Podcasts about clinical excellence

What actually makes a pelvic health business thrive?In this episode, we break down the Three Pillars of Business we teach inside the Business Accelerator: 1️⃣ Marketing + Sales 2️⃣ Business Systems 3️⃣ Clinical Excellence (getting buy-in and taking patients through their full plan of care)Most practices feel stuck because one (or more!) of these pillars is missing or weak. You can't out-market a broken patient experience. You can't build a team without systems. And you can't grow a sustainable business without getting the right people in the door.We talk about what goes into each pillar, common mistakes we see, and how to build a business you're proud of that actually works for your life.

Ankoor Shah, VP of Clinical Excellence at Included Health, joins Kellogg MBA student Sonia Salunke to unpack how Included Health is redesigning the healthcare experience. They discuss what it takes to deliver truly personalized, all-in-one care - blending virtual, in-person, and AI-driven support. From building an integrated care model that centers patient experience to enabling value-based care, this episode explores what the future of connected, tech-enabled healthcare could look like. LinkedIn Timestamps: (1:58) Ankur's background and journey to working in healthcare  (8:11) Overview on the personalized healthcare experience at Included Health (14:20) Understanding Included Health's customers and business model  (20:36) Unpacking the member-first culture at Included Health (22:36) The technical capabilities that drive the experience (27:12) When to deliver care in-person vs virtual vs AI-based  (30:42) Metrics to demonstrate success to members and customers  (38:00) Rethinking the pharmacy experience (42:06) Rapid-fire Q&A  Visit our podcast page for more episodes on trends and innovation in healthcare and follow our socials so you never miss an update. 

In this episode of Agile&Me, host Richard Leaver chats with Marla Ranieri, VP of Clinical Excellence at Prompt Therapy Solutions, about AI's transformative role in physical therapy. Marla shares her journey from physical therapist to innovator, exploring how AI technologies improve clinical practices. They discuss how AI tackles challenges like clinician burnout and reimbursement complexities while addressing concerns about data accuracy and compliance. Tune in to discover how AI is shaping the future of healthcare, enhancing patient care, and offering practical tools for integrating AI into physical therapy practices.To learn more about us, visit our website at https://www.allianceptp.com/

Dr. Corrie Jones, one of our sports residency instructors and our Director of Clinical Excellence answers the question:  What's the biggest realization you've come to as a physical therapy after school?  Having been practicing for nearly 14 years, Dr. Jones shares her insights as to what really makes the biigest difference in patient outcomes and executing a plan of care as a sports PT!Listen to find out what she says!

In this episode of 'Modern Chiropractic Mastery', Dr. Kevin Christie interviews Jeff Moore, a physical therapist from the Institute of Clinical Excellence and founder of Onward Physical Therapy Clinics. They discuss the nuances of leadership in private practice, the importance of mentorship, and how to cultivate conviction in clinical skills. Jeff shares insights into a fitness-forward approach to physical therapy, the structure of his cash-based clinic model, and the role of interpersonal skills in successful practice management. The conversation also delves into strategies to prevent burnout and the importance of skill stacking for career advancement. This episode offers valuable advice for chiropractors and physical therapists looking to enhance their leadership capabilities and practice efficiency. https://ptonice.com/https://onwardphysicaltherapy.com/

In today's episode, I'm joined by Brett Hawes — clinical nutritionist, functional medicine practitioner, and founder of The Academy of Clinical Excellence. Brett delves into the current political climate in Canada, focusing on the awakening of public consciousness regarding healthcare and government policies. We discuss the impact of the pandemic on people's perceptions, the flaws within the Canadian healthcare system, and the threats facing natural health products. The conversation emphasizes the importance of personal responsibility and the need for individuals to navigate the complexities of health and wellness in a rapidly changing world. Brett also discusses the control of health access by governments and corporations, the importance of reclaiming health sovereignty, and the necessity of building local communities for better health outcomes. They explore the political landscape, expressing concerns about disenfranchisement and the future of governance, emphasizing the need for self-sufficiency and personal responsibility in health and wellness.Buckle up friends, this is a GOOD one!!! Connect with Brett Hawes: The Academy of Clinical ExcellenceInstagramThe Onward PodcastSend us a textDon't forget to subscribe and leave a 5-star review.Send your questions & comments to: info.thewowpodcast@gmail.com You can also share it on your social media and tag me @the.wowpod & @iam.drkaylalucasJoin us inside The Faithful Well Broadcast Thank you so much for being a part of the WOW pod community; until next time! Lead with love and joy!

In this episode we dive into the huge value of mentorship!  Anyone with a growth mindset can appreciate the fact that we do NOT know it all.  It takes a community to share knowledge in order to grow and become better at a craft or profession.  Here, our Chief Clinical Officer, Dr. Zach Baker and our Director of Clinical Excellence, Dr. Corrie Jones, share thoughts about mentorship. In this episode they cover:How to progress past what DPT school teaches The need to structure knowledge and how mentors can help with thisMentorship to improve applying our knowledge in the clinical settingWhat needs to be in place for a mentorship to workWho should participate in mentorship?Shoulder mentorship be mandatory?The ability of mentorship to evolveThis is a huge way to improve employee retention and satisfaction as well as improve patient outcomes and remain up-to-date on evidence-based practices.  Hear what they have to say!

Nurse educators are critical to clinical excellence, staff confidence, and patient safety. But are they being leveraged effectively? Join the co-hosts for a candid conversation about their personal experiences, perspectives, ideas, and tips for optimizing your collaboration with nurse educators.    We'd love to hear from you!  Send your thoughts, reactions, and ideas to amsnpod@amsn.org    Also, be sure to SUBSCRIBE/FOLLOW, RATE, & REVIEW Med-Surg Moments wherever you listen to podcasts.    MEET OUR CO-HOSTS Samantha Bayne, MSN, RN, CMSRN, NPD-BC is a nursing professional development practitioner in the inland northwest specializing in medical-surgical nursing. The first four years of her practice were spent bedside on a busy ortho/neuro unit where she found her passion for newly graduated RNs, interdisciplinary collaboration, and professional governance. Sam is an unwavering advocate for medical-surgical nursing as a specialty and enjoys helping nurses prepare for specialty certification.    Kellye' McRae, MSN-Ed, RN is a dedicated Med-Surg Staff Nurse and Unit Based Educator based in South Georgia, with 12 years of invaluable nursing experience. She is passionate about mentoring new nurses, sharing her clinical wisdom to empower the next generation of nurses. Kellye' excels in bedside teaching, blending hands-on training with compassionate patient care to ensure both nurses and patients thrive. Her commitment to education and excellence makes her a cornerstone of her healthcare team.   Marcela Salcedo, RN, BSN is a Floatpool nightshift nurse in the Chicagoland area, specializing in step-down and medical-surgical care. A member of AMSN and the Hektoen Nurses, she combines her passion for nursing with the healing power of the arts and humanities. As a mother of four, Marcela is reigniting her passion for nursing by embracing the chaos of caregiving, fostering personal growth, and building meaningful connections that inspire her work.   Eric Torres, ADN, RN, CMSRN is a California native that has always dreamed of seeing the World, and when that didn't work out, he set his sights on nursing.  Eric is beyond excited to be joining the AMSN podcast and having a chance to share his stories and experiences of being a bedside medical-surgical nurse.   Maritess M. Quinto, DNP, RN, NPD-BC, CMSRN is a clinical educator currently leading a team of educators who is passionately helping healthcare colleagues, especially newly graduate nurses. She was born and raised in the Philippines and immigrated to the United States with her family in Florida. Her family of seven (three girls and two boys with her husband who is also a Registered Nurse) loves to travel, especially to Disney World. She loves to share her experiences about parenting, travelling, and, of course, nursing!   Sydney Wall, RN, BSN, CMSRN has been a med surg nurse for 5 years. After graduating from the University of Rhode Island in 2019, Sydney commissioned into the Navy and began her nursing career working on a cardiac/telemetry unit in Bethesda, Maryland.  Currently she is stationed overseas, providing care for service members and their families.  During her free time, she enjoys martial arts and traveling. 

Dr. Corrie Jones, Director of Clinical Excellence at Rehab 2 Perform discusses how to put your students in the best situations for success. It is always fun having students in the clinic and helping them navigate their personal journey on their path to becoming a physical therapist. With this priviledge, comes responsibility. Dr. Jones talks about how you can foster and facilitate a productive and positive learning environment.

Generally, the definition of success may vary, but in the world of dentistry, patient care, profitability and operational excellence are measures of success that every business is trying to achieve. In the latest episode of The Dental Economist Show, host Mike Huffaker welcomes Eric Pastan, Director, Skytale Group, and a former DSO owner, who scaled his business to 45 locations. Together, they take from Pastan's wealth of experience to explore the critical elements of successful dental organization growth. From insights on maintaining clinical excellence while scaling operations to the importance of data analysis done right, and how to prepare your organization for eventual transactions, this episode highlights the keys to dental success, in today's day and age. Tune in to discover how, sometimes, the best path to growth starts with sitting at the front desk!

This special episode is recording of our recent event, Connecting Physical Therapy with Community Fitness for Older Adults. This event featured an incredible panel of experts dedicated to helping older adults stay strong, active, and resilient long after being discharged from physical therapy.The panel included four specialized physical therapists—Lori DeShelter, Teresa Gingles, and Betsy Spieler, all recruited from the Institute of Clinical Excellence (ICE) Older Adult division—and returning guest Susan Frikken. Joining them was Linda Cantrill, a seasoned fall prevention specialist who collaborates closely with physical therapists to support clients in maintaining their mobility and preventing falls.You'll hear from the panelists about how they've successfully bridged the gap between clinical and community settings through collaboration, sharing real-life examples of what works and how we can all contribute to keeping older adults socially engaged and physically active.This event was inspired by a paper co-written by Jeff Musgrave, a past podcast guest and a faculty member of the ICE Older Adult courses titled “Transforming Lives with Group Fitness: Considerations for Rehabilitation Professionals.the panelists emphasize the importance of warm handoffs, proactive communication, and building trusting relationships between healthcare providers and fitness specialists. They share key initiatives and actionable strategies to connect the physical therapy and fitness worlds—all with the shared mission of helping older adults thrive.Links: Institute of Clinical Excellence: https://ptonice.com/ Transforming Lives with Group Fitness: Considerations for Rehabilitation Professionals paperYouTube recording: https://youtu.be/kOcoO7nC4cI?si=xf5Vf0WwMe4Ahvp-Contact information on panelists:Susan Frikken, DPT, LMTwww.yaharatherapy.comwww.ballroombasicsforbalance.orgsusan@yaharatherapy.comTeresa Gingles, PT, DPTBoard Certified Geriatrics SpecialistBetter at Last,Founder/Executive Directort.gingles@betteratlast.orgwww.betteratlast.org Lori DeShetler, PT, MSPT, OCS, NBC-HWCBoard Certified Orthopedic SpeicalistOhio State Wexner Medical CenterLori.Deshetler@osumc.edusportsmedicine.osu.edu Betsy Spieler PTBoard Certified Geriatric Clinical SpecialistFounder/Coach UBStronger 55+www.ubxomaha.com Linda CantrillFounder Spirited Balance LLC Aging Specialist, Fall Prevention, Pilates, Senior FitnessWebsite: www.spiritedbalance.comemail: balancinglindac@gmail.comConnect with Second Act Fit Pros:erin@secondactfitpros.comwww.secondactfitpros.com

While she loves working with patients of all ages, Dr. Link realized early in her career that busy working adults were a severely underserved population. Dr. Link feels incredibly humbled to be growing a community where hearing loss and hearing aids are no longer stigmatized. You will be celebrated no matter where you are on your hearing journey. She loves looking at you as a whole person and empowering you to tackle the unique challenges you present to her. You can be sure that you will receive personalized evidence based care from Dr. Link while learning from one another.Dr. Link grew up on her family's farm in Ohio and received her Bachelor of Science degree from Miami University. Having grown up on a farm, she is passionate about preventable noise-induced hearing loss. Dr. Link earned her Doctor of Audiology degree from Rush University in Chicago, one of the top 10 audiology schools in the country. She was awarded a Distinction in Clinical Excellence at graduation. Dr. Link cultivated her clinical excellence through mentorship from some of the top audiologists in Chicago in a variety of clinical settings including university hospitals, the VA hospital, Chicago community hospitals, ENT clinics, a hearing aid research and development center, and the Ann and Robert H. Lurie Children's Hospital.When not practicing audiology, Dr. Link finds joy in biking, skiing, and live music in the great outdoors. When she cannot get away to the mountains you can find her catching up on her favorite podcasts, sipping American pale ales, and challenging her family and friends to a competitive game of Ticket to Ride, Mancala or Kings on the Corner.Website: https://www.theaudiologymethod.com/Facebook: https://www.facebook.com/TheAudiologyMETHOD*************************************************************Judy is the CEO & Founder of the Judy Carlson Financial Group. She helps her clients design, build, and implement fully integrated and coordinated financial plans from today through life expectancy and legacy.She is an Independent Fiduciary and Comprehensive Financial Planner who specializes in Wealth Decumulation Strategies. Judy is a CPA, Investment Advisor Representative, Life and Health Insurance Licensed, and Long-Term Care Certified.Judy's mission is to educate and empower her clients with an all-inclusive financial plan that encourages and motivates them to pursue their lifetime financial goals and dreams.Learn More: https://judycarlson.com/Investment Adviser Representative of and advisory services offered through Royal Fund Management, LLC, an SEC Registered Adviser.The Inspired Impact Podcasthttps://businessinnovatorsradio.com/the-inspired-impact-podcast/Source: https://businessinnovatorsradio.com/the-inspired-impact-podcast-with-judy-carlson-interview-with-dr-julie-link-founder-owner-the-audiology-method

Daniel Laheru , MD, is the Professor of Oncology and Co-Director of Skip Viragh Center for Pancreatic Cancer Research at the Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital. He holds the Ian MacMillian Professorship in Clinical Pancreatic Cancer Research. Dr. Laheru has developed a vaccine along with Dr. Elizabeth Jaffee, that supercharges the immune system and causes immune cells, which tend to be tolerant of cancer, to seek out and kill pancreatic cancer cells throughout the body. He is a Member of the Miller-Coulson Academy of Clinical Excellence, Member of Bloomberg-Kimmel Institute for Cancer Immunotherapy, and Associated Director of the Institute for Convergence Science.  “There's no job that's insignificant here. Whatever you're doing, you need to do it to the best of your abilities.” A monumental lesson from Dr. Daniel Laheru's parents taught him to notice the janitor who moves by silently in the corner, the nurse who works overtime without appreciation, and the security guard who passes a silent glance at every passerby. In this episode of The Medicine Mentors, Dr. Daniel Laheru explains recognizing the interconnected nature of every person's role in the infrastructure of medicine, instilling gratitude in our practice, and paying it back by paying it forward. Pearls of Wisdom:   1. Enjoy the time that you're a student because you'll wonder what you did with all your time after. The future is entirely open to you, the ceiling is what you make it. 2. I'm happy doing what I'm doing right now, and if I can do this five years from now, I'll be ecstatic.  3. The fellows, residents, and medical students are the lifeblood of the institution and the next generation so don't be shy about asking somebody if they have time to meet with you.  4. A good mentor is like a parent in the sense that they put your goals ahead of their own. My mentor really saw my future before I was able to understand it for myself. 5. The little things in the course of a day actually make a big difference. Thanking and appreciating someone goes a long way. 

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Dry Needling division lead Paul Killoren discusses the important considerations when choosing dry needling education. As the founder of iDryNeedle and the division lead at the Institute of Clinical Excellence, Paul shares his extensive experience in the field, having taught dry needling for over a decade. He addresses common questions and concerns about training options, emphasizing the need for unbiased evaluation of different educational programs. Whether you're a student physical therapist or a professional in a newly accepting state, this episode provides valuable insights into navigating the diverse landscape of dry needling education. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling, Lower Body Dry Needling, and Advanced Dry Needling.

In this solo episode, Tracy explores the critical mindset shifts healthcare providers need to make to transform their practices from survival mode to thriving businesses. She introduces the concept of the "practitioner's paradox" - where the very mindset that makes someone an excellent healthcare provider can actually hinder their success as a business owner. Through real-world examples and practical frameworks, Tracy explains how practitioners can transition from working in their business to working on their business, without sacrificing the quality of patient care. Key Concepts: The Practitioner's Paradox: How clinical excellence mindset can limit business growth The hidden costs of burnout on business decision-making The Owner's Mindset Shift: Moving from "how can I do this better?" to "how can this be done better without me?" Practical Tools Introduced: The Energy Audit: A simple weekly tracking system marking activities as energizing (+) or draining (-) The Owner's Hour: Dedicated time for high-level strategic thinking Imperfect Delegation: Learning to accept 80% perfect execution from team members Case Study Highlight: The episode features "Sarah," a neuropsychologist struggling with perfectionism and overwhelming workload, illustrating how mindset shifts can transform both practice management and quality of life. Key Takeaways: Success in healthcare practice has less to do with clinical expertise than business mindset Burnout is not the inevitable price of success The most profitable practices are often led by owners who maintain work-life balance Delegation and systems thinking are crucial for sustainable practice growth Moving from "working harder" to "working smarter" requires intentional mindset shifts Download Your Energy Audit here. Tracy's Bio:  Tracy Cherpeski, MBA, MA, CPSC, is an executive coach and leadership development expert. Her mission is to unlock the potential for success in every individual and organization she works with. With a background in operations and a passion for driving growth, she approaches each engagement with professionalism and a keen eye for optimizing structures, processes, and productivity to boost profitability. Tracy's coaching, consulting, and training programs are designed to provide a holistic experience, integrating leadership development, executive coaching, and mindset mastery. Her expertise has been sought after by small business owners, industry groups, networking organizations, government agencies, and corporations alike. Originally hailing from the Pacific Northwest, Tracy now calls Chapel Hill, North Carolina, her home. Wherever she goes, her commitment to helping people and organizations reach their full potential remains unwavering. Connect With Us: Be a Guest on the Show Thriving Practice Community Schedule Strategy Session with Tracy Tracy's LinkedIn Business LinkedIn Page Thriving Practice Community Instagram

Dr. Amit Gosalia is a well-renown Los Angeles-based audiologist with over 20 years of experience. Having served as President of the Arizona Speech-Language-Hearing Association and Chair of the American Academy of Audiology's Public Awareness Committee. In 2024, he received the Clinical Excellence in Audiology Award from the American Academy of Audiology. He co-founded AudBoss, a platform supporting private practice audiologists in business management and professional development, and has since developed one of the most influential groups for Audiologists in the world. In this interview, recorded in November 2024 - he joined me to share his story, how he found himself in Audiology, how he grew and exited his first practice (with the biggest lessons behind it) and where the future of Audiology is heading.

Why is it so important to get all three of these pillars - Marketing & Sales, Business Systems, and Clinical Excellence - right for a well-running business?In this 'sode we discuss the three main pillars of business.  If only one or two of these are working well, the business is going to take a lot of effort and always feel precarious.Marketing & Sales - If you don't have a consistent source of leads and are always worried about getting the phone to ring, marketing your practice is vital.  We need a systematic plan for marketing to avoid dips and the 'rollercoaster' of business.Business Systems - If you're feeling overwhelmed or burned out, it's usually because you're lacking systems.  We often make up for poor systems with more work and late nights, but that's not sustainable.Clinical Excellence - If you're having patients drop off, space out their visits, or stop coming in because 'it's expensive', we aren't getting the clinical buy-in necessary.When all three of these are working well, the business gets much easier to run, grows faster and is actually fun to work in!Accelerator Program - Registration Opens Dec 12th!If you know one - or more - of these areas needs work, consider joining us for the January cohort of the Business Accelerator Program!  We've helped 300+ business owners grow their practice and build a business that truly works for them.  You can see all the details and real-world results at www.pelvicptrising.com/accelerator.About UsNicole and Jesse Cozean founded Pelvic PT Rising to provide clinical and business resources to physical therapists to change the way we treat pelvic health.   PelvicSanity Physical Therapy (www.pelvicsanity.com) together in 2016.  It grew quickly into one of the largest cash-based physical therapy practices in the country.Through Pelvic PT Rising, Nicole has created clinical courses (www.pelvicptrising.com/clinical) to help pelvic health providers gain confidence in their skills and provide frameworks to get better patient outcomes.  Together, Jesse and Nicole have helped 600+ pelvic practices start and grow through the Pelvic PT Rising Business Programs (www.pelvicptrising.com/business) to build a practice that works for them! Get in Touch!Learn more at www.pelvicptrising.com, follow Nicole @nicolecozeandpt (www.instagram.com/nicolecozeandpt) or reach out via email (nicole@pelvicsanity.com).Check out our Clinical Courses, Business Resources and learn more about us at Pelvic PT Rising...Let's Continue to Rise!

With 23 years and counting in CDI, Rhoda Chism has seen a lot. The rise of new regulations and reimbursement mechanisms, and the advent of new technologies that have radically transformed chart reviews.  Rhoda has not only weathered these changes and navigated the turbulent waters, but remains as warm and personable, and pro-person, as you will ever meet.   But not anti-technology.  Today she is the Director of Clinical Excellence and Adoption for the software company Iodine, a new position she's held for just two months. But I think she could be called Chief People Officer.  We get into the blending of human and machine, discussing the following:  Rhoda's journey into healthcare and nursing at the tender age of 19.  The transition from bedside nursing to CDI in 2001  Melissa Varnavas and the lasting impact of a simple message of encouragement and belief  Using authentic, personal stories to communicate difficult CDI concepts and education, including heart failure and AKI  How technology has radically transformed CDI over the last two decades  AI driven technology as human amplifier, not replacement, and the importance of emotional intelligence in CDI work  Career advice for young professionals in a world of rapid change 

In this episode, Christina Moore, Senior Director of Clinical Excellence at IndyVets, shares her journey from practicing veterinarian to transformative leader in the veterinary field. Christina dives into her concept of “vibes” in the workplace—how the energy we bring shapes team dynamics and morale. Through personal stories, including a defining moment with an empathetic leader, Christina reveals the power of compassionate leadership, burnout prevention, and personalized mentorship. Join us to explore actionable insights on creating a supportive, high-energy workplace that empowers every team member to thrive. Additional Resources: Learn more about Skutvik Consulting Learn more about workvibes Check Your Vibe  Follow PeopleForward Network on LinkedIn  Learn more about PeopleForward Network Key Takeaways: Adapting Work Environments to Combat Burnout: The veterinary profession, much like other healthcare fields, is prone to burnout, but innovative solutions like flexible scheduling and personalized support have transformed Christina's impact on this field. Redefining Accountability through Empathy: Christina has created teams where people willingly take accountability by feeling seen and valued, showing how empathy can fuel productivity and self-accountability. Personalizing Leadership Approaches: By understanding the unique needs and goals of each team member, Christina demonstrates how to foster an inclusive, engaging, and fulfilling work environment.

Tuesday, October 22, 2024 First Principles Genetic disease means that gene broken since conception. Novel medicines are possible ways to fix the gene - Genetic Therapies (ASO &/or AAV), this is recent, before now, kids with these diseases were a “go home and love them” situation. These are delivered via spinal tap or directly to the brain in leading medical centers. First though, regulators must approve.   Our job Develop medicines or get industry to - This is happening see Pipeline Get regulators to approve trials Get medical centers up to speed on SYNGAP1-Related Disorders (SRD) What we are building on CHOP ENDD funded externally (see #S10e92) and replicating what was built for STXBP1, check last week's webinar https://curesyngap1.org/resources/webinars/93-endd-chop-2024-syngap1/ Rare-X platform for PRO collection Regulatory pathway being made clearer every day by Stoke (Dravet), Praxis (SCN2A), Ionis (many) all of whom are working on SYNGAP1 as well.   What we are asking for We need to raise at least $500k (3rd site), preferably $1.13M (ProMMiS) Make your largest gift ever to SRF Fundraise with friends and family ACES is now ProMMiS, who knew ACE meant Adverse Childhood Event, not us. Key slides: S1 Path to Treatment | 2024 (09.27.24) 1. Why Now?  Why is it time to go from bench to bedside (research to clinical)? At least 10 companies on our pipeline not to mention multiple small molecule efforts We have limited resources – so the focus has to transition, clinical funding first. CHOP Gift is 1 year down… 2. Why NHS?Understand SYNGAP1 better, go beyond Vlaskamp 2019 and Wiltrout 2024, see #S10e105  FYI at CHOP, as I shared in #S10e151, at year 1, we are at  – 86 (Visits) + 10 (new scheduled) + 19 (2nd) + 4 (3rd)  + 22 (follow up)  Learn what to measure in clinical trials for SRD, remember our seizures are challenging Ideally we develop a Synthetic Control Arm if we use GCP Why top shelf?  We need institutions the FDA will take seriously and our children are very complex requiring experienced clinicians.  3. Why Multidisciplinary. Neuro, Psych, Genetics, PT, ST, OT, GI, Sleep, ENT, Ortho. Beyond the sheer burden of getting our kids out and about for multiple appointments the coordination by a parent is almost impossible.   4. Why Multisite/3 sites?Replicable/scalable required by regulators Accessibility (not primary reason) Establish more locations where trials will be managed Laying a foundation for a national self-sustaining network 3 is the minimum, look at STARR or Angelman, both had/ve 4. 5. How and why so fast? Because we can.  Time is Brain. Following a well trodden path SMA, Rett, Angelman, Dravet, but we are moving FASTER. 6. Does the industry really care? We are next there are so so many behind us, eager to take the resources we have access to today. Market size (Per our Census 425 US/1500 global is tip of iceberg) Multiple players reassuring each other Relatively strong amount of scientific and clinical research Haploinsufficiency (like Dravet – STOKE) – so relatively easy 7. Expensive? No. Clinical Research is more expensive than basic scientific research. Leveraging CHOP and Rare-X, setting up required networks to prepare for clinical trials.  It's time. 8. Why Bother/Help? Now is the time for SYNGAP1, we miss it at our peril. Sure, once in these places we will still see our patients, but the study, the support and the focus may pass. Our kids don't die, regardless of patient age, what we are doing can change their future and that of their loved ones and caregivers. If not us, then who? It is a rare exception when a non-family member gives a gift, and it is always because a family member asked.  We must ask. 9. What can I do? Donate to, share, join our Coast2Coast Clinics Challenge – two SYNGAP1 Squads in West and East – it's critical $500k goal by end of 2024; more than $1M needed just for the SYNGAP1ProMMiS. So far, donations from $25 to $25,000 – each and every contribution matters. This requires our entire S1 network to solicit family, friends, work colleagues, companies, etc. to contribute. Many causes out there – why not ours? Syngap.Fund/C2C   https://Syngap.Fund/C2C > https://secure.givelively.org/donate/syngap-research-fund-incorporated/coast2coast-clinics-challenge   Two teams:  https://Syngap.Fund/West & https://Syngap.Fund/East

In this VETgirl veterinary continuing education podcast, we interview Dr. Marisa Brunetti, VMD, Chief Veterinary Officer and Dr. Christina Moore, DVM, MBA, Senior Director of Clinical Excellence at IndeVets. We're talking about importance of and need for a good system of support for veterinarians. Remember vet school when you were constantly surrounded by support, medical expertise, compassion, and a community of people who shared your passion? We'd probably get more than a few raised hands if we asked a room full of vets if, by contrast, their days now had a lot more isolation and frustration, and a lot less support and collaboration. That's why, seven years ago, Dr. Brunetti helped create IndeVets on three firm conditions that created a radical change from what's become the accepted standard in the vet industry. Join us as we hear from Drs. Brunetti and Moore about the radical support they provide for their vets so they can do what they love with the support they deserve.Sponsored By: IndeVets

“Defensive Dentistry and the fear culture is the number 1 cause of anxiety amongst Dentists” How can we instead foster a culture where we can focus on growth and supporting each other? Does Dentistry have a social media problem? https://youtu.be/wsiENbuIXcE Watch IC053 on Youtube Join us on this episode with Dr Mehy Lo-Presti as we navigate dentistry and social media, the pros and cons of using the online world as part of our portfolio and how we can remove anxiety through effective communication. 2 Events to Attend: DentoRama 18th October Treatment Planning Symposium (Hybrid Event) 16th Nov Highlights of this Episode:02:05 Introduction - Dr Mehy Lo-Presti06:42 Mehy Early On12:04 Dento-Rama15:30 Social Media in Dentistry20:35 Life Before Social Media21:25 Social Media is a Business 23:40 What Causes Anxiety for Dentists?29:45 Overcoming the Fear Factor34:45 Fast Tracking to Success41:20 Wrapping Up47:14 Booking the Event and Getting in Touch This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance. GDC LEARNING OUTCOMES: A AGD Code 770 (Self Improvement) Dentists will be able to: Gain insights into how social media affects clinical practice, patient perceptions, and professional image, learning how to use these platforms responsibly. Manage the pressures of online validation, minimising the impact on their mental health and maintaining a healthy work-life balance. Develop stronger communication methods both online and offline, ensuring clearer patient education, reducing complaints, and fostering better relationships within the dental team. For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. This includes videos on Overlay preps and the famous 'Vertipreps for Plonkers' series. If you liked this episode, check out IC035 - Best Practices in Social Media for Dentists

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore breaks down how purity culture and pelvic floor dysfunction are linked, and ways we can empower and educate women to reduce dyspareunia Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION RACHEL MOOREGood morning, guys. What is up? Happy Monday morning. My name is Dr. Rachel Moore, and I'm hopping on this morning representing our pelvic crew to dive in and talk about a topic that's pretty near and dear to my heart in the area that I live in in Texas. We're going to be diving into purity culture and the pelvic floor. So if you're not familiar with what purity culture is, it is a set of beliefs that really focuses on promoting abstinence for sexual health and well-being and kind of involves a lot of feelings of shame or guilt or even fear focused around sexual functions and sex as a whole. So we know that sexuality in and of itself is biologic and it's instinctual. But there are a lot of overtones and a lot of components of sexuality and the development of sexuality that come from culture. Culturally embedded meanings are just kind of rampant in this space. And we see that one really large cultural component that can lead to issues with the pelvic floor, like dyspernia or vaginismus, is this topic of purity culture. We have studies that have looked at this in a lot of different countries. And what we see is that countries that really emphasize sexual purity hone in on and focus in on male sexual satisfaction over female cultures that emphasize like virgin brides and have a lot of societal contracts or context in place to eliminate or reduce premarital sexual relations have higher rates of vaginismus and dyspareunia. We know that societies that suppress female sexuality have higher rates of pelvic floor dysfunction that are associated with pain with intercourse. In order to understand all of this, we really need to understand purity culture in and of itself and understand kind of the component pieces and things that go into dyspareunia and vaginismus. So we already honed in on what purity culture is just a little bit. A lot of times purity culture is in theory linked with religiosity. And I see that in my area of Texas. I'm in a very conservative part of Texas and I've seen a lot of patients with vaginismus and with dyspareunia that were raised in a very religious household and have a lot of certain feelings and ideals and beliefs around sex and sexuality that are went kind of hand in hand with that is the common thought. However, we actually have a case study that looked at the link between religiosity and dyspareunia and vaginismus. And it was a 2020 case study that sent out a survey to 901 women. 19% of them had pain with intercourse. So dyspareunia or pain with intercourse And what they found is that religiosity was actually not linked with the presence of dyspareunia or vaginismus, whether it was current religiosity or previous religiosity, the way they were raised. But what they found is that the attitudes and connotations around sex and sexuality in and of itself is actually what was linked with that presence of pain with intercourse. So really kind of debunking this idea that religiosity and pain with penetration and intercourse go hand in hand. I think purity culture in and of itself gets linked a lot with the religiosity or that highly conservative group, but it's not necessarily because of the religion aspect. It really boils down to the education that we provide women about their bodies and the attitudes and beliefs about intercourse and sexuality in and of itself. There's actually another study that was done. It was another study that surveyed women that had vaginismus and they asked them, like, what are the reasons or what are the things that kind of led up to this happening? And what they found is that the number two reason for vaginismus was a negative attitude or a negative connotation around sex and sexuality as they were raised. And the number one reason was fear of pain with penetration. So that's pretty powerful that the way that we are taught about our bodies and the way that we are taught about sex and sexuality can have long lasting effects on the rest of our lives as females. It's really interesting because we used to think back in the day before women's health was really studied that vaginismus was just a purely motor response, right? Like with the penetration, these muscles tense up and they spasm and therefore penetration is painful and uncomfortable. and women are not able to have intercourse or are not able to enjoy intercourse. But just like every other realm of physical therapy, we're really diving into all of these different subsets of this diagnosis as a whole. And what we're finding is that the biopsychosocial piece of this is massive. The way that we are taught about our bodies, the way that we are taught about intercourse, the way that we are taught to feel about our natural desires and sexual urges can lead to a physiologic response that is outside of our control. So our pelvic floor has a protective reflexive mechanism when we are stressed or scared, and that protective reflexive mechanism can be maladaptive. But if we're taught from a young age that sex is shameful and that our bodies are something to be ashamed of, or maybe they only serve one purpose and that is only for reproduction and you're not trying to have sex to reproduce, then that can cause this reflexive reaction to kick in, where those muscles tighten and tense up. Even if you do all of the relaxation work in the world, and even if you do all of the things to stop it, that ideal is really deeply ingrained. And so that really leans into a lot more psychological work that needs to be done, not necessarily the physical work. so with that being said kind of segue into how can we help because we can't obviously go back in time and change the way that somebody was raised or change the way that somebody feels about sex and sexuality necessarily from their childhood or from the way that their parents raised them so as pts when we see this diagnosis walk in we see somebody come in who Has pain with intercourse and has or has dyspnea has vaginismus any other sexual condition? That is linked with pain or the inability to have or enjoy intercourse We want to start thinking about this in the back of our mind like this needs to be a way a topic that we come across maybe not necessarily directly asking like how were you raised to view sex and but it's something that we want to kind of keep in our back burner because if this is on board, then it's going to require a lot more collaborative care and it's a great opportunity for us to partner up with a mental health therapist in our area and really refer out and make sure that we're hitting this from all angles. One of the biggest things that we can do as pelvic PTs is educate. It is insane how many people are not educated about their bodies and especially in this purity culture realm, There's a lot of misinformation and miseducation and wrong education that is done that is really kind of focused or driven out of fear. And there's a lot of just lack of education. Women aren't taught about their bodies at all. And if we think about that, if you knew nothing about this area at all and something was going wrong, you would probably start panicking a little bit. It seems silly to reference it to our shoulder because we all obviously see our shoulders and know about our shoulders and For the most part, even if you have no anatomical knowledge, kind of get a sense of like, it does this, it does this, it needs to do all these things. But that's not true about our pelvic floor. Especially in cultures where purity is really honed in on, nobody is talking to women about the proper way to clean their vulvas. people aren't talking to women about the number of holes. Most of these cultures are not, absolutely not teaching about clitoral stimulation and female orgasm. And so keeping that in mind, like not knowing something can lead to a lot of confusion and fear when we do start having sensations of discomfort or pain. So educating in and of itself can be huge. Educating about the anatomy, we have three holes down there in a female pelvis. There are a lot of adult women that do not know that they have three holes. That in and of itself is a large piece of education. Educating them about how our pelvic floor works, what its functions are, how it aids in sex and sexuality, and the ways that we can really kind of lean into that and make sex or make the pelvis in and of itself not even sex, but the pelvis demystified. so that they're not looking at this area as a big black box with a question mark over it. And they have an understanding of the functions and the basic ways and inner workings of their own bodies. The other thing that we can really hone in on is working on parasympathetic drive work. So working on relaxation work, helping them get out of this fight or flight response. This is something that we can start in pelvic floor PT for sure and is a great way to partner with a local therapist or counselor or somebody that is trained in working with people with Sexual dysfunctions because a lot of this comes down to like taking a lot of steps back So we're not even talking about like let's relax while you're about to have intercourse we're talking about like let's lay in bed next to your partner and Hold hands and practice relaxing and then let's talk about maintaining that as your partner touches your leg and just kind of working in on these component pieces and Sometimes it's even like, let's go all the way backwards, just you. Like your partner is not even a piece of this puzzle. Let's talk about ways that you can get comfortable with your own body so that you can go into this partnership and this relationship with a degree of comfort and understanding, and it's not about this other person at all. finding a counselor or a therapist in your area, or maybe not in your area, but virtually, that is somebody that you trust, that can help guide this path. We can absolutely help. We can be a facilitator of that. But the great thing about having that mental health component is they can really kind of go back a little bit farther and more in depth than we can, because they're trained in that, to really break down those beliefs and talk about ways to rebuild that from a psychological level. And then we can go in, with that happening and align that with the physical piece. So kind of bridging those two pieces together so that we're getting this complete rehab component. A lot of the times in this population, the assumption is like, oh, we just need to work on strengthening other areas or whatever. But I think that in the sense of vaginismus, absolutely, we always are promoting strength training our hips and strength training our core and making sure that the muscles around our pelvis are strong and supporting the pelvic floor. So the pelvic floor isn't becoming the hero and becoming super tense and tight in a response to that. But especially when we're thinking about vaginismus, we're really looking at like the attitudes and core beliefs and the situation around the intercourse or the act that is causing that vaginismus to occur in and of itself. So we always can layer those things in. We love that, but really focusing in on that relaxation and finding ways to promote that relaxation paired with education and partnering with a provider that we trust that can help address the psychological component. We know, we have surveys that show that women that are raised in households where the mother had negative views about sex or negative beliefs about sex or talked negatively about it, have higher rates of vaginismus and dyspnea, which is wild to me. It makes sense when we think about it. You know, we always talk about how our kiddos are really mirroring the things that we say and we do in the way that we act. So as adults in and of ourselves, not necessarily even in the PT realm, But making sure that the way we talk about these functions is in a way that is not promoting shame or fear. I think that again purity culture is often linked with religion and so you have kind of these two sides and this can be a really polarized topic. And I think no matter what you believe, the big goal is that at the end of the day, our young women need to understand how their bodies work, they need to understand the functions of their bodies, and then they need to understand what sexuality means. In whatever way it is that we believe that, making sure that sexuality isn't seen as something that is really driven in shame or driven in fear, but it's something that is celebrated because at the end of the day, it is one of our basic biologic functions that we all need in our lives. And so making sure that we are setting our future generations up for not having these pelvic floor dysfunctions down the line. providing education at a community level in any way that you're able to can also be really wonderful. We've set up before like a mom and daughter workshop where we literally just talked about like, this is the pelvic floor, and this is the way the menstrual cycle works, and this is the way the pelvic floor functions, not diving into this is how you have sex, but base knowledge. That base knowledge can be so powerful in a community that doesn't have that knowledge. i hope you guys enjoyed this i hope that this hit a chord with you maybe especially if you're in an area where you're seeing a lot of patients that come in that are raised in cultures where sex is seen as shameful and seen as something that is not to be celebrated and is um maybe fear-based so um SUMMARY If you guys are interested in hopping into one of our courses in the pelvic division we talk a lot about pelvic pain in our l2 cohort which we have seats available for that october cohort coming up we just started our second cohort of the year so that one is kicked off We've got one more cohort of L2 coming up at the end of the year, so if you want to hop into that, look at that online. We've got L1 coming up in two weeks, and then we've got a lot of courses coming up in the end of the year. We are rounding out quarter four with tons of courses. We're on the road a lot. We're all over the United States, so if you are interested in hopping into one of our Pelvic Live courses, go to the website, PTOnIce.com, get into one of those courses. We can't wait to see you on the road. Have a great rest of your Monday, and I'll see you guys around. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the difference between myofascial decompression & cupping, if myofascial decompression works or not, and how to elevate the use of myofascial decompression in practice Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLMyofascial decompression. What is it? How does it work? Does it work? And how can you elevate what you're currently doing practice if you're already implementing this style of soft tissue treatment? WHAT IS MYOFASCIAL DECOMPRESSION? So let's take it from the top and let's talk about what is myofascial decompression, sometimes abbreviated MFD. and how is it different from cupping? So you may consider these in your mind to be synonymous and that is very very wrong. Why? Calling myofascial decompression cupping is really a misnomer because if we dig deep people have been cupping each other for many many many thousands of years. It comes from eastern medicine and you may have seen it in practice, maybe you do it in practice, maybe you've seen it on social media or the internet, and you see people laying in a static position, sometimes with their whole body covered in plastic or glass cups, right? And so that is cupping, that is sitting in a static position, that is using things like meridian or chi points, the idea that maybe we're removing toxins from the body, and you may even heard of something called wet cupping, where we pull blood to the surface with a cup, and then maybe we puncture it with a needle or a knife and we draw blood out of people. So all of that is kind of in the sphere of the term cupping. And what's very, very, very different about myofascial decompression is that we are using some sort of pump, manual or automatic, to get a decompressive effect through the tissue. And in the context of myofascial decompression, we are always, always, always, always, including movement. We are never having people lay statically with just cups on their body. We are not educating them that we're removing toxins from their body or altering their chi or anything like that. And certainly, hopefully, you are not cutting people open and using the decompressive pressure of the cups to suck blood out of their body, right? And so that is the difference between cupping and myofascial decompression. Both use plastic or glass cups, but they come from very, very different paradigms in why we're using it, what we're doing, and the effect that we're hoping to have. So with myofascial decompression, we know now with MRI studies that when we put these cups on, if we have enough pressure, we know that we can put hundreds of millimeters of mercury of pressure through this cup, and that we can sometimes reach the level of the bone. And so we are decompressing not only just the skin and the fascia beneath the skin, but down to the level of the muscle, fascia between levels of muscle, and even deeper levels of muscle all the way down to the bone. And so thinking about the various levels, when you look at your forearm, for example, what is between you and the outside layer of your skin and the bone? Several layers of tissue. We have our epidermis, we have our dermis, we have super fascial tissue and fascia, we have deep fascia, and then we get into the fascia in and around the muscle. We have the epimysium, we have the paramycium, and we have the endomysium. And that we know with a large enough cup and enough pressure from one of our pressure guns that again we can reach the level of the bone. So we're using higher pressures combined with movement to create this decompressive and sometimes sheer force effect on the tissue, combining the decompression with the movement, that is myofascial decompression. And that is how much different it is from traditional maybe Eastern medicine, quote unquote, just cupping. So the second question that we often get and the second point I want to make is often, does it work? There is a lot of myths on social media and the internet that this is not doing anything, that this could never cause a change in tissue. and that is team Patently Untrue. Certainly, if you do this wrong, you can be very ineffective with this style of treatment, but if you do it right, it can be very, very effective. So I wanna give a shout out to Dr. Chris DiPrato. He's a physical therapist out in the Bay Area of California. You may have heard of him. He owns the company Cup Therapy. He teaches myofascial decompression courses. We had the pleasure of taking one of his courses a couple weeks ago when he was here in Michigan, and we had a great time. In particular, I love to learn all the research he had to share. And some of that research around does this actually work is pretty mind opening. And my point with today's podcast is that when we elevate our techniques, we elevate the efficacy and the efficiency of our techniques as well. And again, certainly, if you do this wrong or sloppy, you will have a minimum effect on the tissue. But if you do it right, you can have a profound effect on the soft tissue of the body. DOES IT ACTUALLY WORK? And Chris shares that in his course when he seeks to answer the question, does it actually work? Chris has used cups with myofascial decompression on embalmed cadavers. He has used them on fresh or what may be called wet cadavers. And he has used them on live living people in an MRI tube and looked at what is happening to the tissue when we have a large cup with a lot of pressure in it. What do we see? And what he has seen over the years doing these studies himself of having people in MRI tubes is that with a large enough cup and enough pressure, again, we can begin to decompress multiple layers of tissue, fascia, muscle all the way down to the level of the bone, which is pretty significant. And that in general, the more hydrated the tissue, the more decompressive effect we have seen. So when he has tested this on embalmed cadavers where all of the body water, liquid blood, everything is removed and the tissue is essentially dried out, we see a minimal effect when we use this technique. But when we use it on a fresh or wet cadaver or a living person that still has blood, all the sorts of fluid that we have inside of our body, that we get a much more profound effect. And more importantly, looking at these MRI studies, we see that not only do we see that effect in the moment, but that we see that effect for at least three to five days after we have done the myofascial decompression. So what is it? It is a technique using high pressure with movement to create a decompressive effect and some sheer force on the body. And does it work? Yes, if you do it right. So that's what I want to spend the rest of this podcast episode discussing. INTERLUDE Before I do that, I just want to introduce myself. My name is Alan. I have the pleasure of surfing as our chief operating officer here at ICE and a faculty member in our fitness athlete and practice management divisions. This is Technique Thursday. On Thursdays, we either cover leadership topics or we cover technique topics. Today is a technique topic today. And it is Technique Thursday, which also means it is Gut Check Thursday. This week's Gut Check Thursday comes from our own fitness athlete faculty member, Joe Hinesco, who sent me a nice little number for you all to do this week. It is every two minutes, hop on a fan bike, an echo or a salt bike, hammer out 20 calories for the guys or 15 for the ladies. And then any remaining time in that two minute window, you're going to do max repetitions of a barbell thruster. with the prescribed weight of 95 for guys and 65 for ladies. The goal there getting hopefully at least 10 thrusters every round and your workout is finished when you hit 75 thrusters. So the moment you hit that 75th thruster you are done with the workout. So it rewards an aggressive start, it rewards somebody who can be aggressive on the bike but still hop off and pick up that barbell and do big sets of thrusters. So If you try that and you hated it, send all that shade towards Joe. He's the one that came up with this workout, so send that his way. And then I just want to plug again, Chris DePrato cuptherapy.com. He has live and online courses, a level one course, a level two course, both live and online. And if you finish today's episode and you want to learn more about this, maybe you're like me and you kind of just started doing this without any formal training. I promise you, if you take his courses, you will come away with a lot of very actionable stuff that's going to do nothing but elevate these techniques in your own clinical practice. So let's talk about this. PRACTICAL APPLICATION Let's talk about practical application. First things first, if you have done cuffing before, You have probably seen clear cups. What's the difference? We also have cups. These are rock pods. We have these in the clinic as well. What is the main difference? The main difference is that I cannot control the pressure with something like a rock pod. All I can do is essentially stick it on my skin and get whatever pressure comes out of it, right? That might be not enough pressure to do anything and I may have to reset it. And then I basically am just getting lucky maybe with enough pressure for the patient to maybe feel something. But this is not ideal. It does not have a way for us to control the pressure. It does not have a way for us to objectively measure how much pressure we're using. And most importantly, we can't see through this, right? We can't see the tissue. We can't see what's happening underneath the tissue. There is some important stuff that can happen inside of a clear cup that you'll want to see. and I won't steal Chris's thunder, I'll have you take his course to learn that, but it's really important that we have a clear cup, and that we have some sort of control over the pressure, that we have some sort of pump gun, automatic or manual, to pump up the pressure, and really be sure we're just not getting a random application every time we put on a cup like a rock pot. So what does that look like? We have a manual gun, right? It has a trigger here, you connect it to the cup, and you pull pressure out, right? You decompress. And then with this style of cup, you just squeeze to let the air out. Now, what's great about Chris and Cup Therapy that has really made me feel good about this technique is they have solved the problem of how much pressure exactly am I using so that I can be sure if I repeat this treatment in the future, or maybe somebody else has to repeat this treatment for me, they're using the same pressure as me. Lo and behold, the automatic pressure gun, right? So you can see right here, if you're listening on the podcast, you can't see anything. So go over to our YouTube channel, or our Instagram page and watch me on the video. But what you'll see here is we have a pressure gauge, right? And it's measured in millimeters of mercury. It goes from zero up to 760 millimeters of mercury. And as you apply the cup, you will see the pressure gauge change. And that can dial you in more on how much pressure you're putting through the cup. And again, let you hopefully repeat that treatment in the future. And also be sure you're reaching the levels of tissue depth that you want to be working at. So this is a very, very great tool. This is brand new as of this year, I believe. So if you've taken his course before, you'll want to jump on cuptherapy.com and buy one of these. But this is very, very, very, very nice. And so I'm going to put this on myself. I'm going to put some, just some free up, and then I'm going to show you all how great it is with this auto pressure gun. So just putting some lotion over the area where I'm going to apply the cup. I'm going to apply the hose to the cup like so, and then I'm going to squeeze the pressure gun. Doing this one handed is super tough, but I think we can get it. There we go. And so you can hear the gun working a bit. And now as I take the hose off, you can see some pretty darn good pressure, right? A lot of tissue deformation right there, a couple of inches of skin fascia and muscle pulled into the cup. And I can tell you, this is a very different feeling than just having something like a rock pod or otherwise just a squeeze application silicone cup. This is right on the border between discomfort and pain. However, it is enough pressure that I could move those muscles. I could do a bicep curl. I could do pull-ups. I could move my forearm through whatever range of motion I wanted to, and you can see that cup is not going anywhere, and that comes down to making sure that we have enough pressure through the cup that we're reaching not only enough pressure that we can move with the cup on, but again, that we're reaching the levels of tissue depth that we want to achieve. And that is very, very easy to do with the automatic pressure gun. Let's talk about those pressures. What are they? If we really want to reach deep muscle or reach even the levels of intermuscular tissue and fascia, we need to have a lot of pressure through these cups. We need to have 300 to 600 millimeters of mercury. What is the problem with a cup like this? Or what is the problem with the manual gun? I have no idea what pressure I'm at, right? Hence the importance of the pressure gauge on the new automatic gun. Going down in pressures, if I just want to reach the level of the deep fascia, the pressure comes down a bit, 200 to 400 millimeters of mercury. And then if I want to stay superficial, even maybe if I just want to promote some lymph flow, maybe a patient has some swelling or some lymphedema, I can keep the pressure really light, 40 to maybe 150 millimeters of mercury. Again, how can I be sure I'm keeping pressure light enough to only promote lymph flow? Well, with something like a silicone cup or even the manual gun, I have no idea how heavy or how light my pressure is. And so again, it reinforces the need for that automatic pressure gun. And now I would say the key here, and again, the difference between myofascial decompression and cupping is that when we have these cups on, we're doing some sort of movement, right? Chris will take you through a whole protocol in his course of how to get the cups on and how to slowly introduce movement to an area, especially maybe if it's very restricted or very painful, but also different applications using lighter or deeper pressures to inhibit or facilitate different muscles. For example, he's a big fan of putting cups with heavy pressure on the traps for somebody who does a really contrived trap shrug when they lift overhead. And if you want to maybe isolate the deltoids or the upper back, and sort of think about turning the traps off a bit, we can stick some cups on the trap and really put a lot of pressure through those cups. It's going to be really hard to engage and move those traps, and it's going to promote movement through the muscles that we want to target. Again, maybe the deltoids or the upper back. And he has a number of different examples and circuits scenarios for you in his class but the key is the pressure matters and we can't know what pressure we're at if we don't have an objective way to measure it and then track it over time and for me that was a big game-changer what I learned is I was simply not using enough pressure using something like a silicone cup or or using something like a clear cup, but with just the manual gun. Simply not putting enough pressure into the cup to get the treatment effects that I was looking for. And certainly, probably not being light enough on the other end, if I wanted to do something like promote lymph flow, or I just wanted to have some cups on some muscles to facilitate muscle activation, I was probably going too light for deeper structures and too hard for more superficial structures. or movement facilitation. And again, the automatic gun with the pressure gauge changed all of that. SUMMARY So what is myofascial decompression? It is not cupping. It is using pressure, specifically various ranges of pressure depending on the level of tissue that we want to target. always combined with movement to promote movement through that muscle, movement through that tissue. That is very different from cupping where people typically lay in a static position, have a number of different cups applied to them, usually with no idea how much pressure is being put through that cup. Does it work? Yes, if you do it right, it works. As with most things in life, if you do it wrong, it won't work very well. And so understanding that if we have enough pressure through a large enough cup, we can move through several layers of tissue, including all the way down to the level of the bone, which is probably much more of a pronounced effect than maybe we ever thought possible. How can we get better at this? I would recommend if you haven't yet that you take Chris's course. You learn where to put these cups to target different muscles, to target different movement patterns, and that more importantly than anything else, you get yourself that automatic gun either from Chris's website or that you get with the level two course where you have that objective pressure grade knowing that different levels of pressure will target different structures and have different treatment effects. So it's really important we know what those are and what we're trying to achieve with that patient in front of us. us. So I hope this was helpful. Big shout out again to Chris. I reached out to him before doing this episode and just ran this by him and we really appreciate all of his collaboration. You'll notice that ICE does not have a myofascial decompression course. We think Chris is doing it better than anybody else and if it's not broke, don't fix it. So just go see Chris if you want to learn more about this. He runs a fantastic course, very evidence-based, Very movement focused, which you know, anything from us here at ICE, that's what we're all about. So just go see Chris if you want to learn more about this. I hope you all have a wonderful Thursday. Have fun with Gut Check. I don't think you will. Again, if you hate it, just send Joe those nasty messages. Just pass me right on by and go right to Joe. And I hope you have a wonderful weekend and a fantastic Thursday. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.  

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses important tools for acute care PTs: a good attitude, a backpack, a white board, resistance bands, sticky notes, and gait belts. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JULIE BRAUER Good morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division. and I am coming to you live from my garage. So this morning what we are going to dive into are fitness forward tools that you can use in acute care and I'm going to do my best to demonstrate some of these tools that you can use to start loading these really sick folks up early. All right so We are going to dive in first by talking about the most important tools that you need to have with you as you go through the hospital and you go visit your patients in their rooms. TOOL #1 - THE RIGHT ATTITUDE So number one, the most important tool that you need is the right attitude. You have to have the right attitude about this. So let me unpack that. Bringing fitness forward care to sick older adults in the hospital. It is not about getting them to do a sexy deadlift with a dumbbell. It's not the sexy thing. It is not, holy crap, I just got this patient, they're in a hospital gown, they're super sick, and they're doing a deadlift with a dumbbell in the hospital. It's not about that. It's not about being able to get the video of that or the picture of that and being able to share that. That is sexy and that is cool and it is badass. However, the meaning is deeper. What the attitude you need to have is, is that you have this beautiful, amazing opportunity to plant a fitness forward seed in this patient who is sick, who has a ton of medical complexity, and you only get to see them potentially one time. You've got one shot to plant that seed and potentially be the catalyst that sets this person up on a better trajectory of health. That's an amazing opportunity. And I would encourage you all to be obsessed with that opportunity. Okay. Every single time I would go into a room, I thought, wow, I have this opportunity. I've got one shot. I could be the catalyst that changes their lives. And the thing about you all who work in acute care, man, you are doing some dirty work, right? You are seeing folks, whether they're young or old, they have multiple types of diagnoses and medical complexities. You are seeing them at their worst and you are seeing them in a very, very vulnerable situation. The fact that you are able to plant that seed yet you don't get to see the sexy outcome and yet you give them your whole heart and whole soul is so important. And it's hard to be in acute care and know that you're not going to get to see a sexy discharge where a patient is lifting a super heavy barbell or they are going all out on an assault bike. You're not going to see that. And that's tough, but you have to reframe it to be, I'm going to be obsessed with having the attitude that I could go into every single one of these rooms, plant the seed, and the patient is able to walk into an outpatient clinic. They want to do fitness-forward care because I planted that seed. And I think that's an incredibly, incredibly important story to tell yourselves so that you can continue to have the motivation to go in and see these folks who are sick day after day. And many times you may not actually get to get them to do the cool fitness board stuff. Okay. So that's the most important thing is having that right attitude. Okay. TOOL #2 - A BACKPACK So the second tool that you're gonna need to bring along with you to every single room is a backpack, all right? You absolutely need a backpack. So this is not the backpack I used in acute care. I used the backpack that they gave us as like a Christmas gift one year. This is a Nomadic. This is my travel backpack. This is a very sturdy, but very expensive and nice backpack. I do not recommend getting something like this to go into hospital rooms, okay? But I do recommend that you get something that's sturdy because you're going to be carrying around a lot of stuff in it. So get yourself the backpack. So what are we putting in the backpack? You're going to put weights in the backpack. No, most acute care therapy offices do not have weights. But you can bring your own. So I would bring a 15 pound dumbbell. and an eight-pound dumbbell, and I would put that in my backpack. Now, some of you are not able to bring a backpack potentially into the patient's room. Cool, then you bring it around and you leave it at the nurse's desk, okay? But the idea here is that you're bringing everything with you so that there is no excuse that you don't have the equipment because you're in the hospital. So you have your weights. Now, I've had people say, well, Julie, isn't that tough to carry around? And I say, yes, it is tough, it's heavy, but who else would want to be able to go rucking through the hospital with weights more than fitness-forward clinicians who are here listening this morning? I thought it was awesome. I felt like I was getting a lot of fitness in by carrying this stuff around throughout the hospital all day. TOOL #3 - THE WHITEBOARD Okay, so after weights, you're gonna have a whiteboard, okay? I'm using a whiteboard right now for my talking notes for this podcast. you all are going to want to use a whiteboard to create workouts with your patient. So have your dry erase markers and as you are digging into their meaningful goals and you're coming up with functional movements that match those meaningful goals, you are writing this stuff down, you are coming up with reps and sets, you are doing this with your patient. Now, I will say, you're not going to buy these and leave these in patient's rooms, right? This stays with you, okay? You can take a picture of this and give it to your patient, or the really cool thing about acute care is that they typically have whiteboards in the patient's rooms, and they're usually filled with some random information many times they are covered up with Call don't fall signs Those become great whiteboards. Okay, so I usually they're not helpful We all can can agree that call don't fall signs are not something that prevents somebody from falling. So I they're great whiteboards so I would take those down turn them around and with my dry erase markers cut right down the whiteboard on those signs then I would leave that in the patient's room maybe I would go find a couple extras and I would put some motivational phrases on there like uh i remember one very specifically i'm trying to kick covid's ass so i can get home in shopwood something like that or something that lets the providers know a little bit more about this patient their name is something that i always put on these signs their name and something about them a goal an interesting fact i want to try and have every provider who walks into the room treat this person a little bit more like a human than a number or a diagnosis and that's a way to do that so whiteboard, slash use the hospital whiteboards, use those signs that are all around the room, turn them over, use those as your whiteboard. TOOL #4 - RESISTANCE BANDS Okay, next, resistance band and TheraBands. Okay, so both. So resistance band is something like this, okay? These offer a lot more resistance than a TheraBand. However, I usually would bring a bag of theravans because i want to be able to leave some with patience right you can do endless things with the TheraBands. I would tie them to the bed rails many times. So even folks who are typically they're just lying supine majority of the day because they're so deconditioned, you can tie those around on the bed rails. They can pull from above, they can pull from the side, there's a lot of stuff you can do with them just tying them to the bed rails. with the resistance bands, this is where I would many times get people up into standing and I would do something like a paloff press. So if they're standing here and this is attached to the bed rail, I can have them do a paloff press to work some core. I can have them do some rotations, you can do rows, you can do a whole bunch of stuff with those resistance bands, but those come with me. I'm not leaving those in the room. TOOL #5 - STICKY NOTES Okay, next are sticky notes. Okay, sticky notes are amazing because they're versatile. So I have sticky notes and then even better than sticky notes, I have a really bright, uh, note card. And then I've also used paint swatches that you can get for free at Lowe's or Home Depot. Okay. So what I do with sticky notes or these things, they become targets, right? So if I'm gonna have folks be reaching for things or stepping to things and maybe I'm calling out colors or I will write on a sticky note a number and then they're not only doing a motor task, they're also doing a cognitive dual task perhaps, These are great tools. They're light, they're easy, they're cheap. The other thing I like with the sticky notes is I'd like to put little notes on them for people. So if I'm using targets with a sticky note, perhaps to show them exactly where I want them to do their deadlift, pick the weight up from and put it down on, I will put a note here that just says like, you're a badass or never give up or something like that. And then that's something that the patient can keep. So they're wonderful for targets. They are wonderful to do some dual tasking. So you can have people reach for yellow or reach for a number that is written on one of the colors. So you can yell out the color or the number. Very versatile tools, very easy to carry around with you. TOOL #6 - GAIT BELTS All right, and then also obviously a gait belt. You need to have a gait belt. obvious reasons for safety but also i have used a gait belt before and i have put it around the bed rail and okay i have never ripped a bed rail off of anything by putting the gait belt around it and tugging on it okay so i'll just say that are they the most sturdy things in the world no i've never ripped one off so that's my preface there. But I have looped this around the bed rail and then perhaps someone is sitting in a wheelchair and they have a really hard time just sitting up tall in their wheelchair, their core is very weak, I will do almost a modified rope climb where the gait belt is around the bed rail and they are pulling themselves up to sit tall, and then going back to the back of their seat, the back of their wheelchair, and then pulling themselves up to sit tall. I've done this in home health, where I looped this to the end of the bed, the bed frame, what am I calling it, footboard. But typically, in acute care, there really isn't a big enough space in those footboards, maybe some of them, but definitely a really cool tool to use to do unmodified rope climb really get that core activated for someone who is so weak that they barely can even sit tall in their wheelchair. TOOL #7 - SNACKS Okay and then lastly You need snacks, okay? Don't forget your snacks. I became so much more efficient and so much more productive when I started bringing food up on the floor with me and putting that in my backpack. So, get you some nuts, get you a bar, a little bit of healthy sugars, maybe some, I always had like clementines or mandarins, those were one of my favorite snacks. Make sure that you have some fuel so you are not having to really put a big stop in the middle of your day. You're not going down to the cafeteria, getting crappy cafeteria food, and it just kind of keeps you focused. When you take that break and go down to get a snack or a coffee, I think it just puts you in that mindset of like, I'm going to just chill and not work as hard. When you just keep hammering throughout your day and you're able to do that because you have fuel, it's really important. Okay, so that is what I put in my backpack. All right, so let's talk about some specific acute care hacks to load up your patients when you don't use the weights. Okay, so let's throw the weights out. My favorite hack, one of them, is to use towels. All right, now this is a towel that I have soaked in water. All right, because a soaked up towel is really heavy compared to a towel that's not soaked in water. So I will roll a towel up and I will put it in the toiletry buckets that are in every single patient's room. So usually these buckets come with soaps and little doodads, things like that. I just get rid of that and I soak up towels and I put them in the basin. Now, you can do a whole bunch of stuff with this. So for someone even in sitting, even having to hold on to this basin, can be very challenging. We can increase the difficulty by going overhead. We can increase the difficulty by doing some marching in sitting. We can do a deadlift from sitting. We can then get up into standing and we can do a deadlift as well. So the great thing about this is it's a great way to introduce the hinge to a patient who is post-op lumbar fusion. Yes, I am loading up someone who is post-op lumbar fusion day one. Why? Because they're going to be discharged. They were probably never taught how to do a hinge in the first place, which contributed to them ending up having surgery. and I want to be the person to break that cycle, right? They're gonna go home, they gotta empty the dishwasher, lift up Fluffy's kitty litter box, whatever it is, why not teach them here and now? So I will put the towel in the basin, and then I will teach them how to properly hinge with an elevated surface in the basin. So I'm teaching them a hinge pattern, loading it up a little bit so that they know how to properly hinge when they go home, okay? And less amounts of things you can do with that basin. The next piece of equipment that I love are your bedside commode buckets. Yes, the things that poop usually goes in. But this is not what we're using them for. We are using clean bedside commode buckets, okay? So the cool thing, buckets, they usually have a handle, okay? So it makes it a lot easier to hold on to than potentially the basin. So what I will do is I will put a bunch of crap in the bucket. So I will put my weights in there or I will go and get a bunch of ankle weights because typically therapy departments and acute care have ankle weights, put them in the bucket and now we got some load. So you can do the same thing. You can deadlift with the bucket, okay? you could do my favorite, which are carries. Okay, so loaded carries. So as you're walking with your patient, they could carry on to the bucket. And the cool thing is that it adds a little bit of a perturbation. Okay, so they're getting an internal perturbation just by holding on to an object. There's a truck coming by, I'm sorry. I am out in my garage. and there is destruction going on in my neighborhood. And it's disruptive. So I'm gonna wait until they go by. Okay, they're hanging out. I'm just gonna talk louder. Okay, so with the bucket, Come on, my friends, keep it moving, keep it moving. Don't say no on a live podcast. Okay, with the bucket, what you can do is if someone is non-ambulatory, they can hold on to the bed rail and they can go like this, back and forth with that bedside commode bucket full of equipment and full of weights, okay? They could hold on to it, hold on to the bed rail and march, just like this. They can swing that bucket forward and backwards. There's a lot of things you can do with the bedside commode buckets to add in a little bit of a perturbation. Okay, lastly, we'll talk a little bit about how to put all this stuff together. So when you are with your whiteboard, right? And you're talking and you're sitting with your patient and you're figuring what movements that you're going to do. This is where you can start introducing what an EMOM is every minute on the minute. You could start introducing what a rounds for time is. So very, very early on, typically patients don't hear about this stuff or feel what intensity is like or load until they're way into their journey and they go into outpatient potentially, right? So the amazing thing is that you get to start introducing them to what a workout is like this early on. Imagine that seed that you've planted, then your patient will understand what it's like to lift heavy and to work hard. They go to home health or they go to inpatient rehab and then they go to outpatient and they're able to advocate for themselves and understand, okay, This is too easy. I don't need that yellow TheraBand or I'm not working hard enough. This isn't challenging enough for me. You are able to give them that opportunity, which is absolutely amazing. And remember, you can be the one that has an impact on them. Farther down the road, you are not going to see that sexy discharge, but you were able to be the catalyst to spark some change. Okay. All right, my friends, that is all. The next time I come on here, I will actually show you an example of like an EMOM or a rounds for time, some examples of what I would actually do with patients in acute care. I will also, on the ice stories, I will post some of my reels I made back when I was in acute care, going back into the archives. I will post on our story my reels that show some of this stuff in action. Lastly, talking about our courses that are coming up. MMOA Live will be in Alabama, we will be in Minnesota, Wyoming, and Oregon for the rest, not the rest of September, we're not in September yet, but in September, so many opportunities to catch us live on the road. Alright everyone, have a wonderful rest of your Wednesday. 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.

Robin Jones moved to Florida at the tail end of 2017 to pursue a burgeoning career in CDI. And ever since has done nothing but climb the professional ladder. Leaving behind her home in Cincinatti Ohio and a decorated career in CDI at Mercy Health, Robin started over as Division Director of CDI at AdventHealth West Florida in November 2017. A few years later she was promoted to Director of Clinical Excellence. You might recall that she joined me for an episode of Off the Record in November 2022 to talk about this change. Three months ago she was promoted again, this time to Vice President of Clinical Excellence & Education. And I knew it was time for a return visit. We get into her flourishing career and the broader CDI program at AdventHealth West Florida on today's Off the Record. On this show we cover: Promotion to VP of Clinical Excellence and Education and what it entails New VP level leadership responsibilities, and what new skills Robin had to cultivate to meet them What she had to give up to accept this new role, and the challenges of delegation Commitment to hybrid onsite/remote CDI and a unit-based model of coverage Winning a Leapfrog Emerald Award, AdventHealth's emphasis on public report cards and how CDI can make an impact Retaining and building the workforce of tomorrow

Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Justin Dunaway takes a deep dive into a series of three studies tracking the same cohort of patients over 10 years and what they say about the importance of short term changes! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Persistent Pain 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 JUSTIN DUNAWAYAll right, team, good morning. I am Justin Dunaway, lead faculty with the Institute of Clinical Excellence, coming at you live from Portland, Oregon. Welcome to another Clinical Tuesday. I am lead faculty for Total Spine Thrust and also our Persistent Pain Comprehensive Management course. 32nd cohort just began yesterday. So if you're thinking about jumping in that will the registration will remain open for another day or so So if you're thinking about it, go ahead and take a look But enough about that. Let's get into today's topic today we're gonna talk about full thickness a traumatic rotator cuff tears and looking at physical therapy or Surgery and what what kind of predicts that stuff? and it's really cool because it's a series of three studies over a decade that looked at the same same kind of cohort of humans and And while I'm going to talk a bunch about these three studies, realize that this really is more than a story about rehab for rotator cuff tears. This is really a story about the importance of our ability to demonstrate within session and between session change, early, often, and frequently. And at Ice, we often hear that we are obsessed with incessant change. We are obsessed with our ability to show short-term changes. And I couldn't agree with that sentence more. Like, totally. I am absolutely obsessed with that. The second half of that, though, which I don't agree with, is that short-term change, within-session change, those things don't matter. What we're really talking about is regression of mean or natural history. And short-term change doesn't predict long-term change. And I couldn't disagree with those sentences more on lots of different levels. But I think that the story I'm about to tell, the three studies that we're about to walk through, give some of the best evidence and support for the need for short-term and within-session change, for at least one of the many reasons why this stuff is so important. So let's dive in. First study, study number one, the effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears, multi-center prospective cohort study by Kuhn and Dunn, 2013. Mouthful. But basically what they did is they took a whole bunch of humans, 452 of them, that had full-thickness chronic degenerative rotator cuff tears, and all of them got six weeks of physical therapy. And then at the end of the six weeks, they were asked, you know, how are you doing? And they got one of three options. They could stay cured, in which case they were done, and we'll just check in at 12 weeks, and then at a couple time points over the next two years, or they're improved, in which case they would get another six weeks of physical therapy, or no better, and then they could opt for surgery. And then at the 12-week mark, the people that were left, that weren't cured in the first six, asked them the same question. If they were cured, awesome. If they were anything but cured, they were offered surgery, and then tracked over the next two years. The physical therapy protocol, I couldn't get my hands on the full version of Appendix A that went into detail about what they actually did, but in the study, in the methodology they just talked about doing the physical therapy was range of motion, was postural control, was scapular training, was mobilizations, was general strength training stuff. And I've got some thoughts on that and we'll dive into here in just a second. But the outcome here is what they found is that less than 25%, okay, full thickness chronic degenerative rotator cuff tears, less than 25% of the 452 people in the trial at the end of the 12 weeks needed surgery. At the six week mark, only 6% of people opted for surgery. At the 12 week mark, that number was up to 15. And then over the next two years, a few more trickled in and that went up to like 24%. So at gut shot, 75% of people with full thickness rotator cuff tears went on to have excellent results in pain, disability, range of motion, strength, functional stuff, and went totally back to life. That's awesome. That's huge, right? The second piece The thing I want to think about here, though, is I think that number could be a bit better, right? I'm going to make an assumption that once we dive into the exercise protocols there, were they really doing strength stuff? Were they really looking at multi-joint movements, overhead presses, rows, pushes, horizontal presses, things like that, and dosing them appropriately for strength? you know, thinking about low or high sets, low reps, two to three minute rest at roughly 80% of their calculated one rep max, or are they doing like three sets of 15 with a band? And call it strength. I have no idea. My assumption is that we probably could be a bit more aggressive with exercise, and I bet that number could get a bit better. But 75% is awesome. So let's run with that. And the conclusion of this first study, which is super important, That if I'm just gonna read the quote if a patient avoids surgery in the first 12 weeks He or she is unlikely to undergo surgery at a later time point up to 12 up to two years So this is the first point here if the patient doesn't opt for surgery in the first 12 weeks They're probably not going to get surgery so our ability to to show them functional improvements in the first six, in the first 12 weeks, is absolutely huge. Because if they don't feel like they need surgery at the end of the 12 weeks, they're not going to get it probably ever. And when we think about conservative management versus surgery, both these things can be effective. But there is massive risk to surgery, right? There's massive financial risk. It's super expensive. And then thinking about the risks of anesthesia, of something going wrong during the surgery, of infection, of interactions, adverse events with the medications, opioid addiction. All of these things are risks of surgery that don't exist in conservative management. Okay, so that's the first study. If you don't opt for surgery in the first 12 weeks, it's unlikely that you're going to. 75% of humans got totally back to life without needing surgery. Study number two, predictors of failure of non-operative treatment of chronic symptomatic full thickness rotator cuff tears. Same research team. This was published in 2016. Again, looking at the same cohort of 452 individuals, This time what they wanted to see is, okay, 25% of you failed conservative management, failed physical therapy. Why? Is there anything in there? Is there anything about you that predicts whether you will or won't do well with physical therapy? And this was really cool. So they looked at all the patient demographics. They looked at age, they looked at sex, they looked at pain, severity of the tear, disability, chronicity, activity levels. They looked at work status and education and handedness and really everything under the sun. And what they found, the first thing they found is that structural factors were not predictive at all. Tear didn't matter, pain didn't matter, disability didn't matter, what your MRI didn't look like. None of that stuff predicted whether you needed surgery or not. The number one most powerful and really only significant predictor of whether you went on to need surgery or not for your full thickness rotator cuff tear was belief that physical therapy wouldn't help you. That was it. If you believe physical therapy would help you, you succeeded, you didn't need surgery. If you didn't believe that, then you opted out and went for surgery. And then smoking status moved the needle just a little bit, which makes sense. If you're smoking, your body is widely inflamed. Things heal slower. Your pain systems are far more sensitive. And then the other thing that was a very small predictor was activity levels. If you had higher activity levels, you were slightly more likely to opt for surgery early. And that makes sense too, right? My shoulder hurts. I can't do all the things I want to do. I'm still trying to do them. Things aren't getting better quick enough. Give me the magic bullet. The important thing here, again, one, structure was not predictive. Two, the only real strong predictor was your belief in physical therapy. Now, this is where it gets interesting, right? If that is the thing that determines whether you get surgery in the first six to 12 weeks, or that's the thing that determines whether you get surgery, and most humans are gonna make that decision within the first six to 12 weeks, you cannot make the argument that within session change and short term changes don't matter and probably aren't the most important thing there is, right? Because I cannot, if the thing that determines whether you need surgery or not, whether you get into that MRI tube, whether you get in the OR suite, whether you're getting those injections, pills, things like that, is your belief that physical therapy can help you, I cannot think of a more powerful way to foster that relief than having some tools in my toolbox that when you walk in the door, very quickly, I can modulate your pain, I can change your pain, your pain pressure threshold, turn on painfully inhibited muscles, gain some access to proprioception, and then get out into the gym and do some things that actually build capacity in humans, and demonstrate that thing within session, and then session after session after session. Short-term change and within-session change are the things that get patients to believe in physical therapy. And belief in physical therapy is the thing that keeps the patient out of the OR. Simple as that. That is the most important tool we have to foster those beliefs. Okay, study number three. This one just came out like last month. The predictors of surgery for symptomatic, atraumatic, full thickness rotator cuff tears change over time. Same research team, again, looking at these same humans that were in this study. Now this is tracking them down 10 years later. The first thing that pops out is that at the 10 year mark, only 27% of these people went on to get surgery. So you think about that, at the two-year mark, it was around 24%. So just a few more people kicked into the surgery over the next two, between two years, year two and year 10. Most of them, over half, opted for surgery before the six-month mark, and then the rest of them slowly trickled in over the next 10 years, with it kind of being less and less each year down the road. At the six-month mark, And everything prior to that, the most predictive thing, again, whether you need surgery or not, was belief in physical therapy and nothing else, right? So those beliefs are gonna be powerful all the way up to the six month mark. Everything we can do in that window to convince patients. that this is the path they need is gonna be the thing that keeps them off the other path. Beyond six months, it doesn't switch to structure, it doesn't switch to pain and disability and any of that stuff. The only two predictors beyond six months were if you were on worker's comp, and again, if you reported high levels of activity. Now this is super important too, right? Because okay, we're six months, we're a year, we're two years, we're five years out. We've done physical therapy, it didn't work, we've kind of forgot about it, that's off the table. And now, the stuff that's really bugging us is the fact that, okay, we're still having trouble at work, we're on workers' comp, we're kind of in that system, we still have all these activities that we want to do that we can't do the way we want to do them, now it's time to do something else. It's important to realize that overall, at the 10-year mark, 70-ish percent of humans, again, didn't need the surgery. And this is an interesting bullet point, too, because one of the things that you'll frequently hear is that, great, people do well with conservative management for rotator cuff tears. But if you don't repair it anyway, you set the patient up for degenerative changes, arthritis, problems down the road. What this study showed us is that the 10-year mark, the 70% of humans that did well with conservative management 10 years ago in that six to 12-week PT window, All of them were successful. And the success that they gained 10 years ago didn't decline over time. They didn't have more disability. They didn't have increased pain or arthritis or things like that. Their gains stuck. And this is one of a few studies that look at conservative management for rotator cuff tears, track them out over long periods of time, and show that there is no negative mechanical effects from not repairing that thing. So, the important stuff here, the key clinical factors here, is that team, at the end of the day, beliefs and expectations are the foundation. They're everything. They're the thing that drive the decisions that patients make, right? And if we don't have the ability to demonstrate change to our patient, if we don't have the ability to show them, not just tell them, But show them time and time again, ruthlessly, within session and between sessions, slowly building up functional outcomes, session after session after session, they're not going to buy this. And if they don't believe in what they're doing, if they don't believe in physical therapy, if they don't think that this is the thing, that's the stuff that determines, OK, am I going to get shots? Am I going to be taking pain medications? Am I going to end up in the OR suite? We need, what this research tells me is that we really need to drill down on our ability to have tools in the toolbox that create quick, transient changes in pain, range of motion, muscle activation. And I get that that's transient, but what we're doing is we're open a window. And then once that window is open, we absolutely have to jump through it, get right into the gym and start doing the large functional movements that build capacity in humans. And then be ruthless about your comparable measures, your functional stuff between sessions and your objective stuff within sessions. and make sure that multiple times every session, you're showing patients change. In every session, when they walk in the door, you can show them change over time. This is where you started. This is where we were after the first week. This is where we were after the second week. The better we get at that, the better we get at demonstrating change in the moment and showing them incremental change over time in the short term, the better our odds of keeping these patients out of the surgical suite. If the only thing that separates these two groups, physical therapy or going under the knife, is their belief in the power of what we're doing in the clinic, then we have to invest everything we have in our ability to demonstrate those changes. All right, team, hope you're half as excited about these three studies as I am. I think it's a really cool thing to look at and then track these patients over the last 10 years. If you got any questions, throw them in the chat. Have an awesome day in the clinic, and I look forward to seeing you out there. OUTROHey, 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.

We have talked about ADHD in our Podcast before but more focused on Children's. Today, we have Chelsea Jones who is a Masters in Social Work Student and has dedicated a lot of time researching ADHD in Women. This is a very important topic and one many people do not know much about. Come and learn more about this topic as well as some great resources! Chelsea Jones is currently in her final year of her Master's of Social Work degree from Utah State University.  She created the “Women and ADHD” psychoeducation group at the Sorenson Center for Clinical Excellence at Utah State University and co-facilitates the class. Chelsea strives to create a safe space to talk about difficult topics and build communities of support. Her interests include navigating neurodiversity, exploring identity through a multicultural lens, and honoring the strength that each person holds.  Originally from Florida, Chelsea is the oldest of five kids and is a first-generation American.  She received her B.S. in Elementary Education and worked as an educator in Idaho and Utah. Chelsea currently resides in Logan, UT where she likes to hike and explore with her husband and children. In her free time, Chelsea enjoys playing the guitar/piano, writing standup comedy, and connecting with other humans and learning about their life passions.  Subject Resources - Online ADHD assessment to bring to provider: https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf https://www.additudemag.com/ - "The ADHD Toolkit for Women" by Davis and Hall - "A Radical Guide for Women with ADHD: Embrace Neurodiversity, Live Boldly, and Break Through Barriers" by Solden and Frank  - Feel free to send Chelsea an email with any questions or for info on the ADHD women's group: chelsea4adhd@gmail.com Contact us: -Email us questions or topic ideas: parents@thefamilyplaceutah.org -Record questions here:⁠⁠⁠⁠⁠⁠⁠⁠ https://anchor.fm/theparentsplace⁠⁠⁠⁠⁠⁠⁠⁠ -Parent's Place FB Page:⁠⁠⁠⁠⁠⁠⁠⁠ https://www.facebook.com/groups/196037267839869/⁠⁠⁠⁠⁠⁠⁠⁠ -⁠⁠⁠⁠⁠⁠⁠⁠ https://www.facebook.com/jendalyTFP⁠⁠⁠⁠⁠⁠⁠⁠ Music by Joystock - https://www.joystock.org

Alan Fredendall // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses using the reMarkable writing tablet to reduce daily documentation burden to 5 minutes per day Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLHow can we make our documentation more remarkable? Often a very boring topic, but a necessary topic as we are required by law to do a treatment note for every single patient that we see. So today we're going to talk about what is that law that requires us to do those notes. And then we're going to talk about new technology and a new way to think about documentation that's probably going to streamline everyone's documentation in a very significant manner. How can we potentially reduce our documentation burden to maybe five minutes per day? DO WE HAVE TO DO DOCUMENTATION? So first things first, what is that law that says we have to do a note for every patient that we treat? That law is actually the HIPAA law. Way back in 1996, the Health Information and Portability Accountability Act, or what we know as HIPAA. And so that has a lot of things in it about not sharing protected health information, about in 1996 the emergence of the internet and what we can and can't do with submitting patient data electronically. But the main thing it establishes is that we do need to do documentation on every single patient that we see, and that that documentation be available to be transmitted electronically via fax or email upon patient request. Prior to this law, we just basically handed over copies of paper documentation, and it could be a lengthy amount of time before patients could get access to their records. In this day and age, patients need our notes sometimes for things like reimbursement. If we're a cash-based practitioner and they're trying to get out-of-network reimbursement, they may need it to submit because they got the day off work or something like that. And so there's a lot of reasons why folks may need their documentation and why they may need access to it very, very quickly. So the HIPAA law of 1996 established that documentation must be available to be transmitted electronically immediately to patients or other providers with patient approval upon request. Some of you may have interacted with a patient who needed documentation because they were involved in an automobile accident or something like that and they need that documentation to then send on forward. HIPAA also mandates that we keep documentation for up to six years and that essentially means the best way to do that is to store it electronically instead of maybe in an old filing cabinet. Now the thing about HIPAA is it says that documentation must be available to be transmitted electronically via email or via fax, but what it does not say is that our documentation must be inherently electronic. Documentation can still be written as long as it is transferred or changed into an electronic format, stored for those six years, and then available upon demand to be sent when requested. And so we're going to talk about how that opens up freedom for us today to do documentation maybe in a very different way that we have not considered before. Before we get into that, what are the penalties for not following this? What if I don't do notes? What if I just never do notes? What if I'm a cash-based practitioner? I don't interact with other healthcare providers on a regular basis. My patients pay me cash. Most of them aren't asking for auto network reimbursement, so they're not trying to see those notes or see super bills or see claim forms or anything like that. You should know the penalties here are quite severe because we are dealing with a federal law and we are dealing with the federal government. So with HIPAA, they have a four-tier system for violations, Tier 1 through Tier 4. Tier 1 is the lightest punishment. Tier 4 is the highest punishment. Tier 1 is considered that you were not aware of what you were supposed to do, and that you could have not avoided what happened. Now, this is kind of in regards to maybe accidentally revealing protected health information, but also if you don't have documentation stored electronically, and you literally can't submit it to someone, and also that you didn't know that you had to do that. That little caveat that you're not aware that you committed a violation is going to be, the burden is going to be on to you to prove that. If you can prove that though, that you literally had no idea what you were supposed to do and you have no way to fix it, the penalty for that is only $100. Very, very light. But realistically, no one lives here, right? Everyone is aware of what they're supposed to do and probably has a way to reasonably fix it. And so we kind of immediately move up to Tier 2. Tier 2 is you're aware of what you were supposed to do, but there's no way that you could have avoided that violation. This is a very common area for us to live in, right? Let's say you finish with patients for the week on Friday afternoon, and then hey, you're catching a plane, you're going on vacation with your family for a couple weeks, but oops, in that couple weeks while you're gone, a patient requests a note from you. You are aware that you needed to comply with that, but you're just not able to do that, right? Your maybe physical note is sitting on your desk next to your computer at the clinic still. There is no way for you to convert that to an electronic format and then transmit it to the patient. that comes with a little bit steeper fine, that's a $1,000 fine each time that happens. And then we kind of move things very, very quickly when we get to tier three. Tier three is the tier where we start to use the term willful neglect, that you are aware you need to do this, you did not do it, but you are willing to catch up on all of the neglect that you have committed in the past. Now when this happens, the fine jumps up to $10,000, right, a tenfold increase. And then tier four is willful neglect, but you're not willing to correct it, right? You know you're supposed to do notes, you know you're supposed to store them electronically, but essentially you show a habit, you show a pattern of just not doing that, even maybe if you've gotten in trouble in the past. And so tier four is the most punishing tier. Tier four comes with a fine of $50,000 every time that happens, so a very severe penalty. And so when we talk about that in the context of our brick by brick class, when we're teaching people to open their practice, the easy rule is just do it, right? Don't try to butt heads and win an argument with the federal government. The fines are very severe. The penalties are very severe. Just do it as annoying as it is. And my second and third part of today's podcast is showing you that we can make it we can't get rid of it completely, but that we can make it quite simple. So let's talk about that right now. USING THE REMARKABLE  Let's talk about making your documentation remarkable with the remarkable. So if you're listening on the podcast right now and you're only hearing my voice, go over to our YouTube channel, the Institute of Clinical Excellence YouTube channel, and find the video of this so you can see what I'm doing. So this is a Remarkable. I'll close it up for you. It's got just a little folio and then it opens up and it's essentially just a tablet, right? This does allow finger input, but more importantly, it comes with a very nice stylus that lets you write the same as if you were writing on paper. So what we have been trialing here at our clinic in Michigan is using the Remarkable to replace our electronic documentation. So you can see what I have on here is I have a bunch of body chart templates. And so we have a folder for every day of the week stored on this tablet. And then we have body charts for every patient that has come into the clinic for treatment that day. So let me open up a brand new template for you all to look at. And now you can see here is our body chart template, just like we used to do on physical paper. Now it is on this tablet. We can write all over this thing. We can write eggs and eases. We can shade body charts so we can do our subjective and objective when patients come back into the clinic. And then the nice thing is with remarkable, we can add blank pages so we can itemize our manual therapy. And we can write all over this thing. And whatever we want to itemize, should we choose so can also be included in this template. And so what's nice is as soon as I finish this, it's automatically saved as a PDF, both on this tablet. But more importantly, it is saved back to a laptop or desktop computer. And I'm going to tell you in a second how we can put the tablet together with your EMR and basically have your documentation burden fall off a cliff in a really nice way. INTERLUDE So before we do that, I just want to take a break, introduce myself. My name is Alan. I am the Chief Operating Officer here at ICE. This is Leadership Thursday. We talk all things small business management, practice management ownership, tips and tricks. I am the lead faculty in our fitness athlete division, so you'll see me on Fridays for Fitness Athlete Fridays, and also the lead faculty in our practice management division, where we talk about all things related to practice management in our brick by brick course. It is leadership Thursday, that means it's gut check Thursday. This one, very simple, 30-20-10, toes to bar, paired with single arm devil's press. Rx weight for gentlemen, a 35 pound dumbbell. Ladies, a 20 pound dumbbell. And then just to make it hurt a little bit worse, you're gonna do a 400 meter run after each round. I tested that workout last weekend. I think I came in somewhere around 11 minutes. So not as fast and intense as last week. And then our Brick by Brick course starts up again on October 2nd. That class always sells out. Our current cohort is finishing up week six, talking about Medicare, talking about documentation, doing a deep dive into the stuff that we're gonna talk about. SYNCING NOTES TO YOUR EMR So how do we put our knowledge that we need to do documentation, it needs to be electronically available, with something like the Remarkable tablet. And the nice thing about Remarkable, like we talked about, is that when you finish a document on the tablet, and you close it out, it automatically syncs via the cloud to an app on your laptop or desktop computer, and that document is available immediately. So our previous documentation system, we would still do paper body charts, we would come back to our EMR, and we would hand type our notes. And that was okay. That maybe took three to five minutes for daily note, maybe 10 minutes for initial evaluation. That is all gone now, right? Because we have our body chart on the, on the remarkable and now we're doing electronically and it is updating to our computer in real time. What does that mean? That means we no longer need to come back to the computer and hand type our notes. It also means for maybe some of you that we're doing that and maybe taking a picture of your body chart or scanning it into your printer, that is okay. But again, that is a lot of burden, right? That's a couple more minutes per patient. What's great about Remarkable is that document, that body chart is available immediately as a PDF on your desktop that you can simply upload into the patient's chart on your EMR. And so now our documentation, all of the boxes of our soap note just says see PDF from this date, right? We are no longer typing. That carries over from daily visit to daily visit, see PDF this date, see PDF this date. And in that patient's chart of that date is August 1st, 2024, August 7th, 2024. And it is a PDF copy of the body chart and it is HIPAA compliant, right? It's electronically available and it has all the stuff that documentation needs to be sound and legally compliant, right? It has a subjective, it has objective, it has assessment, it has plan, it has some itemized treatment to justify if we're gonna bill insurance, for example, why we're billing insurance and for how much. And so for us, switching to this system has reduced our total documentation load to about five minutes per day, which is really, really, really incredible when you think about it. We already had given two hours in the workday for admin time, following up with patients, documentation, that sort of thing, and now that administrative burden has reduced down to about five minutes a day. And so that's just extra time that our therapists have that's not spent typing stuff that they have already written down on a paper body chart anyways. What's nice about this, this remarkable system is that you can take it into the treatment room and it looks no different than if you have a body chart on a clipboard or something like that. It's not as intrusive as a laptop. Obviously it's not as annoying as typing, right? just chipping away and typing as somebody's trying to talk to you. It's very, very low maintenance and it's really awesome. Now, what are the cons of this? There are some cons. They are expensive. They're about $500. I have asked for a coupon. I have asked if they do volume discounts. They do not do any of that. They know what they're doing. So there is a con of the price. And then the other con is that this thing is really kind of worthless outside of this specific niche, right? Unless you happen to want to journal on it, unless you happen to hand write a lot of other stuff in your life that you also wish could be available immediately electronically, the remarkable doesn't have a lot of value for you. That being said, We love how nice it writes. It writes the same as paper. We love that because it really can't do anything else, it has a super long battery life as well. So we have transitioned our documentation system to that and we're very, very happy with it. So with documentation, HIPAA law requires that we do documentation for every single patient, that there is a penalty if we don't do that, and that we should probably follow that unless we wanna get in trouble. But there are different ways to think about doing documentation other than just typing forever into those boxes on your EMR. That this might seem like a step backwards, because we're writing now, but because of the technology that powers the Remarkable, because it is available instantly as an electronic PDF, and can significantly speed up your documentation time. So give it a shot. The company's name is literally remarkable. Look it up. There are a lot of other competitors emerging as well. And I'm sure in the next couple of years, we'll see more of these become prevalent. Writing on these has on electronic devices has been around for a while. Many of you may remember the Palm Pilot. However, you know, it had a two inch screen and you couldn't read what you wrote. So this is a significant step forward. The writing is beautiful. We're very happy with it. And if you try it out, let me know how it goes. So make your documentation remarkable. Hope you have an awesome Thursday, a great weekend. Have fun with Gut Check Thursday. See you later, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.  

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich discusses how to know when to challenge or change movement patterns vs. when to be ok with more freedom of movement Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION CODY GINGERICHGood morning PT on ICE Daily Show. My name is Cody Gingerich. I'm one of the lead faculty with the extremity division and I'm jumping on here today to talk about when to be picky about movement. So, The last several years in PT, there has been kind of this shift in differing opinions on how specific do we need to correct every tiny little movement fault that we see in people, all the way to like, hey, however they move, this is just kind of how this person moves and we can just get strong in whatever positions that they feel comfortable with. And so I want to talk about a little bit of the like, finding that middle ground and there's a time when yes, we need to just let somebody potentially move how their body is going to naturally move versus also, hey, that moving pattern doesn't look good, isn't efficient, could be leading to the injury that they're dealing with and how should we and when should we correct that? So the old adage kind of, uh, that I like to use in that like thought process is it doesn't matter until it does, which is basically saying nothing other than, um, there are gonna be points in time where you have to understand that person moving in front of you and understand where their pain is coming from and then is that movement pattern the problem for their pain, okay? And so the number one thing is that there is no way without any context behind the person in front of you. Like if you just see a video of somebody that you have never met and you watch them move and you say, oh yeah, we need to correct that, that would be not a time where you can fully say that. Okay. And so I would encourage you to, to kind of get rid of that out of your brain of like, if you don't have any context behind that person moving and you just think, well, that movement pattern is incorrect and we would definitely need to fix that. I would argue that that wouldn't be the correct mindset going into that. However, if you have that same person and you see their movement pattern and you understand the sport or the activity that they're doing, and potentially if they are dealing with pain, then all of a sudden we can have that conversation of, is that movement pattern creating some of the issues? Are we putting undue stress on different tissues because of the way that they're moving? Okay, and so a couple examples of this, a lot of times this is going to be if we talk about patient population. If we're dealing with someone who is an older adult and they have a very low movement standard already, like they have not really done much moving and they are generally deconditioned and just need to create any type of strength adaptation as possible. Of course we want to teach them how to hip hinge and teach them how to squat and do some of that, but does it need to be the cleanest, prettiest squat or hinge that you've ever seen? Arguably no. Okay, right now we need to just get all of their muscles moving together in whatever capacity they can in order to just start that strength training process, change their their homeostasis change their overall body structure so that they can move one thing to another. Okay. And so with that population, I would say, go more on the air of how they're moving is not quite as important as what they're doing and what they're moving. Okay. Of course, changing from a squat to a hinge or whatever pattern you're wanting to look at a lunge, a step up those type of things. But if their knee shifts a little bit one way or the other, or they have a bit of like a hip shift when they're squatting, or it's not the prettiest hand you've ever seen, like their chest isn't quite upright, like all of those things, you want to try and work towards them, but you don't want to limit their ability to do that movement because it doesn't look perfect. Additionally, if you're dealing then, if we flip the coin and we talk about more high level athletes, If we talk about high level athletes and you are just watching them move and don't have any context yet, and you see them and they say like, potentially this is like top of the top, right? They have potentially created adaptations and movement standards and movement positions that create the proper adaptation for whatever sport they are doing. So if you think more unilateral sports, I've been watching the Olympics the last couple weeks, right? There are some incredible, incredible athletes. Those people are not going to be symmetrical. So if you think about a shot put thrower, like those people are incredible. Both men and women like throwing those weights incredible distances. They are not doing that on both sides. So they're going to naturally have one of their their push off leg and they're throwing arm is going to be stronger. And so when they do then bilateral movements, there is a chance that that might not look exactly the same every time. But if they are not dealing with any pain or discomfort, then maybe that's not really a big deal at all. And that's actually helpful for them. When we want to start looking at actually diving into some of those, like, hey, we need to really adjust how you're moving and pay really close attention is going to be when A, either that same athlete that I just talked about is dealing with pain and it's more of a unilateral thing, or B, if potentially the way they're moving is inefficient for the sport that they're doing, right? So sometimes when we think about, especially our fitness athletes, When the clock is going, their body just says, hey, I need to get from point A to point B as fast as possible. And a lot of times, as fast as possible does not necessarily mean as efficient as possible, and they end up overloading one joint, one muscle, something, because that is the way their body has just started to adapt, because there is a weakness lying somewhere. Okay, so then in those moments when there is actually pain involved, that's when without that context, you're not going to have any idea. But with context, we can start teasing out, are there weak points? Are there mobility deficits? Are there different reasons why they're moving in these poor movement patterns? Okay. And so a lot of times that's where just a poor movement pattern, but if you end up looking at it and say, well, everything is moving or everything is strength wise, pretty equal. Their mobility is pretty equal. Now we're dealing with something a little bit differently, but if there is a weakness leading to a movement restriction or a mobility leading to a odd movement pattern that ends up overloading those tissues, Now we need to start looking at, well, we need to potentially strengthen that area of weakness or improve that area of mobility. And then that freedom of movement can increase. And now we have a little bit less stress taken off of the tissue that's irritated and the other potential tissues can take up some slack as we build them up. So as opposed, this is kind of going backwards again. So in our heads, when we're watching movement patterns, think more so, is this something where we are creating an overload of a tissue that is unnecessary and creating pain? And what is weak that is trying to make that happen? And sometimes the weakness area can be the thing that's irritated or sometimes you could actually have that stronger side or stronger tissue area be the thing that is just constantly being used repetitively, repetitively, repetitively. So with the example of our fitness athletes, think one of those athletes that does, if they're doing burpees and they do like to do step back or step up burpees and they like one side over the other, okay? A lot of times that is not a problem at all. And they just continue to build some strength there and they might have side to side issues. But then all of a sudden, if that starts to show up in their squat and they have a big shift when they're trying to get out of the hole, that is now their body trying to utilize that stronger side to do a lot of that work. And it's going to start showing up in other areas over time. And then if they develop pain along that whole route, these is the context that you want with movement patterns. Now, all of a sudden, we need to build up that strength at the other side, maybe clue them into, hey, when you're doing burpees, I need you to alternate legs every single time so you're not just repeatedly lunging on one side or the other. Okay. And so at that moment, now we are adjusting movement patterns and then working on their squat patterns. So it might, we might need to say, okay, we need a pause and we need to make sure that when we drive out of that hole, we aren't getting any type of shifting this side to side, and we're not overloading that one hip or that one quad that you feel dominant in. Okay? So that's where, with this, when does it matter versus when does it not? Okay? When we're talking about our lower level athletes, people who have not necessarily moved in a long time, those first six months potentially, of course we're building into, like, we want to still coach good movement patterns, but don't limit their ability to move weight and get stronger just because it isn't exactly perfectly correct. Still allow them, still you're always fighting for good movement patterns, but keep letting them build some strength just as they're naturally growing. And then as that starts to build up, now we can hone in on some of those nuances. As an elite athlete, if they potentially need those differences in movement patterns, but in the absence of any type of pain, or anything like that, don't just automatically assume they need to really change how they're moving or that asymmetry in their squat or their deadlift or something like that is a problem. It might be an adaptation that they literally need. When we need to start changing and looking a little bit more closely and honing in on very specific movement patterns, think more so if pain comes on board, with any of those movement patterns or you notice a big mobility deficit or a big strength deficit that causes that shift or that change in movement pattern and if you can then either coach that out or change their strength or mobility, that's then when we can start teasing out some of these nuances in movement. In the extremity course, we talk a lot about extrinsic versus intrinsic cueing. Our extrinsic meaning not saying, hey, squeeze your lats, squeeze your glutes. Those are more intrinsic things that people think about. But instead, it's like, hey, I want you to drive your head through the ceiling. Okay, so doing something like that, I want you to punch that bar through the ceiling, or I want you to drive, like break a board under your feet when you're standing up out of the squat, something like that, where you're going extrinsic cueing. And that's gonna be more so, can you cue some of these movement patterns out? If we notice more of that weakness or a mobility type of deficit, that's when we need to really hone in on, are we really thinking about moving in the right patterns and using the correct tissues and muscles that we want? And can we get a little bit more specific? If you're noticing, hey, that lateral hip is a little bit weak or their quad is a little bit weak, Now, all of a sudden, if you're doing more specific movement patterns, you can start thinking, hey, I really need your brain at your quad and you can like tap the quad, you can have some kind of stimulus at the quad, I really need your brain focusing in on this quad. And that's where at the out of the bottom of that squat, I need you squeezing that really, really hard. or I really need you thinking like that muscle that we just got burning from a leg lifter or doing the side steps like that's that area in your hip that I really need you honed in on. And that's going to create some of those movement pattern shifts as well. So utilize both our extrinsic coaching and or intrinsic cueing in order to change some of those movement patterns. If you have determined like you have that context with your patient, you understand like there needs to be some nuance to this movement pattern that's going to be more efficient for that person. And they have been working around something for a very long time and their muscles have adapted to that. And now it's getting to a point where it needs to be addressed. Okay, that's what I've got for you today. Hope y'all have a wonderful weekend. We have an extremity course coming to you next weekend. I believe Lindsey's going to be up in Bozeman, Montana. So as far as if you're trying to find a late last minute jump into a course, we'd love to see you out there. Otherwise, hope everybody has a great day. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Lindsey Hughey // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey explains the rationale behind myofascial decompression or "cupping" for patellar tendinopathy and provides a technique demonstration. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog. 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 LINDSEY HUGHEYPT on ICE Daily Show, waiting for YouTube and Instagram to catch up. So we are live on both. How's it going? I am joining you again this week on the PT on ICE Daily Show. Welcome. I'm Dr. Lindsey Hughey. I currently serve as one of the division leads at extremity management. And today I want to share with you a myofascial decompression technique for patellar tendinopathy. So today is either Technique Tuesday or Leadership Thursday. So we're bringing Technique Thursday to you all live. My model today is Daniel, my son. So what I want to unpack is a little bit about how do we know someone has patellar tendinopathy and who this might be appropriate for. with patellar tendinopathy, show you the technique, literally just demo it for you live, what you do, and then we'll chat also like how do you know the treatment worked. So we'll talk a little bit about our test retest options for patellar tendinopathy. And then we'll call it a morning technique Thursday, not Tuesday. Great to be with you all again. So first things first, someone with patellar tendinopathy is going to complain of a recent spike in load. Usually it's energy storage and release activities like jumping, sprinting. The other complaint, vice versa, they might have is that a dramatic de-load where they haven't, maybe it's their off season and then they stopped loading completely. this might flare up that patellar tendon. They will complain of pain with energy storage movements, and they'll specifically complain of pain right at the patellar tendon, where that inferior border of the patella sits to the tibial tubercle. When you palpate that as the clinician, that will be tender to palpation. Often when they extend their knees, so you're doing manual muscle testing of quadriceps, that will also cause their symptoms to blip. Having them do a one-legged squat on a slant board is another load test that will often bring on symptoms. The person with moderate to high irritability, patellar tendinopathy, often has coinciding hypertonicity throughout their quadriceps. So when you palpate, it's not just that patellar tendon that is bothering them. Like their quad also is kind of guarded around that knee joint. So myofascial decompression can be a great adjunct to treatment. If you've heard any podcasts that I've done on tendinopathy, you know, that load is our love language, or if you've been at our course, you know that. So ultimately, the teller tendinopathy is going to be healed by high tensile loading that involves loading the local tendon, the local muscle, quadriceps, the chain, and then off eventually gets into energy surge and release. So know this treatment technique that I'm about to show you is just an adjunct to care that creates a modulating window of opportunity to load that person better. So consider it's moderate to high irritability human. And so that's someone that like not just is their activity or sport starting to get interrupted. It's usually our basketball or volleyball players, but also like daily life is starting to get aggravated. They're not sleeping as well. Their performance has dropped. These folks need that treatment that kind of takes that edge off. So without further ado, you kind of understand who the person with teller tendinopathy is, who would be good to execute this treatment on. I want to show it to you. So I'm going to kind of move the camera around just a tiny bit. so that you can really see the quadriceps. So we're going to do one of two things. We'll make sure we've exposed the area. I want to not only get myofascial decompression to the quadriceps and hit each part, but I also want to decompress that patella and the patellar tendon. So to first decompress the patellar tendon and the patella, I'm going to use a silicone cup. So these silicone cups are awesome. The way we'll apply these is we're going to create negative pressure. So you really want to squish this in and then apply firm pressure down with your body, being mindful that this could be an irritating area. The way I would explain it to the patient is we're using this cup to just kind of offload that bone, that patella, and then offload the patellar tendon a bit. So I'm going to create that negative suction and compression. If you have very hairy patients, you're going to want to put some lubricant like a Biotone around that. Just a little bit will go a long way, but again, more hair endowed folks might need a little bit more. So we're going to go here. I'm going to create that negative pressure, I'm going to press down, and then if I've done a good job creating that suction, there'll actually be a little dip or dimple in the silicone cup. The cups I'm using today are from Chris DiPrato and his team. They are amazing cup therapy if you follow them on social media. I love their products. This comes in their kit, this silicone cup, and then their curved cups. These are actually their newest ones are what I'm going to use to hit the vastus lateralis, to hit vastus medialis, and then I really want to get after rectus femoris. I want to make sure I hit all three parts. You can't really get that intermedius without a needle. So we're going to hit those main more superficial areas. So we're going to hit that vastus lateralis first. And then I'm going to place that curved cup and then create suction with our gun. And there's various guns. This is a manual pump that you can use. There's ones with gauges and then electronic gauges. We want about 300 to 600 millimeters of mercury if you do have that pressure gauge that actually gives you a reading. So we'll hit vastus lateralis in two different spots. So one here and then one a little higher. I'll step away so you can see. Then we're going to want to go vastus medialis. So now I'm just on that inner part of the quadriceps. And then we want to hit that rectus femoris and I can hit here and then I can even do one more a little bit higher. I want to show you just there's, these are the newest curve cups. These are awesome as well. So I wanted to show you that. We'll go a little higher and we're really trying to hit that muscle belly here, not tendon. So then this is attached to patient. And I'm not just going to leave him sit here. So I promised him I wouldn't actually make him move. So I'm just going to talk through this. But I'd actually have him do some knee extension with those on. So mod to hired ability, we want to create an analgesic response. So we'll have them do some isometrics, shooting for that 45 second hold, trying to do five reps. So we'd start with just probably doing like a quad set where he'd like push his knee down and then maybe lift a little bit or combine it with a straight leg raise. That would be like level one. As soon as we can get him up and weight-bearing, I want to do like a wall sit or a Spanish squat with these on. So he's in this decompressed, he, they, she, whoever your patient is, decompressed state, and they're still loading. So it's not a static laying there thing or treatment. So once cups are applied, right, I do some kind of active treatment. I've named a few. Lowest level would be that knee extension with a lift and or just doing a nice quad set, then getting to a wall sit or a Spanish squat in a reduced range. We usually start about 60 degrees. And then we take the cups off, right? Reassess the soft tissue. Daniel's probably like, please take these cups off, mom. What we'll do is reassess the soft tissue, but not just the soft tissue. I want to see, is there less hypertonicity? I want to see, is the tendon, after I've palpated it, become a little less tender to palpation? In addition, I want to probably test a load test, like that slant board, if we had just tested that. And you may even see a change in motor response. So if you took your dynamometer, took a quadriceps reading, and then also got an NPRS, did this treatment, Then retested using your dynamometer, you often will see not only a change in pain, but you can even see motor uptick. So an increase in that strength measurement just because pain has now dampened. So this treatment doesn't take a long time, but can be super effective for our patients with that mod to high irritability where life is starting to get interrupted by their patellar pain. SUMMARY Thank you for joining me this morning to learn one of my favorite techniques that I'll use for my folks with patellar tendinopathy. I hope you all have beautiful clinical Thursdays, whatever you do in the clinic, and will consider using this with your patient. If you want to learn more about research concerning patellar tendinopathy and how to load your folks well, join us on a weekend soon in extremity management. So we will be in not only North Dakota, but also in South Carolina, August 24th, 25th. So you have two opportunities coming up, and that'll be our last opportunity of the summer. So really jump in if you haven't yet. And if you want to learn a little bit about some myofascial decompression techniques, our colleague Chris DiPrato, we're a big fan of his courses. We also integrate that in our courses as well. So thanks again for joining me. Cheers. Happy Thursday, everyone. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.  

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave shares shares how by being too quick to limit risk for our patients we can expedite deconditioning, worsen social isolation and mortality of our patients. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about 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 JEFF MUSGRAVEWelcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dr. Jeff Musgrave, doctor of physical therapy. Super excited to be talking to you about everyone dies, not everyone lives. So I am fresh off an epic motorcycle adventure with the CEO Jeff Moore and Matt in the bike fit division of our company. And it was an epic trip. And a great way to summarize this trip is a quote from a motorcycle brand that I've started following recently. We don't promote this brand in any way, I just thought the quote was great, which is, everyone dies, not everyone lives. So just to kind of set the stage a little bit, I'm new to motorcycling, brand new thing, it's something just recently I decided was Important to me a risk that I wanted to take Lots of people in my life very well-meaning that care about me deeply Wanted to just share all the worst case scenarios. They wanted to instill enough fear in me To maybe prevent me from going or to make sure that I'm super safe and and I get that right there is some inherent risk Taking a motorcycle up a cliff face lots of things can happen Some injuries occurred, there were some wrecks, but most importantly, there was the opportunity to really live life. in a very deep, meaningful way to accept some risk, to have a lot of fun, to have some fun stories, to make some fun memories that are gonna last me, I hope, the rest of my life. And I think this is very relevant whether we're talking about older adults or even younger adults. But I think we come in contact with this type of problem with older adults most common. So commonly with older adults, In that same vein, we're trying to help our patients be safe. We want them to make decisions that are going to prevent injuries, prevent falls, and for a lot of our older adults, a fall can be a very serious thing. I'm not making light of that in any way. We know that lots of our older adults are living with low reserve. and low physical resiliency and reserve, so they have very little margin. So if they fall and they have decades of deconditioning, their bones are weak, their body systems are not prepared to help them recover quickly, and this can have a huge impact on their life. So I want to say I recognize that, and we preach this fitness forward approach to try to help build that reserve and build that resiliency, but still what I tend to see when I interact with clinicians, working with older adults, is we treat older adults with kid gloves and we don't want them to be put at any level of risk. But I think the thing that we forget is what they're missing out on. What are the things that they want to do that are risky and how meaningful may they be to their life? So I'd like to give you a few tips just from my clinical experience to help patients live until they die. We want them to live their life as fully as possible, and I think sometimes we don't think about, when we limit our patients, what the downstream effect is for their life. So I've got a few tips here that I think will be helpful, and then we'll go through an example of what this could look like. So, you know, many of our patients, they're maybe not trying to take a motorcycle adventure into the Rocky Mountains. Maybe it's something like walking without an assisted device, or maybe they really need a walker but they're only willing to use a cane. So I think the first thing that we have to do is we have to have an objective assessment here. We can't just make assumptions. We don't want to look at their past medical history, their diagnoses, and decide for them, or heaven forbid, just their age. We know that people age at different rates and have different functional levels. Their age doesn't dictate their treatment. There are clinical findings should, very accurate clinical findings that meet them where they're at. So the first thing I would advocate for is to get an objective assessment of the risk. So how risky is this activity? Say it's some type of walking or balance activity and we're worried that their balance isn't good enough. Well, first thing we should do is say, hold the phone. We need to do a good assessment here, so we need to match up the patient's physical ability to the objective measure and make sure that the activity is represented in our objective measure. One that we really like to use, it's pretty comprehensive, is a mini best test. The mini best test is a great way to look at dynamic balance, looking at reactive components, as well as anticipatory. as well as a vestibular system, and reactive, like how are they gonna react if they do catch their toe? Do they have the ability to react? So if it's a balance activity, we'll wanna make sure that that activity is represented in our assessment. So we can have a very clear picture of how much risk is this. Maybe it sounds really risky, and we have them do the assessment, and it's like, meh, it's maybe not the best, but it doesn't look like it's that serious, On the other hand, it could be that it is very risky. They can't even do the task at all safely in the assessment. So either way, we need to know objectively what's their physical ability to do this task, whether we're doing the task directly or we're trying to replicate it. We need to get an idea of what's required and get an objective measure for that. The second thing we need to know is how meaningful would this activity be to our patients? How risky is this? But how much reward is there for our patient as well? So there's two sides to this. So if we're thinking about, we've got our assessment, then we've got a good idea how much risk is this based on say like their fall risk. It looks like they're having trouble walking and carrying something. So them wanting to carry in their own groceries without their hands would be a pretty risky task. But maybe that task allows them to be independent in their home. Or maybe they don't have the financial resources to pay someone to bring their groceries to them or for some type of grocery delivery service. So that could change their living arrangement. So we don't want to just make these big blanket statements based on risk. So we've got to figure out how much risk is there based on an objective assessment. We also need to know how much reward is there for our patient on the other end of that. Or what are the downstream effects of them not doing that task anymore. Will there be more deconditioning? Will there be lack of social connection? Social isolation, especially if someone is pre-frail, increases their mortality risk by over 25%. So if we, our choices for safety, take away the social reward, and we reduce the value of their life, we may also hasten their death. which is kind of a wild thing to think about, but our trying to play it safe could actually lead to them dying sooner, which is pretty awful, and I know that's not anyone, what anyone wants to happen that's listening to this. And then the final thing is you have to come to some type of agreement that you can work with, that they can work with, that you can work with, right? So that this therapeutic relationship can continue. So I'll give you an example, I'll kind of work through this, and I think this will help make this a little more clear, So an objective assessment of someone's risk. Say we've got a patient who's an independent community-dwelling older adult who has had some deconditioning, they've got some balance deficits on board. They say, I've got a cat, I'm widowed, I live alone, I need to be able to take care of Fluffy, but my balance, I'm really struggling to be able to get the cat food in from my car up the steps into the house, and I've actually had some falls recently, and I'm at the end of the bag of cat food, now what do I do? So the first thing we're gonna do is based on that task, pick an objective measure that's gonna be helpful. So for a community dwelling older adult, we'll probably do some type of quick screen to get an idea of strength and balance, so something like the short physical performance battery. And then based on that, if it looks like there's some serious balance deficits, we may wanna do a deep dive with a mini best test to get an idea of her dynamic balance, her ability to recover if she catches her toe, while she is carrying, it'll also take away her visual field during parts of the test to get an idea of what's her proprioception like, how well is her vestibular system functioning, and then from there, we can get an idea of what is the objective level of risk. So say we run the mini BEST test, and it looks like she is at risk for having a fall. And then the third thing is, we know, based on this patient, maybe she doesn't have a whole lot of social outlets, and this is one of the only times she gets out of the house for a medical appointment. So we need to really go through this filter of, yes, she could fall. If she continues to do this task, she could fall. But if we take away this trip out of the house, we take away a lot of activity from her daily life. So if she's not able to, if she's not lifting, carrying, working on her dynamic balance through this task, even if it's once every couple weeks, that is still a huge reduction in her overall physical outlet in her physical health. I mean it's built into her life so taking that away from her will actually probably expedite her lack of reserve, resiliency, expedite her deconditioning, as well as potentially isolate her from her pets. So if she's trying to take care of Fluffy, she doesn't have a whole lot of social outlets, that may reduce her willingness or desire to even live moving forward if she doesn't have that outlet with her pet. the lack of reward or the loss that that would represent to just say, no, not safe for you to do that. Let's have someone else bring the food, which she loses the physical attributes or the physical activity that is keeping her strong, at least at some level. But then the second piece is, maybe if we went to the extremes like, you know what, you're just gonna continue to get older and more deconditioned, you should probably just give the cat away. which is probably the worst thing we could say if there's any hope of her getting her strength back. She'll have the social isolation, probably some depression, as well as not being able to have that at least low level of physical activity. A way that I would come at this, if this was my patient, is I would describe the risk. Hey Betty, you know what? You are at risk for falling. You do have some deficits on your balance, but I realize this connection with Fluffy is really important for you, and I think we can work together to find some solutions. So some things I would be thinking about is if she needs some upper extremity support, maybe she's not using an assistive device, or she's not using the right one, which also happens pretty often, Maybe we can meet in the middle. Maybe we can say, you know what? I think if you get a smaller bag of cat food, you can put it in a backpack. And if you can get it, if I can teach you how to put this in a backpack and put it on your back, you're gonna have your hands free. And maybe until we get you stronger, just till then, we can use a walker to get you from your car to the steps, and then if you've got enough support or you've got your cane you usually use in the house, maybe we can get you to use the cane for a very short distance. Or maybe even let her set the backpack down and drag the thing into the kitchen. There's so many ways we could get the job done, but we may have to change what it looks like for a short time. And I would almost guarantee you, if that example was your patient, that they would 100% be okay with buying a smaller bag of cat food, which may get them out more often, which may help us reduce their sedentary behavior, improve their activity frequency, how often they're doing that, could be really good, as well as keep the cat, which I think is the ultimate goal. If they get to keep the cat, keep doing the task, maintain their independence, and we can limit their fall risk by giving them some extra support, but the task gets done and it's temporary, I bet they're gonna be on board. So I hope that helps. So I would really advocate before we just give blanket statements for safety for any patient, but especially for older adults. We want to make sure that they have the opportunity to live their life. We need to consider the risk, absolutely. We need to get an objective measure on that, but we need to consider what we're taking away or what their life will look like and the downstream effects of telling them no. With the heart of safety, we may expedite someone's death or reducing the quality of their life. The final phase, after you figure that out, is we've gotta come to an agreement. We've gotta continue that relationship, do what we can to reduce the risk for them, but maybe we have to meet in the middle. And maybe we can make some agreement that it's like, hey, until we get you to this point, would you agree to use this extra support? Or do this task a little bit differently? And almost 99% of the time that I've come at this type of conversation with a client this way, it has always gone well. Team, I hope that you go out there and you help your patients live. I hope that you're careful assessing risk. I would love, if anyone has any examples or stories they'd love to share, please drop it in the comments. If there's a cool story where you've been able to meet in the middle, help someone continue to do something like that, or just have some thoughts. I would love to hear your thoughts on that. If you're interested in learning more from the older adult crew, We've got our level one is kicking off in less than a week. It's crazy. It's time to sharpen those mental muscles, get back into L1. So if you just came off live and you're wanting to get your specialty in older adult, we would love for you to hop in there. If you've already had L1, I'd recommend you hop into L2. The last cohort sold out. The next one of those is gonna be October 17th. As far as live courses, myself and Ellen Sepe, The woman, the myth, the legend is going to be with me in Anchorage, Alaska. We're going to have a great time. That's going to be August 17th and 18th. Great opportunity for some awesome continuing education. Meet us live, work on your skills, and also take in a beautiful state at a great time of the year. We also have live courses on September 7th and 8th in Minnesota and Alabama. Team, that's what I've got for you for today. Go help those patients live. Have a great day. Catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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 role & function of tendons in the body, traditional rehabilitation approaches to treating tendinopathy, as well as a new procedure called TENEX for tendinopathy management. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION LINDSEY HUGHEYMorning PT on ICE Daily Show. How's it going? Welcome to Clinical Tuesday. I am Dr. Lindsey Hugey and I will be your host today and we're going to chat all things TENEX and TENEX care specifically for our tendons. So I'll chat with you a little bit about what it is, what the procedure proposes to do and kind of what we're seeing in regards to its effects So the title officially today is, does TENEX get a 10 for tendinopathy care? So let's dive right in. And I do want to say, spoiler alert, it does not get a 10 for tendinopathy treatment. So first, before we dive into what is TENEX, Let's just chat about in general what tendons need to heal as a little reminder to kind of set the stage. And if you've been to our extremity management course, this will just really be a review. TENDON FUNCTION But our tendons in their most basic function, they connect muscle to bone. They are to act like a spring and they are to be mechanoresponsive, right? To take on load, transmit force up and down and across. they are responsible for speed and acceleration, they need to take on compression and friction. As soon as we spike loads quickly or dramatically deload activity, we will see changes in capacity of not only that tendon, for better or for worse, but also in the structures they're attached to. So consider the muscle, local muscle, and then that bone. So not just the tendon will either gain and be challenged by spikes in load and or will reduce, right, if you dramatically deload. So come to our course if you want to, extremity management, want to learn even more about that, but that's kind of tendon basics. For those that have treated tendinopathy and are in the outpatient space, folks that do a lot of repetitive action or athletes often get tendinopathy at some point in their life. And this results in pain. It can result in sickening and swelling at that tendon, but really it's decreased performance, whether it's in their job that they need to do and or their sport participation. And a lot of folks think this is just going to go away on its own. And they'll try conservative measures, whether it's they've looked it up on Dr. Google or they've consulted their doc. And I want to set the stage of what's really being told for conservative management of our attendants. It's rest, it is NSAIDs, injections, surgery, PRP, stem cell, shockwave therapy, and then physical therapy is on there as well, but we know there's a lot of treatment variation in our profession in regards to building the capacity of that tendon. WHAT IS TENEX? Now on this list for conservative management is TENEX. So I kind of want to set the stage. We now know what kind of tendon function, what will challenge a tendon, and now we know what is really recommended for tendinopathy care. We tend to see, because of this treatment variation as well, right, from rests to anti-inflammatories to surgery and physical therapy, somewhere in between, we see people, and then some folks just not getting care at all, going on to chronicity. telling their docs that, you know, this is hanging on for more than three to six months. I'm not getting better. My performance is lessening. I'm having difficulty at work. And so TENEX was developed. And so we're gonna dive into the treatment. Is this helpful for tendinopathy? So TENEX , T-E-N-E-X, for those listening, is prescribed for those recalcitrant cases that aren't responding from that list we just reviewed. What it was developed in Lake Forest, California by TENEX Health System in collaboration with Mayo Clinic. And what it is, is it's ultrasound guided percutaneous needle tenotomy. It's a mouthful. And what they do is they use a needle, a small incision is made with this specialized device called TENEX, the device is inserted, it delivers ultrasonic energy to the damaged tendon tissue, and it emulsifies that damaged tissue into a soft liquid form, and then that's removed through the same incision. Basically, using oscillations in high frequency to debride and aspirate the diseased tendon, all guided under ultrasound image. The rationale for TENEX, is that it is minimally invasive for those that have been struggling for three to six months to even a year. It's minimally invasive as stated, but they're not going to have a ton of a recovery period. They'll get back to their activities. There is like a very wide variation here, but they'll say anywhere from three weeks to 12 weeks. The goal and kind of the underlying theory of why does TENEX work is that it is stimulating the body's natural healing process. And ultimately that helps restore tendon function. That's what the kind of the proposition is. And then they keep selling that it's minimally invasive and it's shorter recovery than like your typical surgeries that they'll do for tendinopathies. with the cell, they usually will sell the shorter time of two to three weeks back to your sport, back to work without any issue. DOES TENEX WORK? And so what are patients saying about this? So patients, when we look at systematic review level studies, and there's more than a handful of these, we are seeing these patients reporting reduced pain, reporting improved function, returning to their sport, And what's interesting is they're seeing even at a year-end, three-year mark, these patients still reporting improvement in combination with these TENEX procedures. And so we kind of have to take a pause about our biases because here at ICE, you know, and if you've been to our course, we really believe load is our love language for tendon care. And that's really the only way to remodel that tendon is high tensile loads. And so what should we be thinking and advising our patients on, knowing that this procedure exists, it's existed since 2010, knowing that even in the last five years, we've gained some systematic review studies in various areas of rotator cuff, Achilles tendinopathy, gluteal tendinopathy, our lateral elbow tendinopathies, all of these areas are showing evidence of improved pain and function. But there's a lot of unknowns, right? So like, what do we tell our patients? Because they're going to ask, especially if they're kind of looking for that quick fix, and maybe they just started out of care with you as well. Well, I think we have to be honest that we don't actually know a lot of long term data. in combination with physical therapy. So you'll see that often after this procedure, they are recommended physical therapy. So what we don't know is the differentiator yet. Is it physical therapy that is actually helping or is it that TENEX? In addition, that bias that I told you about that I want to share is that you still have to restore capacity to surrounding tissue. So even if you clear out this like dead tissue right this tissue that is specific or excuse me that's been linked to possibly being painful for this patient you still have to lay down new fibers in that tendon, you still have to challenge the local muscle, you still have to help that bone health and so all that doesn't go away. My bias here is going to be that physical therapy when done very well should prevent this TENEX from ever having to happen because we should be able to right away respect that irritability of the patient dampen their pain symptoms right whether they have some degenerative tendon on board or not we might not know but if you respect irritability and then gradually load that person load that local tendon load that local muscle challenge the chain and then as that goes well then start to add in some energy storage where the patient has to take on compression and friction and spring-like movements, we don't have to get to these invasive procedures. But it's that variation in our practice and the things that are just readily recommended on the internet and from docs, which is RESS and NSAIDs and getting stem cells or PRP, these like quick fixes, quick fixes that never really address the underlying problem. So while TENEX, I think there are some promising results and we really have to acknowledge that. I'm going to give it a 5 out of 10 because we do see in those people that are getting TENEX that they have improved pain and function consistently. Only giving it a 5 because We have an opportunity here that TENEX is not the answer, right? We see folks on the other side of that TENEX. It's not TENEX giving the 10 out of 10 pain free, right? Or 10 out of 10 function. It is really in that conjunction of getting the tendon capacity back up. So thank you for kind of going on this little journey with me about TENEX. It's been a question that's been popping up on weekends, you know, what do we think about TENEX and what do we tell our patients? What I'm going to say overall in concluding this is that those suffering from chronic tendinopathy, they may have their mind set that this is what they want to do. Know that you can partner with them. before that and after. Like you are going to be a part of their care no matter what to build up that capacity. You can educate in that way and let them know and I can attach them if you're interested that there are systematic reviews showing promise with this. know that as Dr. Justin Dunaway says, beliefs and expectations are the foundations on which outcomes are built. So if the patient believes TENEX is going to help, it is going to help with pain and function. If they believe physical therapy is going to help, it's going to help. And if in conjunction together, they believe it's going to help, it's going to help. So we really have to have a biopsychosocial approach to this too, not just the facts about the procedure and what TENEX is resulting in on a systematic review level. What really matters is what does the patient believe that's going to help and what's going to get their tendon ultimately more healthy. SUMMARY I appreciate you joining me to chat a little bit about something that's a little outside of the scope of our normal weekend. And if you want to learn more about the tendon continuum, the complex pathophysiology that's happening, we take a deep dive over an hour long lecture on day two of our course that dives into all the latest literature on tendinopathy. our upcoming opportunities to do that and join us. We have two, August 24th and 25th. I'll be in Bismarck, North Dakota, and Cody will be in Greenville, South Carolina. We would love you to join one of us, right opposite ends of the spectrum. And then the next opportunity will be September 14th, 15th in Denver, Colorado. So join us on the road if you can. Thanks for chatting with me a little bit about 10X today. Have a happy Tuesday, everyone. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Heather Salzer // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Heather Salzer discusses a case study involving helping a patient increase her calorie & protein intake during postpartum to improve her recovery & performance. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION HEATHER SALZERGood morning, PT on ICE Daily Show. Happy Monday. I'm Dr. Heather Salzer and I'm here with the Pelvic Division at ICE. And this morning we are going to talk about hacks to hit protein and calorie needs to help us stay out of low energy states and avoid RETs. So at the ICE Pelvic Division here, We talk a lot about REDS, also known as relative energy deficiency in sport. It's something that can have widespread effects. It can affect our immunity, sleep, energy across the day, muscle building function, and then a lot of pelvic kind of class specific things like fertility, increase our risk of urinary incontinence. If you want to deep dive into REDS, please join us in one of our pelvic we go into it in great detail, but when we talk about it, we always get the question of, okay, well, if I need to be eating that much, or if my clients need to be eating that much, that feels like a lot. How can we actually get there? So for the podcast today, we're gonna go through a case example, and as we talk about that, discuss overall calorie needs from Red's perspective, and protein needs, because that's something that a lot of people struggle with as well. And as we go through that example, we'll go through hacks of little changes that someone could make in their diet to make these things a little easier. So meet Kristen. She is our client today, and she is 32 years old and around 160 pounds. She's got a three-year-old at home and a 10-month-old that she is breastfeeding. Kristen runs two to three days a week at a pretty moderate, sometimes higher intensity, and she also crossfits around three days a week. She's also pretty busy chasing around her three-year-old and while carrying her 10-month-old with her as well. So how much does Kristen need to be eating a day when you ask her and are getting some feedback from her? So someone with her general demographics would need relatively about 1,500 calories just at absolute baseline doing nothing else. When we add in her activity across the day, we're looking at closer to 2,500 calories. Then we add in breastfeeding on top of that and she's sitting at close to 3,000 calories a day in terms of her caloric need. if we're thinking about how much protein we want her to be getting, likely we're trying to be somewhere in that close to one gram of protein per pound of body weight, just because of her high activity and breastfeeding. So we're looking at like 150, 160 grams of protein. That can be a lot. When we ask this question to our clients, a lot of times, her it's like, whoa, I am not getting anywhere close to 3,000 calories and you want me to eat how much protein? Don't you know that I have kids that I'm chasing after? When am I supposed to meal prep enough to make all of that happen? So let's go through her day, talk about what she might be eating to start with, and then little tweaks we can make to change it along the way. So we ask her, Kristen, what do you eat for breakfast? And she says, well, some days I have got, I do like two eggs, some toast and some fruit. And other days I do some oatmeal with berries and milk. Okay, if we think about that, we're maybe getting 15 grams of protein and probably like 300 calories on top of that. That's not a super strong start to the day. So we ask her, hey Kristen, Do you think you can add another egg or maybe some egg whites to those eggs and a breakfast sausage on top of it? She's like, yeah, that seems reasonable. Or on oatmeal days, can we do overnight oats instead of hot oats and put a scoop of protein powder and maybe a couple tablespoons of chia seeds in there? And then all of a sudden with either of those options, we've upped protein closer to 30 to 40 grams and now we're sitting at like 700 calories. So starting off strong with a good breakfast is a nice way to already help us get those totals earlier in the day. Side note on the oatmeal, I don't know about you but I have tried putting a protein powder in hot oatmeal and it gets chunky. Overnight oats are fantastic and that protein powder scoop is a good way to up the protein on that. So moving on to Kristen's day, we are about mid-morning and she's like, yeah, usually I don't really have time to eat again till breakfast or till lunch. I get going with my day. I'm pretty hungry when I'm breastfeeding, but then I keep going and I really just don't have time to eat again until lunch. So we say, What can we do to make it easier for you to get a snack? Can we have a protein shake that you make with breakfast that's sitting in the fridge ready to go? Can we have some yogurt that can be easily grabbed? Where are you doing your breastfeeding right now? Do you have a station set up? Can we put some protein bars there? Can you grab your yogurt on your way there? Can we stash some protein bars in your car? So finding a way to get her a snack in the morning that can pack an extra 20 grams of protein and maybe another 200 cals on top of that. Breastfeeding, for this specific example, can be a great time to get it. Baby's getting their nutrients in. I promise they won't mind with some crumbs on their head. Fuel yourself while you're fueling baby. That can work great. So, we've already increased by adding in some snacks, packing her breakfast a little bit fuller, now we get to lunch. And we ask her, okay, Kirsten, what are you eating for lunch? And she's like, well, I've been trying really hard to be good about my nutrition and getting in healthy things, so I've been meal prepping turkey and cauliflower bowls. I say, okay, awesome, I'm so excited that you're taking the time to meal prep, that can take a lot of time. And how much are you eating? And she's like, well, I've got this little Tupperware. And you go through it together and you calculate it. And really, she's getting like maybe 400 calories and maybe 20 grams of protein in her little Tupperware. And you ask her, are you full by the time you're done eating lunch? She's like, eh, maybe. You're like, do you think you could eat a little bit more? And she's like, yeah, probably. So you say, girl, you gotta get rid of your tiny Tupperware. The big mixing bowls with a lid, that is where it's at. And we see if we can increase her serving size just a little bit. Can we add especially a little bit more protein into that, up that turkey percentage? Or also she's using cauliflower rice, which great to get some veggies. but maybe we're not getting enough calories overall, so can we add some brown rice and white rice into that mix in addition? Now, we've taken her lunch from 20 grams of protein to maybe closer to 40, and 400 calories closer to 800, just by slight small ups in that serving size. We hit mid-afternoon, we're back to breastfeeding, happens again, And we have some other snacks set up by her station. Maybe she's grabbing a handful of trail mix with some unsweetened dried fruit and some nuts. And so we're getting another 10-ish grams of protein, maybe 400 calories. And we made it back to dinner. We ask her the same thing. Do you feel really full after dinner? And she's like, Eh, not necessarily. And then, so it's like, okay, her family's making tacos for dinner tonight. And she's like, yeah, normally I eat like two-ish tacos. And then I get distracted trying to feed my three-year-old who's thrown their taco meat to the dog on the floor. And then before I know it, all the food's gone and we're on to the next thing. We say, let's prioritize getting you an extra taco. So yet again, without doing more work from a meal prep or food prep standpoint, we're able to increase protein a bit and increase over calories. So say that bumps us up to maybe again, like another 40 grams of protein and 800 calories. So if we look back at our day, Kristen maybe started off with maybe hitting 75 grams of protein and 1500 calories. which will definitely not be enough. That's like baseline function if she were to do nothing else across the day. With a few of our little swaps, we've gotten her really hitting that 2,900 calorie mark that we talked about would be ideal for her and closer to 150 grams of protein. So again, we boosted up her breakfast, adding in a little bit more, made snacks convenient that she could grab, and upped what she was eating just a little bit for lunch and dinner and made a big difference. Now, obviously, you wouldn't want to jump somebody who had been eating very low to a ton all at once. They may feel way more full, so that might be more of a gradual transition. But if you can even start with just, hey, let's really prioritize adding in one more protein-heavy snack. How can we make that easier? Is it making some protein balls over the weekend that you have in the fridge that you can grab? Like I mentioned, is it stashing that protein bar in the car by the breastfeeding station? How can you make that easy to hit those numbers? Now, in an ideal world, when somebody is dealing with, when we're noticing as we ask them questions about their diet, that we're not getting enough calories if we think they need to have a little more protein, it would be wonderful to refer them to a registered dietitian. It is great to have resources in your community of places that you can refer people out to. But the reality is, a lot of the time, they're not going to make time for another appointment. So you are their nutrition resource. The APTA says that it is within our scope of practice to talk about nutrition. So start asking. You will be surprised about the answers you get Especially, our example today was within that postpartum population, but this could be transferred over to any of your clients. Another great group that we really need to be asking about this is our teenage athletes, especially our female teenage athletes. And it is sometimes wild how low of a calorie count those people are getting in a day. Now, if we're wanting realistic Like if we're really wanting to know exact numbers, it is helpful to track for a day or two and see where they're at. Tracking, you can use like MyFitnessPal as a free app that allows you to track across the day. And that's a good idea to be able to see where the calories at versus where we want them to be and where's the protein at versus where we want it to be. I know tracking can be definitely triggering for some people, especially when we're talking about this population I like to recommend, can we do it for a couple days to get a baseline of what you're eating? And then a couple more days on top of that so that you can see, oh, wow, this is where I actually need to be with that. And maybe it doesn't have to be a long-term thing, because it also takes a lot of time in addition. If that's off the table, again, just go back to what are some of those little changes that you can ask them to make and maybe start with just one change at a time. So again, can we add that snack in or can we increase serving size at one meal? SUMMARY If this feels like a topic that you're like, man, I really wish I was a little bit more comfortable talking about nutrition, ICE does have a self-paced nutrition course. If you go to free resources on the app, you can access that. And if you're interested in learning more about REDS and its impact on all things pelvic, such as fertility, urinary incontinence, you should jump into one of our pelvic courses, either live or online. We've got some coming up. Our next online level one cohort is going to start on September 9th. and level two starts on August 19th, and then there's lots of opportunities to join us on the road as well. We'll be in Hendersonville, Tennessee on September 7th, Wisconsin on the 14th of September, and then Connecticut on September 21st. I hope this helps give you some ideas about little changes that we can make to make sure that our clients and you are getting the calories you need to do all of the awesome stuff that you want. Happy Monday, everyone, and go crush some breakfast. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses three breathwork strategies: box breathing, physiological sighs, and 4-7-8 breathing and their implications to PT practice. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Lumbar Spine Management course, our Cervical Spine Management course, or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ZAC MORGANThanks for watching! Good morning, PT on ICE Daily Show. I'm Dr. Zac Morgan, Lead Faculty here with Cervical and Lumbar Spine Management, bringing you this morning our top three strategies for breathwork. So breathwork is one of those things that clinically I've used a lot more the last couple of years than I did the first few years of my career. And part of that is, or a lot of that is, I think my ability to describe it to people. But another big part of it is personal experience with breath work. So I think early on I had a healthy amount of skepticism myself about things like doing nothing or sitting around focusing on nothing but your breath. And it wasn't something that I practiced regularly. So it was something that was harder for me to implement clinically when I would, when I would suggest it to clients. didn't have good uptake rates. They often did not do the breath work or did not do mindfulness meditation. And there often were just barriers in the way. And really personally for me, this journey started a little bit around a year ago, a little bit over a year ago. My dad had open heart surgery and it just was a stressful time of life, a lot of busy things going on. And then on top of that, a big surgery like that with a family member, And I remember during that time having some realizations about stress internally that clinically have helped me a ton. I mean, for instance, my shoulders, I grew up as a swimmer, so my shoulders have always been fairly mobile. And that was never really an issue for me. But I can't tell you how many clients stand in my office and kind of complain about in the front side of their shoulders and it was something I always had a hard time relating to when I would hear people describe it and I always thought of it as muscle tightness and a lot of just issues surrounding the shoulder and then during that week that my dad was in the hospital the same thing happened to me. So like I said I've always had plenty of mobility and then all of a sudden that just went away. I had that same exact feeling of tightness there in the front side of my shoulder. It's very familiar from a lot of subjective exams And that's where I started implementing some breath work. And starting to implement that breath work, I noticed an immediate impact on my shoulder mobility, which was not what I was expecting. I was expecting to just be able to sleep better or unwind a little bit better. But from a musculoskeletal perspective, my shoulder range of motion improved, shoulders felt better. I was able to kind of return to all the activities that I was looking to return to. So it really made me buy in, which has helped me a lot clinically from a being able to leverage that personal experience with the client in front of me. So I would encourage you to start using this some, but within using Breathwork, I think some really actionable strategies surrounding it are what make for more success. So rather than just saying, hey, try some breath work with your clients, which is probably maybe a little simplified version of what I was doing prior to starting it myself. Now what I do is I give it more like a prescription. So rather than just encouraging trying some breath work, I give a very specific prescription of different types of breathwork for people, all to stimulate parasympathetic outflow. So let's go through the top three that I've had success with. And again, I feel like the more prescriptive you are with these things, the more your client will believe that it's important to you as a provider. And then also something about receiving a prescription makes people a little more compliant. So there's three big ones that I want to talk about this morning. The first one's box breathing. The second one's physiological sigh. And then the last one is 4-7-8 breathing. I do feel like I get the best uptake with box breathing, so let's start there. And let's just describe what box breathing is and how to prescribe this with clients. I've had a lot more success by having them on the front end, prior to starting the box breathing, testing their CO2 discard time. So the reason this kind of came into my purview was the Huberman article that came out a couple years ago. I'll put that link in the comments of this video. But essentially they just kind of described how they use some of these protocols with the clients in that study. They were looking at breathwork, mindfulness meditation, and kind of seeing what helped. And it turned out all of it helped. But they gave a little protocol to determine someone's CO2 discard time. And essentially what you do is have the person seated comfortably. They take four normal breaths, breathing in and out of their nose. And then they take a very large breath in their nose. then they exhale as slowly as possible. That exhale can come from nose or mouth or both. The point though is to exhale as slowly as possible. Now you as the therapist are going to time your client doing that prolonged exhale. And if their time lands between zero and 20 seconds, their box breathing time, so how long they breathe, hold, breathe, hold. So inhale, hold, exhale, hold. The time that they do that protocol, if it's 0 to 20 seconds, their prolonged exhale is going to be 3 to 4 seconds. If they can do a prolonged exhale between 25 and 45 seconds, I'm going to have them do their box breathing with 5 to 6 seconds of each chunk of the box. And then lastly, if they're able to do a really long exhale beyond 50 seconds, then I would have them do their box breathing with 8 to 10 seconds. So that specificity of having them test prior to doing the box breathing protocol, for whatever reason, has really increased the compliance rate for a lot of my clients. I think knowing that it's designed for you versus just, hey, here's some breath work, just for whatever reason, builds some compliance. So definitely box breathing is the one that I get the most success with. Again, to quickly describe box breathing, you're going to inhale for a period of time, hold for a period of time, exhale for a period of time, hold for a period of time. That period of time is determined by that CO2 discard test. Secondly is physiological sigh. So probably a little bit of an easier setup here because you don't need to test anything. But the point of a physiological sigh is going to be two inhales through the nose and then a really prolonged exhale that kind of sounds like a sigh, kind of a sigh. type sigh, that can come through the mouth. But those two prolonged inhales, they're going to come through the nose. And the first one is going to be about 80% of your lungs capacity, and then the second one is going to be the top 20%. So you take a really big inhale through the nose, kind of cap things off with a second inhale through the nose, and then as long of an exhale as you can do, making that kind of sigh sound as you do so. So it kind of looks like this. The longer you can make that exhale, the better. So that's physiological sigh. So there's just another option outside of box breathing. And then the last one is 4-7-8. So for 4-7-8, you're going to breathe in for four seconds through the nose. Hold for seven seconds and then exhale however you want to for eight seconds. So that prolonged exhale in both the physiological sigh and in 4-7-8 breathing seems to really stimulate parasympathetic outflow. So with all three of these strategies, the person has to be really compliant to see success. And honestly, it's a more the merrier type of situation. Now, obviously, if you were only sitting around doing breathwork all day, that would be an issue. But for most people, they're not going to do that. So what I usually try to start with is a minimum of once a day. So the person needs to set a three to five minute timer and just perform whatever breathwork strategy we just dictated with that person. and perform it for three to five minutes. Now, I would really prefer that person to do this three to five times a day, especially if they kind of run higher stress, if they're a little higher anxiety, if their blood pressure is up. If they're basically anyone that we interact with in the clinic, most of those people would benefit from doing this a little bit more frequently throughout their day. And so I kind of describe it to them as an acute way of dropping your blood pressure, an acute way of dropping your stress. And if you can kind of titrate that throughout your day, you'll be able to stay a little bit more regulated. And so within that, I would really suggest spending a little bit of time mapping that person's day out with them, like helping them strategize. Here's where this could work, like perhaps before the baby wakes up, but perhaps before the kids wake up, perhaps at lunch, just finding a quick spot that they could do the quick three to five minutes of breathing. The beautiful thing is we're really only asking for five to 15 minutes of this person's day. which is a really small ask, but they won't be successful without your help figuring out where to put that in their day. So I think that's the biggest tip is really regardless of which of these strategies you choose, I think they all work well. Make sure you help that client figure out where they're going to put it throughout their day. and how to fit this into their habits. Once they start doing it, usually compliance is pretty decent because they feel so much better. So it's really just breaking down that first wall of compliance and I think being specific with your prescription and then helping them fit it into their day are the main ways that I've had success with that. So I think this is a really important thing that should be in a lot of our plan of cares, because you think about when people are so stressed, whether that's because they're in pain or just the other demands of being a human on planet Earth, most of our clientele tends to run a little bit higher stress. And so due to that, it's really nice to help them find that release valve in ways other than exercise or sleep. not that I don't want them focusing on that as well. Just another kind of focal strategy for managing these things. Again, personal experience and being prescriptive has been really helpful for me with. So just some actionable things to try in the clinic. So my big suggestion is breach this subject with people. Be willing to talk about it. Be willing to practice some of these yourself so that that way you have some personal experience with them and then help them fit it in their day. If you do those things If you're able to do those things, you'll have a lot more success getting compliance with breathwork with your clientele. SUMMARY That's all I've got for you all this morning, so just some really quick actionable strategies. Try some of these today in the clinic, whether that's on yourself or with a client. If you have anybody that seems really wound up, I would really encourage trying these things. If you're looking for some upcoming courses, I want to kind of just point you in the direction of the next few cervical and lumbar that we have coming up with ice. So if you're looking for cervical, August 24th and 25th will be over in Bend, Oregon, so on the west coast. If you're looking more in the middle of the country, September 7th and 8th, we've got Midwest City, Oklahoma, and then more on the east side of the U.S., October 5th and 6th in Candler, North Carolina, so right outside of Asheville. If you're looking for lumbar this weekend, we'll be right outside of Pittsburgh in Aspen Wall, Pennsylvania. August 10th and 11th, Longmont, Colorado. So right outside of Denver. And then August 17th and 18th, Grass Valley, California. So beautiful northern California there, not too far from Sacramento. So if you're looking for any courses, we'll be kind of all over the place these next few weeks. That's all I have for you all this morning, team. I'll drop that article that I mentioned in the comments of this video and let me know if you have any successes or issues with breathwork as you're implementing this this week. Thanks, team. That's all I got for you. Have a good rest of your Tuesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore highlights the ways the 2024 Paris Olympics are changing the narrative around motherhood for athletes and providing resources and support along the way Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION RACHEL MOOREGuys, good morning. My name is Dr. Rachel Moore. I am here this morning representing the pelvic crew and I am so excited to talk to you guys about the Olympics and some pretty big stuff that's going on in the Olympics this year. The Olympics is huge in my area. Simone Biles actually lives like five minutes away from me, which is like my claim to fame humble brag. My daughter went to her gymnastics gym. And so if you've seen the Simone Biles documentary that's on Netflix, We were like fangirling and fanboying. We were watching it because we're like, oh, that's where Libby does gymnastics. So Olympics are a pretty big thing in our area, in our neck of the woods. And I think the Olympics this year are really interesting. And I wanted to get on this morning to highlight some of the things, especially when it comes to women in sport. that are really kind of setting apart this Olympics from ones in the past. If you didn't catch it, the opening ceremony was on Friday. It was a really interesting one because they were just kind of doing this parade of river boats down the river. And they incorporated all of these architectural pieces of France architecture into the opening ceremony. So it was pretty interesting to watch. And it just kind of set the tone for how different this year's Olympics are from a lot of the other Olympics in the past. So one of the key things that I think is really interesting, and I didn't even realize this until somebody else on faculty had shared a story about this, is that this is the first Olympics that has been almost equal representation as far as genders go. So the IOC set out to have a goal to have 50-50 participation between male athletes and female athletes. for this year's Olympics. And they actually just barely fell short of that goal. So the way it shook out with the amount of athletes that showed up and qualified and came to the Olympics was 51% male, 49% female. But that's pretty wild to see almost equal representation at this competition on a global level. A lot of us in the ice world are involved in CrossFit. We're kind of used to seeing that 50-50 representation. And that's one thing that really makes CrossFit unique compared to a lot of other sporting organizations. And so it's cool to see this transition or start seeing this change in this shift towards women in sport take this like worldwide platform where it's not a male-dominated thing and we're seeing more females represented and within that we're seeing more women that have children represented so motherhood is really starting to take a front row seat to the Olympics. So Allison Felix, who is the most decorated female track and field athlete, she's a US athlete. She actually made headlines a while ago because she lost her sponsorship with Nike when she told them that she was pregnant. And so that was this huge shakeup as far as women athletes and females in sport of, we are not a liability when we're pregnant. We're not less than because we choose to have children. And a lot of women, we see this a lot where People are delaying having children because of this athletic window and this fertility window kind of overlapping And so when athletes decide to start their families and then there's this response where they get dropped in their sponsorships, that sends us a certain message about what a female's role is and what her worth is in sport when she becomes a mother. And so Alice and Felix really spoke out against this and started this really amazing conversation about this overlap and about maternity leave and about just female in sport and how motherhood fits into that role. She took this to the Olympics this year. Um, so she's at athlete representative for the IOC and she actually started an initiative and it did great. And it's a thing now to open a nursery for mothers with young children at the Olympics. So historically the way it's always shook out in the past is that children are not allowed in the athlete village where athletes and coaches stay for the duration of the competition. So if somebody was breastfeeding a baby and also competing at the Olympics, they either had to choose to be separated from their baby for the duration of that competition, or they would have to kind of foot the cost of lodging for themselves. The problem with that is that Olympics is expensive and not everybody has the funds to even go compete at the Olympics. But then if we're thinking that somebody qualifies for the Olympics and now they have to pay for a caregiver maybe for their child and also they have to pay for lodging for their child or they're not going to be able to To be there that could make somebody not go to the Olympics that had qualified and had earned their spot So it's pretty cool to see this shift start happening. The nursery is actually sponsored by Procter & Gamble So Pampers is like branded all over it it's kind of funny if you look at pictures because they literally put Pampers and like every square inch that they possibly could and But it's a really exciting thing. So it's for children that are diaper age and below and their parents and their caregivers can go and kind of get away from the chaos of everything that's happening at the Olympics and have a quiet space to be together to spend time together. to bond. And then really a big thing is to nurse. The Tokyo Olympics, the last summer Olympics that we had, was right in the kind of height of the pandemic, or I guess kind of the downhill trickling of the pandemic, if you guys remember. And there was a lot of restrictions on the athletes. And so the athletes weren't allowed to bring support people, families, people had to stay behind. They were traveling with this like skeleton crew. And IOC The mothers to spend time with their children and to be able to nurse was Honestly pretty laughable. It was pretty wild if you if you just google like tokyo nursing room olympics Um, there's a picture of one of the athletes like two-year-olds laying on the floor And there's like a folding table with two folding chairs next to it And that's where the athletes would go To spend time with their children in between their events when they weren't training or they weren't preparing for the games again, if we're thinking about the message this sends that really tells people like you're here to be an athlete and everything else doesn't matter like we don't care that you also might be a mom oh it's it's okay you need a space well here's this like folding chair in the corner that message is so different this year the message the ioc is sending this year is that we recognize that the maternal timeline and the athletic timeline might overlap and your worth is not only as an athlete and we recognize that your worth also exists in motherhood. Allison Felix had this really cool quote. She said, I think it really tells women that you can choose motherhood and also be at the top of your game and not have to miss a beat. That's amazing. We preach that all the time in our division. We talk a lot, again, about how the fertility window and the athletic window overlap. And what we're starting to see is this trend of women pushing back and saying, yes, we can still be athletic. Yes, we can still be in the top of our sport. and also show up for our families, and also feed our babies, and us be their primary source of nutrition while we're training for the Olympics. So it's really cool to see this take, again, a worldwide platform to acknowledge that these things can exist at the same time. There's a couple other countries and groups that are showing up for their athletes as well. So the French Olympic Committee is actually paying for hotel rooms for their breastfeeding mothers. to stay in so again before athletes would stay in the athlete village with their coaches partners and babies would stay elsewhere they couldn't go spend the night with them they had to be in the athlete village so the french olympic committee this year has started an initiative where they're paying for hotel rooms for nursing mothers where they can go spend the night with their baby their partner can be there as well so kind of minimizing this interruption between this mother-baby bond and what's really cool is that they made a statement that this isn't just because quote-unquote the Olympics are here in our home ground This is something that we want to see carry over into future Olympics. So they're really again just kind of setting this example that motherhood matters and that we can do both. So really exciting to see when we look at the numbers. The US has 338 women on their team, which is the highest amount of women. on an olympic team france has 293 so these top two countries as far as women and female representation are really just showing up for all uh seasons of females lives um from what i could find i was trying to google like exactly how many moms are on the olympic team and um i even asked chat gpt i was like what percentage of olympic athletes are moms And it was like, we don't have that data. But I did see several articles that said that this year the USA team has 16 moms that are representing the US and five of them are on the basketball team. So kind of astounding that out of 338 athletes, if that number truly is 16, that's pretty wild. But again, it's really cool to see that representation and that acknowledgement as a whole. it's really exciting that we're seeing this culture shift that we have believed in and we have seen again in the crossfit world with annie thora's daughter and now tia and all of these top athletes really embracing their motherhood and talking about how motherhood has affected them as an athlete and watching this happen not just in the crossfit world where we all kind of live and spend time but in athletic world as a whole is so exciting and I just can't get over the fact that the Olympics, which is this massive platform that so many people are tuning into, are really highlighting and bringing attention and awareness to the fact that these athletes are also mothers. These athletes are doing these things simultaneously and it can be done. It's a really exciting message We are all about it here at ICE. We are here for it. We're excited to see it continue. And here's hoping that at future Olympics, we only see these accommodations grow between other Olympic committees, other country delegations, and that this nursery just continues to take off and that the athletes really enjoy it. SUMMARY If you guys want to hop in to our pelvic courses, we have a lot of chances to catch us in September. So we've got Hendersonville, September 7th and 8th, Wisconsin, September 14th and 15th, and Connecticut, September 21st and 22nd. So a lot of ways that you can come hang with us on the road in September. Our next L1 cohort starts September 9th, and our next L2 cohort starts August 19th. So if you're interested in an ice course, especially in that pelvic division, Head on over to PT on Ice and sign up for your course. Otherwise, keep an eye on the Olympics. If you guys have a favorite sport, comment it below. Let me know what it is that you're going to be watching. Obviously, I'm going to be all in on gymnastics because Simone Biles is essentially my neighbor, even though she's really not. But trying to get my daughter into horseback riding, so I keep hyping up all these equestrian things. so that she falls in love with horses. It's not working yet. We'll see. You guys have a great week. I hope you guys crush it. Thanks for tuning in. Bye. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses how effective the strict press & front squat are in developing maximal performance in the clean & jerk and snatch.​ Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLGood morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. We 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 a lead faculty in our fitness athlete division. It is Fitness Athlete Friday. It is the best darn day of the week. We talk all things CrossFit, Olympic weightlifting, powerlifting, bodybuilding, running, rowing, biking, swimming, If you are working with an individual who is active recreationally, trying to be competitive, whatever it is, Fitness Athlete Friday is full of tips and tricks for you. Today we're going to be talking about Olympic weightlifting. Olympics start today. Opening ceremony is just a couple hours away, 12 Eastern. And we'll be watching America's Olympic weightlifters take the stage in a couple of weeks on August 7th. And so talking about if we only could do two exercises to have a significant improvement on our Olympic weightlifting, what those exercises might be. We certainly see a lot of interesting suggestions on social media about ways to improve our performance, improve our technique, improve our clean and jerk and snatch. WHAT DOES THE RESEARCH SAY? But if we look to the research, what is actually the most effective? So today, we're going to be referencing a paper from Arthur Zetshin and colleagues back from 2023. In the Journal of strength and conditioning research, the title is associations between foundational strength and weightlifting exercises in highly trained weightlifters support for general strength components. And so we're going to talk about what this paper is, what this paper looked at, what this paper found, analyzing the outcomes of this paper, and then how to take those and apply them in the clinic, in the gym with our patients and athletes. So, with this paper, what was the research question? The research question, is there an argument for doing some specific general strength movements that would translate to higher skill, higher technique barbell movements, specifically in Olympic weightlifting, the clean and jerk and the snatch. And if those movements exist, what are they and how much do they contribute to the performance of the clean and jerk and the snatch? And so this paper, looking at it really quickly, took 19 highly trained Olympic weightlifters. They all had been performing Olympic weightlifting training for at least five years. and had them perform a one rep max of a couple different movements across the two week period in randomized order. So they asked them to max out their clean and jerk, max out their snatch, max out their deadlift, max out their strict press, and max out their front squat, and across 14 days, every couple of days, perform one of those max attempts, and then analyzing the data and trying to observe any sort of relationship in the variance between performance on what we consider the power lifts or the strength movements, which would be the deadlift, the strict press, and the front squat, and then compare that to how does that translate to what that person's max clean and jerk and what that person's max snatch is. And some really interesting data here, finding that 59% of the variance of the contribution to the clean and jerk is associated with maximal strict press and front squat strength. And that 62% of the variance in contribution to performance on a snatch is also associated with maximal performance on a one rep max strict press and front squat. And so finding in this paper that there is really no association at all between how strong someone's deadlift is in their performance on the clean and jerk and snatch. And you might think that's interesting because I might assume somebody who has a heavier deadlift should be able to have a heavier clean and jerk or snatch. But as we've taught in Fitness Athlete in our Level 1 course, our Level 2 course, our live course, for many, many years, when we really dig deep into the research on what's happening with the deadlift, we know it's not a pull off the floor and neither is the clean and neither is the snatch. That when we take somebody, whether they are going to just deadlift to the hip or whether they're going to bring that barbell, to the front rack position with a clean or all the way overhead with a snatch, that first pull off the floor is really kind of a misnomer to call that a pull. That is a press off the floor and we have several studies that look at EMG activation in the body of what is happening with a deadlift, what is happening with the first pull of a clean or snatch. And we know that the quadriceps are the most active muscle during that first pull. And that tells us it's not a pull, right? It is a press off the floor. That's how we instruct athletes in the gym, patients in the clinic, that this is a press off the floor. Imagine you're sitting on a leg press machine. If we took you in your deadlift setup position and rotated you 90 degrees, got rid of the barbell, put the weight on a plate underneath your feet, you would look like you were sitting on a leg press machine. And so it is a press off the floor. And so it makes sense that because it is a partial range of motion press off the floor, that it just does not contribute as much as we might think to our clean and jerk and our snatch performance. But finding that we had moderate to high correlations between strict press and front squat strength with both clean and jerk and snatch performance. So why is that? Why these lifts? How can we interpret that analysis? When we really think about what a clean is and what a snatch is, Try to keep it simple, especially in the CrossFit realm where people may have never been exposed to these movements before. Often our cueing is very simple. Hey, a clean, we're going to jump off the ground and land in a front squat. A snatch, we're going to jump off the ground and we're going to land in an overhead squat. And so Olympic weightlifters already do a lot of front squats, they need a lot of thoracic and shoulder strength, they need to keep their clean as close to the front squat as possible, because that is half of their score in Olympic weightlifting, right? Just two movements clean and jerk and snatch, you got to be got to be good at both of them. Likewise, a snatch is a jump into an overhead squat. And while the study didn't look at performance of overhead squat compared to snatch, It makes sense that a front squat would pair really well with a snatch. When you think about the receiving position of a snatch, a very vertical torso, very strong, stable shoulder position, it requires strength and mobility out of every joint in the body. You need to have excellent shoulder mobility and strength. You need to have excellent thoracic mobility and strength, excellent hip mobility and strength, excellent knee and ankle mobility and strength. a really, really vertical torso position in the bottom of that snatch. And so that front squat really sets us up a strong, tall, vertical torso position. We are training our legs in a squat pattern. We're working on our thoracic and shoulder strength and mobility at the same time. And so it checks a lot of boxes that we see and makes sense that it translates well to the snatch position. What we see, though, in a lot of other research is that we always look at the back squat, and we look at relationships between back squat strength and Olympic weightlifting, and we often find almost no relationship. And that also makes sense. Back squats tend to have more of a forward torso, more of a hinge-dominant position, especially if somebody is a powerlifter, in a way that just does not translate as well to movements like the clean and the snatch. And so understanding that it makes sense that these relatively simple, boring movements, the strict press and the front squat are showing to be really good developers for our clean and our snatch. APPLYING THE RESEARCH So what can we do with this data? What does that help us do in the clinic, in the gym with our patients and athletes? Well first things first, you're probably not going to blow any Olympic weightlifters mind if you tell them they need to get a stronger strict press and they need to get a stronger front squat if they want to be a better Olympic weightlifter, right? Most of them are probably gonna say, yeah, I knew that before I came to this appointment. Do you have anything else for me? When we look at folks who are training specifically Olympic weightlifting, they are already doing a lot of overhead lifting, they're already doing a lot of squatting, often several sessions per week, right? It's not uncommon to find competitive Olympic weightlifters performing some combination of back squats, front squats, overhead squats every other day throughout their week as they're training. Likewise, they're doing a lot of strict press, they're doing a lot of push press, they're doing a lot of jerks, they're doing a lot of accessory work that's going to reinforce overhead lifting. and squat patterns as well. So you're probably not gonna really rock the boat with a true, dedicated, even recreationally competitive Olympic weightlifter and definitely not somebody that is trying to be a professional or is already a professional Olympic weightlifter. They are hopefully already doing all of this stuff in a way that you don't have a lot to intervene on. But outside of that, somebody who maybe wants to get more into Olympic weightlifting, and especially with our functional fitness athletes, our CrossFit athletes who are doing clean and jerk and doing snatch as part of their CrossFit training, they always want to have a heavier clean and jerk and a heavier snatch, right? If they're coming to you and saying, is there anything I could do? I have an extra 30 minutes a week. I have an extra hour a week. I really want to get a stronger clean and jerk and a stronger snatch. For that population, it's tough to recommend to them just do more clean and jerk and snatch. because they're likely already doing it as part of their CrossFit training and they may even be doing it throughout the week in different variations, right? To be doing a high repetition, low load, power snatch and then metabolic conditioning workout and then maybe to maybe later in the week doing a strength piece that looks like higher load, lower volume snatching focused on developing the snatch. So it'd be tough for that person to recommend that they somehow find time in that same week to do more snatching. Instead, what is going to be a really effective and safe recommendation as far as not introducing too much volume to that equation is to recommend to that person, hey, find some time to do more strict press and more front squat. We talked a lot back in episode 1745 back during deltoid week of the importance of the strict press for developing the deltoid, that the deltoid is the powerhouse of the shoulder, but strict press is often neglected or completely ignored in programming. People skip strict press day when it's at the CrossFit gym. They may skip it when it shows up in accessory programming because it's not fun, right? They may do a push press or push jerk or split jerk instead. which doesn't really help improve our clean and jerk as much as it could and our snatch as much as it could because we're not training the shoulder as much as we're now training the legs when we transition to a push press or a jerk motion. Way back, episode 1567 with Midge Babcock, the title of that episode, Don't Be a Jerk with Your Jerks, he covered a lot of research that shows as we transition to that push press, as we transition to that jerk, we're now using 60 to 80% from our legs to get that weight overhead. And so we're not really developing true shoulder strength as much as if we do the strict press. And so just recognizing with that CrossFit that functional fitness population, they're probably skipping or not doing really foundational strength movements like the strict press, And like the front squat, because they are seen as boring, right? They are seen as maybe repetitious. But that is kind of the point that by doing those things more consistently, more frequently, we're going to bump up our front squat strength, our strict press strength, and we'll see a nice translation to improvements in our clean and jerk and snatch. alongside also continuing to do the clean and jerk and the snatch. And so my recommendation for a lot of folks who come to see me for help with maybe performance of what can I do, I have some extra time, is to give them some sort of undulating program that allows them hopefully in the span of the same week to touch a clean, touch a jerk, touch a snatch, a front squat and a strict press maybe even within that same week. And so, teaching those patients, those athletes, of how to optimize their sessions. Of hey, if you're gonna go into the gym, and you wanna introduce more of this stuff, what does it look like? It looks like we should do the Olympic lift first, we should do the power movement first, because those muscle fibers are gonna be the easiest to fatigue, and the longest to recover. So if we're going to clean or snatch that day, we should do that first. We can follow that up with what we might call a power lift, a strength movement. we don't need to be as explosive with those movements, those fibers are not as fatigued. And so we can do something like a clean, and then do a front squat, we could do something like a snatch, and then do a front squat, we could do a clean, and then we could do a strict press. And then at the end of the hour, towards the end of our session, whatever our timeframe might be, we have time for maybe a conditioning piece, if we're a crossfitter, and we want to keep working on our metabolic conditioning, or maybe just some extra accessory work to further develop leg strength, overhead strength, core strength, all the stuff that we need to be a really solid Olympic weightlifter. And so that might look like moving back and forth between power variations of the snatch and clean and adding in extra front squatting, making sure that we're not squatting too much, we're not lifting overhead too much, and just trying to find them a nice blend where they can add in some extra volume without increasing their risk for injury in a way that they're gonna find that time well spent and see those clean and jerk see those snatch numbers go up. And I always love when somebody just wants to do weightlifting, they don't want to do any conditioning that day or anything else. I love my favorite piece for developing overhead strength. Every two minutes for 15 sets, you're going to do five sets of three reps of a strict press somewhere between 70 80% of your max. You're going to transition to five sets of three push press, again, somewhere 70 to 80% of your max push press, and then finish out same rep scheme, same idea with the jerk. And so as our shoulders get fatigued, we bring in more and more of the legs in a way that overloads the shoulders really nice and gets us a nice 30 minute weightlifting session. And so that can always be beneficial for patients as well. SUMMARY What can you do? What can you advise someone when they want to improve their clean and jerk and snatch and they're not already a professional elite Olympic weightlifter, share with them that the most bang for their buck is going to be working in more strict press and more front squat into their training. Ideally, if we can do that every week, increase that consistency, increase that frequency, we know that's going to be a way that's going to productively overload the system. We know the research supports that those two movements have the highest contribution to performance on the clean and jerk and snatch, and that's really where we can help athletes work that into their programming and see them develop the clean and jerk and snatch the way they want so that they can hit new PRs. Team, if you like to learn about this stuff, if you like to hear about this stuff, our next class of clinical management fitness athlete level one online begins this next Monday. We have about eight seats left. Those will definitely be gone by the end of the weekend before the class starts. That literally happens every cohort and has happened for every cohort for many, many, many years. So don't be that person that emails on Tuesday morning. We're going to have to tell you the class is full. And then if you've already taken Fitness Athlete Level 1, Fitness Athlete Level 2, start September 2nd after Labor Day, and that class is already over half full, that'll probably be the last class of Fitness Athlete Level 2 for the year, so don't miss that one if you're on your way to working towards your Clinical Management Fitness Athlete certification. That's all I've got for you this Friday morning. I hope you have an awesome weekend. Enjoy the opening ceremony, the start to the Olympics, and keep an eye out for Team USA lifting on August 7th. Have a great Friday. Have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the current state of healthcare & rehab as an industry, who the big players are, what (if anything) is being done to change things, and how individual therapists can begin to affect meaningful change Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLGood morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. We hope your day is off to a great start. My name is Alan, the pleasure of being our Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete and Practice Management Divisions. It is Leadership Thursday. We talk all things practice, ownership, business management. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday comes directly from ICE's CEO, Jeff Moore. sent this to me last week said hey I was just goofing off in the gym trying to get some lifting and cardio in together and so he sent me a workout of 100 bench press with the weights on the barbell 135 for guys 95 for ladies and a hundred calories on a fan bike for guys 80 for ladies with the caveat that you can break up that work however you like you can Do 100 bench press straight through, 100 calories on the bike straight through. You can break it up into 10 rounds of 10 and 10, 20 rounds of 5, 5, 5. Whatever rep scheme suits your fancy, you are allowed to do that as long as you get all of those bench press and all of those calories done. that bench press weight should be light to moderate for you enough that you could potentially do five to ten reps unbroken. If it's so heavy that you could only do maybe singles or doubles or triples it's going to take you a long time to work through a hundred so keep that in mind. Other than that just pace yourself on the bike. There is no use racing that bike to finish a couple seconds maybe faster than normal only to lay on that bench for 30 seconds before you feel like getting some reps in. So just treat it a moderate approach on that bike and hammer out that bench press as able. So that is Gut Check Thursday. Today we're talking about changing the status quo. What does that mean? We're talking about the status quo as it is across healthcare in general, but of course specifically to rehab today on PT on ICE. So we're gonna talk about what is business as usual in rehab, who are the major players, We're going to talk about what is currently being done to address some of the issues across the rehab professions and again in particular physical therapy. And then are there more effective ways to try to change things. WHAT IS BUSINESS AS USUAL IN REHAB? So let's get started first by talking about what is business as usual. And in the rehab industry, the healthcare industry in general, we have what is really going on across pretty much every industry in the country of a slow merger acquisition consolidation of small to moderate companies being bought out by larger companies and slowly paring down the amount of organizations who really offer the same or similar service. A good representation of this is the airline industry. We only have four major airlines left. Southwest, Delta, American, and United. 20 or 30 years ago, there were over a dozen. And in the wake of some of the IT issues we had last week, we may even see that Delta and American could be going away soon if they don't fix their IT infrastructure and get their feet back on board. And so we see that there are just a handful of major players in the industry. And we would label those too big to fail kind of organizations. We have the same phenomenon going on in physical therapy and again in healthcare in general. When we look at healthcare, when we look in particular at rehab, we really have four major players. We have health insurance companies that control the care that patients are able to receive. and the amount of time providers have to spend paperwork wise on providing that care and also the amount of money that providers get. We know that almost every American has health insurance and so that health insurance for the foreseeable future is going to be part of the equation and therefore these health insurance companies are a big player in this industry. We have just a handful of health insurance companies, about 10, that generate $1.3 trillion collectively and employ over half a million people, with an average profit increase every year of about 9% year over year. And these 10 companies insure about three-fourths of Americans. So again, a very consolidated, condensed industry. where if any of those companies were to go out of business or something, it would have a lot of ramifications for the economy, for patients, and for providers. And so health insurance companies stand as one of those too big to fail type of organizations in this equation. Right after health insurance companies are health care companies. Large, national, across state lines, corporate, health care clinics, whether they are primary care clinics, dental clinics, urgent cares, physical therapy clinics, whatever, we see the same issue across all health care professions is that over time we are slowly paring down that the vast majority of clinics are owned by a large corporation and that usually as we get near the top of these organizations, Nobody involved in the leadership or management of the company is actually a healthcare provider. And so these are large, for-profit clinics that provide some sort of healthcare treatment. In the rehab industry and physical therapy in specific, just eight companies are closing in on owning 75% of all outpatient physical therapy clinics. And so that's very similar to health insurance, right? A small amount of companies own the vast majority the organizations and clinics within the industry. We have universities as our third player in the equation. They are responsible for educating entry-level students and getting them prepared to become new clinicians. They certainly have a stake in the equation here. And then finally we have the government itself. That can be kind of vague when we say the United States government. We're kind of really referring to enforcement organizations, Medicare, IRS, who are trying their darndest to try to regulate the other three organizations, big players in the industry. And what we find when we look at the intersection of all these giant, large, too-big-to-fail organizations is that we find that Over time, they have become intertwined. They have developed a symbiotic relationship with each other such that it would be really hard to affect significant change on one piece of the puzzle without it affecting everything else downstream. We see that universities have grown their cohort sizes so much that they are now graduating hundreds. Hybrid programs with multiple cohorts starting per year are getting close to graduating thousands of physical therapists per year. And all of those students need clinical placements. Those large corporate health care clinics are happy to take those students and put them to work for some free labor. I think we've probably all experienced that. at one point or another in our student career. And when those universities grow these cohort sizes, they begin to need those large clinics to have places to send their students to. And those clinics rely on those students, again, as part of their labor force alongside their staff therapists as well. We see that health insurance companies need, at some level, some providers to take their insurance so that they can offer to their customers, our patients, that there are some providers who take your insurance. If we get to a level where no one is taking insurance, health insurance companies are gonna be in a lot of trouble, and so we see that they are trying to hang on and kind of fight back against a shift across healthcare towards cash-based physical therapy and trying to go around the insurance system. And then finally we see that the United States government hasn't necessarily quit trying to enforce curb all the fraud waste and abuse in Rehab in health care in general what we see is they've kind of changed their policy over the years instead of throwing people in jail or busting up companies or that sort of thing that they have shifted their strategy to just collect fines right if they can't and stop it, then they will collect a piece of the revenue that all these different organizations are making. And so you see that fines are becoming much more popular than actual legal action when the government tries to get involved in significant issues with fraud, waste, and abuse in healthcare. So that's business as usual currently. Universities pumping out students, big corporate clinics taking students, offering students a job, health insurance companies playing both sides against the middle and then the government just trying to come in and take a little bit off the top at the end of the day. And really what we see happening is at the end of the day, there's really no impetus to change business as usual, the status quo among those four groups. It is working well enough that there is no significant push to really change things. WHAT IS BEING DONE TO CHANGE THINGS? What is being done to change things? You may have noticed what we did not mention in one of those big players was an organization like the American Physical Therapy Association. Not much is being done here because not much can be done. If we take a second, and please don't hear that this episode is just an episode designed to dump on the American Physical Therapy Association, but structurally it is not designed to hang on and try to enforce or weigh in or make any sort of decisions or affect really a lot of long-term change on any of the issues we see among the big players in our industry. That when we look at what is the APTA, really it is a non-profit member organization. It's not a charity. It's not a church. It's a member organization, it's a non-profit, it doesn't pay taxes, and so at the national level it really can't affect change. Nothing about our profession is regulated on the national level, it is all regulated on the state level. Your scope of practice, whether you can manipulate the spine, dry needle, whether who can prescribe exercise, who can do cupping, who can do blood flow restriction, all those different scope of practice issues are all handled by individual state legislations. And because of that, the APTA cannot really weigh in. They can also not weigh in because they can't legally weigh in. When we look at how the APTA is structured, it's structured as a non-profit corporation. It is forbidden by law, as is every non-profit company, every church, every anything, from engaging in political activities. So what the APTA has is a secondary organization called the PT PAC, the Political Action Committee. That is an entirely different organization. It's an entirely different pool of money. And that is the group that can try to lobby for things like mitigating Medicare reimbursement cuts. But that in general, on the national level, by design, it can't be effective. And just being an APTA member without donating any extra money to the PT PAC itself doesn't really allow us as individual clinicians to help the APTA effect change either. HOW DO THINGS ACTUALLY GET DONE? So, how do things actually get done then? Things really get done in our profession at the state level. State legislation, changing scope of practice, doing things like expanding direct access, opening up the ability to dry needle. We saw Washington just get access to dry needling a couple months ago. That was a state-led initiative from the clinicians in that state, from the state physical therapy chapter, and from the state legislature in Washington. That is how things actually begin to move around in our profession. And the unfortunate thing is you cannot join, just join your state chapter. You have to join the APTA and then also join your state chapter at the same time. So you can't be a part of just your state without being a part of the national organization, which I personally believe is a little bit unfortunate because I'd rather see my time and money go towards the organization that's going to affect the most change, which is going to be my state chapter. A really good example right now, we're close to completely removing direct access restrictions here in Michigan, and that is led on the state level. A guy over on the west side of the state, Dustin Karlich, he is pushing that initiative with the Michigan State Physical Therapy Association through the Michigan State Legislature, and we're hoping that that gets heard in the fall meeting of the state legislature. and that we have direct access restrictions completely removed here in Michigan. And again, that is all done at the state level, not at the national level. So what can we do? What can be done? If that is the status quo, if that is what is currently being done, and most of it is being done at the state level, What can we do to try to change the status quo? We hear a lot here at ICE, you know, what is being done about this issue? What is being done about that issue? And the truth is, not a lot, right? We're not expecting to see reimbursement probably go up ever again. We've talked about why that is. The math just doesn't math with that. And so if we can't meaningfully affect the change that we want to see, especially at the level that we want to see it, what can we do as individuals and what can be done to try to change things in our profession? The first is to recognize, like, hey, we're in a Cold War event, kind of, right? These big organizations that don't really want to change things are pitting themselves against each other, and again, they don't really have an impetus to change. We see a lot of proxy fighting going on, arguing back and forth about who and who cannot dry needle or use cupping or blood flow restriction or whatever. We kind of have these proxy fights across the country. We go back and forth constantly. And the truth is, we need to recognize, hey, how did we actually win the real Cold War? We've significantly changed our strategy, right? How did we do that? We stopped expecting that doing the same thing over and over again would create meaningful change, right? We stopped going into small countries and propping up a government to fight against the Soviet Union. We recognized after 50 years of that, that that wouldn't work. What we did instead was we shifted to focus on our economy, we shifted to focus on being self-sufficient with natural resources, and we went an economy-driven strategy instead of a military-driven strategy, and that's what actually ended the Cold War. We see a very similar recommendation here inside the PT profession. What is the strategy? Literally anything except what we're trying to do, which has not worked in decades. This is one of my favorite books of all time. This is a hefty book. None of you are probably going to read this. That's okay. This is Army FM 7-8, Field Manual 7-8. It is infantry tactics. What I love about this book is probably a thousand pages of how to fight a war. What I love is that almost every section starts with, if what you're currently doing is not working, stop trying to expect a lot of change by doing the same exact thing over and over again. Change your strategy, right? Do the unexpected. There is a whole page in here on how to react to an ambush and the first sentence is, if ambushed, attack back immediately. Why? It is the unexpected thing to do. We have to do the same thing in physical therapy. Do the unexpected strategy because the expected strategy, the thing we've been trying, for the past 50 years or so has not really changed anything and we should not expect that doing the same thing over and over again will affect any sort of meaningful change. If we just stick our head in the sand and say, certainly someone is going to fix all of these issues soon, we should not expect that those issues will be fixed anytime soon. So, what are our recommendations? Support your local state PT association. You can't join it directly, but you can support your state PT PAC, your political action committee, which means that you can give money to your state physical therapy association that they can use to pass meaningful legislation in your state. So if you're in a state and you want access to dry needling, you want access to spinal manipulation, cupping, blood flow restriction, you want better direct access, you want whatever, it's going to change most likely at the state level and so support your state level association. As an industry, as a profession, we need to recognize that slowly over time, we're moving towards a state where it is not going to be possible to accept every single insurance and run a sustainable and profitable practice that lets us pay our therapists what they need to make to make a decent living while working at a reasonable volume, right? We have moved over the years from 40 patients a week to 60 patients a week to 80 to the average now is climbing towards a hundred patients a week that is Unsustainable and the again the idea that we can just do the same thing over and over again and expect change is not going to happen we're not going to to really make any meaningful change by trying to see a hundred patients a week or 120 patients a week and to try to generate more money to be able to pay more people. There are limits to how much you can get, how much you can work, and we need to recognize that over time, if things don't change with insurance, we need to let that ship sail. That is a tough transition, that is a hard transition, but it is a transition that is going to have to happen to some degree at some point in time for almost every physical therapy clinic in the country. unless things meaningfully change. How can those things change? There are systems in place for us to report our outcomes and increase our reimbursement from insurance. Almost nobody does that because it takes time, but it is possible. We're going to see our reimbursement here at our clinic here in Michigan go up 20% in 2025 because we are reporting our outcomes and And we are getting rewarded with more reimbursement. So there are systems in place, but if you don't want to use those systems or do those tasks, you need to recognize that you need to let that insurance ship sail. And it means that you're not going to be on it. And then over time, we'll need to probably pare down our insurances and potentially be cash only across the majority of the profession. And then as individuals, what can we do? Yes, we can support our state physical therapy association and state PT pack, but we can also stick up for ourselves. Every time you go to work for somebody that overworks you and underpays you, you confirm to the leadership of that organization that there is another sucker out there who is willing to accept that, right? And we just perpetuate the cycle that we have been trapped in for many decades. And again, what is the best strategy? Anything different than what we're already doing. So when you are given that quote unquote opportunity from that organization, and it looks terrible, don't take it. There are 34,000 physical therapy clinics across the country. Find a different one. There is a clinic for you that is going to pay you well and respect your time and autonomy. I guarantee it. It just might not be three minutes from your house, right? We sometimes need to choose a little bit of discomfort to make a meaningful bump in our own individual practice and our own individual work inside of the bigger profession. SUMMARY So changing the status quo, recognizing we're kind of stuck in a cold war with several organizations that are too big to fail, that don't really have an impetus to change what they're doing because it's working well enough for all of them. What is being done currently? Not a lot on the national level because it can't. We have to stop expecting that black helicopters with agents in suits from the American Physical Therapy Association are going to drop out of helicopters and just fix things. There are only 160 people that work at the APTA. Almost all of them are administrative roles. There are very few people there that are doing a lot of of groundwork because the groundwork of our profession happens at the state level. So what can we do to support that? Support your state physical therapy association. If you're like me and you don't want to join the American Physical Therapy Association just to support your state association, you can still support your state's physical therapy political action committee PAC PAC by donating money. If you go to that website I think you'll be surprised by how few people donate and in reality how much gets done at the state level with a relatively small amount of manpower and money and that if we all just gave a hundred bucks to those organizations I think we'd be really surprised at how much more change we see affected if only in our individual states, but how effective and how large that change could be across our profession. So, when in doubt, if your courage strategy is not working, literally do anything else, right? Write from the Army Field Manual. If you are being ambushed, attack back because that is the strategy that is least expected. Do something different. Go around insurance companies, support your state political action committee, and stop working for employers who don't respect your autonomy and who don't respect your livelihood, who are trying to overwork you and underpay you. That's all we have for today's episode. I hope you found this helpful. I'd love to hear any discussion you all have about this. You can leave a comment here. I'll be back tomorrow. We're gonna talk about Fitness Athlete Friday, how to develop really brutal strength in a way that translates to improvements in your Olympic weightlifting. So we'll see you again tomorrow morning. Have a great Thursday. Have fun with Gut Check Thursday. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. 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Dr. Julie Brauer // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses the ins & outs of daily life as an acute care physical therapist. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JULIE BRAUERWelcome to the PT on ICE Show brought to you by the Institute of Clinical Excellence. My name is Julie. I am a member of the older adult division. Thank you for spending some time on your Wednesday morning with me. Let's dive right in. So one of the most common questions that I receive from students and clinicians is is asking me about acute care. Should I go into acute care? Should I choose home health over acute care? And I'm having a lot of conversations with folks about pros and cons. and sharing my reflections from having been in acute care and home health and inpatient rehab and outpatient and private and home with older adults. So I figured I would do a podcast and bring all these thoughts that I've been having in these individual discussions to all of you. Okay, so what I'm going to do is I'm gonna go through a list of five to seven things that I believe are the most important characteristics of acute care and will help you decide if acute care is the right setting for you and if you are going to thrive in that setting. Okay, so number one, this is what I believe is the most important characteristic that sets acute care apart and will be the biggest factor in helping you determine if you are going to thrive in this setting. All right, number one is that in acute care you have complete autonomy over your day. You have complete autonomy over your schedule. This ended up being The reason why I feel like I thrived the most in acute care is because I wanted full autonomy over how I structured my day. So let me explain what that means. So when I was working in the hospital, I would walk into work, you clock in, and you are more than likely going to be given a list of patients. It is then up to you to decide which of those patients you're going to see. Are they appropriate to be seen? So you're doing some triaging there and you have autonomy to make that choice. And then you get to decide, most importantly, what your day looks like. When do you go see those patients? And this was so key for me. I don't like to be in a box. I don't like to be back to back all day. I like to create my own day. And so I would look at my list and depending on how intense or complex the patients were, depending on my energy levels for the day, I would decide, like, okay, I'm going to knock out a bunch of my patients in the morning. Back to back to back, get it done, and then go eat lunch, and then in the afternoon when my energy stores are down, that's when I do the majority of my documentation. So my afternoon, I wouldn't really have to see any patients, maybe one, and the majority of it was documenting. Or if sitting around and documenting for a long time is something that fatigues you, you can do a system where you go see a patient, then you document. You see a patient, then you document. So if you are someone who really needs that energy reset after pouring into a human, typically one that's very sick and there's lots of complexities and you need a little bit of a break and a breather, you can set your day up so that you get that break after every single patient or perhaps after two patients. So you really have a lot of flexibility there. I remember I was the type of person who I would love to knock everyone out in the morning. I would go find a quiet room or a room that was near some natural light. I would put my music on and I would just sit there and document. So you have full flexibility there. When you look at other settings like inpatient rehab, you are back to back to back to back. It's one of the things that I liked the least about the setting is that I did not feel like I had autonomy over my day. And I realized that that was professionally a big core value of mine. And then if we think about home health, you do have a lot of flexibility. You schedule all of your patients yourself. However, I learned my experience was that that was a big burden for me and I never really knew what I was walking into. I didn't get the choice of who was on my schedule. Scheduling patients was typically fairly time-consuming and frustrating when you're trying to reach out to all these people and they may not be answering and you're trying to very efficiently, Tetris them into your schedule so that you're not driving all around your region. Trying to schedule patients became just this extra task that really stole a lot of my energy. So after having been in multiple settings, I think that was the biggest plus to acute care. And if you are someone who likes to have that flexibility and you feel you can be efficient and effective and productive by making your own schedule, then acute care may be the setting for you over other settings. Okay, that's the biggest one. Number two, When you work in acute care, you learn how to be a master of scale. You have to learn how to come up with unique and creative loading strategies because you are in an environment where you don't have weights. You are in an environment where maybe you are just stationed to the edge of the bed because your patient is, they have tons of lines and tubes attached to them. So you have to figure out how to do a lot with a little. And that skill right there has become, it became my superpower going forward into every other setting. I never encounter a time where I'm with a challenging patient, they're complex, or we are in a less than ideal setting, for example, someone's home, and I have never felt I'm stumped. I don't know how to bring a fitness forward approach to this person. I can't come up with an idea. I don't have weights, and so I just don't know what to do. That has never happened. And the reason for that is because over several years, I learned how to get incredibly creative. So in the acute care setting, that could be as easy. I carry around dumbbells in my backpack. and I'm like rucking through the hospital, I bring my own equipment. We paused, we paused, we're back. That could also look like the, this is my favorite hack, the toiletry buckets that are typically filled with shampoos and soaps. I dump those out, roll up towels, soak them in water, put them in the toiletry bucket, and now that becomes a little bit of load, I would have folks deadlift that toiletry bucket, press it over their head. That was one of my favorites. I would use the tray table for a sled push. I would turn the hospital bed into a total gym and put it at an incline and have them reach at the bar above their head and they're doing pull-ups or I'm having them basically do a leg press with the hospital bed. I just was able to always find a way to bring that fitness forward approach and the acute care setting really forces you to get creative. And that was just such an amazing skill that has carried me through every single setting with every single patient that I've had throughout my career. So that's number two. Okay, number three. You do not, for the most part, have to take any work home with you. Yes. How nice does that sound? So for a lot of you who are in other settings and you typically at night, you get home from work, you maybe go to the gym, you eat your dinner and then you're like, well, here's my glass of wine and I'm going to sit down and I have one to two hours of documentation to do. That is not something that is typically happening when you are in acute care. Now in the very beginning as a new grad, a hundred percent, I was taking documentation home for me. But the vast majority after that learning curve, you know, after I got through that steep learning curve, I was not taking any work home from me. With me. You actually get to leave work at work. The administrative burden is very, very low. The EMR is very easy. It's a very low, low, low documentation burden. Something that I didn't know and I learned when I went into home health is that my god, documentation burden was enough for me to, was a big reason why I quit home health. I truly was so frustrated and cognitively overloaded by how extensive the documentation was that I could not even be present or enjoy the time with my patients. And for me, that was enough to say this setting is absolutely not for me. So if you are someone who you're really trying to create a barrier of when I'm at work, I do my work and I do a fantastic job. And then when I'm out, I'm off, I'm done. You go home and your energy stores go to your partner, they go to your friends, they go to your family. Acute care is definitely a setting where you can more easily create those boundaries. Okay, documentation burden low, that's number three. Number four, you are gonna do a lot of things in acute care that don't look like traditional therapy. Okay, so what I mean by this is that your role beyond improving someone's mobility and getting those sick patients, those, you know, individuals who need to get out of that bed and trying to start to get them stronger. Beyond that, I would say The majority of my time was actually spent being a fierce patient advocate, a fierce patient advocate. That is truly what my role became. And I actually evolved to loving that part of the role even more sometimes than going in and doing the functional mobility strengthening stuff. I thought it was such a beautiful opportunity to be able to advocate hard for my patients. So in MMOA, we call that significance over sexiness. You're not always going to get this patient doing squats or deadlifts or bringing in weights, but what you can do is you can fight to the end so that your patient can get over to inpatient rehab. I will never forget one of my first patients that I experienced working on the trauma floor was an individual who had a spinal cord injury. He fell down the stairs, ended up in the hospital. He did not have insurance. And he worked hard every single day with us. I worked with him for months. But because he didn't have insurance, acute rehab was saying, no, no, no, we're not going to take him. Even though everything else made him the perfect candidate to go to rehab. And we know that his outcomes were going to be so much better if he was able to go over and get that intensive rehab. So me and my colleagues were able to just hammer on that goal and we brought it up to the physicians and we got them to do an appeal and face-to-face peer review and we worked closely with case management and we were able to get him over to rehab because we went after that so hard. and that was more beneficial than probably anything we could have done in a more traditional therapy sense. So you have this awesome ability to really dictate the outcome of these folks and it doesn't look anything like PT. Another example is if you have an interest in working in the ICU you have an amazing role there to advocate. Meaning you're going around with the physicians and case management and the nurse manager and sometimes higher up execs in the hospital and you're looking at these folks who are on sedation and on the vent and you know that you want to get that sedation down so you can get these people up and start that early mobility. and you get to look at their settings and look at what's going on and say, look, can we get this person off Propofol and put them on Propofol? Or sorry, the opposite, take them off Propofol and put them on Procedix so that we can try and decrease the sedation burden that's going on with our patients and get them mobilizing faster. That is so cool. I thought that was amazing. I loved feeling like I was like this mama bear trying to protect all of my patients and get them to the next best. setting and really improve their outcomes. And much of that did not look like teaching them how to do sit to stands or deadlifts. So if that's something that you feel you would love to do, acute care is a really wonderful setting for that. Conversely, if you are an individual who, you know, I talk to a lot of clinicians and students who love the fitness part, like their core values when it comes to their professional career are that They want to be able to work with someone when they are in the stage of being able to load them up. That's what brings them value. They want to work more from a sports performance perspective. And they want them to be at a level where they're able to do all the exercise. Like that's what you love to treat. And so I give them the, you know, I let them know, acute care may not be the setting for you. You really may belong more in outpatient instead. So something to think about just the how dynamic of the role can be in acute care. Okay next you learn how to communicate and you learn how to be on a team. All right you will hear all the time that in acute care you have to have really solid interprofessional communication. 100%, you've heard that word over and over again. But what does interprofessional collaboration actually mean? You learn very quickly that the world does not revolve around you and your therapy plans. These patients are so complex. They have so much going on with them. You are one small piece of the puzzle that actually helps them move on to the next level of care, or helps them get home and be safe. You learn it really quick. You cannot operate in a silo. You start to learn what the nurse's roles are, what the nurse tech's role are, truly what your OT partners and your speech partners can do. And you learn how to work with case management. You learn how to have conversations with physicians. They're all right there, and you have to figure out You have your patient's health and mobility, and you want them to get stronger. That's the forefront of your mind. But you've got to deal with all of these other individuals who have their own priorities when it comes to the patient. the physicians or the surgeons, like I'm trying to keep the lungs and the heart alive, or I'm just trying to keep that brain alive. Like that's what their focus is. You know, the nurses are, Hey, I got to get these meds into my patients and they're overloaded. And you start to learn to have grace for people when maybe they're not fitting the idea of what you think should be done for the patient because you're thinking about your bias of mobilization and strengthening. So you start to understand, how to create allies with individuals who have various priorities when it comes to your patient case. You learn how to argue, you learn how to be direct, but you learn how to respect everyone else's role and everyone else's time. And that can become a really beautiful collaborative effort where you can work together and move people forward. And you just don't get that opportunity in other settings. When I went into home health, I really missed the fact that I could easily collaborate with my OT partners or my speech partners, or I could easily, you know, talk to a physician. In home health, a lot of the time it feels a lot more siloed and My goodness, if I was able to get even just a PA on the phone to tell them about a concern I had with a patient, that was a big win. So if you are someone who values and loves the fact that you're surrounded by a team constantly, acute care may be the setting for you there. Okay, only a few more, I promise. Let's do two more. Okay, next, the emotional toll slash connection is very high in acute care. Now, every single setting you are going to be emotionally connected to your patients, right? You could be in very vulnerable situations with the patient. However, I do believe acute care has the highest amount of emotional connection and along with that emotional toll because you are with folks that are dying, that have been through catastrophic accidents, that are, you know, I will never forget the day where I was working in trauma and a patient came in, terrible car accident. That individual lived, but her spouse died. And you are pouring into this human, they don't even know that their spouse is dead yet. I mean, you are going to face these situations so often, especially if you work more in the ICUs. You are surrounded by death quite frequently, and you're surrounded by a lot of sadness and loss and grief. And that can take a significant toll on you. I think it's beautiful that you are able to be someone who can support your patient, your patient's family during an incredibly tough time. But that can also be something if you are, um, if you are an empathetic person to a fault, sometimes like I am, that you can take on a lot of that grief and that can end up being incredibly heavy for you. So something to consider if you love to be in those vulnerable positions with your patient and you want to help them through dying and sickness and grief and loss, it may be a great setting for you. And that's not to say you don't experience intense joy as well. You can. see folks who were minimally conscious after a stroke or traumatic brain injury, and you can see them, you know, spontaneously start to recover. And that's absolutely incredible as well. But the emotional roller coaster is incredibly high. So if you are prone to taking on a lot of energy and emotion, and that's something that you know is not necessarily a positive for you, then maybe acute care isn't the place for you. Okay, last one here, last one. you do not get to see the sexy outcome. You do not get to see the sexy outcome. In acute care, you truly have to be okay with being the person who sees this person once, you plant a seed and you hope that that grows and that ends up changing this person's trajectory. But you don't get to see that outcome most of the time. And that's really hard for individuals. Many clinicians, they want to build that relationship and go along that journey with someone and see discharge day, see how far they've come from the amount of effort and work and progress that you've been making together. That longer term relationship is so important. This is one of the, um, this is definitely one thing that I didn't like about acute care as much is that I didn't have the ability to see this see this outcome. On the flip side of that, I definitely adopted the perspective that, hey, I've got maybe one or two chances to work with this patient. I'm going to do everything possible to set them down the right path. I'm going to pour into this human 200% to try and make sure that I can hand off the baton to the next person and it's a fitness forward individual and I can continue to keep them in that lane. And I was okay with that. I loved knowing that as a fitness forward professional, when I walked in those doors of my patients' hospital rooms, I knew, I just felt that their outcome was going to be different because I was coming into their room. And I loved being able, I loved being able to have that impact with them, even if it's for a very short amount of time. If that is something that you feel like you can get on board with and you can really learn to value and you can be okay with planting the seed and not seeing the outcome, acute care could be a really wonderful setting for you. If you are someone who knows that they want to go along the journey over a long period of time, they want to see discharge day and know what those efforts look like at the end and what the outcome was, probably not the setting for you. Okay, all, that's my list. It's not an exhaustive list by any means. I would love for you all to add to this list to kind of let more folks know some pros, some cons, some other considerations. Please add to this. Put it in the comments. Send me a message. I'd love to post other thoughts about all the things that go into acute care and whether it is going to be the right setting for you. Okay. So I will end with talking to you all about what we have coming up in the older adult division. So in August we, Oh, first let's talk about July. My goodness. So this coming weekend, we, uh, the whole team is in Littleton, Colorado. And then once we go into August, we are in California, Salt Lake city. in Alaska, as well as our Level 1 online course, that starts August 14th as well. PTINice.com, that's where you can find all of that info. If you're not on the app already, make sure you get on there and get into our community. We're on the app so much more now, so if you have questions or comments, find us in there. All right, team, have a wonderful rest of your Wednesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Miller Armstrong // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Miller Armstrong makes his debut on the podcast discussing what separates the top 5% of physical therapist from the rest of the profession. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Lumbar Spine Management course, our Cervical Spine Management course, or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION MILLER ARMSTRONGGood morning, everyone. My name is Dr. Miller Armstrong. I am a lead faculty for cervical and lumbar spine management, and I'm out of the Nashville, Tennessee area, and super excited to talk about today the topic of clinical success, one choice being required. So what I mean by this, and I'm gonna do a few parts here, so I'm gonna be on over the course of the next couple of months talking about this, but it starts here. What is that one choice? And at ICE, we are quite literally obsessed with thinking about what makes the top 5% of our population and of our profession, what makes them the top 5%. Like what is different about those people that are the best? What do the experts do differently than the rest of us that make them the experts? And so to frame this, I really have to tell you a little bit about my background so that you're able to better understand where I'm coming from. A side note, I couldn't resist hopping on the back porch. It's a rainy day here in Nashville, so it's a beautiful morning. So I couldn't resist jumping on the back porch today. But I was born in this area. I was born and raised in Nashville, Tennessee, actually just south, about 30 minutes, in a town, and now it's a city, called Murfreesboro, Tennessee. And in Murfreesboro, there's a university. And that's where, I mean, throughout my entire life, and throughout my entire childhood, I was in Murfreesboro. Elementary, middle school, and high school. I was down in Murfreesboro, and the college down there is called Middle Tennessee State University. So if you're not familiar with MTSU, they're a mid-major Division I when it comes to sports. So Conference USA, they play schools like Western Kentucky. Conference has switched around a ton since I've been there. When I was there, it was like Marshall, Western Kentucky, Florida Atlantic, Florida International, UAB, things of that nature, kind of in the southeast region of the country. And so I played football throughout my entire childhood and growing up, and then I eventually played football at MTSU. And team, after my second, or after my first year, heading into my second year, we had a coaching switch. And so my first year there, I was playing quarterback and I was on like scout team, practice team quarterback. But going into my second year, we had a defensive coordinator switch. And so the new defense coordinator, of course, brought alongside with him a lot of other staff. So we had a lot of new faces on the other side of the ball. And in that offseason, I got switched over to So I ended up playing linebacker the last few years that I was at MTSU. But you have to imagine that it was not only a new room, like in the college sports world, especially football, I knew a lot of those guys that I was playing linebacker with, but I didn't know them that great. So it was a little bit of a new feel as far as walking into a position room. What was even a newer feel was now we had new staff. And so it was not only a new position, it was a new linebackers coach that I had to get to know. And this guy's name was Siriki Diabate. And Sariki, he's one of my favorite people on the face of the planet. And he was a younger guy. So for the college coaching world, being in your late 20s, early 30s is really young to be a position coach. So Sariki was leading the linebacker room. And Sariki had such a fascinating story. Almost so much so that we couldn't really relate to this guy. So, Sariki was from the Ivory Coast, and he came over to America in his late teens. The dude was like 17 or 18 by the time he showed up in New York, and he experienced a lot of unrest. growing up. Growing up in the Ivory Coast, like, there was a lot of civil wars, there was a lot of unrest in the town that he lived in. So much so that there would be times where, like, militias would come into the town, and he would have to get out of there with his dad for days at a time, just in order to stay safe. So it was a really tumultuous time growing up for Seriki. And so his family saved up some money, and they sent Seriki overseas to America to have a better opportunity. And so Siriki showed up in America, didn't really know any English, didn't really know any direction, but he found American football. And through American football, he found that he had a really nice talent for it. And as he started playing a lot and getting a lot better, he ended up at a juco down in the Bahamas, where he eventually got recruited and ended up playing for Syracuse up in New York. And so as he's playing for Syracuse, Siriki was an undersized guy for the ACC. So the ACC is one of the major conferences across the country. So a lot of big schools, Florida State, Clemson, a lot of these teams. And so those humans are huge. These people are massive. Siriki was about 5'10", 5'11". And at the time he played at Syracuse, He was only about 215, 220 pounds, which is sounds big to the normal American, but for a division one power five conference middle linebacker, that's a small size. Most of those guys these days are walking around 6'1", 6'2 plus and well over 230, 235 pounds. We would watch Siriki's tape. So we would find his highlights basically as a linebackers group and we would watch him when he was playing at Syracuse. Sometimes the GA that was in our room would watch or would bring it up so that we could watch it all together. Because when you watch Sariki run around the field, there was something different about this guy. There was something different about what Sariki looked like on film. So just to give you a little bit of context, in the world of football, especially on the defensive side of the ball, players are graded, a lot of times, individually and as a group, and as a defensive group, they are graded according to how many people are in the frame on film when the play is over. So when the ball carrier is tackled, how many defensive players are in the frame. So if you only have like two guys in the frame that the camera captures, that's not very good. It doesn't show a lot of effort. It's a way to grade effort versus if you have like nine or 10 guys out of the 11 on the field that are in the frame at the end of the play. Coaches, defensive coaches love that. Defensive coaches love that. Individually, they will grade these guys based off of how many times or what percentage of times that an individual is in that frame. So if you're not in the frame at the end of a play, 40, 50% of the time throughout the game, the coach is saying, hey, you're not giving enough effort. Like you're not showing up around the ball when we're watching film. So knowing that, when we would watch Siriki's tape, when we would watch film on our coach, he was literally in the frame every single time. You couldn't find a play where this guy was not in the frame. It was so impressive. He was all over the field making plays in the backfield, making tackles, and if he wasn't making tackles, he was near it. He had the epitome of what good effort looked like. And so it was really interesting to watch, and it was really interesting to hear his mindset. And what he would talk about, team, he would walk into the room, and then he would watch our tape, or we'd be on the practice field, and he'd be all over us as far as trying to get us to make plays. And he would say things like, hey, run through that guy's chest. Like a pulling guard, and if you're not familiar with football, a guard is an offensive lineman. Those guys are usually 315, 320 pounds or more. A pulling guard coming around trying to put hands on you, Siriki would just simply say, run through him. The ball carrier is behind him. So run through that guy. And we would look at him and almost laugh. We were frustrated, but we would almost laugh. We'd be like, Siriki, what does that even mean? Like, what do you mean run through this guy? So much so that throughout that offseason, throughout the first few months that Siriki was there, even through the first few games, like game three, game four, we're watching film, he's still on us, like just decide, just get in there and make a play, run through that pulling guard, whatever it might be. We had such a hard time with this as a linebackers group that eventually we were like, coach, like shoot us straight. What do you actually mean by this? And team, what Sariki was saying next quite literally changed the way I view everything that I do in my career and in my life because of the mindset that he portrayed. What he said was he said, Miller, well, he said, team, crew, he said, guys, what we have to understand is that you really only get one decision. You get one decision. And that decision is whether or not you want to be successful. That decision is only decided by you, and it's really the only decision that you get to make, is whether or not you wanna be successful. Okay, what do you mean by that? And what Seriki said was, if you, and this is in the context of college football, but he said, if you want to be a good college football player, if you wanna be one of the best in the country, you watch film. you learn the playbook. You not only learn the playbook, you show up early. Maybe you get a good stretch in, maybe you get your body warm before the workout, and then you're the first one going as hard as you can in the workout. Even school, you can't get on the field if you have bad grades. So you show up to class, you do your work, you study, you take your tests, you perform well on your tests. But all of that is just what follows making the initial decision that you want to be successful. And that's what he was trying to get across to us. So making that play is just quite literally making the decision that you're going to do what's required. He said that this also comes down to doing everything that the coach says. He said, if you fail, but you're doing every single thing that I'm telling you to do, it's not on you. Your success is determined by your decision. that really started to broaden the way that I viewed a lot of different things because I started to think of, okay, now that I'm in the physical therapy profession, what does that mean? What does being successful look like in physical therapy? And that's what we obsess with here at ICE. In our cervical and lumbar spine management courses, we talk about that. Like, what makes the top 5% the top 5%? And at the end of the weekend, we share a slide. But we talk about a lot of different things throughout the weekend about what makes those experts the experts. Some of those things are like doing the basics really well. not making bad decisions because you don't have bad data. You're not sloppy in your physical exam or your straight leg raise or things like that. You're about it. You lead from the front. You have competency across multiple domains. All of these sorts of things is what attributes a great physical therapist. And so what we have to realize is that that That is preceded by making the decision to be successful, to be the top 5%. It's not like the top 5% or the experts have some magic pill that they take and then they become this great physical therapist. What they've done is they've decided on the front end that I'm gonna be successful. And what that looks like is eradicating all of their weaknesses, making sure they have four asterisk signs that they can chart and that they can track over time. making sure that they, in the first five minutes of every single session, making sure that they never forget to retest their asterisk signs, doing trial treatments, adhering to the test retest model, having a nice hypothesis list because they do their symptom behavior first, like all of these sorts of things that we talk about at ICE, it's all preceded by the experts making the decision on the front end. Because Siriki would argue that if we are not, say you're not rechecking asterisks after a trial treatment on day one, He would argue that that's not getting sloppy, that's deciding to not be successful. Once you make the decision to be successful or be the top 5%, every single thing else, everything else follows. Everything else follows. It's extreme ownership. This guy got to that mindset before the book came out, right? But I love that idea of, Okay, if I don't feel like I'm getting good outcomes, it's probably because I may have woken up that morning and not decided on the front end to do what it took. So whether or not, the fork in the road is whether or not I want to be successful. Once I make that decision, you just do whatever is required of you. And what is required of being a successful PT? All of the things that we preach here at ICE. So if you're not being about it, maybe then you actually didn't decide to be successful. All of those sorts of things. So team, chew on that for a little bit. So excited to be able to jump on here with you all. I love talking about those things. I love sharing a little bit about Sariki, and he had a lot of other sayings throughout three or four years rolling around with that guy, but yeah, it was a lot of fun, a lot of fun. We do have some courses coming up here soon. So, if you want to get into a lumbar or cervical spine management course, August is your month. We're coming in hot all of August. So, August 3rd and 4th, I'm going to be up in Aspen Mall, Pennsylvania, just outside of Pittsburgh, rolling with lumbar spine. The next weekend, August 10th and 11th, in Longmont, Colorado, Brian Melrose is going to be out there in Colorado. And then the following weekend, August 17th, 18th, I am going to be out in Grass Valley, California, over at Body Logic PT with that crew. If you're looking to get into cervical, August 3rd and 4th, if you're in the Cincinnati area, we might only have one spot left or so. It might even be sold out by the time I'm saying this, but cervical management was Zach Morgan. And then the last weekend of August, August 24th and 25th, over in Bend, Oregon with Brian Melrose as well for cervical spine management. So quite literally every single weekend of August, if you want to take a spine course, we're somewhere in the country doing it. Lumbar or spine or lumbar or cervical team. Thank you so much. I can't wait to see you next month talking about the next thing here and have a great day. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jessica Gingerich // #ICEPevic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jessica Gingerich discusses pushing strategy during labor. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION JESSICA GINGERICH Good morning, PT on ICE podcast. My name is Dr. Jessica Gingerich and I am on faculty with the pelvic division. Today's Monday, so you know that we are kicking off our week with some pelvic content. So today I'm going to talk about a question that I got from a client. So I wrote this down because I didn't want to get it messed up. And so She asked me, she said, if my uterus contracts to push my baby out during birth, then why do we as women feel or need to push during that second phase of labor? And I love this question because she has, she's done her research, right? She read that the uterus contracts to help push her baby out. And sometimes there are some nuances to our patients that we want to make sure that we clear and explain, and especially around birth, because we can decrease that fear around birth. Or if she wasn't having fear, at least empower her. So the uterus plays a key role during labor. So it expands during pregnancy to accommodate the growth of the fetus. There's also a thick muscle called the myometrium that expands to hold the baby, but it also contracts during labor, um, in this wave like pattern, starting from the top of the uterus down towards the cervix. And it helps to open or dilate the cervix. And it helps to thin or efface the cervix to allow the baby to move towards the birth canal. The contractions become stronger, more regular and more frequent as labor continues. So that is the role of the uterus. The pelvic floor's role is to be in a relaxed position. I like to think holes open, and I even say that to my clients. So it gives this really nice kind of internal cue. Now, while the uterus has a lot of work to do during labor, the role of pushing just helps descend the baby towards the birth canal. So it's just something that helps. And that's all we can that's what we can explain to our patients if they have this question. Now, this is kind of outside of the scope of this podcast, but I want to mention this is Because we do push during labor, we can imagine that the stronger our cores are, and really from an endurance and aerobic capacity, this can be a huge advantage, right? The stronger we go into labor can be a huge advantage to help with this. And so we want to make sure we're encouraging exercise in specifically core work, and even programming that as accessory work for our clients. So let's get into pushing. And there's two specific ways to push, and I'm going to talk about those today. This happens during the second phase of labor. I want to also mention that when we talk about pushing, we've got an open glottis and a closed glottis. The closed glottis is very similar to what athletes do when they are lifting weights. And so we really want them to practice how to push, especially those athletes that when they hold their breath, down below there are holes closed. And so as we talk about these strategies, I want you to be thinking about your clients who would really, really benefit from this. So the first one we're going to talk about is the closed glottis push. This, you think about your canister, so you've got your diaphragm at the top, your abs at the bottom, or excuse me, in the front, you've got your pelvic floor at the bottom and your back muscles in the back. You've got holes in the top and you've got holes in the bottom. And so as we create that intra-abdominal pressure by either tensing our core and holding our breath or tensing our core and exhaling, these are different strategies that create a different amount of force with each. So the first one is closed glottis or closed glottis pushing. This is going to be where we close our mouth, we close our nose and we bear down or strain putting the base or putting the pelvic floor in the basement or in that descended position. This creates a lot of force. This is going to be very helpful if mom is right at the end of that finish line and she can feel maybe she reaches down and she can feel the baby's head. or she, um, someone's telling her that her baby's crowning. She can close her mouth, close her nose and push. The second one is going to be an open glottis push. And so you can imagine we are creating a force through our abdominal muscles as air is coming out of our mouth and our noses. This is typically going to be really noisy and really loud. Maybe mom's screaming, maybe she's, making some really loud mooing faces, maybe noises, or maybe she's cussing because it hurts and that's okay. So this is gonna be a little less powerful, but it can be a really wonderful technique to help control their heart rate and help mom hold on longer, especially if she's got that marathon birth going on. Both of these pushing strategies can be influenced whether mom has an epidural or not. There's going to be less likely them to feel what they're doing. And so they're going to need coached pushing. That's going to be a nurse telling mom when to push. This is important to talk about because they need to practice. Practicing these birthing these pushing strategies for birth prior to birth can help mom come back to that and remember, Oh, this is what I did. This is what I did to prepare for this. I had a client tell me that she was in her second phase of labor. So she was pushing, she was so confused because she could not figure it out. She also had had an epidural. And then she remembered, she was like, wait, I remember that we practiced this, that you, you had me every day practicing how to do this. And so she went back to what she had been doing and she ended up being really, really proud and really, um, happy with how her birth went. But it took her a minute to like, remember, Oh wait, I did this. I knew going into my birth, how to do this. So she came out of that. She was really empowered, felt really good. So that is what I've got for you today. Um, we have our last cohorts coming up. So if you head over to ptonice.com, our last L one is kicking off on September 9th and our last L two of this year is going to be kicking off on September 15th. So head over there, snag your spots. Um, we'd love to have you have a great Monday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the differences between front and rear mount bike trainers, which is preferred for different bike types, as well as budget options.  Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION MATT KOESTERWhat's up everybody? Good morning and welcome to another episode of the PT on ICE Daily Show. Today I'm going to be your host. I'm Dr. Matthew Koester. I'm one of the lead faculty in the endurance athlete division with a specialty in bike fitting. I am super stoked to hop on here today and talk about probably the most popular question that we get in every live course and one of the most important things when you're getting into fitting for the first time as far as equipment goes. But before we dive into those topics, I want to talk about the opportunities that y'all are going to have to come and find us on the road. with number one being in Denver next weekend. We've only got four seats available for that course, so if you're interested in popping in, it's gonna be in South Denver in the Denver Tech Center area. We are really, really stoked to be heading out there soon, but if that's not gonna work out for you, we have another option, which is gonna be in Bellingham, Washington again, because the last time we were out there, it was completely sold out, the wait list was filling up, and we decided we'd run it back and set up a second course in Bellingham, Washington later this fall. There's gonna be another opportunity as well to see Jason London, who's the original content creator for this course, which is an absolute opportunity in Park City. That's a really cool location. We're gonna be out there in October as well for that course. So if you're looking to get a jump on some of this education and use this stuff in the clinic, the live course is the best way to get through it. So by all means, come find us on the road and check out one of those course options. Now, I said I was gonna talk about probably the biggest question in the course. The biggest one is really the thing that gets you into this. And it's what type of trainer do I need? We have two options in most cases. So to my left and behind me here, we have a front mount trainer, which offers a whole lot of options as far as what bikes can go on. And then we have the tried and true rear mount trainer. And what I want to do today is talk about probably like the biggest pros and cons of each. I want to talk about which one is probably the most appropriate for you and your clinic, depending on what type of bikes you're typically seeing. And then the ones that kind of have, I'd say, more budgetary constraints and or are just limited in availability sometimes. So, to start off first, I want to talk about the rear mount trainer because that is the one that is tried and true. That is going to be, in most cases for us, this green guy here. This is the Curt Kinetic trainer. Now, if I slide that thing forward, You'll see we've got the rear roller, which is basically what compresses the tire and allows you to kind of go through resistance while you're pedaling. You've got this rear cup that basically compresses the back axle of the bike and allows you to keep the bike nice and steady. And then we typically put something underneath the front wheel. Sometimes it's a custom wheel block. Sometimes it's an adjustable wheel block that allows you to lift that thing up and down and change the positions. But with this trainer, one of the things that people really, really love about it is that it's been around forever. They're used to it. When somebody comes into your clinic for a bike fit and they see something like this, they're like, ah, I know what this is. This makes perfect sense to me. I even brought my training skewer, which is typically the axle that they have to replace in the back of the bike if they're going to get on this bike. Because these metal cups here that compress the rear axle when they're tightened up are gonna basically act to lock the bike in place only on the contact points they get to touch. So if those contact points are plastic, which is pretty common as a way to save weight, save money on a bike, you have to replace that either with a training skewer, which just has metal cups on the sides, or in many cases nowadays with how bikes have gotten, these new through axle skewers. So the through axle skewer is typically a lot thicker, it's a lot more robust. It's common on bikes that allows them to put disc brakes on the bikes, which is really more and more ubiquitous these days. So having these options for different through axle skewers allows you to put metal on metal and compress it in the rear end of the trainer. Now depending on what types of bikes or what brands of bikes you're seeing more in the clinic, the skewers that you're going to need are going to change. So they all have various thread types that go on them. Some are very fine, some are medium, some are coarse. Now the Other kicker to this is that even though you might have the thread type dialed in, the distance, so the width of the actual screw itself might change. Last time I checked on the Kirk Kinetic website, which is the name brand for these guys, they had somewhere between, I think, five different options. I think it was like five different ones, three that were the different thread types, and then two more that were XLs for different distances. And each one was running about 50 bucks. So there's a bit of a financial investment to have all the options so that folks can come to see you and have all the options available to them. If you don't have one of these available to you and their bike doesn't have that, you're going to be kind of stuck in a place where you don't have an option with this style of rear mount trainer to throw them on and do the fit appropriately. That could be a bummer. got to have all the pieces. I'll say there's one other option out there, or not one, but two other like styles of these that are completely adjustable. CycleOps makes one, and I'm forgetting the other brand right now, but they basically have plugs and things that you can change in and out to put on. In my experience, they can be a little challenging to work with. They don't always match up exactly the way that I want them to distance wise. I like the tried and true nature of these ones from Kure Kinetic, but if you're in a bind, and you can only afford to grab like one adjustable through axle, I think you can figure it out. You just have to spend more time with it and go through the trials and tribulations of working through it. So, to recap real quick. This guy, tried and true, everybody knows it, everybody's used to it. It's a trainer they spend their entire winter on. The adjustability in terms of having different through axles is definitely a key. You gotta have them, especially nowadays as bikes have gotten more and more modern, going to disc brakes. These through axles are just like almost a non-negotiable So you gotta have all the different types so you can match the different brands and the different bikes that they come in. So, tried and true. Now, we step into one thing that Jason and I have been seeing over probably the last few years that's really become more popular is this front mount trainer. It really started to make its way in probably like a couple years ago in staging areas or like warm up areas for cross country cycling and downhill cycling. Specifically in downhill cycling, you'll see these guys everywhere when it comes to just getting through warmups. What this guy has to offer is two pieces that basically slide together. These two pieces include the front end triangle here, which allows me to remove and add the front fork of the bike. So we take the front wheel off, slide the forks over top of this guy, and snug it up nice and tight. The next piece from there is the rear rollers, where we have to get the tires centered in the rollers so they can smoothly pass back and forth as it's rolling. Cool part about this, they only have one adjustable piece as far as the actual front axle goes. So, and they send it with them. So when you buy this piece, you have everything that you need in order to do the fit. You can put any bike on here, because the front mount options will work for a standard fork, so they'll work for through axles. You can often put their own through axle back into the same bike. When you're talking about the distances here, there's a little track here that allows you to work with different size bikes so that when you overcome that issue, you can even separate them or buy the extenders. It just has to get, you have to make sure they're nice and perfectly aligned. Otherwise the back wheel might want to roll off one side or the other as you get started. So the rear trainer here offers a whole lot of options for being able to just throw a bike on quick. Now, the challenge that comes with that, as you start to get into like, oh, this thing works for everything, is that it kind of has that jack of all trades where it's not quite really any good at one thing. The challenge behind this thing is that it's not near as stable. It kind of sacrifices the stability and the tried and true nature of the rear mount for something that can be a little bit tippy if your patient or client gets on it and you're not paying attention. If they just throw a leg over it, it can kind of pull the weight with it, I'll say I've never had anybody fall off one. I've never had an actual incident, but I can definitely tell you that when I am with a client in the clinic and we're setting up to do a bike fit, I talk to them about getting on and off the bike carefully. I talk to them about how, like, when they're going to transition on, I'm going to grab ahold of the bars just to create that element of stability. But then even once they're up and on, an experienced rider, so I would say a good example of this would be a triathlon athlete. So somebody who's in the Madison area for me, who's doing Ironman Wisconsin and is coming in for a fit, If I throw them on this guy, it will work, and it will be fast to throw it on, but it lacks some of the stability and control that they're used to having when they're on the rear mount trainer that they spend all their time on. So they might hop on this, and they might notice that they just don't feel as confident. They don't feel as great. So they're more thinking about the experience of being on the trainer than they actually are thinking about the fit as they're going through it, which can be a negative. Okay. So there's the negatives to it, and there's the positives to it. From a financial standpoint here, if you were in a clinic where you were going to have to buy things new, and I'm going to kind of make that a subject for a moment, you can't just go on Facebook Marketplace and buy new stuff and throw it in at your organization. This guy's going to run you somewhere between $400 to $500, but it's kind of that jack of all trades. You can put anything on it. There's no bike you need. There's no custom pieces that you have to go through. You can just get any bike on here. The rear mount trainer, gonna be a similar ballpark. In many cases, it'd be like 250 to 450, depending on how nice you go, you can certainly spend more. It's gonna be limited in some ways because you're gonna have to have all of the different through axles to accommodate any different bike that walks in the clinic, but you're gonna have that stability and just steadiness that people really rely on and like when they're riding a trainer at home. So it's familiar, so that's kind of a nice option. If we take a step away from the idea of having to buy new, and you're like, okay, I'm going to budget my way through this in my clinic. And I know that if I buy something used, I can just make sure that it's good quality and it's broken. We started to get changed the tone here a little bit. These are harder to find use, but they are definitely. Hmm. They're harder to find used, you can get a hold of them, but they definitely have deals all the time on new ones. So you can find the ballpark, if you go on Amazon or various websites, you can get anywhere between that $400 to $500 mark. And this is where I would spend the bulk of the money, because you're going to have almost no scenarios in which you can't get the person's bike on the trainer. That is going to get you through more fits, even if it's a little bit less ideal of a setup. On the flip side, if I've invested in this one right here and I've got the money spent, I'm probably going to start looking at Facebook Marketplace because these guys are a dime a dozen. There were so many folks during COVID that were buying up bike trainers and they were going to spend more time on them at home. We saw the same thing with Pelotons and indoor bikes. These things are on Facebook Marketplace, Craigslist if you still go down that rabbit hole. They're everywhere for sometimes like under 100 bucks, maybe 50 bucks sometimes. And then from there, most of your investment on this guy goes towards the actual, through actual skewers that allow you to get all the bikes on. So your investments kind of change a little bit as you go through this. This guy's going to be the most money up front. This guy's definitely going to be cheaper as you go through it. But you got to get more components, more pieces. If I only had one in the clinic, which is kind of the question that people boil it down to, if I only had one, it would be the front mount trainer. and that comes with one more layer to it. I love the ability for a private practice or a clinic to be able to get out in the community and showcase the things that we do on a high level. If I want to go out to our local high schools here and go talk with them about mountain bike fits and making sure they get the best performance, injury rate reduction, all of those things, I can pop out to the local high school on one of their opening practices, which is actually coming up in a few weeks. I can throw up the front mount trainer, and in a very short time, take out their front wheel, put that thing right over top of this guy, pull the back up, and go right through things like seat height, have a quick look at their reach. I can make adjustments to small things on the bike very fast and make quick transitions to the next bike and not have to fiddle around with various components and other changes. So the, not only in the clinic does this kind of become the absolute jack of all trades, getting it on, It also makes some of those like community events that much more approachable and that much easier to go through. So I am always going to lean on this guy, but I will tell you it's nice having both for that occasion when somebody comes in and I'm like, Ooh, I really want the stability of the rear mount trainer for this person to throw it on. But I would say nowadays as I've gotten more and more comfortable with this, those things are few and far between. There are a few more nuances that would definitely go into this. There's more questions that surround them about the live courses. but deciding between which one is right for you. Hopefully this is a helpful conversation, a helpful talk to get you through that decision. Feel free to drop a comment, ask us questions here, send me a DM, but we will be in Denver next weekend. If you're ready to join us, we'll talk this stuff through even more. Thanks, y'all. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses reimaging the objective examination for patients presenting with low irritability, especially only in specific positions or under specific loads.  Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JORDAN BERRYWhat is up? PT on ICE Daily Show. This is Dr. Jordan Berry, Lead Faculty for Cervical Spine and Lumbar Spine Management. Today we're chatting about a topic called Low Irritability Equals Function First. Okay, so I hope you're having an awesome Thursday. We're about to break down just a concept that I think matters when you're thinking about the novice versus the expert clinician and how they're efficient during their initial evaluation. This key concept of when you're thinking about going into the objective exam and you know the irritability is low or at least moderately low, we're always gonna test the functional movements first. Okay, so a few concepts that we talk about during our live cervical and lumbar spine management courses, when we're thinking about the objective exam and what the expert clinician does different as opposed to the novice, one of those things is that they have a very long, detailed, subjective exam, and they have a short, clear, and crisp objective exam. and how as you gain more experience and more pattern recognition, typically that will sway even more lopsided towards being a longer subjective while having a shorter and more dialed objective exam. And then another concept we talk about is that when the patient irritability is low, you have to be really aggressive during the physical exam testing in order to recreate the symptoms, right? Because if you under test, then you might not actually recreate those familiar symptoms to know that the treatment that you're about to apply is going to work and that you're moving in the right direction. And so, one way that you can accomplish both of those things, right, with keeping a short, clear and crisp objective exam, and then making sure that you're going to be aggressive during the physical exam testing when the irritability is low, is always thinking about testing the functional movements first. Okay, so let me give you a clinical example with this, and then we'll break it down and talk about why it matters and why it's important. So, Imagine that you're in an initial evaluation and you've done your body chart and you know that the symptoms are somewhere around the area of the lumbar spine, like we'll say low lumbar into the right glute wrapping around towards the right hip, maybe even like anterior lateral right hip as well. But you know there's some vague diffuse symptoms that are somewhere in the lumbar spine and somewhere in the hip as well. And during this objective, you also gather that an aggravating factor is squatting anything over 95 pounds. And so day one, during the initial eval, you know you're gonna be trying to differentially diagnose if the symptoms are coming from the lumbar spine, or if they're coming from the hip, or maybe both. But primarily, again, the initial evaluation, day one, during the objective exam, we're trying to tease out What is the primary symptom generator? We have to nail that down day one. What a novice would do is as they're going into the objective exam, they would likely just hammer through a battery of tests for the lumbar spine and the hip. So they'd probably have that person hop up and you're going through all the basic stuff, right? You're going through active range of motion, your joint exam, your segmental exam, potentially neurodynamics, your test and hit PROM and strength testing and palpation. You're essentially just working down this battery of tests to try to see if anything recreates the familiar symptoms. And so let's say that you go through that 12, 15 minutes of objective exam testing and you figure out that hip passive range of motion, like internal rotation or fader recreates that familiar hip pain. And so now we have an asterisk sign, right? We've got our, um, let's, let's call it internal rotation is what we're going to retest and we've recreated the familiar symptoms. So you've done a good job, right? You haven't done anything wrong, but I would argue that that is not expert level because number one, it took us a fairly long time to get to that answer of what is recreating the symptoms. And honestly, the patient doesn't really care about any of the stuff that you just tested. So, an expert here is going to look at function first. So, we might do some of the same objective testing that we did just a minute ago with the novice, but the first thing that we're going to do if the irritability is low to moderate is look at function. So, if the subjective exam we found out that anything over a 95-pound squat recreates the familiar symptoms, well, I'm going to look at a 95-pound squat. So I get that person out in the gym, maybe we do a warm-up set, and then we load up to 95, and right when they drop down, right when the patient drops down into the bottom of the squat, they get that familiar hip pain. Now, right then, you have one of your asterisk signs, but we could also modify that movement or try to tease out in real time if we can change the symptoms or affect them in any way. So let's say that person drops down into the squat, bottom of the squat, they get their symptoms, and you grab a big mobility band. wrap it around the hip, and give a big lateral distraction, a lateral pull, while they go down into a second rep of the squat, and the symptoms are completely gone. So think about what you've now done. Number one, you have a better asterisk sign, I would argue, because it's something that the patient actually cares about. It's functional, it's very easy to retest, but you've also clued yourself in on your differential diagnosis. Because if I can do something to the hip, right, do a self-mob to the hip or do a lateral distraction for the hip and immediately change the symptoms that we got with squatting, then I know when I go back to the table and I do my more traditional objective exam testing, I'm going straight to the hip. So maybe on day one now, I can leave all of the lumbar spine testing and maybe hold it off until day two. because now I know that I can affect the hip. Now we go back to the table. We do some of the objective testing and I go right towards PROM and I jam that hip up into IR and fader and recreate those familiar symptoms. Boom. Now we've got our two objective asterisk signs. We've got one passive range of motion. We've got one that's functional, the squat. So now when I apply it to some sort of treatment, I've got two ways that I can retest. SUMMARY So number one, why this matters so much of testing function first when irritability is low is differential diagnosis. It's just a fast way to identify oftentimes where the symptoms are coming from or at least cluing you in as to what direction you need to go in instead of just testing all the lumbar spine stuff and all the hip stuff. Now I've clued myself in that I'm probably going to focus on hip day one. So the second thing why it's important is efficiency. We always say during objective exam testing, as little as possible, as much as necessary. So I only want to test the stuff that's absolutely necessary so I'm efficient, but also I don't risk flaring up the patient with doing a bunch of tests and measures that aren't necessary to begin with. And if I can eliminate a few things right off the bat from that functional testing, why not start there? And then lastly, it's way better buy-in. It's way better buy-in. So day one, you're always trying to have the patient walk out thinking, man, I'm finally in the right spot. This person totally gets my issue. And they're definitely going to be walking out saying that if you're first off testing the functional stuff, the stuff that they actually care about that you pick up in the subjective. No patient cares about hip IR, cares about lumbar AROM, cares about palpation. They don't care about that. They care about the thing that they want to get back to that they love. And if you're including that in the physical exam, the buy-in is going to skyrocket. So think about that over the next week or so. About maybe changing the order of your physical exam if this is not typically how you order things. When the irritability is low to moderate and you pick that up during the subjective exam, then when you go into the objective exam, you make sure that you're testing function first. It's gonna help with differential diagnosis, it's gonna help you be efficient, and you're gonna get way better buy-in. All right, so think about that this week. Next week in the clinic, I'd love to hear feedback on that as well. Just to leave you with a few upcoming courses that we have with cervical and lumbar, this coming weekend, we've got cervical management in Oviedo, Florida, few seats left for that. And then also this weekend, we've got lumbar spine management in San Luis Obispo in California. And then coming up August 3rd and 4th, we've got cervical in Cincinnati, Ohio. And then also August 3 through 4, we've got lumbar spine management in Aspinwall, Pennsylvania. All right. Thanks so much for listening. Have an awesome Thursday in the clinic. And if you're going to be a cervical or lumbar spine management course coming up soon, hopefully I will see you there. All right. Have a great day. Thank you. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.  

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones as he compares & contrasts the different roles of heavy & light lifting in the scope of geriatric rehabilitation. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION DUSTIN JONESWelcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dr. Dustin Jones with the Older Adult Division and today we're going to be talking about heavy versus light loads, particularly in geriatrics. Which one is better? Is there a certain time, place, person that we may want to use heavy versus light? I want to take a dive into the research and some of the themes that we're seeing in the literature and also just from experience in clinical practice and in fitness. of how we want to think about these different types of load because to be very honest we have a big bias here at at ICE I would say and then definitely in the MMOA division where you will hear us talking about the need to push for higher intensities right especially with our professional pandemic of under dosage where we have individuals that are not being challenged and have the ability to change right like this is a big big issue and something that we really need to speak to and it's very easy to mix that message with that higher amounts of load heavy load is the only way to go and that could not be further from the truth all right so let's kind of get into the pros and cons of you know heavy resistance versus lighter resistance and when we may want to use these because it's really important to be very thoughtful in your approach of applying load to individuals I wanna start with talking about some of the advantages of lighter resistance training. That's the one that we typically associate, oh, that's under dosage, or that's too easy, or that's not gonna be that effective, right? That's not necessarily the case. So when we think about light resistance training, lighter loads, you know, maybe 40, 50% of someone's estimated one rep max, if you're doing those types of calculations, Those loads are really, really great for introducing movement. I think we can all agree that if we have individuals that haven't exercised before, that are relatively new to a movement, have a lot of fear on board, maybe a lot of irritability, that a lighter load is going to be easier to get the party started, if you will, with those individuals. And for some, it may be first set where you're doing a lighter load, check the box, things are looking good, and then we're going to progress to a heavier load. But in some settings, and I'll speak for home health at least, that's where most of my experience is, is that takes weeks and sometimes even months with individuals where we are doing somewhat of a lighter load before we really have a green light to really progress to a relatively heavy load with certain individuals. So introducing movement, I think light resistance training is a great place, a great tool and time to use that. I also mentioned irritability. When we have folks that are highly irritable, A heavy load is not necessarily a great situation, right, for those individuals. They'll often increase irritability and the behavior of those symptoms. They want to be respectful of that irritability and often lighter loads can allow us to introduce movement and helpful movement and activities without causing a big increase in their symptoms or a change in the behavior of their symptoms. So introducing movement, high irritability, those are great places. Another great place to introduce or use lighter resistance training is when we're really focused on movement velocity, of really creating speed with a particular movement, which in geriatrics, oftentimes, it's very helpful when we're working on reaction timing, for example, or performing movements that require a lot of speed, like stepping strategies to regain balance, for example. the lighter loads are gonna allow them to move quicker than if they were bogged down with the super heavy loads. We can use that in our training. Light resistance training also improves strength and hypertrophy as well. There is a lot of kind of mixed literature of showing that, man, heavy resistance training is kind of the gold standard, right? If we're wanting to get people really strong, if we're wanting to improve muscle mass as well, like we gotta lift heavy loads. but particularly in older adults and deconditioned older adults that they can see improvements and significant improvements in strength and hypertrophy with relatively lighter loads, 40, 50, 60% of their 1RM. Now, oftentimes you have to adjust the other variables of dosage, right? Typically higher volume, but we can see an improvement in strength and hypertrophy in older adults, particularly deconditioned older adults with light resistance training. And that's really good news. I think it's really helpful, especially if you're in a more acute setting, you're in home health, acute care, SNF, Those types of settings, the lighter resistance is typically more accessible to these individuals and we can still get benefits from it. So I hope you can see some of the value of lighter resistance training. There are certain times and places and people where we are going to want to use light resistance training over heavy resistance training. Now let's talk about heavy resistance training. What's some of the evidence showing and theme showing of where that really stacks up? What are the benefits? The obvious one is strength and hypertrophy. Most of the literature It's going to be looking at improving strength, improving hypertrophy is with heavier loads, you know, usually that 80-85% of someone's one rep max, you're going to see really good results with a lot of the individuals if you can be able to apply that. One thing that is not often discussed and why you'll often see the MOA faculty use, give a little bit more preference to heavy resistance training is the stimulus it will give to bone mineral density. that heavier loads are going to be a greater stimulus to improve bone mineral density than lighter loads. Most of the research that's showing pretty significant changes or a reduction in decline in bone mineral density are usually doing resistance type activities in higher percentages of someone's one rep max in the 80s, 85% for example. So bone mineral density is a huge one and that's why we'll often use it somewhat preferentially with folks when we can apply it. Another big one, and this is purely anecdotal and from what I've observed working with lots of folks, is the confidence piece. Introducing light resistance training can help build confidence, right? It can get people moving. They can start to do things that they didn't think were possible or what they thought they'd be able to do. initially, but once we get past a certain point, heavy loads are going to be the only tool to really change people's perceptions of themselves. There is nothing like, and this is in my experience so purely anecdotal here, but there is nothing like lifting a relatively heavy barbell off the ground and doing a heavy barbell deadlift with someone that perceived that they are weak, that they're old, that they're fragile, that they're slow, that they can't improve, they can't change. That is such a powerful tool for these people to improve their confidence, but change the perceptions of what they're truly capable of doing. And this has so many ripple effects, right? If I am able to deadlift my body weight, for example, and I'm absolutely shocked and surprised, usually for a lot of members of Stronger Life, a gym for folks over 55 in Lexington, that's where I'm working, it's usually the 100-pound mark. If people can deadlift over 100 pounds, it just blows their mind, and many of us know, like, 100 pounds, that's okay, cool, awesome, but can you do your body weight? Can you do two times your body weight? But for 100 pounds, for some reason, for these individuals, it just, like, kind of, flips the switch, and then they start to think of other activities in a different light. They start to see, well, if I could do that, a hundred pound deadlift, man, going to Lowe's and getting my own bag of mulch is no problem. I don't need help. I can handle that myself. I don't need to go ask Bob across the street to do this for me at my house. I can handle that. Oh, that trip that I wanted to do, I may be strong enough to do that now. I may be able to do X, Y, and Z. Oh, I'm more confident in maybe being able to take care of my grandkids because I know I can pick up 100 pounds off the ground. It has a ripple effect of how they perceive all kinds of different situations. And what I've observed is that behavior often changes, hobbies often change, leisurely activities often change, and overall their life becomes better and more rich and more lively all from an exercise, right? I shouldn't say all, but it's a very profound moment. So heavy resistance training does a great job of achieving that. Another reason heavy resistance training is very, very beneficial, especially in the context of rehabilitation, is it minimizes a detraining effect. So if I'm performing light resistance training over a period of six weeks, eight weeks, for example, I will likely have more of a detraining effect. I will likely lose more of the gains that I've received over that eight week period. I will lose more of that after I'm done, as opposed to if I were lifting heavy weights the whole time. So if you are working with individuals where you're not sure what's going to happen upon discharge, What are they going to do? Are they going to start that exercise class down the road? Are they going to watch that YouTube channel, fitness channel that you recommended? You don't know, right? Are they going to do that home exercise program? It's all up in the air. You're not really sure. We can use heavier loads. to typically get more results, especially related to strength, especially related to functional capacity, related to transfers and independence, we can use heavy resist strain to get more progress over that period of time and they're going to have less of a detraining effect upon discharge and they will maintain their gains for a longer period of time. For me, in the context of home health, this was absolutely crucial, that if I was pretty sure that whenever I discharged Doris, and I was probably gonna see Doris within five, six months, I needed to account for that five to six month period. Doris, I need to get you as fit as possible in this eight week period before we're gonna discharge. So I'm gonna give preference to heavier resistance training as soon as I can apply it with her situation. It'll minimize that detraining effect, all right? So there's lots of different reasons, but I hope you can appreciate the benefits of light resistance training, of when you may want to use it, what situations is it really helpful, but then also for heavy resistance training. There's certain situations where, yeah, we definitely need to avoid light weights and stick with heavier weights. It's very nuanced. There's a right time, there's a right place, there's the right person. We're going to apply these different types of load or amounts of load. We can also appreciate that oftentimes it's overlapped, right? There's going to be times where I'm doing heavy load and lighter load in the same program. They can coexist. And this is why at any ICE course, you're often going to hear us talk about and not or. That we're not here to be dogmatic. We're not here to polarize. We're not here to say, you know, this is absolute garbage. You only need to stick with this particular intervention. That is very rare in our profession of rehabilitation and fitness that oftentimes it's an and not or approach. And that's definitely the case whenever we're talking about the amount of resistance that we're applying to our individuals.SU SUMMARY So let me know your thoughts. Any other scenarios, situations I didn't touch on? I didn't even talk about tendon health, soft tissue, related adaptations to resistance training. Drop some of your thoughts and some of your experiences while using light versus heavy resistance training and geriatrics in the comments. YouTube, hop on Instagram, we'll talk there. But we appreciate you all for watching, for listening. I want to mention a few MMOA or Modern Management of the Older Adult courses that are coming up. We have our certification that is for folks that have taken all three courses. Our Level 1, which is going to be starting August 14th, that's eight weeks online. Then our Level 2 that's starting October 17th, that's eight weeks online as well. And then our live course. So all three of those culminate in the ICE certification for older adults. Our live course is coming up too that I want to mention. This weekend, Victor, New York is going to be going down. Jeff Musgrave is going to be leading that one. It's going to be an awesome crew up there in upstate New York. And then the following weekend is our big MMOA Summit. This is where all the MMOA faculty descend. In Denver, Colorado, we do this one time a year where we all come together, have an absolute blast. We do a lot of activities, hikes, we'll have a big cookout pool party with all the students afterwards. So if you're in the Denver area looking for something to do next weekend, we'd love for you to join that course. All right, y'all have a good rest of your Wednesday and I'll talk to you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the different deadlifts variations and who may best benefit from their performance. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONGood morning, everybody. Welcome to the PT on ICE daily show. It is the best day of the week, Fitness Athlete Friday. My name is Guillermo Contreras, here with you today from the Fitness Athlete crew, talking all things deadlift. So this is an exciting topic here. We just finished up our level one course last week and we just had our fitness athlete summit a couple of weekends ago. One thing that we know that throughout the one course as well as the live courses is that deadlift is typically going to be one of the most spicy topics. Should everyone be deadlifting? Why should we, why should we be deadlifting and why should we be deadlifting heavy? One of the questions we most commonly get both in the live course as well as the online course is the question of all the variations we see. The conventional deadlift versus the, you see back here, the trap bar deadlift versus the sumo deadlift. What is the best position? What is the setup? How do we coach it? How do we look at it? And if you want to dive into all that, that nitty gritty, that really deep detail stuff, highly recommend you jump into the L1 course or you join us on the road for a live course. But today, all I'm going to be talking about are the different types of deadlifts. And the topic title is a deadlift for everybody. Right? So not everybody, but everybody. Because there are instances where individuals will be using a different setup or a different variation of the deadlift to be able to move the greatest amount of load in the deadlift movement. So the ones we're going to specifically talk about today are the conventional deadlift, the one we see the most often and the one that we coach typically in the L1 course, you see in CrossFit gyms, you see done all over the place. The sumo deadlift, which we see a lot more in competitive powerlifting where they're trying to lift the heaviest amount of weight humanly possible off the ground. We trap our deadlift because we see it a lot in athletic sports and individuals using it in different ways and we'll talk about the differences there. That'll be more of like an end of the conversation discussion there. And then lastly, some variations known as kind of the hybrid deadlift. And that is just going to be a slightly different for individuals who maybe can't get into position for conventional but don't need to go sumo, we find something in the middle. So first things first, we're going to talk the conventional deadlift. we look at the conventional deadlift we want to ensure that we are set up in such a way where that bar is close to our bodies. So when I coach this out I'm telling athletes that they want to set up hip width apart so their feet are right underneath their hips for this conventional deadlift setup. From there the bar should be lined up closer to my shins. I typically will tell athletes when they look down, they should see that the bar is lined up over their shoelaces and not too far forward, because now that barbell is far away, which makes moving a heavy, heavy load a little bit harder, because it's going to pull you out of position. So we want that bar nice and close. From here, with the conventional setup, what we tend to see is my hips are going to go back. And when I'm set up in this double overhand grip, my hands are outside of my shins. And when I get all that tension on board, my knees are below my hips, my hips are below my shoulders, and I have this really nice stacked set of position in which, again, my shoulders are above my hips, my hips are above my knees, and that bar is nice and close to my body. That is going to be our conventional setup. That is the most common variation you're going to see in the CrossFit gym with any athlete that walks in, someone that's just a recreational weightlifter and is doing deadlifts on a day-to-day basis. The second most common variation we're gonna see is something called a sumo deadlift. With a sumo deadlift, that barbell, and I apologize, if you're listening on the podcast alone, some of this won't make any sense, so I'll try to talk as much as I can, but the video will give you a lot more detail on this. With a sumo deadlift, we set up with a much wider stance. So my feet, if this is hip width apart, This is shoulder width apart. This is just outside of shoulder width apart. With a sumo deadlift, we are going wider than that wide stance. The reason for this, the reason we see this in power lifting is because we are essentially just decreasing the amount of work being done. Meaning that the amount of distance the bar has to travel is less because now, rather than having to go from here to here, the motion turns into here to here. so it's a much shorter distance to travel or a much shorter distance to pull that barbell off the ground. The other big differences we see with that sumo deadlift outside of that much wider setup is gonna be that the torso angle is more vertical. So because I have this wide stance with a slightly more toed out position, or sometimes excessively toed out position, I can now set up with a much more vertical torso, and that bar can stay right underneath me. This means my erectors can be locked in a good position, I can stay nice and tall, and I'm driving through my thighs, boom, to lock that barbell out and overhead. Because I'm so wide with my legs, my grip is now just inside of my hands in this nice narrow position. Because again, I'm trying to decrease the amount of work being done by reducing the distance that bar has to travel. So that is our sumo deadlift. The points of performance still stand when I set up for a sumo deadlift here. my knees are still below my hips, right? It's just a slightly much less difference there, and my shoulders are still way above my hips, but I am much more vertical and I'm driving straight up off the ground. So it's a very different looking movement. The emphasis on load is going to be moved to different muscle groups, but it's a way to do essentially less work because you are moving a shorter distance and you can move much, much greater loads typically if you train it enough. So that is your sumo deadlift. The one here that most people don't know about, that most people don't do, is the hybrid. The hybrid is typically only given for athletes who might struggle to get into position with a conventional deadlift, but want to still be in a more narrow stance position because it's going to translate more into Olympic lifts or other type of lifts from the ground. And what that is, is if this is our conventional stance, this is our sumo stance, we break the difference and we are just slightly wider. So we're no longer just under our hips. We're now maybe just outside of our shoulders and our grip is just inside of our legs there. That setup mimics that conventional deadlift a lot. So I'm still in that hybrid deadlift. I'm sorry, I'm still in that hybrid deadlift stance here. The bar is still lined up nice and close to my shins. I'm sitting back, I'm getting over that bar, my hips are still above my knees, my shoulders are still above my hips, my hands are still nice and close to my body, and I'm pulling there, sitting back and tapping down. That one is most commonly given to athletes who just might not be able to handle that position of hip flexion in a conventional deadlift for one reason or another. or that just slightly wider position, allows them just enough room to sit comfortably into that setup for the deadlift. You'll see athletes, especially longer, taller athletes, when they go to set up in conventional deadlift, they set up here and they can only get there with this kind of nice, kind of rounded position because of how long their femurs might be, or their limbs might be, or if they have a shorter torso. So by just giving that little bit of clearance in that hip, they can sit there in that same deadlift stance, pull, and then get back down. So that would be your hybrid. So again, to recap, we have our conventional deadlift here, slightly wider for our hybrid deadlift, even wider and more upright for our sumo deadlift. That is how we pull heavyweight off the ground. Regardless of how you do your deadlifts, we know that the deadlift is one of the best ways to improve low back pain, to reduce low back pain, to reduce kinesiophobia, to build strength, resilience, and just overall good quality life and function because of the way that you're moving a heavy load off the ground, training every muscle group, strengthening your grip, strengthening your back, strengthening your hips, strengthening your posterior chain. So the deadlift should be something we should have in our arsenal. The one thing I want to give some love to is the trap bar, right? So this behemoth bar over here, we see this a lot. and it's shaped like a, what would that be, a hexagon, I think? Hexagon. We see this a lot in sports, a lot more in like, you'll see it in like football, basketball, because they just want to reduce risk. So they claim that the bar being out in front is just too unsafe. But in reality, what happens a lot of time when you have a lot of athletes, the time it takes for a strength and conditioning coach, if they don't have a large strength and conditioning staff to really coach, cue, and ensure good quality movement with a barbell deadlift, it's hard. So the trap bar takes away a lot of those things that you would normally coach by allowing an athlete to set up with the bar at their sides here and be in a more squatty position. You can get more hingey with it if you'd like, but most people are going to tend to falter back towards that more squatty movement pattern when it comes to a trap bar. There's nothing wrong with using the trap bar. The trap bar is a great way to load up that hinge pattern, that deadlift pattern, get comfortable pulling weights off the ground, even like jumping or heavy farmer scares. You can do a lot of different things with the trap bar, but it's not going to be the same thing as loading up that barbell, having good quality coaching, ensuring that that back is being nice and strong and holding that really stiff, strong position as you hinge forward. And that's where a lot of that magic happens with the barbell deadlift. So again, trap bar, a wonderful tool to use. It also, if you're dealing with crossfitters, it's not going to translate to literally anything else besides maybe some loaded carries, heavy carries, sandbag carries, jerry can carries, things like that. But it's not going to transfer over into strength for Olympic lifts such as the clean and the snatch. So we want to really try and work and improve on that deadlift. So again, one final recap. What do we see? Deadlift, one of the best things we can do for low back pain. Improved kinesiophobia, just get rid of it all together. Improved strength, resilience, quality of life, everything there. This is the health lift, what it was normally known as back in the 20s, I believe. We have a conventional deadlift in which our stance is around hip width. Bars close underneath our shoelaces, hips above our knees, knees, hips above our knees, shoulders above our hips, and that really nice pattern there. We have that hybrid, we'll be slightly wider stance, and now our grip, instead of being outside our knees, goes inside our knees. and we are still driving with that same shoulder above hip, hip above knee position of our body. And then lastly at that sumo deadlift, that really wide stance that again allows us to reduce the distance that bar has to travel so we can do more load typically. the hips are still above the knees, the shoulders are still above the hips, we have a much more vertical torso, and we are driving straight from the ground, standing tall with it. Sumo deadlift, hybrid deadlift, conventional deadlift, and special shout out to the trap bar deadlift as well. So there's a deadlift that anybody can do, we should be deadlifting in the clinic with our athletes, especially if you're dealing with fitness athletes and crossfitters, they're gonna deadlift, so be really good at coaching it, understanding these different variations that they can use to train in different ways. If that's just a little bit, and you're like, oh, I want to learn a little bit more, please, please, please join us on the road. We are not traveling a whole lot in August and July, but starting in September, we are on the road right away. 7th and 8th, we are in Austin, Texas with Fitness Athlete Live. Then the 14th and 15th of September, we are in Longmont, Colorado. And then the 28th and 29th, we are back in Texas, in Springs, Texas, which I believe is down on the coast near Houston, I could be completely wrong, so I apologize for anyone from Springs, Texas if I got that wrong, but please come check us out, we're on the road. If you want to see, learn a lot more, be able to dive into it a lot more, into the science of everything a lot more, the level one, the fitness athlete level one starts back up on July 29th, so that'll be in about three weeks. We're starting up our next cohort of the CMFA L1. And then the CMFA L2, if that's the one course you are waiting to finish up to get your CMFA certification, that starts up on September 3rd. That course is only twice a year. That course always sells out. So please, if you're thinking about getting your CMFA cert and you want to take that L2, dive into all things programming, movement modification, some business aspects, high-level skill, gymnastics, and Olympic weightlifting, Sign up for that one on the PT on ICE website. CMFA L2 starts up September 3rd, CMFA L1 July 29th, and we are on the road in Texas on the 28th and 29th and the 7th and 8th of September, and then out in Colorado on the 14th and 15th. Gang, thanks so much for tuning in this morning. Have a wonderful weekend, and we will catch you Monday on the PT on ICE Daily Show. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jeff Musgrave // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Older Adult lead faculty member Jeff Musgrave discusses how choosing pain now can help you avoid pain of regret later in your career. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Welcome to the PT on ICE Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy, currently serving in the Institute of Clinical Excellence in the Older Adult Division. It is Thursday, so it is Leadership Thursday. Super excited to be bringing to you a message that I think a lot of people are going to relate to. Pain now or pain later? When thinking about this topic, it really came very organically out of a class that I was coaching. So I get to coach people 55 and up, we're all about pushing high intensity, we celebrate sweating, we celebrate heavy weights, and really pushing things in a business called Stronger Life. But we were finishing up class, it was a really tough workout, and I was talking to our members and I said, you know, the reality is, team, you can have a little bit of pain, a little bit at a time, or you can have some uncontrolled pain later in life, maybe years from now, maybe decades from now, but that pain, you're unlikely to get to choose. And we all know this, if you're listening to this podcast, you know that we're all about being fitness forward. We're all about choosing that little incremental consistent pain to avoid greater pain later, right? Whether we're talking about building reserve for not even just older adults, but all people, right? The stronger we are, the fitter we are, the less likely we're going to have those uncontrollable pains through health complications, whether we're thinking about heart attacks, type 2 diabetes and amputation, strokes, Those type of things, for the most part, are very avoidable by choosing a little bit of pain, a little bit at a time. So this really just resonated with me, and as I was reflecting on it, not that I have that many great quotes, but this one, I was like, this one kind of lands. It connects a little bit. And then it made me think about my career. It made me think about people that, in scenarios that I've been through, as a clinician, and my journey in my career. So I think this not only relates to us from a physical standpoint, but thinking about our career, where we're headed, having big dreams, like what do you want out of your life? Who do you want to serve? And how are you going to get there? And the reality is, I truly believe you've got to choose some discomfort. You've got to choose a little bit of pain if you want to reach your goals. Likely, if they're worthwhile at all, they're going to be hard to obtain. They're not going to be easy to get to, and you're going to have to push yourself. And you're going to have to seek some pain. If you're choosing comfort in your career, you're unlikely to reach any big, meaningful goals. That's just the reality of it. So I'm gonna give you some examples, thinking about the perspective if you're an employee and if you're a business owner, if you're an entrepreneur. So for these, really we're just gonna talk about two scenarios. So the first trap that can lead to you not choosing pain is really just seeking comfort, career comfort. And it can be a career comfort as an employee and as an entrepreneur. So the way I see this is if you're early in your career or maybe you're later in your career, it doesn't really matter. But if you were choosing comfort as an employee, it could look like choosing prioritizing a paycheck over growth. right? And I've been there too, right? Student loans, debt, paying the bills, that's a reality. We all have to pay the bills, right? And the more financial margin we have, the easier our life is from that perspective. But that's not always the path to a meaningful career. Those two things can coincide. You can make great money and you can be serving your life's passion, the mission, the thing that you are here as a clinician to do, you can get both. But oftentimes, there are so many more opportunities to choose a paycheck and comfort over growth, over meaningful growth. Some signs, because I've worked at these places before, I've been there, team. Some signs that you are in the wrong place and you're choosing career comfort over growth or that small incremental pain is you're working with a bunch of burned out clinicians. They've been there for a long time. Their interventions are ancient, right? They're not up on the research. They're the ones doing shake and bake with heat and e-stem. They're using the ultrasound machine, whether it's plugged in or not, right? We know it's going to work. Not to say we won't do that to meet a patient's expectations. If they believe that's what they need, we'll do that and then we'll get after it later, right? Another sign you're in a place of just comfort, seeking a paycheck, is all of your clinicians or maybe you have gotten into the habit of using handouts. There's like, here's my older adult knee program. Here's my shoulder program. Here's my hip program. Team, we know if it works for everyone, it works for nobody. Right? Care has got to be individualized. We've got to meet people where they are, do an individualized assessment, and then we can dive in and really bring them the goods. But there's a good chance if you're in a work environment where everyone's super burned out, they're there for the paycheck, it's probably a pretty good one. and the expectations are probably pretty low. No one cares what the quality of care is. All they typically care about is billing units. If billing units is more important than quality, if you're not getting your sword sharpened by the people you're working around, you may be choosing career comfort over growth. I think another area where people can fall into a trap, there are lots of different companies that are gonna offer mentorship. This happened to me. I was switching settings early in my career. I was promised mentorship. What I got? Super full schedule, no help, no supervision. I wasn't even treating during the time my mentor was supposed to be there. No conversations about mentorship happened until I told them I was ready to leave and put in my 30-day notice after I'd been there for five months. No mentoring, didn't execute on the schedule they said they would give me to slowly on-ramp and sharpen my skills. Look around. If your mentor is not available, if your mentor is not someone you want to emulate, that's at the cutting edge, that's constantly growing, that hasn't reached the peak of their career, if you've peaked and stopped, you're done. You're learning or you're growing. So that's another trap that I typically see. So if that is you and that is what your situation is like, you need to run. If you're interested in growth, you're interested in being the best, you can't hang around in a work environment for very long with people that are burned out, that aren't trying, that are doing the minimum, that are there for the paycheck, it will crush you eventually. You can swim upstream for a while, but you need people to go with you. And if you're in that scenario and you can't change your scenario right now, stay connected with us. Listen to the podcast, go to good content courses, and we can help you get through that period. But long-term, if you want solid growth, you've got to find a solid mentor. You need to be surrounded by like-minded clinicians that are going to push you You want people that are gonna point out the things that you're doing poorly. You need a mentor that's gonna say, you know what? I think you can do better. I know what your capacity is. You're smarter than this. You're better than this. Let's get better. Let me show you how. And that person better be someone you're ready to follow. Okay, so that's if you're an employee seeking career comfort. If you're an entrepreneur or a business owner, one of the traps that I see with seeking comfort is you probably busted your tail to get started. I hear Jeff Moore talk about this all the time and it's so true. Getting that boulder, pushing that boulder at the beginning to get some momentum is so hard. It's so challenging to do that. Once you get it going and get some momentum, it's easy to just be like, oh man, I did it, like this is good, I'm making money, I like this, and it's easy to get comfortable there. When really, there's so much more that you could do and I think Sometimes that is not bringing on someone else to help you. You're seeking comfort through just doing it all yourself. Not trusting someone else with things maybe you're not great at. relying completely on yourself. And basically you've turned yourself into an employee for yourself. You don't have time to work on the business. You don't have time to expand. You don't have time to bring on more business or new employees that are smarter than you or better than you in a certain area to really grow your business, to have a big impact. If you're really good, bring more good people with you. Serve your community well. Push yourself, push your business. If you are seeking comfort and you're an entrepreneur, this is my challenge to you, to grow your team. Find something that you suck at and find someone better than you at it. Offload some of those things, a little bit of time if you can. You don't have to go all in. I'm not saying cancel your schedule. What I'm saying is bring someone on that can help take on a little bit of the burden that's better than you in a certain area. That can help shake off the comfort. That'll make you feel a little uncomfortable. It'll be a little harder to teach someone else. It's gonna take some time investment, but it'll pay huge dividends. So that's one of the main ways that I see that happen. But you've got to free up enough time that you can work on the business, not just in the business. That quote I pulled from the EMF Great Book. If you're an entrepreneur, you've never read it. That's a trap that I fall into. I wanna do the work myself, but I've gotta get comfortable giving other people tasks that I'm just not that great at. We can't be good at everything. We can be good at a lot of things, but if we're gonna grow a business, we're gonna have a big impact. We've got to share the load. We've got to share that burden. The other, on that same note with hiring someone, another thing that we see, is if you get too disconnected. So the one extreme that I see with entrepreneurs that you can fall into this trap and I tend to fall into is I want to do too much work and not delegate or let other people do things I'm not good at. The other extreme that I tend to see is we have people that then continue to micromanage really talented people. You give them a job, you give them tasks, but you're upping their grill all the time. You're checking up on everything. You're not giving them the space to be creative. You're not giving them the space to spread their wings and do their thing, to let them fly out of the nest. You're hovering over them, micromanaging everything. You've got to find smart people. You've got to set some clear expectations. You've got to give them good support. Be clear. Just as a side note, when you think you're being clear, you're not being clear. I fall into this trap all the time with not having enough clarity. But the biggest key, once you get someone talented on board, is get out of the way. There's a reason you hired them. Give them the space to do their thing. Okay, so that's part one, career comfort. The second piece, risk little, gain little. If you risk little, you're likely to gain little over time. So if you're interested in growth, being the best in your area, being the go-to in anything, you gotta risk a little bit. You've gotta throw some money at your skills in an efficient way. You've gotta go through the discomfort of getting real feedback. If you're not getting real feedback on your skills, whether you're in the clinical or you're doing some type of mentorship or you're continuing education courses, people should tell you when you do something wrong. They should be bold enough to tell you, hey, that's not great. You can do that better. Here, let me show you and have a trusted source for that. But you're going to have to see some incremental pain and discomfort of being told that's not great. The other thing is if you are one of those people that were like me, you're in a career, you're ready to make a jump, you want to do your own thing, you're gonna have to suffer some pain. You're gonna be on the bubble for a while. You're gonna have to have some revenue streams to help support that jump as you're getting things going, and you gotta be prepared to not make money for a while. For most scenarios, there are very few scenarios where you can just hop straight over, go completely from being an employee into being an entrepreneur. So you need to have a period of time to build an on-ramp for yourself, and this is going to be uncomfortable. You're going to have to have revenue streams that are going to help support you through the period of time that you're working on building a business or building up your referrals so that you can make enough money to sustain things. That period of time will not last forever, but you need to have a solid plan. and you need to have a long runway. The longer the runway you can create financially, the more reserve financially you can create before you start doing a second thing or a third thing. Whatever it takes to be able to build your dream, build your business, you gotta do it. There's no path forward without some pain, without some discomfort, without some extra hours. I've just never seen that happen. If you've been able to do it, please share in the comments. I'd love to know how you pulled that off. So that is the second piece if you're an employee and you're trying to move forward. and you want to start your own thing. If you're an entrepreneur, I think another big mistake through being comfortable and not not risking enough is not risking to make yourself an expert in one area. I see this a lot too where clinicians are well-rounded. They can do a lot of things and that's great. You need to be able to treat all of the things that you want to treat, but eventually, after you become successful, you've got to niche down. You've got to find that specialty area. You want to be the go-to for this. When their friend says, oh, I've got someone that's got pelvic floor dysfunction, you need to go see Amy. Amy is the best at it. No one's going to do a job for you like Amy will. That's who you want to see. That is so clear. The message to your customer is so clear. You need to niche down. And maybe you've got a couple different areas. That's great. Crush it with those. You'll still get word of mouth referrals, but you want your clinic to be known for something in particular. This is great for getting people active. Maybe you're the older adult go-to. If you're over 55, you really want to go see Sally. Sally is the best in the world. She gets it. She understands what's going on. She's going to treat you with respect by challenging you as you're ready. I've got a friend who did X, Y, or Z, or those are the type of stories you want to hear. But you can't be too broad. If you want to grow, eventually you've got to niche down. You've got to be the best at things. Or maybe you're growing your team so that you've got a team of people that are the best at things. The only exceptions I can think of here is if you're in a super rural area, you kind of have to be a jack of all trades, but you want to hit those things that are the most common. And then people are going to trust you by proxy too, right? If you crushed it in this, it's like, well, I'll trust them with that too. And that can be helpful as well. SUMMARY Team, I hope this was helpful. This is something that I'm really passionate about. I found in my own life. personally, professionally, in the gym, seeking some discomfort early is going to help avoid pain later, uncontrollable pain later. So seek that little bit of pain for the growth, for your dreams, the things that you really want to do in life, and you will be much better off for it. Team, if you've got thoughts or questions here, I would love to hear your thoughts. I hope this was helpful. So we want to avoid seeking career comfort and if you risk little, you will gain little. Team, enjoy the rest of your Thursday. We'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.  

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses reframing the conversation around post-operative guidelines for physical therapy treatment. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in our geriatric division. I'm coming to you from the University of Ottawa, so if there's a little bit of background noise, that is exactly why. But today, what I wanted to talk to you about, and the reason why I'm on here a little bit early is because I feel like this is gonna take me a little bit of time to get through, is to start reconceptualizing our post-operative guidelines when we're thinking about not just musculoskeletal injury, but many of our post-operative protocols when we're thinking about early healing and early recovery. in the post-operative window. And so I just posted a reel on our ICE Instagram account that's talking about hip precautions and how we have research going back from as like synthesis of research systematic reviews of research going back as far as 2015 to show that these precautions that were intended to reduce risk of early hip dislocation actually don't do that and what they actually do is they exacerbate post-operative deconditioning and they increase fear of movement. And we see this all the time in clinical practice, right? Individuals go for surgery. They're given these restrictions. These restrictions are not evidence informed. They're never discharged. And what it does is it causes people to disengage with activities of daily living, with sports, with activities that they enjoy. They become more sedentary. And then downstream, we see that the amount of postoperative deconditioning is greater and their capacity to engage back into the things that they enjoy before surgery is less. You know, I've had clients that have said to me, I'm so much worse. Like, my pain is better, but I feel worse than when I went in for surgery. Like, why did I even get this done if I could have dealt with this surgery? And so over the last couple of months, I have really been thinking and noodling on this. I did a podcast on the pelvic section on our Mondays around how our pelvic restrictive guidelines around lifting are not evidence informed at all either. And that when we remove those guidelines, and we have now multiple RCTs that have said, you know, other than don't have penetrative intercourse for six weeks, when we say here are your buoys, and here's how you can progress based on how you feel. not only do you not see an increased risk of postoperative complications in those individuals with liberal restrictions, but they actually have a reduced pelvic floor burden in that postoperative window. And so that early recovery is actually enhanced. And so we have to kind of understand where some of these guidelines come from and how are we as a profession in allied health going to start pushing the narrative and where is our role in that because I think we have a really massive role. So the first thing that needs to be acknowledged that is really front of center when it comes to post-operative guidelines is that when we do research and we take surgeons and we have done cross-sectional surveys, not we other researchers, and asked, you know, where did these lifting restrictions come from? Like, where is your evidence? Or do you believe that your restrictions are evidence-informed? In our pelvic literature, we saw that 75% of urogyne surgeons recognized that the reason for their restrictions is because this is what they have always done. And only 23% of the surgeons surveyed believed that the restrictions that they were giving were evidence-informed. Now that is a massive problem, right? We so often in medicine come through the lens of let's avoid bad outcomes that we don't acknowledge that the lack of doing something by restricting a person's movement can actually lead to adverse outcomes down the road, right? Because yes, they're not saying we did X activity and caused X outcome, but the removal of activity, now what we know in all of our accumulated literature on the effect of deconditioning on trajectory of aging, clinical geriatric syndromes, and post-operative deconditioning that can lead to changes in independence, that deconditioning also needs to be acknowledged in our algorithm of what we are thinking when it comes to our post-operative guidelines. And so what we are acknowledging first is that one, we have evidence that does not support restrictive guidelines in many different examples, right, our arthritis literature, not sitting in bed post cardiac surgery, our lifting restrictions post pelvic surgery, we now have a variety of different areas across different organ systems, musculoskeletal surgery, cardiovascular surgery, urogyne surgeries where we are acknowledging that our restrictions are overly restrictive and that that restriction does not create better outcomes. The step forward that I want to make is that not only are they not leading to better outcomes, but that subsequent deconditioning by overly restricting a person is an adverse outcome in itself in the opposite direction. And what this is highlighting is that we have a big knowledge translation gap problem. We acknowledge in many areas of medicine that this exists, but this is front of center for our allied health clinicians around what we are allowing in our practice or what we are acknowledging in our practice. And so you're gonna say Christina, okay, where are these restrictions coming from and why as a clinician am I hesitant to push back on these guidelines despite the fact that I know that these are not evidence-informed, right? So because there's a hesitancy on the side of the clinician and We want to acknowledge those. Those are the elephants in the room, right? So the first thing is around the fear of an adverse outcome, right? When we don't do anything, we don't have that same feeling of responsibility if something was to go wrong, right? Because I didn't push them. So it wasn't me that caused that adverse outcome, right? And we can't always avoid adverse outcomes, but what we do a lot at MMOA is we try and flip the script of, you know, we think about the harm of loading people, but what's the harm if we don't load them? And that's a slower churn, a slower burn, but it's important to acknowledge that that's relevant too, right? So that fear. But the fear also comes from going against the surgeon and liability and referrals. And so I want to acknowledge that piece and I want to acknowledge it on a couple of different stances. Number one is that our messaging is never to, you know, speak negatively to the surgeon and speak about the person. We speak about the concept. And so the way that if I'm trying to remove restrictions that have been placed on somebody or deviate from a protocol, which I tend to do a lot, when the surgeon has outlined this, I will say where your surgeon was looking at was this is their scope. They're looking for lumps, bumps, infection, early complications. Where my lens is here. based on their assessment of you two weeks ago, they may have felt X from where I am assessing you today. Here's where I think our steps are going forward. So it is not bashing the surgeon. It is not going against the surgeon. It is using my scope as a doctorate level clinician to be able to make further recommendations going forward. And as a newbie clinician, the thought of going against the protocol set out by the surgeon used to terrify me, right? I'm a rule follower and our medical system has placed medicine at the top, which, you know, they have the brunt of the liability. I understand where that is coming from. But as I get into my research degree or when I get into my research career and I acknowledge the level of the evidence when I see the outcomes that are so much better when I ditch these protocols and load people more aggressively earlier and I recognize that a surgeon has never never actually rehabbed a person after their surgeries, it changes my mind, right? I would never go up to the surgeon and say, you know, you are going to go with that anterolateral approach for that hip replacement. I really think you should take a posterior approach. It would be better. Because that's not my scope of practice, right? That's not what I do. That is not where my skill set is. So why are we so shackled by a surgeon telling us what our job is, who has never, never rehabbed a person after their surgery, has not actually seen them for more than 15 minutes in an appointment after their surgery. And so I I would never take continuing education from a PT who has never treated the condition that they are teaching about, right? Like you would never go to see me and teach in geriatrics if I have never rehabbed a person who is over the age of 65. So why is our system created in a way where we are taking rehab advice from someone who has never done rehab, whose medical degree does not actually have an exercise prescription component in a lot of cases. And so that acknowledgement has really shifted my perspective on this is maybe foundational work that they are giving and they are catering also to the lowest common denominator, right? Like when I am working with a person and they are trying to give a blanket statement guideline that has exercises on it, they have to cater to the person with the most amount of deconditioning in order to believe that this protocol is safe for everyone. And we acknowledge as clinicians that that blanket statement never ever works, including blanket protocols, because our people come in with a variety of different chronic diseases, comorbidities, positions, supports, biopsychosocial considerations, motivations and drives, and musculoskeletal reserve around that postoperative joint. And so what we have to acknowledge is the flaws in the system, but I'm not saying that as a bad thing, I'm saying that as this is where I come in. High five me in, this is my job, and I need to advocate for my profession in making an opinion on this, right? And this is where we need to lock shields with medicine and surgery, not blast each other with swords and acknowledge where our scope is and where their scope is. The final thing is around liability, right? And I think the post-operative guidelines around joint replacement are a really good example of where the liability, we have to be acknowledging liability, but we also want to make sure that we are thinking on the other side of the equation, where when we are working with individuals post-operatively, we are worried about post-operative dislocations. And what we see is that those with low musculoskeletal reserve going into surgery and have a fall in the early postoperative window are the ones who are more likely to dislocate or those that have a size fit issue or get a deep infection in the early postoperative window. So what we are doing by deconditioning is we are impacting one of those risk factors in a positive way. If we are creating more deconditioning, if we are lacking reserve around that joint and we are not supervising them, potentially in the early post-operative window, that is where we can have liability on creating an adverse outcome. But we don't have any evidence around pushing individuals too far from an exercise perspective early on, creating adverse outcomes. Now, if that was to change, sure, we're gonna change our strategy, but we want to really be thinking about this from a clinical and critical lens, because it's really important that we acknowledge these things. So, What do I think we actually need to think about with our post-operative guidelines? Or what do I think we are missing with our post-operative guidelines? I feel like we are missing our confounding variables that are going to dictate how quickly we're going to be able to progress individuals. So what do I mean by that? We acknowledge as clinicians, because we do this all the time in our assessments, that there is going to be different things in a person's background that is going to allow us to be more aggressive in rehab or is going to cause us to take a slower approach. Those are not acknowledged in our postoperative guidelines right now. So what are some of those things? One is our level of frailty, burden of clinical geriatric syndromes or complex comorbidities. Secondary is musculoskeletal reserve going into surgery or the amount of deconditioning we are able to stave off with early postoperative mobility. And so what we are acknowledging or what we want to acknowledge is that some individuals, we obviously have that early protective phase around a graft. I'm not saying that we're just going to blast that out of the water, but we know that after two weeks, most of our collagen synthesis is there and now it's remodeling in order to get stronger. And that remodeling requires load. But then we create a brace around an individual for six weeks where we're actually not creating a lot of loading through that joint or we're not actually having pulsing forces from our muscles that are acting and contracting to start creating tensile forces in order for our collagen fibers that are coming down or our healing fibers that are needing that load in order to get stronger. And there's a huge amount of variability in our in vivo studies around the strength of collagen resynthesis and that range is probably related to musculoskeletal reserve. And so, one, we need to acknowledge that yes, we have that early protective phase, but their amount of reserve going into their surgery is going to be a predictive factor of how aggressive we can potentially be post-operatively. Their complexities with respect to comorbidity are going to incur a higher or lower inflammatory load that is going to dictate how fast we're gonna be able to progress exercises, right? When we really step back from all of our comorbidities, a lot of them are related to inflammatory cascades, depending on the organ system that is impacted by the disease. And so when we have individuals with a high comorbidity burden, they are gonna have a higher inflammatory load, and that higher inflammatory load is going to impact how fast we're gonna be able to get individuals working, but on the flip side of that, exercise is anti-inflammatory. but it's going to slow down our progressions. So all of this to say is that one, we need to be confident in our assessment skills that includes early postoperative management. We need to acknowledge that our role is one of critical thinking that allows us to take information medically from the surgeon and some of their early protective phase issues, and then be able to progress them as we see fit, because we're the ones who are seeing individuals that are progressing and we are responsible as well for their wellbeing and their capacity to return to activities of daily living. And that baseline musculoskeletal reserve going into surgery is going to be a big confounding variable or a big protective variable in order to think about their postoperative reserve. And so where I see our postoperative guidelines hopefully going in the next several years is one, blanket statements are gonna go out the window, right? We are going to remove these lifting restrictions. We are gonna give individuals buoys, okay? We're gonna say, hey, you just had surgery on X joint. This is what I want you to think about. I want you to be thinking about gradually returning to movement within your comfort zone, and I want you to look for X, Y, Z. And if you are experiencing X, Y, Z, that is your body telling you that you've probably pushed it a little bit too far today, okay? You're not hurt. sore is safe, but it's your body telling you that you just had surgery and we need to stay within these buoys and those buoys are going to change. And as you get further from surgery, you're going to be able to experience more and more of life and you're going to be able to come back to more and more things and that is going to be okay. And we're going to be able to guide you along that process. In rehab, what we tend to do is think about things very linearly, where we say, okay, we're going to do range of motion passively, range of motion actively, maybe in combination with some isometrics, and then we're going to load through range. I think that's a huge mistake. And you guys can give me your thoughts on this. I feel like, you know, Ice talks a lot about and not or, that we need to be strengthening through the range that individuals have in that moment. And then as they gain more range, we're gonna continue giving them strength in the upper ranges that they are now gaining, right? I think waiting to exercise through range or strengthen through range actually deconditions the joint more, and it ends up being a huge issue. We see this all the time in rotator cuff post-op management, right? There's a protective phase that now, thankfully, a lot of the surgeons in my area are not prescribing to, thankfully. And then we go range of motion first, and then we go strengthening through range, and then getting that strength in those upper ranges, especially over 90 degrees, is a bear in rehab. And where I have seen a shift in my practice, and I've seen better outcomes anecdotally from it, is that I am strengthening through range and with weight bearing earlier, and they're gaining their strength back a lot faster. And so I think this and not or approach to orthopedic post-operative rehab is going to be important. Now, I acknowledge that I'm in an outpatient setting and I'm going to be seeing people who probably have a little bit more musculoskeletal reserve going into surgery than others who are in skilled nursing facilities, et cetera. But that means that your deconditioning effect is going to be that much more detrimental, right? When I have a person who doesn't have a lot of reserve going into surgery and then I see that dip postoperatively, that is going to be very, very impactful for them versus my person who has more reserve going in. And so it makes me not change my stance, but actually be more diligent about my loading principles in that early postoperative period because that deconditioned individual cannot handle more deconditioning. And we see this all the time, right? It's why our hip fracture research is so poor. You know, we have those statistics that if you break your hip and you need a, or if that your 50%, 50% of people who have that surgery end up in a nursing home or don't end up making it over a year or whatever that may be. And that's likely because they have a period of deconditioning on a deconditioned person that creates a lack of reserve around that joint. And then they aren't able to come back from it. So our role in rehab becomes even more urgent where we need to prevent that from happening, right? We, we can't wait. on a lot of those things. Obviously weight-bearing status is going to be one of the things we have to be mindful of, but being able to strengthen a joint around non-weight-bearing status in order to try and reserve as much capacity around the hip and pelvic musculature as we can is going to be really, really important. So I hope all of that made sense, right? We have this gap and I want us to have so much strength in our convictions around how important it is for us to push back against these guidelines. Yes, it's scary, right? We don't like pushing back against medicine because sometimes I think we are not as confident as we should be in our doctoral level education and our evidence is on our side. And so we don't have to be jerks about it, but we have to acknowledge that our outcomes could be so much better. And I want to let you center in on the fact that you are the expert here. The surgeon is the expert in the actual surgery. You are the expert in managing them after. That handoff should be seamless. And it is important for us to advocate. And until we advocate and have respectful conversations that, yes, are scary, yes, your heart rate is going to be up, yes, you're going to feel like you have that adrenaline going through your system, but have the evidence in your back pocket Acknowledge your scope of practice and your skill set and make sure you are there to best serve your older adults. All right, that is my rant for today. If you were trying to see us live in person over the summer, Julie is in Virginia Beach, July 13th, 14th, so this upcoming weekend. Jeff Musgrave is up in Victor, New York, July 20th and 21st. And the entire crew is up for MMA Summit in Littleton, Colorado, July 27th and 28th. So if you were looking to see us on the road in the month of July, you have a couple of opportunities. If you're hoping to get into our online courses, our next MMOA level one starts August 14th. We are just finishing up our last cohort and we have a bit of a break for the summer. And then our advanced concepts level two course is starting October 17th. So I hope you all, I want to know your thoughts around this. Am I going crazy? Am I on the same boat or same page as you all? And what can we do collectively to make this a little bit better? All right, have a wonderful week everyone and we will talk to you all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses details that can be easily missed when treating out tendinopathy! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Good morning, PT on ICE. My name is Cody Gingerich. I'm one of the lead faculty in our extremity division. And I'm coming on here today to talk about the hidden details of tendinopathies. Um, so in our extremity management course, we cover tendinopathy. We have an entire lecture on day two, as detailed as we can on tendinopathies. But what we know is tendinopathies in general are incredibly difficult to treat. Um, they last a long time. There are a lot, a lot of different variables that you have to constantly be playing with in order to really treat these people out and get them all the way back better and feeling good. And sometimes in an hour, hour and a half long lecture, we still can't cover everything that we, uh, possibly know about tendinopathies. And so I want to cover some today, just some of the hidden details of tendinopathies, things to look out for, and just a couple like additional clinical pearls, um, that may help you next time you're working with someone that has some tendinopathy going on. And there's a couple of different areas that I want to specifically address, and that's going to be more so like elbow tendinopathy. So think medial lateral epicondylalgia or tendinopathy in general. Um, and then patellar tendinopathy as well. Those just tend to be some areas that are pretty common. And so the first thing that I want to really emphasize with tendinopathy is looking at why the additional stress is happening to that tendon. So what we know about tendinopathy up front is that it is a chronic overuse injury, right? It could be acute, but typically it's gonna be in a chronic situation. And that means that that tendon is not doing the capacity or the work that you are asking of it. Okay. If it is an acute situation, a lot of times that is just negligence on that human and saying like, let's say, you know, for an Achilles tendinopathy or a patellar tendinopathy, let's say, you know, they haven't played basketball in 10 years and they decided that over one weekend they wanted to play, you know, two days straight of basketball. And it's pretty reasonable in that situation to be like, well, yeah, your patellar tendon couldn't handle all of that jumping and running that you were doing all at once. And so it's reasonable to think that a tendinopathy could accrue. And that's not necessarily something where you have to really look at like, all right, well, why is this happening? That's just pretty clear on like, well, that person just, you know, blew past their acute to chronic workload ratio. But oftentimes that's not how these things pop up and it's over time and they are long lasting and they are lingering and things like that. And that's the point where we need to really look at, okay, we definitely know that that tenant is not able to keep up with what we're asking of it. But why is it doing so much work that it is getting overused, right? Is there a movement pattern that they are doing that is potentially faulty? Is there a weakness somewhere else that we need to address and that tendon and that those tissues are just taking up more of the slack for a weakness elsewhere? And that's really where I want to hone in today. Because the other thing that we know about tendinopathies is it's pretty much a bullseye when those people come into your clinic and they say, hey, I have pain right here, or they point right to their patellar tendon. That can very quickly tunnel vision us into saying, okay, cool, I need to do wrist extensions, we need to build up that tendon, we need to do isometrics, we need to do eccentrics, we need to do heavy, slow concentrics, we need to really go after that tendon. And that can just pigeonhole us at that spot because it is such a bullseye when those patients tell you, this is where it hurts. And you're like, cool, I know where that is. I know what's happening. We need to get that tendon stronger. And that is true. But there are also other factors involved as to why that thing got pissed off in the first place. So we have those isometrics to help pull pain down and we need to address the tissue that hurts. but additionally addressing why it's doing that, right? And so in the fitness space where there is a lot of like grip heavy things and we see tendinopathies at the elbow, what I see frequently, there's two real things that we need to look out for as far as like those hidden details. One of those is shoulder capacity. How much shoulder capacity do they have? And are they trying to make up their lack of shoulder capacity with hanging on for dear life onto the rig, onto a barbell, onto a dumbbell or whatever, because that is now where they feel like their power is coming from. And that is causing some overuse because their shoulder capacity is not at an ability to really handle all of the things they're doing. And so that leaks down the chain to the elbow, wrist or hand. The other thing that I see very commonly, specifically when dealing with medial elbow tendinopathy, is that a lot of times people with generally weaker grip tend to try and make their grip stronger by doing this like false grip. And that is what is taught and what is appropriate in weightlifting. If you're doing dead lifting, cleaning, snatching, we want knuckles down. And that puts us into a position like this. If we are hanging or doing gymnastics movements, we want knuckles over the bar like this. What that does is every then movement, they then grab a kettlebell for a farmer's carry. They're gonna hook grip it like this. What happens is they're always using this, rarely getting the actual capacity to the other side of their forearm and those gripping muscles. We know the strongest grip is going to be in a little bit of wrist extension as well. And so then we can start pulling out like, well, in your workouts or in your day-to-day life when you're gripping things, I want you to actually start to pay attention to some of your traditional grip and let's see if we can't utilize some of our wrist extensors a little more when you're going to grab a door, when you're going to pick up things like hey let's get our knuckles back a little bit and now all of a sudden instead of just consistently trying to like hammer this tendon and get it stronger, we got to get it stronger, it's like well Yes, we can get it stronger, but we can also help to pull some of that tension and some of that irritation and overall use back to help it calm down. And that's the big thing is like tendinopathy, we want to improve the capacity because that's what overall needs to happen. But if we can improve the capacity while also taking away some of the work that that tendon overall has to do, now we're going both directions at the same time and pushing them forward faster. Right? And so that then leads to like, we're asking less of the tendon and it's getting stronger at the same time. So then that tendon can start that healing process a little bit faster. Okay. A similar thing can happen at the knee. where we have patellar teninopathy. But if you watch that person move, and they are trying to squat, and they are trying to push press, or power clean, or things like that, and they have a bit of a muted hip, where they are not using their hips effectively, and most of that work ends up coming through the quads, that's another situation where Yes, that patellar tendon needs some work and it can improve the overall capacity, but if you don't help that person and coach that person's overall movement pattern, they're going to consistently continue to aggravate that tendon. Whereas their hips should be the most powerful thing that is producing force, right? So get them into a little bit more of that posterior chain, get them using their glutes out of the bottom of the squat, get them using their hips when they're doing it in a power position, when they're doing push press. The examples are numerous where we want people to start using the hips and take away some of the stress from that patellar tendon while you are doing all of the additional isometrics, wall sits, Spanish squats, heavy slow concentric, cyclist squats. These are all great. But sometimes we also want to pull down some of the stress that those tendons are taking on and relearn some movement patterns that could be contributing to this longstanding tendinopathy. Sometimes that might mean adjusting their squat stance a little bit or their deadlift stance, just getting them used to using their hips a little bit more effectively while you're treating out that tendinopathy. So that's going to be one of the really big ways is like, don't get tunnel vision on. We need to strengthen, strengthen, strengthen, strengthen, and don't look elsewhere. Because a lot of times with these chronic tendinopathies, there is a reason there is a weakness in the chain somewhere. There is a weakness in movement pattern where that is causing the overuse of that tendon to happen. So simultaneously, while you're trying to decrease pain at that tendon via some strength training, some isometrics, building that tendon capacity, we also want to be working and trying to figure out, well, what is the underlying cause of why we're overusing this tendon in the first place? So I really want to emphasize that today. The other factor that sometimes gets overlooked in tendinopathy is going to be compression and speed of the tendon and what it is doing and in what space is it operating. So every tendon is going to pass by a bony prominence. That is where the bony attachment is going to be. And anytime we are working through tendinopathies, we want to appreciate that compression that happens in whatever exercise you choose to do. So if we're talking about a patellar tendinopathy, the deeper that person gets into their squat position, the more compression that patellar tendon is going to go under. Same thing when we are doing, if we were doing elbow or wrist exercises, the more that we stretch that tendon, if we straighten our arm, that will, and then extend or flex our wrist, that will put that tendon over more compression around your epicondyles. And that exists for pretty much every tendon in the body. And so Being able to navigate that variable and pull some of those different exercises out or changing exercises, it's not always necessarily that the exercise is wrong, but maybe the range of motion can be adjusted because that tendon can't tolerate the current compression that it is under. Okay. Finally, the speed. The speed is where tendons really hit kind of a fork in the road on what can it tolerate. So we like to live up front with isometrics, concentrics, heavy, slow building blocks of the tendon, but ultimately most tendons get aggravated under speed. So if you think you're runners and you're jumpers and you're throwers If you're crossfitters, where they're pulling a lot under speed on the bar, that's usually where those tendinopathies occur. Quick wrist movements, all of those type of things. And that ends up becoming the aggravating thing. So if we don't end up building in more speed, we aren't going to end up being able to get them all the way through their plan of care. And so that can start with using a metronome, right? So you can track how is this tendon tolerating speed. So you go a 60 beats per minute on whatever exercise you're trying to do. Then you go to 70 beats per minute or 80 or you start, you know, that's where you can very easily track and then you can start getting back into their actual functional movement with speed and knowing that it can tolerate certain levels of that speed. So overall, I saw a question here, stretching the tendon equals compression. Essentially, yes. That is a good way to think about it. If you are stretching the tendon, you are pretty much adding compression around those bony prominences most times. That's gonna be a pretty accurate statement for most of those tendons. Wrapping it around whatever bony prominence is adding compression, and most of the time that's gonna be if you're stretching it. And that becomes typically a more aggravating position for most tendons. SUMMARY So overall, the three really main things that I want to point out as far as additional details to tendinopathies that you don't want to forget about when you're treating tendinopathies. The first one is why specifically is that tendon getting irritated and getting overused in the first point? That is oftentimes going to be a weakness up the chain somewhere or potentially a movement pattern fault that you want to coach out. You want to look at, get your eyes on how they're moving and can we decrease stressors and get change some of that movement pattern while we are treating out the tendinopathy. Number two is going to be really paying attention to the compression around that tendon. Can we change or adjust range of motion of that exercise to help improve some of that compression or potentially add compression if they can tolerate it? finally is going to be speed. If you need to really truly know we are building them out through that full plan of care, getting them back to functional sport activity, you have to get them into speed. And I would track that with a metronome or something like that. So, you know, for a fact that that tendon is able to tolerate more speed, that's going to be more likely to reflect the activity that they are doing. Okay, that's all I've got for you today. Just wanted to touch on a couple different points of tendinopathy. As far as catching extremity management on the road, we've got a couple courses coming up later this month. So we have a course this coming week, looks pretty full out in Kent, Washington. Next weekend, we are in Henderson, Tennessee, couple seats open there. And then in July 27th, 28th, Bend, Oregon. So pretty much all across the country, we've got courses coming to you. from the extremity management. Would love to see you out on the road. Thanks for watching. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses uphill & downhill running, the differences between flat running, and how to progress into vertical running with patients & athletes. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONAll right. Welcome everyone. Happy Friday. Welcome to another episode of PT on ice daily show. Uh, hope everyone had a wonderful 4th of July holiday and have a great weekend ahead. My name is Jason Lunden. I am the lead for the endurance athlete division. Uh, so teach rehabilitation injured runner live and online as well as a professional bike fitting course. And what I'm going to cover today is. what vertical adds to the equation. So talking about uphill and downhill running, both hills and in the mountains, and what the differences are compared to level running, why that matters, and then how to safely progress that training for yourselves and your patients. So uphill and so Adding vertical to one's training obviously means adding some uphill and downhill running, and those are obviously different than running on level ground. So uphill running is characterized by a lot more mechanical work, meaning there's a huge increase in the load on the muscles, as well as changing the biomechanics of running so that one is landing in more of a flexed position at the hip and the knee as well as more dorsiflexion at the ankle and that the amount of hip flexion, knee flexion, and ankle dorsiflexion is much higher in uphill running than level running and or certainly downhill running as well. Stance times are longer, the amount of time in flight is lessened, and impacts are overall less. As far as contrasting that with downhill running, downhill running is characterized by landing with a lot more, the knee in a lot more extension, a lot less hip flexion. And then depending on the experience of the runner for running downhill, If it's more of a novice runner, they're going to be characterized by striking with a rear foot strike pattern or heel strike pattern. If it's a more experienced downhill runner or trail runner, it's going to be characterized by more of a mid-foot strike pattern. Here, downhill running is basically characterized by negative work, so it's all eccentric work. So a lot of more impact to the runner and a lot less load specifically on the muscles, just more of an eccentric load. And so why does this matter? So, you know, thinking about your patients that you might be working with, if you have someone with a high hamstring tendinopathy, that's likely going to be loaded a lot more and potentially irritated more. with uphill running, right? Because that hip is going to be in more flexion. There's going to be more muscle work, particularly on the posterior chain with that uphill running. And that repeated high hip flexion angle is going to also cause some compression at that hamstring insertion. Whereas if someone is dealing with patel femoral pain or maybe medial tibial stress syndrome, Downhill running is going to really increase the stress on those areas with that increased impact and eccentric load and definitely irritate those symptoms. And so you want to be thoughtful when prescribing or getting those runners back into dealing with a vertical that, you know, if it's a high hamstring tendinopathy, you may want that runner to be hiking the uphills and then running the downhills. And then conversely, if it's someone with patel femoral pain, you'll want them to be running the uphills and hiking or walking the downhills. And in addition, If someone is running, whether it be on the road or on the trail, and they have a race that has a vertical profile with some elevation gain and loss, you definitely want them to be implementing hill workouts or running in varied terrain. early on in their training so that they have the time to adapt to those new loads on the muscles and on the joints, as well as, you know, adapt their running mechanics appropriately too. So typically, you know, if it's someone who's new to trail running and, you know, they're going to be running their first trail race and there's, you know, 5,000 vertical elevation gain and loss, they're going to be wanting to implement that training far out in their training. So months ahead of time, again, because of the differences in the mechanics and the loads on the muscles with uphill and downhill running. As far as ways to, you know, implement this safely, there really isn't any scientific evidence on this. It's mainly anecdotal, you know, a lot of kind of looking at a lot of the advice that coaches will give is really based on the 10% rule or the literature that we have on progressing training volume in running. So, you know, no more than 10% increase in vertical per week or certainly no more than 15% over the course of two weeks is a common piece of advice that you'll hear. So what does that look like? You know, if someone is running 10,000, or sorry, 1,000, vertical in the first week, uh, you wouldn't want to increase by more than another, um, a hundred the following week, if you're doing that 10% rule. And that's going to be really more for your novice runners. Um, and generally for your, your novice trail runners or novice runners that are, or novice runners running hills, um, it's going to be looking like, you know, probably being able to add a thousand feet of vertical. in their first week and then progressing from there with that 10% per week or no more than 15% for two weeks. If it's a more experienced trail runner that you're working with who has had a lot of experience of doing a lot of vertical, start at approximately 50% of what their vertical was prior to dealing with their injury. And then the last thing to consider is, okay, so we're talking about vertical, but how are we progressing that in the space of also progressing just running volume as well as intensity? And so a good rule of thumb here is to not, ideally, the safest way is to not progress all three of those elements in the same week, but realistically that's probably going to have to happen. And so the best place to start out is not increasing all of them combined by more than 15% per week. So what that would look like is, you know, I am running, you know, 50 miles a week. I'm doing a thousand foot of vertical a week. And then also within that week, probably, you know, adding in a speed workout as well. And so for the next week, I would want to not increase my weekly volume by more than 10%. So we keep that at, you know, 10% and then not increasing the combined vertical and amount of intensity work by more than 5%. So that would get us our 15% total there. So again, just to recap, you know, adding vertical or dealing with vertical with endurance athletes, uh, is going to be very common. Um, especially if, for those of you living in more mountainous regions, um, where trail racing is, is King. Um, but even for your, your road racers too, if they're going to be running a race with, you know, a vertical profile, so not Chicago marathon, but, um, you know, maybe Boston marathon. where there are some hills, you really need to be thoughtful of how to, one, implement that training, as well as how to progress that training, and how running uphill is going to stress their body differently. how it's going to change your mechanics. So again, uphill running is going to be a lot more load concentric on the muscles, especially on the Achilles, the glute, the hamstrings. And it's going to be characterized by a lot more, a much deeper angle of flexion at the hip, knee and ankle. Whereas downhill running is going to be characterized by a much larger eccentric load with potentially being at a rear foot strike versus a mid foot strike and adding a lot of impact. To progress that, we want to kind of draw on the information and experience we have from both coaching and the literature, which is going to be drawing on just level running. So not increasing vertical by more than 10% per week, or not increasing vertical volume and intensity for a sum of more than 15% per week. And wanting to implement this early on in their training so they have time to adapt to the stresses of training. I'll leave you with just one really cool article that came out more recently, which was looking at downhill running and adaptation to that. And really as little as one bout of 30 minutes of downhill running on a 20% grade results in what they call the bout effect, or it's really a protective effect on eccentric muscle damage and delayed onset muscle soreness. So after that one bout, the next time the runner runs downhill, they're going to have less eccentric muscle damage and therefore less delayed onset muscle soreness. So that's pretty cool. So definitely wanting to implement that downhill running as soon as you can into their training so they start getting those adaptive effects. SUMMARY All right. Well, thank you everyone for listening. We do have some endurance athlete courses coming up. of coming up right around the corner on July 8th is when our next cohort of rehabilitation injured runner online starts. So that is the last one for the summer. So we'd love to see you online for that. Our next professional bike fitting course is going to be in Denver at the end of July. And then our next rehabilitation injured runner live is going to be in Sparks Glencoe, Maryland. in September. So we'd love to see you at those courses. Reach out if you have any questions. Have a great weekend. Get outside. Do something fun. See y'all. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. April Dominick // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick shares how YOU can make a huge impact on the quality of life of a client with an upcoming prostatectomy simply through education on pelvic floor muscle retraining, lifestyle changes and physical activity AND learn the ESSENTIAL clinical pearls to include in a pre-operative physical therapy session when working with this population. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION APRIL DOMINICK This is Dr. April Dominick. I am on faculty with the ICE Pelvic Division. Today we are chatting about prehab for a prostatectomy surgery. Why is prehab important and what should be included in your PT session with that pre prostatectomy client? This topic, it is so near and dear to my heart. it's because these humans just don't have the treatment or education that they deserve prior to going into these surgeries and afterwards when they come out. And if I can convince you why it is so important to be able to connect with these humans and to even just educate them on, hey, there is Help for you. There's pelvic floor muscle training that can be done education about behaviors whether that is you actually doing the PT session or you referring them to someone else it can have incredible outcomes for them post-op just because they are aware of pelvic floor physical therapy for their surgery the prostatectomy so Let's dive into what a prostatectomy surgery actually is. It is something to treat prostate cancer, and that's going to be by removing part or the full gland of the prostate. They're also going to remove surrounding tissues and seminal vesicles. The gold standard for surgery is a radical prostatectomy where they remove the entire prostate gland. I didn't have a walnut, so here's what we're working with. This fig represents the prostate. So let's run through some real estate of where everything is situated in someone with a prostate in terms of the pelvic floor and the organs. So we have our bladder here and then we have the bladder neck with the urethra that goes through our prostate. and this is going to be representative of the urethra itself. So the urethra goes from the bladder neck through this fig or the prostate and then down into the penis and that is how everything is set up. With a prostatectomy, after the prostate is removed, that extra support around the urethra is now lost, and the remaining bit of that urethra now needs to be reconnected back to the bladder. This reconnection, we can think about it like a bridge, or a fancy term is the anastomosis, and that anastomosis needs time to heal. So a Foley catheter is placed in for about five to ten days. That means that the bladder is or the urine is emptying passively. The bladder is not doing its job. It's off on vacation. And then once the catheter is removed, the bladder acts like it forgot how to start or how to store urine. It doesn't know what to do with it. And so we have a lot of urinary leakage. So among other things, this is why urinary incontinence or urinary leakage is a major side effect with these prostatectomy surgeries. post-op, the external urethral sphincter is relied on for maintaining continence. So good news for us, the pelvic floor muscles help to close that sphincter and keep pee in until it's appropriate to release it. And that's why pelvic floor muscle training with physical therapy can be so important pre-op and post-op, at least from the bladder side of things. So who does the prostatectomy surgery affect? Well, obviously those diagnosed with prostate cancer. It is the second leading cause of death from cancer in males. It's going to affect our individuals who are older than 50 years old and who are African-American. So if you think about who you are treating currently, if you're treating individuals who have prostates who are older than 50, one in eight of them are probably gonna have some run-in with prostate cancer, whether that's treated with a surgery or not. That's where you come in. You could have such a profound effect with these individuals just by educating them that pelvic floor muscle training exists And whether you're again, whether you're doing the treatment or you're referring out to someone else, you can have such an incredible impact on their post-op outcomes potentially. So, We talked about with a post-prostatectomy, we talked about that surgery can result in urinary incontinence or leakage. It can also affect sexual function. There can be reduced physical function. Think about it. If you're leaking all the time, is that really going to convince or motivate you to go work out? For some, no. And then it'll also affect the overall health-related quality of life. Take 65 year old Phil. You've got a Phil in your clinic. You're already treating him for low back pain, um, with his hikes and his weightlifting, say. And he went in for his annual physical, and then he walked out with a date for a surgery for radical prostatectomy. Besides being in shock that he now has this potentially life threatening diagnosis, Phil comes in and is like, this happened. He's like, am I, am I ever going to be able to hike with my hiking group and not be the person that smells like pee? Am I going to be able to be cool with being in the changing room in the, in the locker room after my weightlifting session, like removing this soggy pair of underwear, or am I going to be able to enjoy sexy times with his partner? Well, since you're here and you intently are listening to this podcast, You, your first line of question is, hey, Phil, did they recommend any sort of physical therapy for you? Um, whether it's pre-op or post-op. And of course, Phil's like, no. So you teach him that pelvic floor muscle training can be so effective and helpful, um, and play a huge role in those side effects that he's worried about. Y'all, what if we could have an incredibly bigger impact, building the foundation, setting the stage for what to expect post-surgery, just with PT sessions? Clinically, I've been treating this population, hopefully you can hear my passion behind it, for about seven years. I've interacted with so many fills that come in, if they even get to me, right? and they are just slapped with that surgery date, and the side effects are kind of breezed through during their appointment, it seems like. And their concerns aren't really heard, their well-being and their questions, they're just kind of like not given a lot of attention. I didn't always do pre-op sessions, but once I started, hoo-wee, I was just blown away by how different the clinical outcomes were in terms of improving, whether that was decreasing the volume of urinary leakage for some or having them return back to their ADLs exercise a little bit sooner. The biggest thing, which was so powerful for me, is these people came in extremely uncertain, having no idea even why, if their doctor did send them to PT, why they were there. And they were just uncertain about these really scary side effects, about how maybe for the first time they were going to experience some sort of losing control of their bodies, from peeing unexpectedly to changes in their erections. And they walked out of that first session feeling a little more confident, a little more certain. And that is the power, I believe, of these pre-op sessions. And then from a research side of things, what's shaking out in the few RCTs that we have for these pre-op sessions and their effects on prostatectomy, some may be helpful in improving quality of life. they may affect a shorter hospital stay. They may reduce post-op urinary leakage in the short term. So some studies find around month one, three, or six, that the individual is leaking less, meaning they're drier faster. Now, when you compare someone who had some pre-op PT to someone who did not around 12 months, they are about the same with their rate. But I would argue that I bet folks are going to be a lot more satisfied if they did that prehab and they are drier sooner, right? So let's go into what a prostatectomy PT session entails before that surgery. We've got these sessions already in place. for folks who are going in for surgery for their ACL repair, for their hip replacement. But just like we're fighting with our pregnant and postpartum population, we are somehow having to fight for someone to have a pre-obsession for something like a prostatectomy, and that impacts so many daily functions. Let's outline what is involved in that pre-op PT session. Again, you can educate someone on what to expect if you're referring them to someone to do this. So we'll go over subjective, objective, and the treatment. From an assessment side of things, from that subjective piece, what you can be talking to your patient about is what are their current bladder and sexual habits? How many voids do they have during the day? How many times do they go pee? Do they have an urge? Do they have urinary leakage or hesitancy? And there are some outcome measures that go over these things. The International Prostate Symptom Score goes over those things. Plus they ask about nocturia or nighttime urination. And then the NIH Chronic Prostatitis Symptom Index is another outcome measure. And I love it because it asks about the impact of these symptoms. How is it affecting your quality of life? Then you want to also ask about their sexual function. How would they rate their erection strength or their satisfaction with their sexual life? From an outcome measure standpoint, you can give them the International Index of Erectile Function. This is something that asks them to rate qualities of their erection from the past four weeks. Then you want to also get a good idea of their current physical activity regimen. What a wonderful time to, if they're already a little physically inactive, hey, let's like plug in for, here's why it would be really great if you could up that physical activity. Not just for that immediate post-op surgical outcome, but also, hey, we can lower all cause mortality. And then from an objective side of things, so we went over the subjective, objectively speaking, we want to get a pelvic assessment. Whether that is over the clothes, external, near that midline, or it is a visual or tactile palpation, or an internal rectal assessment, if that's what you're trained in. So we're looking for, what's their awareness? Do they even know that they have this group of muscles that they can control? called the pelvic floor. We want to be looking at their coordination, timing of the pelvic floor, and then also getting an idea of what is their breathing and bracing strategies for things that increase interabdominal pressure, like fitness activities or functional lifting of the groceries, coughing, running, weightlifting. Typically, this population tends to be a breath holder. So we're gonna spend some time, there's just so much that we can do to help them in this area, to help them have improvements in their methods with that. And then we also wanna be doing some sort of general orthoscreen because what if their hips are cranky? Obviously that's gonna affect pelvic floor, low back, and all those surgical outcomes. From a treatment side of things, so we went over subjective, objective, highlights from the treatment side of things. where we'll talk about education, what to expect post-op, and some homework for them to work on. Education. I cannot stress this enough. The education piece here is vital for affecting their outcomes and well-being. Let's educate them on the pelvic floor. Here's what it is. Here's the anatomy and physiology. Here's how it affects your penis. whether that's for sexual health or for the urethra for urination. Here is what happens during the surgery. Get to know the surgeons in your area and which methods they use. What are their outcomes, right? And then you want to be explaining the risk factors for these side effects like urinary leakage and sexual function. dysfunction. Non-modifiable factors. If you're older, it's not going to help you as much. And if you already have some reductions in urinary function, like you're already leaking, that is not going to help you on the backside. Modifiable factors, tons. So things like smoking, poor nutrition, That is gonna delay healing post-op. Can we identify some current bladder irritants and reduce those immediately post-op? What about poor mental health? Things like low self-efficacy or if they're experiencing anxiety or depression, helping them ID these things and finding them some psychosocial support to have upcoming for the surgery and post-op, so key. and then reduced physical activity. Hard health is heart health. What do I mean by that? Erections, ejaculation, is related to vascular health. Hard health is heart health. So what affects our vascular system? Aerobic and resistance training exercise. If we can have them and talk to them about how it's important and how increasing that physical activity is going to improve their physiologic resilience to the surgery itself and any complications that come up, that is gonna be having such a huge impact on their quality of life. Regarding physical activity, in a 2014 RCT by Mina et al, they found that men who were meeting physical activity guidelines prior to surgery had greater health-related quality of life at six and 26 weeks post-op compared to men who were not meeting those physical activity guidelines. So, from a post-op perspective, we want to tell them what to expect. Urinary incontinence and sexual dysfunction. From the urinary incontinence side of things, they will have a Foley catheter in for five to 10 days. Remember, the bladder doesn't work during this time. Once that catheter is removed, we gotta retrain that neural pathway to help control the bladder so that they know, oh, my bladder is filling, or this is how I'm gonna stop that leakage from coming out, and how to fully empty the bladder. Another huge tip, have them bring a hygiene product, whether that's a pad or a diaper or something, with them to the hospital so that when they are discharged, they have something to help protect them on their way home or on their way to the store to grab their meds. And then urinary incontinence could be present from a couple of months to a year post-op. We see a significant improvement in that three to six month range, but it could be affected by things like, hey, it gets worse at the end of the day because the pelvic floor muscles are tired, or with transitional movements like sitting to stand. So working on these movements with them is gonna be super helpful pre-op. And then maybe talking to them about how, if you're not going to see them for 10 days or so post-op, we may be using the pad weight or the number of pads in a 24-hour period as a marker for our progress. So just having that in the back of their mind. When it comes to what to expect from a sexual function standpoint post-op, it can take up to two years to recover to baseline function from an erection standpoint. We want to set these expectations from an ejaculation standpoint. Dry ejaculate is going to happen now because those seminal vesicles were removed, and that's what helps produce that ejaculate. There may be some changes in their orgasm sensation. Erections, it could be dependent on surgery outcomes. How much nerve sparing was there in that procedure? They have the potential to get better with this, especially with pelvic floor muscle training or things like pumps. And then loss of penile length. This is something that we want to let them know can happen so they don't get a little surprise. Homework wise, we want to address any of those pelvic floor deficits we found from that objective piece, especially that breathing and bracing strategy. We can do that with biofeedback, whether that's with a mirror, with a palpation from the therapist or from them, and just to really improve their awareness and coordination there. And then giving them cues that connect them to the pelvic floor. Evidence supports, hey, pelvic floor contractions with the following cues, like shortening the penis, though I've been told nobody wants to have that. So something like nuts to guts or stopping the flow of urine is great for that. One side of the range of motion, the contraction side of the range of motion of the pelvic floor, and then something for the relaxation side, like let the testicles or base of penis hang loose. I did an Instagram post recently, so you can check that out on the ICE or Revitalize Pelvic Physio page. And then we wanna be, for homework, modifying their poor lifestyle habits. Can we reduce those bladder irritants, process sugar? Can we increase your physical activity and mental health? And then finally, we want to be scheduling their followup visits on the calendar. So whether that's for pre-op, a couple more sessions, or as early as 10 days, once that catheter is removed, they can pop back in to your office. SUMMARY So, I hope you found that information helpful. We reviewed how prevalent prostate cancer is, especially for those who are 50 plus. We know that radical prostatectomy is the gold standard for treatment. Two major things that are affected post-op are urinary incontinence and erectile dysfunction. Pre-op PT sessions are fairly new, but we have some evidence that says, hey, those who partake in pre-op sessions are drier sooner than their counterparts. And then from a PT session standpoint, thinking about asking what their current bladder and sexual function is, asking them about physical activity, mental health, objectively getting a measurement of the pelvic area, and helping them connect with that area a little bit more. Treatment-wise, we want to really harp on that education. about what the pelvic floor is, how it can help with their function, and also what to expect, possible side effects, modifiable risk factors, and then giving them homework to work on those deficits, and then finally scheduling that additional follow-up before surgery and then getting their post-op session on the calendar. My next podcast, I'm going to go into detail on what a post-op session post prostatectomy looks like. So tune in for that. And then if you want to learn more about pelvic floor examination, join us live. We have our next two courses. One is July 20th, 21st in Cincinnati, Ohio. And then July 27th and 28th, we are gonna be in Laramie, Wyoming. If you're wanting more of a virtual option, we have our two different courses that are eight weeks, L1 and L2. And in L2, we go over the male pelvic health conditions as well. Thank y'all so much for tuning in from my prostate slash walnut. Happy Monday, and I'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.