue before stress there was not the same amount of improvement whether it was strength hypertrophy or muscular endurance so low loads can be used on single joint movements however strength is most often applied in compound movements coordinated multi-joint efforts i.e. squats deadlifts presses lunges all those type of things and so we want to make sure that if we are trying to help someone improve their squat improve their deadlift strength improve their rowing strength we're trying to create these compound movements that are are functional in nature to what they're doing we have to be getting comfortable with the barbell movements we have to be comfortable loading them heavily right so if you're going to be working with athletes who are doing functional movements you better be loading them with functional movements you better be loading them heavy with functional movements if the goal is to do actual strength improvement and that actually is nice because it it shows two things right one yes the one to five rep range eighty one hundred percent max of these movements is where we want to be for strength and two if we're trying to do very specific rotator cuff bicep quad hamstring strengthening then it's okay to use lower loads maximize that intensity range and we're going to see strength improvements there if we're very specific with what we're doing there number two moving on to hypertrophy hypertrophy getting the gains bigger bigger arms shoulders back legs quads hamstrings you name it everything there well we typically see in the realm of like bodybuilding in the realm of anyone who's trying to put on mass is we're going to be doing somewhere around that eight to twelve rep range sixty to eighty percent so submaximal loads add an effort when you get to that mid-range you're creating some sort of mechanical stress that causes that muscle to basically in essence break down a little then build back up and get stronger as long as you know all the fuel and everything is there for it and in the study the meta analysis showed comparing high loads which are greater than 60 percent of one rep max versus low loads which are less than 60 percent one rep max is that there was no real difference in hypertrophy which is kind of interesting right you can again offer an example of you can use low or high loads moderate loads kind of in that range to build hypertrophy the notable effort though again that they mentioned in here is that when individuals were using low loads the effort was much higher so it was a higher level of effort because it is critical for maximizing hypertrophic adaptations so again if our goal is to have someone who has a very very atrophied quad and we are not going to try and pursue something that allows for 60 to 80 percent of that one rep max relatively heavy loads right moderately heavy loads that are challenging and fatiguing and stressful then we'd better be using low loads but eliciting a maximal effort where they are working hard for 15 18 20 reps whatever it may be that kind of ties in a little bit with with anyone who kind of plays around with blood flow restriction training where you're doing 30 15 15 and you're maximizing that effort there it's a very low load somewhere around 20 30 percent of one rep max for a lot of reps there too but that's again there's another topic there right effort is dependent on this are we are we using maximal or high level of effort to maximize hypertrophic gains strength gains etc the one thing this study did show the review did show was cool is that for from an age-related standpoint the light load training appears to be as effective as heavy training so when we're looking at our older adults where we might see more of those joint related conditions when they can't sometimes tolerate heavy loads on their knees on their hips whatever it may be using light loads at this this higher effort level might induce a similar hypertrophic change because it's going to stimulate both type one and type two muscle fibers when we're using lower loads we're in essence what they mentioned in this review is those type one fibers might be stimulated stimulated more because you're doing more of an endurance or long bout of exercise and effort which is going to stimulate those more when you're having it's more type two muscle fibers so either way we're building them both up and we're trying to build hypertrophy in that way so there we go and even in the really said that some researchers propose that you should train both like high level volume with high effort and lower volume with higher effort as well again working in those things there too so minimum threshold though if we have to like throw a number out there is where they're in there it's somewhere in the range of 30 one rep max right we should not be training anything below 30 of our one rep max or if you're using rp like a three out of ten so hopefully that makes sense right low loads are fine high loads are fine they're both good again as i mentioned with strength and now hypertrophy effort is dependent right we need to be working hard we need to be pushing individuals and lastly there's the endurance response right less than uh greater than less than 60 percent of one rep max 15 or more repetitions right lots and lots and lots of reps trying to really fatigue those things out and um in the look review right this is probably the shortest section in there that kind of looked at and it kind of just demonstrated that like there's a lack of dose response relationship right whether you were doing uh high loads or moderate loads light loads there wasn't a significant change in overall muscular endurance and i believe uh the lighter loads for endurance were more beneficial for like lower extremities which would make sense right you're running it's a lot of like impact and going doing a lot of air squats uh things like that's going to help build that muscular endurance uh versus doing like really heavy back squats and hoping that's going to translate to doing a 5k or doing like a really long hike and stuff like that it can there's aspects of it that will help but with resiliency and like injury prevention we're talking like muscular endurance so it's the ability to go longer in that way you can look at a powerlifter who just does powerlifting and know that they ain't doing like a 5k anytime sooner a long cycle right so those those are the main kind of areas we looked at right so again a lot a lot of talk there a lot of like little details about this lit review and what i want to specify again this conclusion right what is what is the grand arching scheme or grand arching topic uh or takeaway from this it is that what we're looking at trying to build strength strength related advantages of heavier load are dose dependent right so if we are going to have someone get stronger at the squat the deadlift or the press they better be doing heavy squats heavy deadlifts and heavy presses if we want someone to specifically improve quad strength we can do squats we can do step ups we can also do isometric leg extensions at lighter loads for higher volume and what matters here is the effort and also if you are trying to train for a specific thing you're trying to help someone improve their squat or increase strength with squat they better be squatting right specific adaptations to impose demand for strength is the greatest area that we see that that has to be specified there strength is going to improve strength hypertrophy we can use high loads we can use low loads we can use moderate loads if you want to build muscle we can use them all the one thing they mentioned though is you have to remember with low loads it's a lot more effort dependent there's going to be a higher amount of metabolic stress which can lead to just general discomfort in the muscle and some people don't like that so the the likelihood of them sticking around to doing for doing like three sets of 18 at maximal effort where they're feeling like an eight or nine out of 10 difficulty is not there the compliance might not be there high loads you need more volumes more more volume right so you can you only do two or three sets two or three reps i'm sorry at 80 90 percent which means you're probably doing seven eight nine sets to get the appropriate amount of volume to elicit the hypertrophy response and what we know is that's not fun if you've ever done 10 sets of three something really really heavy that is a miserable session and it's also hard on your on your joints on your tissues it's a lot of stress so if anything is off in your training continuum whether it be your sleep your recovery your nutrition right you're going to feel that much much more which is why we probably go with that middle moderate range where it's hard enough difficult enough but it's not going to elicit any type of ill feeling or pain discomfort etc and then lastly with endurance as i mentioned already the lighter loads are going to be more beneficial for the lower extremity musculature otherwise it's pretty much equivocal like whether you use heavy loads or lighter loads for endurance you're not going to see too significant of a difference as far as gains go in that area cool i will link the study in the comments for anyone who wants to check it out for themselves that's all i got for you this morning on this fitness athlete friday if you're doing some hypertrophy work today play with some heavy load play some moderate load play some light load if you're doing some strength work get after that barbell get heavy with it and hopefully everyone enjoys their weekend thank you for tuning in and we'll catch you next week on the pt on ice daily show take care again

19:04 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 www.ptonice.com while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to ptonice.com and scroll to the bottom of the page to sign up

 

Jul 27, 2023

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the state of physical therapy in 2023 with regards to pay. In this episode, the question of whether pursuing a career in physical therapy is worth it is addressed. It acknowledges that individuals may have concerns about the return on investment for the time and money spent on education and training to become a physical therapist. Alan mentions that some may be discouraged by the long time it takes to see a return on their investment, as it can take 15 to 20 years to pay off the debt associated with advanced certifications or residencies.

To address this concern, Alan suggests the need for better guidance for future physical therapists in terms of education and career choices. He emphasizes the importance of providing information to students considering entering the profession, as well as those already in school or practicing as physical therapists. Alan suggests informing future PTs about alternative routes to becoming a physical therapist that may be quicker and more cost-effective, such as completing prerequisites at a community college and transferring to a four-year program if necessary.

The episode also highlights that not all PT schools require a bachelor's degree and that there are various paths to becoming a physical therapist. Alan suggests providing better guidance to students during observation hours or while they are still in high school or undergrad, to inform them about the available options and help them make informed decisions about their education and career paths.

References

Take a listen to the podcast episode or read the full transcription below.

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

EPISODE TRANSCRIPTION

00:00 INTRO
Good morning, happy Thursday morning. Welcome to the PT on ICE Daily Show. I hope your morning is off to a great start. I'm happy to be here today as your host. My name is Alan. I currently have the pleasure of serving as the Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete Division. Here on Thursdays we talk all things Leadership Thursday, small business ownership, practice management related to physical therapy, that sort of thing. Leadership Thursday also means it is Gut Check Thursday. Today's Gut Check Thursday is a little kind of cardio party, bodyweight only, combination of running and some bodyweight reps. So it starts off with descending distance. So we start with a thousand meter run and then we hit 25 burpees and then we hit an 800 meter run and then we hit 50 air squats and then we hit a 600 meter run and then we hit 75 walking lunges and then we finish with a 400 meter run. So just a little bit shy of a 3k run, about a mile and three quarters of running and then some bodyweight reps as well. Probably for most folks in the 20 to 30 minute time domain, certainly those of you who are faster runners and those of you who really want to push the pace can really get after the run and those bodyweight reps and really get your heart rate up. Or this is also a great workout even though it's Gut Check Thursday, if you're feeling beat up at this point in the week to just take those runs nice and easy, take those bodyweight reps nice and easy and kind of treat it more like an active recovery piece. So that's Gut Check Thursday for this week. Courses coming your way, we have a whole bunch of courses coming up in August, the weekend of August 5th and 6th. We have Paul down in Greenville, South Carolina for dry needling lower body and then we have Alex Germano in Frederick, Maryland for Older Adult Live. The next weekend August 12th and 13th, we have Lindsay Huey here in Michigan, Rochester Hills, Michigan for extremity management. We have the Older Adult Live Summit, that's going to be all of the older adult lead faculty and TAs at Stronger Life headquarters in Lexington, Kentucky. I'm going to that course, that's going to be a great weekend. We also have out on the west coast, Justin Dunaway for Total Spine Thrust out in Bellingham, Washington. The weekend of August 19th and 20th, Lindsay Huey is again on the road with extremity management, this time in Fremont, Nebraska, right outside of Omaha. Paul will again be on the road for dry needling, this time with lower body out in Phoenix, Arizona. And then two chances at Older Adult Live, either in Bedford, Texas right outside of Dallas or in Minnetonka, Minnesota. And in the last weekend of August, August 26th and 27th, cervical spine management will be at Onward Charlotte with Jordan Berry. Older Adult Live will be in Carpinteria, California, that's out on the west coast, just north of LA for Older Adult Live. And then again, Paul will be on the road for dry needling, this time upper body, same venue the next weekend in Phoenix. So we have back to back dry needling weekends at the same venue out at Exos in Phoenix. If you're looking to get both courses knocked out in a short amount of time, you can look at those courses at the end of August. So that's what's coming your way for courses. Again, everything related to ice can be found at ptniice.com. Today's topic, the state of physical therapy 2023. Now, you might be thinking, Alan, that sounds arrogant. Who are you to inform me on the current state of physical therapy in 2023? And before we get started, I just want to say this is coming directly from our national member organization, the American Physical Therapy Association. So if you're not aware right now, the House of Delegates is going on kind of the annual meetup of state delegates from every state meeting and discussing various policy related things to physical therapy, kind of like the Congress of American Physical Therapy. And today's topic is really focused on what was announced related to both pay and residency from APTA. This was at the end of last week. So they released a publication, a series of infographics called the state of physical therapy in 2023. They talked about PT pay over the past about two decades, the past 20 years, they talked about the state of physical therapy, residency and board certification. And probably most importantly, for the first time, really ever, they released some concrete data on pay related to going through a residency and obtaining a board certification, how much extra money can you expect to make. So let's start first with the pay of it's interesting that this was released, because it doesn't bode well for physical therapy that the the information released by APTA shows pay changes from 2004 to 2021. So about a 17 year change, showing that the national average for pay in 2004 was about $68,000, and that it is now about $91,000 in 2021. They also released a breakdown based on geographical region showing a little bit more geographical specific information, especially as it relates to cost of living. But they summarize it all average it all out for that national average. Now you might be thinking Alan, that sounds great, man. 68,000 to 91,000 is significant. That's almost a $30,000 increase. But we have to step back and say, that's not how money works. That's not how economics works. That's not how math works. That if we track money across 17 years, we have to of course, adjust for inflation. And then if we do indeed adjust for inflation from 2004 to 2021, then if we were making an average of 68,000 in 2004, we should be making over $110,000 in 2021. Now, we know inflation has been crazy the past couple years. So it's probably going to be even above 110,000. But we know based on the data released that we are not meeting inflation, which is to say that nationwide on average, across the country, physical therapy pay has been flat or even negative for about the past 20 years, which is a little bit concerning that we have had so many years of essentially flat pay. Based on forecasting from 2021 forward, if we keep this same trend, physical therapist average pay in 2030 should be $135,000 a year. Now, I don't know about you, but I'm not going to hold my breath on that. I don't think it will ever get that high, even in higher cost of living areas. So that my first point is the state of pay is quite concerning that our pay in general is flat or maybe even adjusting for inflation a little bit negative. And that's something we need to be concerned about both is employees and employers of what steps can we take to reduce costs so that we can continue to improve pay and continue to at least match pay based on inflation with the folks that are working on our teams with us. On the employee side of things, this should be concerning to you because if you are below this, this means you're even more flat or possibly even more negative than the national average of if you are not getting a raise every year that is at least in line with inflation, you are technically losing money. The cost of everything in your life that costs money is more expensive. If your pay is not matching that, then you are slowly losing ground financially. So we need to know the state of physical therapy in 2023 is that pay seems to be flat, which is concerning. The second data point, the second infographic released by APTA listed out board certification specialties based on a percentage of physical therapists who hold that board certification. We know that there are 26,308 physical therapists who are board certified out of about a licensed population of 300,000 or so. The vast majority of folks who hold board certification hold a board certification in orthopedics. Almost 60% of those 26,000 people have a certification orthopedics. So right away you should be thinking, wow, very saturated market right of pursuing that OCS of pursuing that residency and board certification orthopedics is really not going to make you stand out that much when the vast majority of people who are board certified are already board certified in orthopedics. After orthopedics board certification really kind of falls off a cliff. 13% of board certified physical therapists hold board certification with their NCS in neurological physical therapy. 10% have their GCS in geriatric physical therapy. 9% are sports certified, hold their SCS. 7% pediatric certified with the PCS. Only 2% women's health certified with the WCS. And then it really falls off a cliff even more. 1% of those folks who have board certification have a cardiopulmonary board certification, the CCS, and then about half a percent each for clinical electrophysiology, the ECS, and half a percent for the OPT, the oncological physical therapy specialty. So you should know where most of us work in outpatient orthopedics is already saturated market and it's even saturated with board certification. So just know if you're thinking in your mind, man, I want to do that orthopedic residency. Man, I really want to go get that OCS. It's really going to make me stand out. You should think again based on this data. Again, based on flat pay, based on the market saturation, you should be thinking twice before you think OCS is really going to make me stand out among orthopedic clinicians. Not really, right? A lot of people already have it. That gets into my third point of what pay increase can you expect for going through your residency obtaining your board certification? This is a question many people have and now thanks to APTA we have some concrete data on it. The short answer is you shouldn't expect much of a pay increase at all. An average of $2.27 more per hour for having a board certification or about $3,500 more per year after taxes. You should know the pay bump based on certification varies greatly. When we pull back from that average and look at those individual board certifications, what stands out? Clinical electrophysiology stands out a lot. Those folks make about $27 more per hour. We know that's a very subspecialized area of physical therapy where most people don't work. Only about 100 people in the country have that board certification. It jumps up a little bit from the average. We look at the NCS, the board certification for neurological physical therapy, about $7.55 more an hour. The OCS, about $3.89 more per hour. Unfortunately, after that, the rest of the board certifications you can expect to really not make much more per hour if anything more than your base pay. For example, women's health certification, the WCS is right at baseline pay for physical therapists, which is to say you can expect to make no more money above baseline than you do with or without the certification. Now you might be thinking, well, $2.27 more per hour on average is $2.27 more per hour than not having it, so why not go through my residency? Why not go and sit for the board certification and try to get that little pay bump? It's really important to actually go through and understand how much it costs you to get to that point and really do the math to think, is it going to be worth it for me? We need to take the account of money and time that takes into going into residency and sitting for and passing your board certification. Then we look at costs. The average residency program is about a 16-course series, usually somewhere between 12 and 24 months long. About a quarter to half of those courses are going to be in-person, which means you need to travel. It's essentially the same as going to a weekend continuing education course, so you need to buy a plane ticket and get a hotel or a rental car and all that kind of stuff that comes with travel. The rest of the courses are online or virtual lab experiences, but in general, on average across all residency programs, you can expect to pay about $15,000 for that residency and tuition, and you can expect to have some travel costs as well to attend those live weekend courses. The board exam itself is also not cheap or free. It's about a $1,000 cost for the application fee, and it's $1,500 to take the test. It's about $2,500, and that assumes that everything is correct with your application and that you pass the test on the first time. If you are missing stuff for your application or you fail the test, then obviously that cost will go beyond $2,500. In a residency, you should know that most residency programs pay you about 70% of what they would pay a full-time physical therapist, although you may also be expected to carry a full clinical caseload. What does that look like? Here at Health HQ, if we were to reduce everybody's pay to 70%, that looks like folks here would make about $30,000 less per year. Across an average of an 18-month program, that means you would make about $46,000 less than you would somebody working here full-time. So when we take all these little costs, they don't seem really that bad by themselves, but they're all part of the process to work yourself towards completing that residency and to eventually take your board certification and obtain that credential after your name. What's that total cost? It's about $60,000 to $65,000. And we look at tuition for residency, travel for weekend courses, application fees, testing fees, and lost clinical revenue because you are either doing mentorship hours or otherwise you're doing unpaid stuff in the clinic that across about a 12 to 24-month span, you're missing out on about $65,000. Some of that is lost revenue and some of that is money you have to directly pay. So now when we zoom out and think, if I make $3,500 extra per year having this board certification, how do I know it's worth it? Well, when we do the math, you need to understand that it's going to take you about 18 and a half years to break even on that investment. That an average increase of pay of $3,500 per year with a cost of a combination of lost revenue and paying into tuition and travel and fees of about $65,000, it's going to take you about 18 and a half years to break even and then finally begin to move ahead and quote unquote profit off that initial investment. So that's quite staggering, right? I'm 37 of thinking if I went to my wife and said, hey, I want to spend $65,000, I want to be gone from home even more than I already am. By the way, this investment that we're going to make of time and money will start paying it off to me when I'm 55 years old. My wife would be very upset if I went and said that to her. And I imagine a lot of you would be in the same boat of that is an extremely long time to see some sort of return on that investment. So this brings me to my last point here of the question that many folks have, whether you are watching this, listening to this, and you're thinking about entering the profession, whether you're already in school or whether you're already a member of the profession of the answer to the question of physical therapy, is it worth it, worth it? How do we know that? Where does our role play already as members of the profession? Well, we should probably do a lot better job at guiding future PTs of when we have students in the clinic who are doing observation hours, who are maybe still in undergrad or maybe even in high school of really guiding them as much as we can and letting them know, yes, it's possible to become a physical therapist, it's possible to do it in a manner that's quicker and cheaper, that there are many different routes to become a physical therapist and that if you are truly looking to get ahead in life financially and you want to have a rewarding career as a physical therapist, it's probably going to look like some combination of doing most of your prereqs at a community college, getting as many hours done in a community college as you can, get it done cheap, get it done fast, maybe even be able to work a little bit and only transfer to a four-year school if you need to take classes at that four-year program or your PT program requires a bachelor's. There are a lot of PT schools that do not require a bachelor's. They simply require 80 to 100 credits of prereq work and in some cases you can get most or all of that done at a community college. That's going to get you to PT school a lot faster and cheaper than a four-year program, especially if you don't need that bachelor's degree. And then looking at PT schools, we need to do a better job at directing these future students towards programs that maybe offer a hybrid or a flipped classroom model where they can do the majority of their didactic work online and meet up in person less often to be able to do in-person hands-on stuff that needs to be done in a lab setting. Again, the goal there is to get through PT school faster and cheaper than a traditional model so that when we look at the traditional route through PT school of a four-year or maybe even a five-year undergrad program to get your prereqs and a three-year grad school experience of a lot of folks coming out a hundred to two hundred thousand dollars in debt seven or eight years of school. That looks like a lot when we know that there are faster, cheaper routes that maybe we can get community college done in three years and maybe we can get PT school done in two years. So we enter the workforce sooner and hopefully we did it cheaper so we have less student loan debt as we start to work. That is the way we need to talk to current PT or sorry future PTs. Speaking to current PTs, the education really needs to be on don't fall for the trap. The data is here, it's clear, it's from the organization that's selling you the program of don't get caught on their hamster wheel. Don't get caught in a lifetime of school of a four or five-year undergrad program, a three-year PT school program, a two-year residency program, a five-year fellowship program where you might spend 10 to 15 years in school. You might have five hundred thousand dollars in student loan or credit card debt before you actually start to grind away at that debt, making money even if yes you will make more money per hour of it will probably take you the majority of your career to pay off that investment. So don't get caught on that hamster wheel. What should you do instead? Well we're biased but we think you should pursue meaningful education that yes improves your clinical reasoning but also lets you expose yourself to new clinical subspecialties that lets you attract new and different patients to your clinic to serve them well so they keep coming back so your caseload is fuller, you're having more fun in the clinic, and hopefully along the way you're making more money while not having this giant burden of debt hanging against your shoulder that you need to pay off. So where's the state of physical therapy in 2023? Pay is flat or negative. The pay for increased subspecialties, board certification, letters after your name does not seem to be there and what little bit is there might take you the majority of your career to actually start to pay off and see a return on your investment. Help guide future PTs on better ways to make their way to and through PT school and if you're a current PT just know that if you're thinking a board certification, a residency is really going to set me apart, there's not a lot of people especially in orthopedics that's not the case and just know that it's going to take a very long time to pay off that investment potentially somewhere between 15 to 20 years if you're still thinking about pursuing that advanced certification, that advanced residency. So I hope this helps. This is great information to have. We'll post links directly to what we share from APTA. We'll post those both in the show notes on the podcast as well in the comments here on Instagram. So we'd love to hear comments and discussion about this. I hope you all have a fantastic Thursday. Have fun with Gut Check Thursday. If you're going to be at a live course this weekend, I hope you have a fantastic time. Have a good weekend. Bye everybody.

Jul 26, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses  how treating individuals with sensory-based approaches at an early stage of their disease progression may help prevent or delay limitations later on. Alex suggests incorporating a variety of sensory challenges into treatments for individuals with Multiple Sclerosis (MS). These challenges include exercises that activate the inner ear and engage the eyes, aiming to improve proprioception and challenge the integration of sensory information. Alex emphasizes the importance of carefully dosing and scaling the exercises, taking into account the limitations of fatigue, in order to maximize the benefits of these interventions. Furthermore, Alex encourages starting the sensory-based approach in individuals with MS in their 20s and 30s, as it may potentially prevent or delay the onset of limitations later in the course of their disease progression. This approach focuses on enhancing sensory fitness and training the visual system through ocular motor training. By utilizing central vestibular system outcome measures and incorporating a variety of sensory challenges, clinicians can effectively identify and address the sensory integration component in their treatments for individuals with MS.

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

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

EPISODE TRANSCRIPTION

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

01:33 ALEX GERMANO
Good morning everyone and welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. Welcome to today's segment of Jerry on ICE. I'm Alex Germano. I'm a member of the older adult division and today what we're going to do is discuss some of these effects of multiple sclerosis on the vestibular system, what we need to look out for as clinicians, how we can assess better and treat this population. First, let me tell you some of the offerings within the older adult division before jumping into these questions. We have two courses coming up this weekend, one in Watkinsville, Georgia and the other across the country in Boise, Idaho. We have some seats left for both courses. We also have a course coming up in Frederick, Maryland, August 5th and 6th. We have our MMOA Summit in Lexington, Kentucky on August 12th and 13th and we have courses in Minnesota, Texas and California to round out August. First, let's talk about multiple sclerosis. This is a chronic, immune-immediated inflammatory disease. It causes neurodegenerative processes within the central nervous system. Now, typically onset of this condition is somewhere between 20 and 50. That's when people are getting diagnosed. We've seen a shift, however, towards people getting diagnosed a bit later in life and then these people go on to become older adults. So that's why we're kind of, we're having this discussion land within Jerry on ICE or this older adult discussion because we are out there treating a lot of people who have MS and have had it for a number of years. Now based on where these demyelinating plaques occur, people with MS can present in a wide variety of different ways, right, different patterns. And very often what happens with some of this demyelination is it occurs across the vestibular system, right? It impacts some of this vestibular information. Remember that vestibular system is vast. It touches many different points within our peripheral and central nervous system. We have parts of the vestibular system, not just in the inner ear, it's part of the cranial nerves, part of our brain stem, parts of our cerebellum. And interestingly, the vestibular nuclei in that root entry zone of the eighth cranial nerve have been shown to be some of the most common neuroanatomic locations for sensory demyelination. Okay? And very commonly the vestibular nuclei in the entry zone of the eighth cranial nerve have some demyelination. And oftentimes people with multiple sclerosis have abnormal tests on vestibular function both centrally and peripherally. Centrally people with MS may struggle with the ability to sensory reweight with most of their reliance of balance coming from the visual and proprioceptive systems. So they're not really integrating that vestibular sense. They're maybe too visually reliant. Really our brain is just trying to balance out all this information to give us a sense of balance. Now researchers really think that this central integration of peripheral input is where the dysfunction lies within the disease process. Interestingly, this type of central integration problem could actually be causing one of the leading debilitating features of MS, which is fatigue. The hypothesized relationship between central vestibular integration and fatigue could be explained by this poor ability to gate sensory information. The person with MS is unable to process all the signals incoming. The cerebellum can't do its job to override some other sensory noise such as like the vestibular ocular reflex as it normally does. That causes a poor perception of verticality. That contributes to increased sway. And imagine all this little sway that's going on all day. That can contribute to fatigue. So this information can really help guide us on our journey in assessing people with MS and their vestibular system. Now most of the information I'll talk about today regarding testing and the treatment of the vestibular system in people with MS comes from a group out of the University of Alabama at Birmingham led by Dr. Graham Cochran. And I'm going to link all these on Instagram for you. But this group really looks at the influence of the central vestibular system on function in people with MS. They concluded that we should be selecting measures that actually test central vestibular integration versus purely peripheral vestibular function. Because some people with MS don't have that peripheral vestibular dysfunction. Really the problem is central. So what tests can we use to capture that central integration problem? Now these central integration tests are more significantly correlated with measures of fatigue and walking capacity. They do mention a limitation of the studies that they perform on people with MS are that they are using this more on ambulatory patients. They're really testing the ambulatory community of people with MS. So it's very much something to consider if you go to apply this to non-ambulatory populations or people kind of much further in their disease progression. Now the two tests that they think we should be performing are VOR cancellation and the subjective visual vertical. The VOR cancellation tasks, remember that's our ability to kind of override our vestibular ocular reflex and remain fixated on a moving target. The VOR cancellation, it requires the integration between vestibular signals and visual system to produce an equal smooth pursuit eye movements, right? To keep vision stable on a moving target, moving at the same speed as our head. So VOR cancellation can really give us insight into this sensory integration. The subjective visual vertical, for example, is a task that requires integration of our otoliths, right? Our kind of gravity dependent inputs of our vestibular system and the visual system to help us orient to a true perceived vertical. So if you've ever seen people kind of presenting with maybe a tilt of the head or folks that are kind of leaning one direction or the other, they might have a sense of, they might have a mismatched sense of verticality and they're aligning their head or their eyes a different way to line up with what they perceive as vertical. So the subjective visual vertical task, or sorry, the subjective visual vertical assessment can give us insight into the combination of otolith input and visual system input. So again, that sensory integration that we're looking for. The subjective visual vertical test can be measured via a bucket test. There's like research-based, lab-based ways to measure this that are more accurate, but we can do this clinically with what's called a bucket test. Reactive therapy and wellness has a really good video on YouTube for that test and how to set one up with like a Home Depot bucket. Pretty simple. Vestibular rehab is a great addition to therapy protocols for people with multiple sclerosis. Vestibular rehabilitation programs have not only shown change in our folks' balance and disability due to dizziness or disequilibrium, but has also been shown to impact fatigue, which is amazing. The protocols for vestibular rehab and the research look like a lot of sensory integration work. We want to work on visual, vestibular, and proprioceptive inputs over a variety of different conditions. What we're really trying to do is beef up someone's sensory fitness, so to speak. So you are going to see the themes of eyes closed, standing on foam, moving the head around in different planes, moving the body both forwards, backwards, and laterally. You're going to see working in a variety of different positions, standing, kneeling, changing up that base of support, performing dynamic movement as well, such as walking. Then you're going to see some ocular motor training added to the mix to enhance that visual system. We want to train up the visual system as well. So you are going to be seeing some ocular motor training. Now, they perform this in a progressive manner, just like we would do with resistance exercise. They're consistently progressing the difficulty of set exercises, just like we would do. That is what makes the biggest difference for these patients. The missing piece to some of our treatments with people with MS might be that sensory integration component, or that central vestibular system work. To identify these problems, we need to use central vestibular system outcome measures, and we need to look at the VOR cancellation and subjective visual vertical. We need to include a variety of sensory challenges to our treatments. We need to select exercises that turn on the inner ear, that make the eyes work, that improve proprioception, and challenge the way our patients with MS integrate all of this information. We need to be masters of dosing and scaling, loading up people in a progressive, stepwise manner, while respecting the limitations of their fatigue in order to see the benefits from these interventions. I hope this gave you just a little bit of a different approach to folks with MS that you might be seeing that have balance or disequilibrium. Hopefully you can start to apply some of these concepts a bit earlier in the trajectory of their disease progression. So imagine starting to treat someone in their 20s and 30s with this sensory based approach. Maybe you can work to stave off some of these limitations later in the course of their disease process. I think that's really exciting stuff. I hope that helps you out in your clinical practice. I hope you have a great rest of your Wednesday, and we really look forward to seeing you on the road with MMOA Live soon. Have a good one.

11:25 OUTRO
Thanks for tuning in to the PT On Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning 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.

 

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