Podcasts about clinical management

In a bold step to strengthen national emergency preparedness and gender-based violence (GBV) response, Saint Lucia hosted a pivotal two-day training workshop on May 26 and 27, 2025, at the Harbor Club in Rodney Bay. The Gender-Based Violence in Emergencies (GBViE) training brought together key representatives from government agencies, civil society, and healthcare institutions. The event was co-convened by UNFPA, UN Women, and the Government of Saint Lucia, in collaboration with the Caribbean Development Bank. The workshop aimed to build national capacity on Gender Equality, Social Inclusion, and Gender-Based Violence, particularly in the context of emergencies and climate-related disasters. A key milestone of the training was the official validation of Saint Lucia's Clinical Management of Rape Protocol signaling a significant improvement in coordinated survivor support services.

En este episodio, profundizamos en uno de los fenómenos más devastadores pero menos comprendidos en neurorrehabilitación: la denervación muscular tras una lesión medular. A través de una revisión exhaustiva de la literatura científica y de la experiencia clínica, abordamos qué ocurre realmente con los músculos que han perdido su inervación, cómo se transforman con el tiempo y qué posibilidades tenemos para intervenir. Hablamos sobre neurofisiología, degeneración axonal, fases de la denervación, y cómo la estimulación eléctrica —especialmente con pulsos largos— puede modificar el curso degenerativo incluso años después de la lesión. Exploramos también el Proyecto RISE, los protocolos clínicos actuales y las implicaciones terapéuticas reales de aplicar electroestimulación en músculos completamente denervados. Si trabajas en neurorrehabilitación o te interesa la ciencia aplicada a la recuperación funcional, este episodio es para ti. Referencias del episodio: 1. Alberty, M., Mayr, W., & Bersch, I. (2023). Electrical Stimulation for Preventing Skin Injuries in Denervated Gluteal Muscles-Promising Perspectives from a Case Series and Narrative Review. Diagnostics (Basel, Switzerland), 13(2), 219. https://doi.org/10.3390/diagnostics13020219 (https://pubmed.ncbi.nlm.nih.gov/36673029/). 2. Beauparlant, J., van den Brand, R., Barraud, Q., Friedli, L., Musienko, P., Dietz, V., & Courtine, G. (2013). Undirected compensatory plasticity contributes to neuronal dysfunction after severe spinal cord injury. Brain : a journal of neurology, 136(Pt 11), 3347–3361. https://doi.org/10.1093/brain/awt204 (https://pubmed.ncbi.nlm.nih.gov/24080153/). 3. Bersch, I., & Fridén, J. (2021). Electrical stimulation alters muscle morphological properties in denervated upper limb muscles. EBioMedicine, 74, 103737. https://doi.org/10.1016/j.ebiom.2021.103737 (https://pubmed.ncbi.nlm.nih.gov/34896792/). 4. Bersch, I., & Mayr, W. (2023). Electrical stimulation in lower motoneuron lesions, from scientific evidence to clinical practice: a successful transition. European journal of translational myology, 33(2), 11230. https://doi.org/10.4081/ejtm.2023.11230 (https://pmc.ncbi.nlm.nih.gov/articles/PMC10388603/). 5. Burnham, R., Martin, T., Stein, R., Bell, G., MacLean, I., & Steadward, R. (1997). Skeletal muscle fibre type transformation following spinal cord injury. Spinal cord, 35(2), 86–91. https://doi.org/10.1038/sj.sc.3100364 (Burnham, R., Martin, T., Stein, R., Bell, G., MacLean, I., & Steadward, R. (1997). Skeletal muscle fibre type transformation following spinal cord injury. Spinal cord, 35(2), 86–91. https://doi.org/10.1038/sj.sc.3100364). 6. Carlson B. M. (2014). The Biology of Long-Term Denervated Skeletal Muscle. European journal of translational myology, 24(1), 3293. https://doi.org/10.4081/ejtm.2014.3293 (https://pubmed.ncbi.nlm.nih.gov/26913125/). 7. Carraro, U., Boncompagni, S., Gobbo, V., Rossini, K., Zampieri, S., Mosole, S., Ravara, B., Nori, A., Stramare, R., Ambrosio, F., Piccione, F., Masiero, S., Vindigni, V., Gargiulo, P., Protasi, F., Kern, H., Pond, A., & Marcante, A. (2015). Persistent Muscle Fiber Regeneration in Long Term Denervation. Past, Present, Future. European journal of translational myology, 25(2), 4832. https://doi.org/10.4081/ejtm.2015.4832 (https://pubmed.ncbi.nlm.nih.gov/26913148/). 8. Chandrasekaran, S., Davis, J., Bersch, I., Goldberg, G., & Gorgey, A. S. (2020). Electrical stimulation and denervated muscles after spinal cord injury. Neural regeneration research, 15(8), 1397–1407. https://doi.org/10.4103/1673-5374.274326 (https://pubmed.ncbi.nlm.nih.gov/31997798/). 9. Ding, Y., Kastin, A. J., & Pan, W. (2005). Neural plasticity after spinal cord injury. Current pharmaceutical design, 11(11), 1441–1450. https://doi.org/10.2174/1381612053507855 (https://pmc.ncbi.nlm.nih.gov/articles/PMC3562709/). 10. Dolbow, D. R., Bersch, I., Gorgey, A. S., & Davis, G. M. (2024). The Clinical Management of Electrical Stimulation Therapies in the Rehabilitation of Individuals with Spinal Cord Injuries. Journal of clinical medicine, 13(10), 2995. https://doi.org/10.3390/jcm13102995 (https://pubmed.ncbi.nlm.nih.gov/38792536/). 11. Hofer, C., Mayr, W., Stöhr, H., Unger, E., & Kern, H. (2002). A stimulator for functional activation of denervated muscles. Artificial organs, 26(3), 276–279. https://doi.org/10.1046/j.1525-1594.2002.06951.x (https://pubmed.ncbi.nlm.nih.gov/11940032/). 12. Kern, H., Hofer, C., Mödlin, M., Forstner, C., Raschka-Högler, D., Mayr, W., & Stöhr, H. (2002). Denervated muscles in humans: limitations and problems of currently used functional electrical stimulation training protocols. Artificial organs, 26(3), 216–218. https://doi.org/10.1046/j.1525-1594.2002.06933.x (https://pubmed.ncbi.nlm.nih.gov/11940016/). 13. Kern, H., Salmons, S., Mayr, W., Rossini, K., & Carraro, U. (2005). Recovery of long-term denervated human muscles induced by electrical stimulation. Muscle & nerve, 31(1), 98–101. https://doi.org/10.1002/mus.20149 (https://pubmed.ncbi.nlm.nih.gov/15389722/). 14. Kern, H., Rossini, K., Carraro, U., Mayr, W., Vogelauer, M., Hoellwarth, U., & Hofer, C. (2005). Muscle biopsies show that FES of denervated muscles reverses human muscle degeneration from permanent spinal motoneuron lesion. Journal of rehabilitation research and development, 42(3 Suppl 1), 43–53. https://doi.org/10.1682/jrrd.2004.05.0061 (https://pubmed.ncbi.nlm.nih.gov/16195962/). 15. Kern, H., Carraro, U., Adami, N., Hofer, C., Loefler, S., Vogelauer, M., Mayr, W., Rupp, R., & Zampieri, S. (2010). One year of home-based daily FES in complete lower motor neuron paraplegia: recovery of tetanic contractility drives the structural improvements of denervated muscle. Neurological research, 32(1), 5–12. https://doi.org/10.1179/174313209X385644 (https://pubmed.ncbi.nlm.nih.gov/20092690/). 16. Kern, H., & Carraro, U. (2014). Home-Based Functional Electrical Stimulation for Long-Term Denervated Human Muscle: History, Basics, Results and Perspectives of the Vienna Rehabilitation Strategy. European journal of translational myology, 24(1), 3296. https://doi.org/10.4081/ejtm.2014.3296 (https://pmc.ncbi.nlm.nih.gov/articles/PMC4749003/). 17. Kern, H., Hofer, C., Loefler, S., Zampieri, S., Gargiulo, P., Baba, A., Marcante, A., Piccione, F., Pond, A., & Carraro, U. (2017). Atrophy, ultra-structural disorders, severe atrophy and degeneration of denervated human muscle in SCI and Aging. Implications for their recovery by Functional Electrical Stimulation, updated 2017. Neurological research, 39(7), 660–666. https://doi.org/10.1080/01616412.2017.1314906 (https://pubmed.ncbi.nlm.nih.gov/28403681/). 18. Kern, H., & Carraro, U. (2020). Home-Based Functional Electrical Stimulation of Human Permanent Denervated Muscles: A Narrative Review on Diagnostics, Managements, Results and Byproducts Revisited 2020. Diagnostics (Basel, Switzerland), 10(8), 529. https://doi.org/10.3390/diagnostics10080529 (https://pubmed.ncbi.nlm.nih.gov/32751308/). 19. Ko H. Y. (2018). Revisit Spinal Shock: Pattern of Reflex Evolution during Spinal Shock. Korean journal of neurotrauma, 14(2), 47–54. https://doi.org/10.13004/kjnt.2018.14.2.47 (https://pubmed.ncbi.nlm.nih.gov/30402418/). 20. Mittal, P., Gupta, R., Mittal, A., & Mittal, K. (2016). MRI findings in a case of spinal cord Wallerian degeneration following trauma. Neurosciences (Riyadh, Saudi Arabia), 21(4), 372–373. https://doi.org/10.17712/nsj.2016.4.20160278 (https://pmc.ncbi.nlm.nih.gov/articles/PMC5224438/). 21. Pang, Q. M., Chen, S. Y., Xu, Q. J., Fu, S. P., Yang, Y. C., Zou, W. H., Zhang, M., Liu, J., Wan, W. H., Peng, J. C., & Zhang, T. (2021). Neuroinflammation and Scarring After Spinal Cord Injury: Therapeutic Roles of MSCs on Inflammation and Glial Scar. Frontiers in immunology, 12, 751021. https://doi.org/10.3389/fimmu.2021.751021 (https://pubmed.ncbi.nlm.nih.gov/34925326/). 22. Schick, T. (Ed.). (2022). Functional electrical stimulation in neurorehabilitation: Synergy effects of technology and therapy. Springer. https://doi.org/10.1007/978-3-030-90123-3 (https://link.springer.com/book/10.1007/978-3-030-90123-3). 23. Swain, I., Burridge, J., & Street, T. (Eds.). (2024). Techniques and technologies in electrical stimulation for neuromuscular rehabilitation. The Institution of Engineering and Technology. https://shop.theiet.org/techniques-and-technologies-in-electrical-stimulation-for-neuromuscular-rehabilitation 24. van der Scheer, J. W., Goosey-Tolfrey, V. L., Valentino, S. E., Davis, G. M., & Ho, C. H. (2021). Functional electrical stimulation cycling exercise after spinal cord injury: a systematic review of health and fitness-related outcomes. Journal of neuroengineering and rehabilitation, 18(1), 99. https://doi.org/10.1186/s12984-021-00882-8 (https://pubmed.ncbi.nlm.nih.gov/34118958/). 25. Xu, X., Talifu, Z., Zhang, C. J., Gao, F., Ke, H., Pan, Y. Z., Gong, H., Du, H. Y., Yu, Y., Jing, Y. L., Du, L. J., Li, J. J., & Yang, D. G. (2023). Mechanism of skeletal muscle atrophy after spinal cord injury: A narrative review. Frontiers in nutrition, 10, 1099143. https://doi.org/10.3389/fnut.2023.1099143 (https://pubmed.ncbi.nlm.nih.gov/36937344/). 26. Anatomical Concepts: https://www.anatomicalconcepts.com/articles

When it comes to pharmacy benefits, no topics make headlines like GLP-1s and weight loss programs. On this episode of HR Benecast,  Dr. Lia Rodriguez and Erin Bacon from CVS Health share what makes a clinical weight loss program really work. Listen to hear the latest obesity stats, obesity's link to other chronic conditions, the importance of lifestyle changes and more. 

Dr Kevin S Hughes from the Medical University of South Carolina in Charleston and Dr Mark Robson from Memorial Sloan Kettering Cancer Center in New York discuss current BRCA1/2 genetic testing practices and the clinical management of localized breast cancer with alterations in these genes. CME information and select publications here.

Featuring perspectives from Dr Kevin S Hughes and Dr Mark Robson, including the following topics: Introduction (0:00) Optimal Approach to Genetic Testing for Patients with Localized Breast Cancer (BC) — Dr Hughes (10:22) Available Data with and Practical Application of PARP Inhibition as Adjuvant Therapy for Patients with BC — Dr Robson (38:06) CME information and select publications

Dr Kevin S Hughes from the Medical University of South Carolina in Charleston and Dr Mark Robson from Memorial Sloan Kettering Cancer Center in New York discuss current BRCA1/2 genetic testing practices and the clinical management of localized breast cancer with alterations in these genes. CME information and select publications here.

"Designer benzodiazepines" are lab-created chemical derivatives of prescription benzodiazepines. They have not been approved for medical use and there is limited information on their safety and toxicity. More potent than their prescription counterparts, this subset of novel psychoactive substances have been growing in popularity in recent years and pose the potential for dangerous levels of intoxication. In this podcast, Dr. Sahil Munjal, program director of the Atrium Health Wake Forest Baptist psychiatry residency program, leads a discussion of the article “Clinical Management of Designer Benzodiazepine Intoxication: A Systematic Review," with his coauthors Dr. Gregory Noe, Katelyn Li, and Nicholas McDuffee. They provide an overview of designer benzodiazepines in comparison to prescription benzodiazepines and describe the findings from their review of 35 case reports. They discuss clinical presentations of designer benzodiazepine intoxication, common approaches to clinical management, and key takeaways from their review of the literature. Their article appears in the March-April 2025 issue of The Journal of Clinical Psychopharmacology.

Researchers Compare Dentists' and Hygienists' Awareness and Clinical Management of Xerostomia By Today's RDH Research Original article published on Today's RDH: https://www.todaysrdh.com/researchers-compare-dentists-and-hygienists-awareness-and-clinical-management-of-xerostomia/ Need CE? Start earning CE credits today at ⁠⁠https://rdh.tv/ce⁠⁠  Get daily dental hygiene articles at ⁠⁠https://www.todaysrdh.com⁠⁠ Follow Today's RDH on Facebook: ⁠⁠https://www.facebook.com/TodaysRDH/⁠⁠ Follow Kara RDH on Facebook: ⁠⁠https://www.facebook.com/DentalHygieneKaraRDH/⁠⁠ Follow Kara RDH on Instagram: ⁠⁠https://www.instagram.com/kara_rdh/

Although there is currently no FDA-approved treatment for pruritus in primary biliary cholangitis (PBC), symptoms can be mitigated with nonpharmacologic or pharmacologic agents. In this episode, Marlyn J. Mayo, MD; Stuart C. Gordon, MD; and Pam Rivard, RN, a person living with PBC, discuss the clinical management of pruritus in PBC, including:Pruritus assessment toolsOptimal use of tools, including frequency of assessmentCurrent management of pruritusNonpharmacologic interventionsPharmacologic agentsStrategies to optimize assessment and management of pruritusCollaborative careDevelopment of a treatment planOngoing assessment and adjustment of therapyResources and support for patientsPresenters:Marlyn J. Mayo, MDProfessor of Internal MedicineDivision of Digestive & Liver DiseasesUT Southwestern Medical CenterDallas, TexasStuart C. Gordon, MDProfessor of MedicineWayne State University School of MedicineDirector, Division of HepatologyHenry Ford HealthDetroit, MichiganPam Rivard, RNPerson living with PBCLink to full program: https://bit.ly/3Dnfb2E

Although there is currently no FDA-approved treatment for pruritus in primary biliary cholangitis (PBC), symptoms can be mitigated with nonpharmacologic or pharmacologic agents. In this episode, Marlyn J. Mayo, MD; Stuart C. Gordon, MD; and Pam Rivard, RN, a person living with PBC, discuss the clinical management of pruritus in PBC, including:Pruritus assessment toolsOptimal use of tools, including frequency of assessmentCurrent management of pruritusNonpharmacologic interventionsPharmacologic agentsStrategies to optimize assessment and management of pruritusCollaborative careDevelopment of a treatment planOngoing assessment and adjustment of therapyResources and support for patientsPresenters:Marlyn J. Mayo, MDProfessor of Internal MedicineDivision of Digestive & Liver DiseasesUT Southwestern Medical CenterDallas, TexasStuart C. Gordon, MDProfessor of MedicineWayne State University School of MedicineDirector, Division of HepatologyHenry Ford HealthDetroit, MichiganPam Rivard, RNPerson living with PBCLink to full program: https://bit.ly/3Dnfb2E

How has tinnitus care evolved over the decades, and what does the future hold for its management? In this presentation from the 2024 'InFocus: Rethinking Tinnitus Symposium', Dr. James A. Henry, a renowned expert in tinnitus research, offers a comprehensive overview of tinnitus clinical management. He explores the evolution of care from the 1970s to today, emphasizing evidence-based approaches like cognitive behavioral therapy (CBT), tinnitus retraining therapy (TRT), and progressive tinnitus management (PTM). Dr. Henry also discusses emerging innovations, including bimodal stimulation and migraine-based therapy, while highlighting the need for standardization across the field. With decades of experience, Dr. Henry shares practical strategies for addressing the effects of tinnitus, such as improving sleep, concentration, and emotional well-being. This session is an invaluable resource for clinicians, researchers, and anyone seeking a deeper understanding of tinnitus care—past, present, and future. Be sure to subscribe to our YouTube channel for the latest episodes each week, and follow This Week in Hearing on LinkedIn and X (formerly Twitter): https://www.linkedin.com/company/this-week-in-hearing/ https://twitter.com/WeekinHearing

Banner|Aetna, Blue Shield of California, Healthfirst and TytoCare explore innovative strategies that health plans can leverage to drive meaningful lifestyle modifications among members, improve health outcomes and reduce the rising costs of chronic disease.    Our expert panel also discusses the role of primary care in empowering members to adopt healthier behaviors.   Topics include: Building a culture that fosters habit formation for long-term success Supporting members using GLP-1s for weight management Addressing Social Determinants of Health (SDOH) to improve outcomes Leveraging technology to encourage sustainable lifestyle modifications   Panelists: Joe Brennan, Vice President, TytoCare Robert Groves, MD, Executive Vice President and Chief Medical Officer, Banner|Aetna Eric Glazer, Host (moderator) Angie Kalousek, Senior Director, Lifestyle Medicine, Blue Shield of California Amanda Parsons, MD, MBA, Vice President, Clinical Management, Healthfirst Bios: https://www.brightspotsinhealthcare.com/events/innovations-in-lifestyle-change-the-role-of-primary-care-2/   This episode is sponsored by TytoCare   TytoCare is a virtual healthcare company that enables leading health plans and providers to deliver remote healthcare to the whole family through its Home Smart Clinic. Combining a cutting-edge, easy-to-use, FDA-cleared device with AI-powered guidance and diagnostic support, the Home Smart Clinic enables the whole family to conduct remote physical exams with a doctor, replicating in-clinic exams for immediate answers from home. TytoCare drives utilization rates that are six times higher than traditional telehealth services; reduces the total cost of care by an average of five percent; diverts ED visits by an average of 10.8%; and has a high average NPS of 83. The Home Smart Clinic includes Tyto Engagement Labs™, a proven framework of engagement journeys designed for the successful deployment and adoption of the solution. To complete its offering, TytoCare also provides the Pro Smart Clinic, for professional settings outside the home to serve rural clinics, schools, workplaces, and more. TytoCare serves over 250 major health systems and health plans in the U.S., Europe, Asia, Latin America, and the Middle East. For more information, visit us at tytocare.com.

The IUD is a very safe and supremely effective contraceptive method. Given its increasing rate of use, practitioners are bound to see its relatively infrequent complications with greater regularity. Typical complications are considered “lost strings“, uterine perforation at placement, and expulsion. But there is another complication, device FRACTURE at removal. This can cause distress to the patient and can lead to additional interventions. Fracture of an intrauterine device (IUD) upon removal is a very rare complication, with a prevalence rate of 1–2%. However, the numbers have been rising since 2021, causing the FDA to track these complications. There has even been a bizarre case report of the copper coils being found in the pelvis WITHOUT device fracture! How?? In this episode, we will describe and review this relatively recent issue, its diagnosis, ways to minimize its occurrence at removal, and management strategies.

On today's episode, I'm joined by Dr. Alan Fredendall as part of our CrossFit series to discuss the power of the CrossFit methodology for health promotion and the growth of fitness-forward clinical care. Alan is a father, husband, physical therapist, CrossFit Level 3 coach, and educator. He serves as Chief Operator Officer and the division leader of the Clinical Management of the Fitness Athlete (CMFA) and Practice Management divisions at ICE Physio. He co-owns & operates his own outpatient physical therapy clinic, HealthHQ, in Michigan where he also coaches & participates in CrossFit next door at CrossFit Fenton. . In today's conversation, you'll hear about Alan's personal fitness transformation from weighing 400 pounds to becoming a fitness junkie, the art of creating habit change and helping others get active, what makes the local CrossFit affiliate a breeding ground for setting and achieving long term health and fitness goals, and so much more. If you're curious about CrossFit OR have somebody in your life that you want to help get healthy, this is the episode for you. Enjoy my conversation with Alan.  Alan's Links: Instagram: https://www.instagram.com/alan.fred.dpt/ ICE Physio: https://ptonice.com/ Health HQ: https://healthhq.fit/ Julie's Links:  https://thegoalsetmindset.com/ Instagram:  https://www.instagram.com/goalsetmindset_jb/ Shownotes: 05:30- Introduction & The Early Days of ICE 09:10- The Start of Alan's Fitness Journey, Losing 200 Pounds, and Joining the Army 16:15- What made you finally accept an invite to CrossFit? What your initial experience like? 26:30- “80% of people in our country aren't doing any fitness. We need to market to THAT person.” 29:45- “If we're going to create habit change with people I do think it needs to be fun. It can't be this fertile, quiet environment… it has to trigger a positive emotion.” 32:00- Many people perceive CrossFit as “crazy” or “dangerous”. What is your response to this? 38:45- “If you want to live both a long and a high quality life, some discomfort has to come into the equation somewhere.” 46:15- Moving Patients along the Sickness-Wellness-Fitness Continuum 54:00- Defining “Constantly Varied, High-Intensity, Functional Fitness”

In this episode, Sam Ashoo, MD and T.R. Eckler, MD interview Corey Hazekamp, MD, MS, one of authors of the June 2024 Emergency Medicine Practice article, Managing Emergency Department Patients With Opioid Use DisorderCurrent State of Opioid EpidemicOverview of overdose deaths and trends.Data and statistics about opioid overdose mortality rates.Three Waves of Opioid Overdose Deaths in the U.S.Opioid Classifications and Urine Drug TestingTypes of opioids: synthetic, semi-synthetic, and natural.Urine drug testing limitations and false positives/negatives.Practical use and research on co-ingestionsEmergency Medical Services (EMS) and Pre-Hospital CareImportance of ABCs in acute opioid overdose cases.Naloxone usage trends and an empirical approach.Anecdotal insights on changing naloxone administration dosages.Clinical Management in the Emergency DepartmentBuprenorphine InitiationProtocols for initiating buprenorphine in ED settings.Assessment using the Clinical Opiate Withdrawal Scale (COWS).Safe dosing procedures for buprenorphine.Withdrawal and Overdose CareLaboratory testing recommendations.Capnography and VBG in overdose management.The role of end-tidal CO2 monitoring and respirations.Methadone vs. Buprenorphine ConsiderationsMethadone to buprenorphine transition protocols.Personal testimonials and clinical experiences in managing overdoses and withdrawal symptoms.Patient Discharge and Follow-upPreparation of discharge prescriptions.Referral to addiction medicine clinics and resources.Educating patients on continued treatment and harm reduction.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses incidence of knee injury in functional fitness, common types of knee injuries seen in this space, and how to begin to treat knee pain for the fitness athlete. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.   ALAN FREDENDALL All right. Good morning, everybody. Good morning, Instagram. Good morning, YouTube. Good morning to those of you on the podcast. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. My name is Alan. Happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and our division leader in the fitness athlete division and practice management divisions. It is Fitness Athlete Friday. We would say that means it's the best darn day of the week. And here on Fitness Athlete Friday, we talk all things for folks who are recreationally active. So those patients and athletes active in CrossFit, functional fitness, running, endurance sports, whatever, that person who is getting up every day and getting in their daily movement, we're here to help you help them. So today we're going to be talking about knee pain in the fitness athlete. And in the context of today, we're going to be talking about specifically those folks who are probably squatting on a regular basis. So CrossFit and functional fitness athletes, folks who are maybe squatting, squatting heavier, higher volume on a more frequent basis than maybe some of our endurance athletes. INCIDENCE & TYPES OF KNEE INJURIES IN FUNCTIONAL FITNESS So I want to talk about what types of injuries do we see in the knee in this space, describe a little bit about those injuries, and then discuss the beginning stage of how to begin to treat some of those conditions. So first things first, What do we see with knee pain in the fitness athlete population in general? The great news is over the past decade or so, we have got a lot of great high-quality research out of the CrossFit and functional fitness space about what regions of the body are injured most frequently, and then kind of what conditions follow those injury diagnoses. So we should know that in the fitness athlete, we primarily see shoulder as the most injured region. About 45% of injuries are from the shoulder. Really close behind that is the low back about 35% and then really musculoskeletal injury kind of falls off after shoulder and low back. Specifically today talking about the knee we see about 15% of injuries are related to the knee. Beyond that we have elbow, wrist and hand, ankle and foot, that sort of thing. So primarily shoulder and low back and then a real sprinkle of the knee. With those knee injuries, we're not seeing really major traumatic injuries. It's very rare, probably never in your gym, anecdotally, have you seen somebody fracture their leg, fracture their patella, tear their ACL, get hit by a vehicle, fall off a thing. That usually doesn't happen in the space of the gym. Primarily what we see in the fitness athlete population, folks who are doing a lot of impact, a lot of squatting, is that we see a lot of patellar tendinopathy and we see a lot of what we maybe would describe as a meniscus issue but really something that we could just generalize as medial knee pain. So now breaking down those two major conditions patellar tendinopathy and meniscus or medial knee pain first things first I would tell you if you haven't yet taken our extremity management course with Lindsay Huey, Mark Gallant or Cody Gingrich I would recommend you get to that course as soon as possible. That course is a really great complement to our fitness athlete courses as far as being able to recognize and diagnose and stage a tendinopathy, diagnose an extremity condition, but also treat it and learn a lot of progressions and regressions to treat those injuries. Specifically, they spend a lot of time the entire afternoon on Saturday addressing the knee in a lot of detail. So make sure you're really comfortable with these conditions. if you hear words like patellar tendinopathy or meniscal care and you think, quad sets? I don't know. PATELLAR TENDINOPATHY & MENISCAL CONDITIONS So talking about patellar tendinopathy, what do we know in overuse condition? who is that person in the gym that we maybe need to be aware of, or questions in our subjective exam with that person that would let us know this person may be in that bucket. Somebody brand new to squatting, think of somebody in their 40s or 50s, sedentary, maybe their entire life, that's not out of the realm of possibility these days, who is now jumping into CrossFit, jumping into Orange Theory, jumping into F45, being expected to squat at higher volume and higher loads than obviously they ever have in their life. Folks who maybe are not new to this space but are maybe incurring and encountering a higher level of squatting volume than normal may also fall into this bucket. There are also movement patterns that tend to show up in these folks. I like to stage these as two different movement patterns. The first is what I'll call the close enough squat depth pattern, right? That person who is getting to maybe just above or just at parallel. what do we know about that range of motion in the squat we actually know that's when force on the knee is at its highest that above that point at about 45 to 60 degrees or less of knee flexion and then below 90 degrees of knee flexion we know we have a deloading effect at the knee so those folks who are trying to squat to full depth but are in just that close enough bucket are putting a lot of mechanical force on their knee that they could get rid of if they either squatted more shallow, which is not ideal, or ideally squatted a little bit deeper. The second group of movement pattern folks who fall into overloading their knee is that back and down squat pattern person. So that person who does not break at the hips and knees at the same time. So as we instruct the squat, we like to tell people, imagine there's a rope around your hips and your knees and they're pulling in opposite directions at the same time. That means your hips should flex and your knees should flex. And ideally with a relatively vertical torso, you sit down, sit straight down into that squat pattern. The down and back folks tend to initiate their squat with a hinge, and then to get to depth at the last moment, bottom out that squat and drive all of that force into the anterior knee to hit depth. This is kind of how powerlifters tend to squat, especially with a low bar back squat. But folks who just have not grooved out the motor pattern of the squat yet, when they hinge back and then sit down to finish the depth, the knee again is taking up a lot of force that really we could clean up with some coaching and cueing, right? Maybe we could elevate that person's heels, give them a corrective to hold a plate in front of them, but otherwise encourage a more vertical torso and a more sit straight down squat pattern that distributes force equally between the hips, knees and ankles in their squat pattern instead of at the moment of truth, putting all the force in the knee as they try to hit depth. So that's the patellar tendinopathy bucket. What about the meniscus, the medial knee pain bucket? These are folks who are encountering a lot of impact in rotation. So we do see this a lot in the functional fitness space, right? We do running. We might not go run marathons, but we do a lot of workouts with 200, 400, 800 meter runs. We do a lot of box jumping to train triple extension. We do a lot of double unders for model structural cardio work. And we have begun to introduce shuttle runs, at least in the CrossFit space, to be able to run indoors during the winter in a competition environment where maybe we don't have access to run outside or we don't have the treadmills to be able to run inside on a machine. With shuttle runs comes not only the impact of running, but now a turning rotation moment. not too dissimilar from catching a box jump in the bottom of your squat with your double unders or with running in general. Also in this group are folks who might be new to squatting full depth or otherwise increasing their squat volume, right? No different than the patellar tendinopathy bucket that they are now encountering extra volume. So understanding who that person is is really important and that's where knowing that this person is a functional fitness athlete knowing if they are new to this or not, if they're returning after a break, if they've never done something like this in their life. Uncovering all of that in the subjective history is really important because it's going to give you a better idea of where your treatment might take you. TREATING KNEE PAIN IN THE FITNESS ATHLETE So let's talk about that treatment. What should be our priorities in treatment? With our functional fitness athletes, we're demanding full range of motion at every joint whenever possible. That means one of our primary goals should be if we find an asymmetry, a lack of range of motion, particularly in knee extension and knee flexion, we need to restore that as soon as possible. Again, I'll point you towards our extremity management course. I'll point you towards our fitness athlete live course to learn techniques to self-mobilize to load to restore that full range of motion. But as we're restoring that full range of motion, respecting the irritability of the patient, we need to begin to strengthen in whatever available range of motion we have. These folks do not need more volume, right? They're coming to you with an overuse, a repetitive use injury already. Giving them a 20-minute AMRAP or a 30-minute AMRAP and having them do hundreds of squats or lunges in the scope of their PT session is just adding insult to injury, especially if we are thinking that this is a patellar tendinopathy case, for example. These folks need strength, they need capacity and resilience in those structures, so that they can continue to not only stay in the gym, but perform in the gym, ideally, beyond the point at which they got injured, right? We don't wanna just return somebody to the exact moment at which they got injured. Ideally, once we clear them fully, hey, you don't need to do your PT exercises anymore, they are a stronger person than when they first began rehab with us. So we need to strengthen that full range of motion of the whole knee. Now PT school has closely associated in our brains that the knee means quadriceps and that's it, right? It's all over the research. It's all over knee extension machines and really, really focused on making sure that we have really, really strong quads, which is not a bad place to start, especially if that person is missing some knee extension, right? Some, some traction banded straight leg raises can do a lot to both begin to restrengthen quadriceps, but also restore knee extension. but we can't just stop at the quadriceps. We need to strengthen the whole knee, right? All four muscle groups of the leg that attach to the knee. So we also need to make sure we're targeting our hip abductors, our hip AD ductors. We need to target, yes, the quadriceps, but we also, especially if we're thinking this is a rotational-based injury, if we are thinking this is medial knee pain, call it meniscus, call it whatever, we really need to focus on the hamstrings because why hamstrings flexed and rotate the knee. They are pulling the knee into medial or lateral rotation in a movement like running. Ideally, hopefully, they're firing pretty much in sync so that we don't have a lot of rotation in our knee. We're primarily going through flexion extension, but our knee does have the capacity to rotate, obviously, and it's primarily driven by our hamstrings pulling the knee into flexion and in rotation. What is the problem with hamstring strengthening? The problem with hamstring strengthening is that in most functional fitness environments, we don't primarily isolate and train the hamstring. We certainly do a lot of deadlifts, we do a lot of kettlebell swings, that sort of thing, but if you think about the range of motion from the knee and the hip in motions like deadlift, kettlebell swing, it is not full range of motion of the hip and or knee, which means we're not strengthening the hamstring through its full range of motion. Yes, you'll feel a little maybe glute, high hamstring burn on high volume deadlifts or kettlebell swings, but you are not getting that deep behind the knee stimulus that you are with things like Nordic curls or even just isolated knee flexion on a knee flexion machine or banded knee flexion or anything like that. So understanding that the hamstrings flex and rotate the knee is really important to kind of finishing the drill on a really comprehensive knee strengthening program. Understanding that biceps femoris is responsible for knee flexion, but also yes, lateral knee rotation, and that semimembranosus and tendinosis are responsible for flexion and medial knee rotation. So particularly with those medial knee pain bucket folks, we wanna get into semimembranosus, semitendinosus, maybe with our hands, with needles, with cups, whatever, try to restore both that flexion and rotary component of the knee, and then get out in the gym and really strengthen those hamstrings on top of, yes, the quadriceps, the hip abductors, and the hip adductors. TIME UNDER TENSION IS KEY The key with strengthening the knee, again, is time under tension. The folks you're working with are already doing higher volume, higher repetition, relatively moderate to higher load training for the knee in a Metcon style workout. So adding in more air squats at high volume or light wall balls or thrusters or goblet squats is really just doing the same thing that they're already doing in the gym, which led them to be sitting on your table in the first place. So just giving them more of that isn't necessarily a prescription. When we have students at Health HQ, they're so excited to have people out in the gym moving, folks who are interested in taking care of their health and fitness, and they love to jump up to that whiteboard and write out, Remom 24, Amrap 30. We have to go, wait, stop, stop. That's not appropriate for this patient, right? This patient is already dealing with the consequences of too much volume. We need to back their volume down, especially in physical therapy, and focus on time and attention. So be careful that we're not actually exacerbating or at least prolonging the healing time of that patient's condition because our volume in PT, our volume for our home program is too high. Slow it down, less reps, less sets, more time under tension. Depending on the patient's irritability will let you determine how much tension you can apply both in the clinic, in the gym, and for homework. When someone's really irritable, I'm thinking maybe isometrics, and I'm thinking something like a reverse Tabata. 8 rounds, 10 seconds of work, 20 seconds of rest. There are apps out there. I personally like GymNext. It is a timer. It has a Tabata built in, EMOM, AMRAP for time built in. It can connect to a Bluetooth clock that the company sells, but you can also just use it as a standalone app and play it through a Bluetooth speaker or just through your phone speaker for your patient to hear. So reverse Tabata, eight rounds, 10 seconds of work, 20 seconds of rest, that gets us 80 seconds time under tension. That's a pretty good start, especially if we're doing it isometrically and the patient is really, really, really irritable. Now, as symptoms calm down, as function begins to improve, as tolerance to loading begins to improve, we want to increase that time under tension dose, especially if we're convinced that this is a tendinopathy based condition. So I like to move next to 10 sets of 10 seconds of work. I'll usually do 10 seconds on, 20 to 30 seconds off for 10 sets. That bumps the needle about 20%. That gets me 100 seconds time under tension. Then, when that patient appears ready, we'll probably progress to a Tabata. That's 160 seconds, right? It's the opposite of a reverse Tabata, a full Tabata. 8 rounds, 20 seconds of work. 10 seconds of rest. So the inverse of a reverse that gives us 160 seconds. So now we're close to pushing three minutes time under tension through that structure. At this point, you're probably away from isometric exercise, but if you're not great, keep rocking the isometric exercise for more attention. And then really for me, kind of the hallmark that someone is getting close to the end of their plan of care is when we can do isotonic movement, we can do five sets of five, and we can do some really gnarly tempo right think about a slant board goblet squat right so he was really elevated a lot of focus on tension through that anterior knee and that medial knee structure three seconds down hold the bottom and as deep of a squat as you can show me three seconds and then three seconds standing concentrically out of that squat. That's nine seconds per rep, five reps per set, five sets. That gives us 45 seconds time under tension per set. That gives us 225 seconds across the five sets. That is what the tendinopathy research tells us we need to be hitting as a benchmark for our time under tension. So understanding, depending on that patient's irritability, depending on how long this condition has been going on, that person may not be able to walk into the clinic and do a slant board, heels elevated, goblet squat, five sets of five at 3-3-3-1 tempo. That might be a lot, right? Certainly probably going to make them sore, but it might aggravate their condition. So understand how we can regress and progress, time and retention is needed. And then make sure as well that we're doing that for every structure of the knee. Again, that we're hitting the medial knee, the lateral knee, the anterior knee and the posterior knee, particularly doing things for the hamstrings like Nordic curls, curls on the rower, furniture slide curls, anything to really target the hamstrings as they insert at the knee as they flex and rotate the knee. and not just strengthening mid-range of the hamstrings and mid-range of the quadriceps. SUMMARY So knee pain in the fitness athlete. How frequent? About 15% of all injuries, so relatively low compared to all the other injuries that this population encounters. Primarily, folks, patellar tendinopathy, meniscus, medial knee. Why? Overuse, either a sudden spike in volume from a more competitive athlete or a new athlete, or someone who is maybe doing extra stuff outside of the gym, extra running, extra squatting, whatever. Folks to watch squat when they're with you, are they the close enough depth person? Do maybe they need some help in their ankles or hips to hit better depth and take load off the knee? Are they the back and down squat person? Do they primarily squat with a hinge and then bottom out through the knee to hit depth? That is a person that can benefit from sequencing their squat pattern a little bit better, especially if they do have a goal to be a functional fitness athlete. They need to be able to show a relatively vertical torso squat, a high bar back squat, a front squat, a thruster, a clean, that sort of thing. With our treatment, make sure that we're working as soon as possible to restore full range of motion of both extension and flexion. We need full knee flexion to squat. We want full knee extension for impact. We want to strengthen the whole knee, not just the quadriceps. Hit the hip abductors, hit the AD ductors, and particularly full range of motion hamstring work, not just things like deadlifts and kettlebell swings. They're already doing partial range of motion hamstring strengthening in the gym. And then remember, it's not about volume. It's not about coming into PT and doing 500 air squats. They can definitely do that. It's probably going to exacerbate their symptoms. What we're focused on with our strengthening with their home program is time under tension. Start with the reverse Tabata. 10 seconds on, 20 seconds off, eight rounds. 80 seconds time under tension. Move to 10 sets of 10 on, 20 to 30 off. That's 100 seconds. Move through a full Tabata. Now 160 seconds, 8 rounds, 20 on, 10 off. And then the gold standard is can we do 5 sets of 5 of a movement at 3 seconds eccentric, 3 seconds isometric, 3 seconds concentric. Can we get to that 225 second time under tension benchmark? So I hope this was helpful. I'd love to hear questions you all have, throw them here on Instagram, shoot us an email, shoot us a message over on the ice physio app. Some courses coming your way from the fitness athlete real quick before I let you go. Our next cohort of fitness athlete level one online starts April 29th. That course is already almost sold out and it does not start for three more weeks. So if you've been looking to get into that class, that class has sold out every cohort since 2017. This next class will not be the exception, I promise you. So if you've been on the fence, get off the fence. If you've already taken that course, your chance at level two online to work towards your certification in the clinical management fitness athlete begins September 2nd. And then some live courses coming your way. Mitch Babcock will be down in Oklahoma City this weekend, April 13th and 14th, if you want to join him. He'll be back on the road again, May 18th and 19th out in Bozeman, Montana. And in that same weekend, Joe Hanesko will be up in Proctor, Minnesota, which is in the Duluth, Minnesota area. That will also be the weekend of May 18th and 19th. So hope this was helpful. Hope you all have a wonderful Friday. Have a fantastic weekend. Bye everybody. OUTRO 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.

Zeena is the founder of Good Reps Physical Therapy. A clinic located in Brooklyn, New York that specializes in treating Olympic weightlifters, Powerlifters and Crossfitters. As a group they have treated all levels of barbell athletes- from novices to Olympians. She has 10 years of clinical experience and has worked in various setting from hospital care to now Sports Physical therapy. Zeena is passionate about health and wellness. She used to run marathons until she discovered her love for barbell sports through Crossfit. Currently, she trains and competes as a 55kg lifter in Olympic weightlifting. When not in the clinic or the gym, you can find Zeena in prospect park walking her beloved pup queen elizabeth with her wife. -Clinical Management of Barbell Athletes -What it means to take up space as a female physical therapist in strength sports -Starting a practice IG @goodrepsphysicaltherapy Want to create live streams like this? Check out StreamYard: https://streamyard.com/pal/d/5353468462366720

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses the concept of kipping in 2024. After 128 years of kipping movements in Olympic gymnastics, we still have high levels of contention over the use of kipping in recreational fitness despite poor evidence to support or refute the safety or efficacy of these movements. What evidence do we have, and what can we do in the gym and the clinic regarding kipping? Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLGood morning, PT on ICE Daily Show. Happy Friday morning. Hope your day is off to a great start. Welcome to the PT on ICE Daily Show. My name is Alan. Happy to be your host here today on Fitness Athlete Friday. Currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member here in our Fitness Athlete Division. It is Friday. It is Fitness Athlete Friday. We would argue it's the best darn day of the week. We talk all things Friday related to that person who is recreationally active. The CrossFitter, the Boot Camper, the Olympic Weightlifter, the Powerlifter, the endurance athlete, running, rowing, biking, swimming, whatever, that person that's getting after it on a daily basis, how to address that person's needs and concerns and be up to date on the research in this space. THE STATE OF KIPPING IN 2024 So today we're going to talk about kipping, a sometimes usually, it's fair to say, usually contentious topic. related specifically to the CrossFit space, but now as more and more functional fitness gyms open that are doing CrossFit style exercise, we see that even folks who would not say or know that they're even doing CrossFit style exercise are doing kipping movements. So I want to have a discussion. on where we're at in both the public facing, the clinician facing aspects of kipping, what kipping is, and really, what is our goal, especially when we have our clinician hat on? What is our goal when we're looking at kipping and considering Is Kipping safe? Is Kipping dangerous? Is Kipping right for this athlete? So let's start and talk about Kipping. So if you don't know what it is, or if maybe you have athletes or patients who don't know what it is, the public facing side of searching for things related to Kipping can be really gnarly, right? If you just type Kipping into Google, you get a real bunch of crazy stuff. What do you get? You get endless videos on kipping pull-ups specifically, but also a bunch of articles on why kipping is dangerous, why it's cheating. My favorite Google search is the top two results are in direct contention with each other, right? The top result for kipping is an article from Men's Health. Why swinging around at CrossFit isn't for everyone right so a little bit a little bit of a mean article a little bit condescending of an article But then the next article is from our very own Zach long the barbell physio the truth about kipping pull-ups right a lot of research on kipping a lot of practical information on kipping and a lot of the stuff that we're going to talk about today that is public facing, but in a very educational manner. So you see a lot of stuff. It can be very confusing for our patients and athletes because they're being given this message of, Hey, if I'm already doing this, here is really an endless wealth of human knowledge on how to get better at these, how to improve my performance. But also I'm seeing articles from people who tell me that this is dangerous. that this is cheating. This is actually reducing the effect of exercise on my body. It could be making me weaker. All of these different essentially thought viruses are going around simultaneously. RESEARCH ON KIPPING IS NON-EXISTENT So stepping back away from what's public facing, the social media content, the blog articles, what else is available on Kipping? Not a lot. If we're being really honest and we go way back in history to the start of modern gymnastics, we know that it started in 1896, so 128 years ago. Across that 128 years, we have watched the sport of gymnastics develop We see gymnasts use kipping on their hands, on the mat, up on the bars and rings, doing things like muscle ups and handstands, and using a lot of kipping to do so. But across that 128 years, we really still only have one research article that is relatively recent in that big span of time. that even discusses anything related to kipping. It's an article that we share in our Fitness Athlete Level 1 course by DiNuzio and colleagues. It's a randomized controlled trial back from 2019 in the Journal of Sports and Biomechanics. and it's titled The Kinematic Differences Between Strict and Kipping Pull-Ups. So a very basic article looking at subjects who performed a set of five strict and then five kipping pull-ups and just looking at what are the differences in the muscular activation patterns between folks performing the five strict pull-ups and between folks performing the five kipping pull-ups. And what we already know to be true was found in the research that we see a little bit less activation of shoulder muscles and bicep muscles and a little bit more activation of quads and of core muscles when we look at the difference between when somebody begins to kip their pull-ups or when somebody does strict pull-ups. And that's it. That's it. That's all the research we have, right? When you kip, you offload your shoulders and your arms a little bit, and the force is taken up a little bit more by your lower extremities and your core. And that's all the research we have on kipping. We have no research that it's dangerous. We also have no research that it's safe. We really have almost no research in this space, and we need to be cognizant of that. We have absolutely no research related to injury. of how many strict pull-ups can we do before we should kip. What level of strict pull-ups makes our shoulders safer from kipping pull-ups? What is the limit of kipping pull-ups volume-wise that we'd want to see somebody perform? Some sort of structured progression towards performing kipping pull-ups. We have absolutely no research on that. We need to be aware of that. And we also need to realize that's probably unlikely to ever happen. If you think about the recruitment for a study that would evaluate some of those concepts, it would look totally insane and be unethical, right? Let's take different groups of people, let's randomize them, and let's see, based on strict pull-up capacity, who does a certain amount or a progressive amount of kipping pull-ups, and then let's see how long it takes for someone to develop an injury, if ever, and then crunch that data and come up with some sort of Conclusion that we'd all love to hear, or at least be interested in seeing, of how many strict pull-ups is enough, how many strict handstand push-ups is enough, before we begin to create and allow, quote-unquote allow, kipping in our athletes. So we need to know the public facing space is out of control with this, can be very confusing to our patients and athletes, but the clinician facing, the research side, there is almost no information and there's probably not likely going to ever be something change here in a really substantial manner. WHAT IS KIPPING? So what do we do in the absence of research? Step back and better understand what kipping is. Kipping is just momentum creation and transfer. If you have taken fitness athlete level one in the past couple years, you know that we talk about this in week four when we talk about metabolic conditioning. We talk about why are we doing kipping? Why are we doing things the way we're doing them in the functional fitness gym, in the CrossFit gym? Well, we're primarily doing them to get our heart rate up, right? We're primarily exercising for power output. to create a cardiovascular response. That's why we're primarily going to CrossFit. Yes, we lift some heavy weights every now and again. And yes, we do some lower intensity, maybe zone two, zone three, steady state cardio from time to time. But primarily, we take a couple exercises, we smash them together in an AMRAP or rounds for time or an EMOM. and we're doing them in a manner that facilitates our heart rate getting up ideally into zone four and maybe if we're not careful, maybe sometimes a little bit of zone five. So when we talk about kipping, we're just doing it for momentum transfer. It's allowing us to do more work in the same or less amount of time. so that we can keep that heart rate elevated. You all can imagine that it would take a very long time to do a workout with 100 pull-ups if you did them all as strict pull-ups. We just had a great workout last weekend at Extremity Management up in Victor, New York. We had some pull-ups, or should I say pool-ups, as Lindsey Huey would pronounce it, programmed in the workout, and the folks that kip their pull-ups or butterfly their pull-ups got a lot more work done in that workout than the folks who just did strict pull-ups. So kipping is just momentum creation and transfer. I think it's important to understand we so intensely and closely begin to associate kipping just with gymnastics, specifically vertical pulling gymnastics, pull ups, and toes to bar and muscle ups and that sort of thing, that we forget that as humans, we kip almost everything in our life, right? I am standing still right now, if I begin to walk, I'm going to begin to use global flexion to global extension patterns, to propel myself forward. If I want to transition from a walk into a run, that is going to become even more intense. I'm going to begin to use more of my core, more of my shoulders, more of my glutes to produce a flexion to extension, back to flexion moment that generates momentum. If you don't think humans should kip, I want you to jump into a pool and not use your shoulders, core, or hips to swim. What you'll find is that kipping is very functional to daily life. If we begin to disassociate kipping from being up on the pull-up bar, on the pull-up bar, we recognize that we kip almost everything, right? It's a very functional thing. We kip to go from walking, from standing to walking and from walking to running. We kip when we stand up from a couch. We kip when we're swimming in the pool, or the pool, I should say. And we need to understand as well, some part of this, of why we don't just do strict gymnastics, why we don't just do strict weightlifting, is that it really limits our top end performance, right? Imagine if you watch the Olympics, and gymnastics was strict work only, right? Only the very strongest people would be able to do that stuff, and they wouldn't be able to do a lot of it, right? We would watch somebody come out on the floor, we would cheer for them, This is this is Steve from Belarus. Hey, Steve. And he does like maybe three strict muscle ups, right? He's not swinging around on the bars anymore. We don't really care about his landing, because he can't generate momentum to swing around to land. Imagine if Olympic weightlifting did not allow momentum and people just performed a deadlift to a strict high pull to a strict press, it would limit top end performance, we would not see people clean and jerking 500 pounds, we would not see people snatching 300, 400 pounds. So that momentum generation is a very functional part of being a human being and of performing these functional movements. And we can't take that away from people. Because even if for nothing else, it would become really boring, right? So not only is it functional, at some level, it's kind of fun to do. And it's fun to move along that progression from Okay, I can do some strict pull ups. Okay, I can do some kipping pull ups. Cool. Now I'm working on muscle ups, so on and so forth. WHAT IS THE GOAL WITH KIPPING? So what is the goal? If we put our clinician hat back on and we think, what is the goal with our athletes? Really the kind of the question we're answering in our mind, and when we ask questions like, how many strict pull-ups is enough? What we're really asking is, what level of strength in the shoulder begins to be protective of injury? And the answer we don't wanna hear is that it depends. And what does it depend on? It depends on that athlete's history, right? Somebody who has been performing a lot of strength training for a very long time that comes into a CrossFit gym or a gym where they might be doing kipping movements, that person has a lot less concern for the momentum on the shoulder or the momentum on any other joint in the body, right? We could say the same thing about runners, right? That person comes in with a higher what we call training age and therefore less worry about the capacity of that person's body as we begin to produce and create momentum with it. So the answer is, it depends. We can't say one strict pull up is enough. Five is the minimum. 13. Is five safer than one? Is 13 safer than five? It depends on that athlete. It depends on their training age. If they have never done any sort of vertical pulling, exercise, then we're just a little bit more concerned, right? We want to see that person begin to develop that strength. We'd love to see that person get one strict pull-up. We'd like to see them continue working on it. The answer, at least in our gym and the way that we coach, is that you should always be working on your strict gymnastics. You should always be doing strict pull-ups. You should always be doing strict handstand push-ups. We had a workout just last week with a bunch of strict pull-ups, and I coached it, and I was very, very adamant. Do not kip these. Do not use a band to kip these. I want a strict pulling stimulus today. If you can't do strict pull-ups, here are the scales that are going to help you get a strict pull-up. We're not going to bypass the strict training stimulus just to be able to go faster. If you can't go faster with strict work, we need to scale and work on that strict work. The other thing is, anecdotally, if you work with these athletes in a gym or you work with them on the patient side as a clinician, having a super high strict pull-up capacity does not guarantee high quality kipping pull-ups. That person who comes in who's been doing lat pull-downs and strict pull-ups for 30 years They can do a ton of pull-ups, but their kip probably needs a lot of work. What we see is opponents of kipping don't kip, and so they don't interact with individuals who do kip. And so we begin to develop this false belief that being able to do 10-strick pull-ups guarantees large, high-quality sets of kipping or butterfly pull-ups, which is completely unfounded. We all know that athlete who can jump up on the bar and do 10 or 15 or 20 strict pull-ups in a set, and then we ask them to, hey, try kipping those, and you're like, oh, God, what's happening, right? You are just swinging around on the bar. So just having the strength doesn't necessarily guarantee the technique that's going to lead to efficiency in that movement. So the truest answer is we always have to be working on both. When it's time to do strict work, strict pull-ups, strict handstands, whatever, we need to be doing those strict or finding a scale that allows us to progress to strict, and when it's time to allow momentum, kipping pull-ups, kipping, handstand push-ups, toes-to-bar, whatever, we need to find maybe also scales there, even if the person has the strength to do them in an ugly fashion, that allows the development of the technique, so the person that can do 10-strip pull-ups is somebody that goes on to be able to perform very large sets of high-quality kipping or butterfly pull-ups or toes-to-bar or muscle-ups or whatever. So once someone has demonstrated that they really have that functional shoulder strength, we need to recognize that they're naturally going to increase the volume of vertical pulling, and it's slowly going to ideally increase over time. And at that point, we're really dealing with an issue of volume management, we're no longer dealing with an issue of foundational shoulder strength, that person has the capacity to do strict work. Now we just need to carefully watch that person's volume, making sure that when they begin to develop kipping pull ups, they can do sets of five, they don't decide to help themselves to a workout where maybe they're doing 150 pull ups in a workout or 200 pull ups in a way that Volume is now the concern for the shoulder and not necessarily the foundational strength. SUMMARY So where's kipping at in 2024? The same place that has been for 128 years. There is a lot of public facing information out there that is confusing to our athletes and patients of how to get better. how to work on these for performance, how these can improve your performance in the gym, but also an equal amount of information on why these are dangerous or deadly or detrimental to your fitness progress. So understand the concerns that your athletes and patients are going to have when it comes to the KIP. Know that on the clinician facing side there is almost no research for or against kipping. We have just one article that looks at muscular activation patterns between strict pull-ups and kipping pull-ups and shows that when we kip we reduce the demand on the shoulder a little bit and increase the demand on the lower extremities in the core. Understand really fundamentally what we're looking at with kipping. We're just looking at momentum transfer and that we do this in a wide variety of movement patterns away from the gymnastics bar in the gym. Yes, we can kip pull-ups and toes to bar muscle-ups and handstand push-ups, but we also kip when we stand up. We kip when we transition from walking to running and jumping in the pool and swimming and so on and so forth. What is our goal? Our goal is always the pursuit of as much vertical pulling strength as we can get. So when things like strict pull-ups show up, things like strict handstand push-ups show up for vertical pressing, we need to make sure that we're working on strict work and not bypassing the foundational strict work with kipping just because we can't do the strict work. What's the answer to how many strict pull-ups is enough? Two answers. Strict work does not guarantee performance, efficiency, safety with kipping, but also you can never be strong enough. So always continue to work on strict pull-ups, even once you develop kipping pull-ups. And even once you believe that your kipping pull-ups or butterfly pull-ups or toes-to-bar or whatever are in high capacity and high quality, you're still working on that fundamental strengthening of the shoulder because we know Strengthening is protective of injury. And understand that once someone develops the strength work and begins to kip, we're not really dealing with a volume management issue. We're dealing with maybe the future potential development of a tendinopathy, not necessarily a lack of functional shoulder strength once that person can do a couple of strict pull-ups. So I hope this was helpful. I know it's a very contentious area across the functional fitness space. Happy to take any questions, comments or concerns you all have thrown here on Instagram courses coming your way from the fitness athlete division. Our next level one online course starts April 29. Our level two online course starts September 2. and then we have a couple of live courses coming your way before summer kicks off. Mitch will be down in Oklahoma City on April 13th and 14th. Joe will be up in Proctor, Minnesota on May 18th and 19th. That same weekend, Mitch will be out in Bozeman, Montana. The weekend of June 8th and 9th, Zach Long will be down in Raleigh, North Carolina. And then the weekend of June 21st through the 23rd is a really special weekend. It's our Fitness Athlete Live Summit here in Fenton, Michigan. We'll have all of our lead instructors and teaching assistants here. So Zach will be here, Mitch, myself, Joe, we'll have Kelly, we'll have Guillermo. We'll have all the fitness athlete crew here for a special offering of Fitness Athlete Live at CrossFit Fenton. So I hope this episode was helpful for you all. I hope you have a fantastic Friday. Have a wonderful Easter weekend if you're celebrating Easter. We'll see you all next time. 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.

Mild asthma. For patients showing wheezing and shortness of breath on moderate exertion, it's one of the most common diagnoses, even when breath sounds are clear and pulmonary function testing is normal. What makes mild asthma “mild”? The key guidelines base the stage of a patient's asthma on how difficult it is to treat. Does that mean the frequency of symptom occurrence? How often a rescue inhaler needs to be used? The frequency and severity of pulmonary exacerbations? How should mild asthma be treated? What are the risks and benefits of short-acting beta agonists versus long-acting beta agonists versus inhaled corticosteroids? Which combinations might be appropriate for which patients?Join us in this issue of ePulmonology Review, as Dr. Fawzy from the Johns Hopkins University School of Medicine's Division of Pulmonary and Critical Care discusses these and other issues important to providing the best care for patients with mild asthma.Post test for CME/CE credit: https://elit.dkbmed.com/issues/197/test Hosted on Acast. See acast.com/privacy for more information.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the strategy behind helping athletes & patients consider adding extra training volume on top of their normal exercise routine. Why should we add it, when should we add it, how should we integrate it into our normal training, and who is appropriate for extra volume? Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLWelcome in, folks. Good morning. Welcome to the P-Town Ice Daily Show. Happy Friday morning. I hope your day is off to a great start. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader here in our Fitness Athlete Division. It is Fitness Athlete Friday. It's the best darn day of the week, we would argue here, from the Fitness Athlete Division. Those of you working with crossfitters, Olympic weightlifters, powerlifters, endurance athletes, anybody who is recreationally active, part of that 10% minority of the human race that exercises on a regular basis enough to produce a meaningful health and fitness effect. We're here to help you help those folks. INCREASING TRAINING VOLUME So here on Fitness Athlete Friday, today we're gonna be talking about increasing training volume. A hot topic, especially this time of the year, the CrossFit Open has begun as of yesterday. This is often the time of year as people go through the Open, maybe they did not perform as they thought they would, and they begin to ask questions about how can I make my performance look more like someone else's, right? So 24.1 was released, a couplet of dumbbell snatches and burpees over the dumbbell. I just finished it this morning, just finished judging a few hours as well. First workout, usually very approachable. People maybe have questions of how can I get faster as we get into the later weeks of the Open. Heavy barbell comes out, high skill gymnastics comes out, people begin to have more questions. What else could I be doing besides coming to CrossFit class? This relates to other athletes as well. Endurance athletes who maybe want to get faster in their mile time, faster in their race times, stronger to have less injuries. All of those questions tend to come up of what else could I be doing? So today we want to focus on asking in the concept, in answering the question of increasing our training volume. Why should we do that? When should we do it? Who is the person that's appropriate for it? And then how should we actually begin to introduce increasing training volume? WHY SHOULD WE INCREASE VOLUME? So let's start from the top. Why should we increase training volume? I think this is really important and that's why I have it as the first point today. often folks are maybe disappointed with their performance in the open or a recent road race or competition or something like that and they want to do more training and just adding in more training without understanding why we're doing that training or having a goal for that training can be a very rocky foundation to build upon and can really ultimately maybe set us up for an unsuccessful addition of volume that doesn't meaningfully improve our performance and maybe leads to an increased risk of injury for no reason. because we don't really know why we're training for more volume, right? Just doing more CrossFit metabolic conditioning workouts or just doing more accessory weightlifting or just running or biking more miles without a goal is really just adding meaningless volume to the equation. We need to understand why should we do this. So when folks come to you with that question of What should I be doing extra outside of my running or outside of CrossFit class? We should be asking back, why do you feel the need to add more training volume in? What specific deficit are you understanding or do you feel has been recently exposed that we need to add more training volume in? To just improve general fitness, with those folks we would say, Be patient, right? Continue going to CrossFit class. Continue if you've only been running for a year or two, continue your normal running training, right? Understand that high level performance often comes with most folks. When you look at them, they have a large training age, which means they have been doing whatever they're doing for a long period of time. And so expecting to close that fitness gap in just a couple of years by just adding in more volume is not really an intelligent way to approach that. But if we have identified some specific deficits, then that can be an argument to maybe add in some extra volume. So, folks who are maybe long endurance athletes who are noticing the longer my runs, the slower I become. I perceive that I maybe need to add in some speed work. Folks may be doing CrossFit that say, you know what, I'm great when the weight is body weight or when it's a low to moderate weight, dumbbell, kettlebell, barbell, whatever, I'm okay. But as we get heavier, I perceive that my strength, my upper limits of strength is limiting me from moving the weights around. In CrossFit class, where I'm perceiving that if I added in some more resistance training to whatever I'm doing, Maybe my tissues would be healthier or I don't have some of the skills and I would like to begin to practice them, right? I would like to practice double unders outside of class. I would like to practice pull-ups or muscle-ups or handstand push-ups outside of class or maybe add in an extra day of running if I'm a CrossFit athlete. So understanding why we're adding volume in is very, very, very, very important and it should be to address a specific perceived deficit and all the better if we can actually objectively test that so that we know if we're starting to make up ground on that deficit or not with the extra volume that we're being asked to add into our programming. So starting with why is very important. WHEN SHOULD WE INCREASE VOLUME? The next question is, when should we do this? I would argue that we should really only add in extra training on top of what we're already doing when we feel like our current training has plateaued. Of that person who says, I have been going to CrossFit six days a week for 10 years, and I feel like my ring muscle ups are not getting any better. I feel like I have literally not added a pound to my max, clean and jerk, whatever. When a perceived plateau is there, That can be a good argument to begin to add in some extra volume, especially those folks, uh, endurance athletes as well. Like, Hey man, I have been running for a decade and my marathon pace got faster, faster, faster the first couple of years, but it's been pretty much the same pace for the past two or three years of races. I feel like something needs to change. Or, again, those folks who do not have a skill. So that's when we begin to action that extra volume. For me, over the past year, my extra volume looked like adding in some more running. Doing pretty well, pretty happy with my CrossFit performance, but when runs showed up, especially in workouts where the runs were longer, 800s, miles, workouts like Murph Hero workouts with a lot of running, really, really, really impacted my performance despite doing pretty well on the other stuff that wasn't running. So beginning to add in extra running outside of CrossFit class. HOW DO WE INCREASE TRAINING VOLUME? Now, how do we do this? This is as important as why. How do we add in volume in a very intelligent manner? The key is with anything else, just like when somebody first began an exercise program, we need to start low. We need to go slow. We need to stair step this volume. A lot of folks perceive a deficit or otherwise feel like they want to add in more volume and they just do more of what they're already doing. And sometimes they do it every day, right? The person who leaves CrossFit and goes to Planet Fitness and does an hour on the stair stepper. or does an hour of machine weights, whatever. Adding in a big chunk of volume, again, if we don't have the foundation of why and when we should be doing this, can be a really unintelligent decision. So we should do this carefully. For me, this looked like one extra day of running for a couple of weeks, two extra days of running for a couple of weeks, so on and so forth. Using a running coach to very carefully and controlled add running volume in on top of working with a nutrition coach to make sure that I was fueling appropriately. So making sure that if we do come to the decision that we could benefit from extra training aside from what we're already doing, that we do it very, very, very, very carefully. What we're trying to do adding in extra exercise pieces is we are trying to push ourselves maybe into a short period of what we would call overreaching, functional overreaching. We're pushing the margins just a little bit, but we also need to be mindful of all the other training that we're doing, and we have to be careful that this functional overreach does not become overtraining, right? We need to make sure that if we're adding an extra stuff, we respect this new volume. We do it carefully. This extra volume should come with a progression in a deload. So for example, my running coach always had me on four week cycles. where every fourth week was a deload, added a little bit of miles every week for three weeks, and then a deload, add, deload. That deload week is a chance to give my body a break, go back to essentially my pre-running amount of volume, but it's also a great week to assess how did my body respond to the previous three weeks of training. Should we continue with the next block of extra volume? Or should we stay where I was at? Or should we maybe even regress a little bit because it was a little bit too much of an overtraining feeling rather than that functional overreach? And again, being objective with why are we doing this can really help us know did that little burst of extra volume create a change? Did mile split times go down? Did a race time go down? Did strength go up maybe two pounds or five pounds or whatever? Can I do two muscle-ups now instead of one muscle-up? So on and so forth. Having those objective indicators lets us know, okay, we're making the progress we want to see, and as long as everything is feeling good, we're good to continue going to that next step on the staircase of increasing volume. And when we think about how we add in this training, most importantly, we have to ensure that this extra training does not impact the normal training, right? The worst thing you can do is have your extra volume, make it so that when you show up to your normal training, so in my example, I never wanted to get to a point where my running made it so that I could not come to CrossFit, right? That's a dangerous spiral to get into, where now my normal baseline strength and conditioning program can't be performed, and now I'm adding extra volume even though I can't handle the current level of volume I was already doing before I added in my extra training. So being sure that whatever we're training at baseline, CrossFit, weightlifting, running, whatever, that does not become impacted by whatever extra stuff we're doing. Now that being said, if we're feeling good, we feel like we're making progress, we are objectively making progress, and our normal training is not impacted Okay, continue to either maintain that extra thing, whatever you're doing, or maybe even progress it a little bit. WHO IS APPROPRIATE FOR EXTRA VOLUME? Now the final part of the equation is who should do this? I would argue the answer is very few people should do this. Who is the type of person that is appropriate for extra volume? that person should be incredibly consistent with whatever they're already doing, right? Which by default erases most of the people who want to do extra volume. A lot of people perceive a gap in fitness between maybe themselves and their friends in CrossFit class or themselves and their friends and their run club or whatever. They want to close that gap even though What they don't want to hear is that maybe the gap there is because they're already not consistent with what they're doing, right? They hit the snooze alarm a couple days a week on CrossFit class or going for their run, right? I want that individual who is already incredibly consistent with their normal training. They are training four to six days a week, every week. They understand the importance of active recovery and rest days. They are prioritizing their sleep and their nutrition. The volume means nothing if we can't match that volume with an appropriate dedication to recovery. Again, we're trying to create bouts of small windows of functional overreaching. We're trying not to throw somebody into a downward spiral, a death loop of overtraining where they're going to be at increased risk for injury, where their fatigue, their soreness, whatever is going to impact all of their training, not just the extra volume that they're now doing. Most people are not consistent enough with what they're already doing to consider taking on extra volume. And I think that's tough to hear, but it's the right decision. for you as the coach, the clinician, whatever your role is, to have in a conversation with that athlete. If you are only coming to CrossFit on Monday, Wednesday, Thursday, you sleep in on Tuesday because Monday wrecked you, you sleep in on Friday because you're sore, you don't come to the gym on the weekend, let's see what your fitness looks like when you're consistent with your current fitness routine, and then maybe later on we can revisit talking about extra volume. I have found in my coaching career that the folks who come up to me and tell me, hey coach, I'm ready for butterfly pull-ups, happen to also be, coincidentally, the people who maybe can't even do strict pull-ups, right? The folks who are able to tolerate extra volume, extra skill progression, are the folks who are already very consistent and it's very clear that they, because they are consistent with their normal level of training, recovery, attention to their sleep and diet, They are aware, and I am also aware, that they can probably handle extra stuff, and that the people who want it really, really, really, really bad are almost always likely the people that should probably not do it because they are so inconsistent already. CASE EXAMPLE: RYAN A really good example I have is our friend here at the gym. His name is Ryan Battishill. You may know him. He develops a lot of your websites. He's a website developer by trade. He's a member here at our gym. I love how calculated and intelligent he is with just a little bit of extra training every day after class. So I want to tell you a little bit about him and then tell you the volume that he's added in in the results. So Ryan's been doing CrossFit for five or six years now. He has a history of running as well. He has a good morning fault squat. So a very kind of hingy squat. It tells us there's maybe a deficit in the quads, wants to get better at gymnastics, and wants to train for a half marathon as well. So, a lot of different goals, but it's good. Again, why are you adding extra volume? Are you just doing it meaninglessly, or do you actually have a goal? Okay, we have a couple of goals here. We want to improve our foundational lifts, we want to improve our back squat, our deadlift, We want to improve running. We want to improve our gymnastics. Okay, good. We have concrete objective ways to know that volume is working. What does that extra volume look like? And I think you would be surprised to hear that his extra volume is about 10 to 15 minutes a day after class. It's nothing crazy. One day he does an EMOM, usually a 10 minute EMOM of strict pull-ups and push-ups to help his gymnastics foundations. One day he focuses on front rack barbell step ups to focus on quad strength. Another day he does hip thrusts to work on his posterior chain and low back strength. And a fourth day of the week he adds in a couple extra miles of running. Nothing he does conflicts with his ability to come to CrossFit five days a week. He's a Monday through Friday regular, very consistent with five days a week of CrossFit training, very consistent with his nutrition, very consistent with his recovery, right? Somebody that's getting on most nights, eight plus hours of sleep, getting plenty of fuel as well. What are the results? A lot of people might look at the work he does and say, there's no way that 10 to 15 minutes of extra work could translate into anything meaningful, right? A lot of us look at extra volume, we think, if I want to be better, I need to run five miles extra a day, I need to do an extra hour of CrossFit a day, right? I need to do more and more and more volume instead of really intelligently planned extra accessory work. Over the past year of adding in that extra volume, he has broken through plateaus on his back squat, his deadlift, and his bench press from all of the strict gymnastics, the front rack step ups, and the hip thrusts. He has improved his running, even though he's already a great runner, in accordance with his goals to be able to run and complete a half marathon. and his gymnastics are certainly becoming on another level. His kipping pull-ups, his toes-to-bar, his muscle-ups, his handstand push-ups are all also improving accordingly because of his focus on strict gymnastics work. So I hope from that you glean that when we're talking about adding extra volume, it doesn't need to be this grueling stuff. It doesn't need to be very high-intensity stuff. It just needs to be intelligently designed in a way that does not affect our current training, And that puts us in a short state of functional overreaching, but does not become this long-term overtraining issue. Understanding that as we increase that volume, our nutrition, our calorie intake should increase as well. And we definitely need to make sure that our recovery is on point because we're now taking on extra physical volume that our body will need to recover from. SUMMARY So extra volume, why should we do this? We should do this only to address a specific perceived deficit that we can objectively measure the impact of extra volume on. When should we do this? When we have perceived a plateau, right? If every time we're testing a lift or testing a mile pace or a 5k pace and we are still getting faster, getting stronger, whatever, we have not yet reached that plateau. And so I'd argue it's not yet a time to consider taking on extra volume. If we do decide extra volume, extra work, extra accessory work is appropriate, how should we do that? We should do that very carefully. We should do that as a stair-step approach. We should do that in a manner that we can reassess the impact of our extra training. Is it actually working? And we should do it in a way that our normal training is also not impacted. We should never be skipping our normal run because of our strength training or our speed work. We should never be skipping CrossFit class because of our extra running or our extra accessory work that we maybe do before or after class should not impact our normal training. And then who should do this? Again, I would argue a very small amount of people should actually do this. Folks who are already incredibly consistent with their normal training routine, who are training four to six days per week, understand and are consistent with recovery, right? The stuff that happens outside of training, diet, sleep, nutrition, recovery. and folks who are aware of the nutritional goals are meeting them and are also aware that adding extra volume is going to increase the demand on how much and the dedication we have to our recovery. And then finally understanding it doesn't have to be crazy high volume, crazy high intensity to have an impact. 10 to 15 to 20 to maybe 30 minutes of extra work just a couple of days a week can go a really long way if the extra volume is done in a meaningful manner to address those extra deficits. finishing a metcon and doing another metcon is usually just going to result in that metcon being of even lower intensity that you may have to scale the weights and the ranges of motion more rather than coming over and doing some front rack step-ups or doing some strict pull-ups or doing some sort of skill practice or really judicious strength piece or run piece, cardio piece, something like that, right? Extra metcons, a 60-minute AMRAP, at the end of a 40-minute AMRAP is really not going to push the needle. Again, we're looking for that functional overreach and making sure we don't push that into overtraining. So, extra training, who, when, why, and how, those are our thoughts. So, hope you have a wonderful weekend. If you're going to do 24.1, I hope you have fun. My advice, go fast at the start, go fast in the middle, go fast at the end. It's designed as that kind of workout. Low skill, high work. one of my specialties. So hope you have a great Friday. Have a fantastic weekend. If you're going to be on a live course this weekend, we hope you enjoy yourselves. 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 // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses current recommendations on protein intake, new possible recommendations, and barriers to showing efficacy with different amounts of protein consumption. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALL All right. Good morning. PT on Ice Daily Show. Happy Friday morning. Hope your morning is off to a great start. My name is Alan. Happy to be here today. Currently have the pleasure of serving as the Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Friday. It is Fitness Athlete Friday. We talk all things related to CrossFit, Olympic weightlifting, powerlifting, endurance athletes, If you are working with a patient or client who is recreationally active, out on the road, on the bike, in the gym, Fitness Athlete Friday is for you. Just a quick announcement before we get into today's topic. If you're going to be at CSM or you're already at CSM, join us tomorrow morning, 5am, CrossFit Southie. We have a free workout going on, led by me. I'm getting on a plane later tonight to fly out there and run the workout tomorrow morning. So whether you have many years of CrossFit experience, whether you have zero minutes of CrossFit experience, we're going to have a fun workout tomorrow morning at five. Please go on our Instagram, go into the pin post and sign up for the sign up form. The link is in that pin post. So today, Fitness Athlete Friday, what are we talking about? We're talking about a paper that just came out at the end of 2023 and was published a few weeks ago, looking specifically at protein digestion. Hang on, buddy. Come here. Sorry about that. We're going to talk about protein digestion and the upper limits of what we think can happen with protein digestion. So we're going to talk about current protein recommendations based on the current body of research. We're going to talk about what this paper found and the conclusions it drew that may change those protein recommendations. And then we're going to talk about barriers to this research. CURRENT PROTEIN CONSUMPTION RECOMMENDATIONS So the paper we're referencing today, the title is the anabolic response to protein ingestion during recovery from exercise has no upper limit in magnitude and duration in humans. was a paper published in December 2023 by Tromelin and colleagues, pardon my sick son coughing, and the journal title is Cell Reports in Medicine. So that's the paper we're referencing. Current protein recommendations quite old and they typically recommend and advocate that humans can't digest or otherwise synthesize protein in amounts above about 20 to 25 grams of protein per hour and If you're like me, you were sitting in a lecture in undergrad maybe 20 years ago and you heard that based on literature from the 90s and the early 2000s and you thought, hmm, that seems really specific and also really impractical given how much protein we're recommending that people eat. How can somebody possibly only synthesize and utilize 20 to 25 grams per hour. That would mean an individual, especially a larger, more muscular individual, would basically need to be always eating protein, right? A lot of these studies look specifically at whey protein, a faster digesting version of protein. Whey protein is essentially the watery portion of milk with all the fat strained out. But even at moderate protein consumptions, think about an individual who's maybe 6'6", 300 pounds. No, no. No, no, okay, we're gonna hold you all the time. Somebody who's 6'6", 300 pounds, that person would need to eat 20 to 25 grams of protein for 12 to 14 hours in a row to get all of their daily protein in, maybe just at a maintenance protein level. That is really impractical and yet, up until this paper was published in 2023, we don't really have any other recommendations that we could give. So cue this paper being published at the end of the year. You see yourself, hi. NEW PROTEIN CONSUMPTION RECOMMENDATIONS This paper, fantastic methodology, amazing study, really good incorporation of inclusion and exclusion criteria of the subjects used, but also did a really good job of being very thorough in measuring and tracking the protein synthesis in the subjects in the study. So let's talk about that study. This study looked at 36 healthy males between 18 and 40. Inclusion criteria, they had to have a BMI between 18 and 30. They had to have already been exercising one to three days per week, so they needed to basically be familiar with exercise, particularly resistance training. And exclusion criteria included anybody who smoked, anybody who was lactose intolerant, and anybody who was taking any sort of prescription medication. So basically we looked at rather young, rather healthy men. What did we do? We had them all perform the same type of resistance exercise. We had them perform the same resistance exercise protocol. They went into the gym, they performed one set of 10 reps at 65% of their max on lat pulldown, leg press, leg extension, and also chest press, so bench press machine. They then did four sets to failure at 80% of their max. So they did all the same resistance training protocol. And then what changed, what varied in this study was how much protein they consumed after the resistance training protocol. So some subjects were given no protein, that was the control group. Some subjects were given 25 grams of protein. And then another group was given 100 grams of protein. So four times current best recommendations. And the hypothesis was, how much protein synthesis might we see compared to the 25 gram group in the 100 gram group. We looked at immediately post-exercise, we looked up to 12 hours post-exercise and we found some really interesting results that essentially the higher protein group saw continually increased levels of protein synthesis out to the end of the study, the end of the 12-hour period. So the 25-gram group had increased protein synthesis obviously compared to the zero-gram group, but the 100-gram group had 20% increased levels of protein synthesis in the zero to four-hour measurement window and 40% higher in the four to 12-hour post-exercise window. So this paper is great because it really opens up the notion that we can front load our protein and that we can potentially catch up on a protein deficit later in the day. For a lot of our folks, especially our active folks who are also maybe working, wrangling kids during the workday, trying to get enough protein in and trying to get it in those 25 gram feedings is probably just not feasible when we're looking at individuals eating 200, 250, maybe even 300 grams of protein a day. Simply not possible to get that. So a lot of those folks have issues with timing of protein intake. and also the belief that any consumption beyond 25 grams might be wasted. This article is really a landmark paper because it shows that that might not be the case, that we can front load large doses of protein or catch up with big doses of protein later in the day and see really long windows of protein synthesis after resistance training. Again, 40% higher at the 12-hour mark compared to 20% higher at the 4-hour mark tells us protein synthesis actually increased the further away we got from both the exercise and the actual consumption of that protein. RESEARCH BARRIERS Now there are some barriers with this research, we need to be mindful of what this paper does not say. This paper did not look at objective measurements of things like strength or hypertrophy, so it would not be fair, hi buddy, you're gonna knock my tripod over, It would not be fair to use this study to say that eating 100 grams of protein at a time makes you stronger, makes your muscles bigger because the study did not look at this and therefore we cannot conclude that 100 gram doses are better. What we can conclude is that this may be an alternative way to consume our protein that results in equal or even higher amounts protein than the traditional recommendations of 25 grams per hour. What we also need to be mindful of is that all of the research on 25 grams per hour looks specifically at subjects fasted eating whey protein. This study literally did the opposite. It looked at individuals who were fed, who had just performed resistance training, and who were essentially eating casein protein, the fatty portion of milk protein. So eating basically the opposite aspect of the protein and doing it under a different mechanism, doing it after exercise as compared to doing it fasted. So it is a little bit of comparing apples to oranges. Nonetheless, what we can take away from this paper is an alternative feeding strategy, especially for those individuals who we see in the clinic, who we see in the gym, who may tell us that they simply don't have time in their day, time in their schedule to eat protein in 25 gram feedings. If those patients, if those athletes, if those clients are already saying, hey, I know I'm not getting enough protein because I don't have time to eat 25 grams every hour for 14 hours, and I'm just simply not eating protein, then this is a very viable alternative solution of, hey, let's try front-loading your protein before you leave the house for the day. Let's try eating, you know, 50, 75, 100 grams of protein, maybe half, maybe 75% of our protein intake for the day before we leave the house. Now again, what we can't promise those people is that they will have equal or better levels of muscular strength or hypertrophy gains, but nonetheless we know how important protein is at least for recovery. so we can make that alternative recommendation to those patients and clients. SUMMARY So, protein, is 25 grams an hour the maximum? It doesn't appear so. It appears that the more we eat, the higher levels of synthesis that we have, at least in the scope of this paper, up to 12 hours after we've consumed that protein. Is it better? We don't know yet. We need more research. We need to now look at a study of folks eating 25 grams versus 100 grams and now measuring them more longitudinally and seeing what does muscular hypertrophy look like, what does muscular strength look like, even what does functional outcomes look like, different functional tests. but that being said this is still a very landmark foundational paper that should change our mind about how we think about eating protein that we can think about front loading if we need to we can think about catching up at the end of the day eating a big dose of protein maybe with dinner. I know Mitch Babcock who teaches here in the fitness athlete division a big fan of a big bowl of cereal with protein powder on it on the end of the day just to get a big lump of protein in before the day's end and that might be a viable successful alternative for a lot of our patients and athletes. So protein get it in get it in where it fits in even if it's a bigger dose than previously you may have been led to believe would be effective. Courses coming your way really quick. If you want to come learn more about protein, recovery, nutrition from the Fitness Athlete Division, our Level 1 online course starts again April 29th. Our Level 2 online course starts September 2nd. And we have a number of live courses coming your way throughout the year. A couple coming your way the next couple months. We have Zach Long down in Charlotte, North Carolina. That'll be February 24th and 25th. Zach will again be out on the road, this time in Boise, Idaho, March 23rd and 24th. And then we have a doubleheader the weekend of April 13th and 14th. Joe Hineska will be out in Renton, Washington, near Seattle. And Mitch Babcock will be down in Oklahoma City, Oklahoma. So I hope you have a wonderful Friday. Please join us at CSM if you're going to be there. 5 a.m. tomorrow morning, CrossFit Southie. Other than that, we hope you 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.

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty member Mitch Babcock discusses developing youth strength & conditioning programs, including optimal timing & frequency, age groups, and training progressions. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MITCH BABCOCKAnd good morning. Welcome to the PT on ICE Daily Show. It is Friday, that means it is Fitness Athlete Friday. We are excited you are here. If you're on YouTube, thanks for watching when you're catching this recording back. And if you're on Instagram, thank you so much for being here as well. Thank you to our listeners who are loyal and downloading this podcast on Spotify and Apple Podcasts and anywhere else that you get your podcasts from. If I am talking to you on your morning commute, I wish you a great day in the clinic. And if you're on your way home or anywhere else, I wish you a great day as well. So I am Mitch. I am your host of this Fitness Athlete Friday. I'm a lead faculty in the fitness athlete division. And I want to talk today about youth sport, youth fitness athlete programs and what you can be doing as a fitness forward clinic to really be reducing those injury risks that we all talk so much about in the youth athletes. Before we jump into that, I just want to draw your attention to two main fitness athlete courses that we have coming up for the month of February that we're in now. On Super Bowl Sunday weekend, I will be in Richmond, Virginia. I was getting a little worried. My Detroit Lions making a once-in-a-lifetime run at the Super Bowl. I was getting a little nervous that maybe I did some scheduling error there. fortunate or unfortunate as it may be, they won't be in the Super Bowl. So Super Bowl weekend, I will be in Richmond, Virginia. And I know what you're thinking, I don't want to take a course on Super Bowl Sunday. We're going to get out in plenty of time early enough for you to go make it to your Super Bowl party and enjoy the rest of the weekend with your friends and watch the game. So if you're in the Richmond area, join me there on February 10th and 11th. And then at the end of the month, February 24th and 25th, you can catch Zach, the Barbell Physio. He's going to be at his home gym in Charlotte, North Carolina. for a fitness athlete course as well. And we just kicked off our next cohort of our Level 1 Essential Foundations course online, and so I wanna make a special hello to all of you that are starting the process of the CMFA certification online with us. We're excited to do the next eight weeks together. We've got a lot of learning that we're gonna engage in, so I'm stoked for that. YOUTH INJURY REDUCTION STRENGTH TRAINING & CONDITIONING PROGRAMS So without further ado, let's get into our podcast today. Youth Injury Reduction Strength Training Conditioning Programs. Here's what we know about injury risk reduction. The screening tools that we have been given, the systems that were promised to help identify and reduce risk of injuries, they're no good. They don't mesh out in the data. We have enough long-term studies now to be very conclusive that these movement screen systems that we think that we're putting kids through to help reduce their risk of injury are in fact doing nothing to help actually reduce their risk of injury, and they're no better than a coin toss oftentimes of being able to identify kids that are at risk. What we know conclusively in the evidence, and then we're looking at now in adolescent athletes and also collegiate level athletes, is that the more that they're engaged in a strength and conditioning program, that the stronger their legs are, the stronger their core is, many of these programs focusing on those two elements primarily, that the better they do at reducing actual risk of injury and the more prepared these athletes are for the demands of their sport, whatever that sport may be. And so when you think about the constraints that the youth athlete is under, oftentimes, and we know this problem exists, where these kids are involved in a one singular sport for 9, 10, or even 12 months out of the year, they're hyper specialized into that one athletic arena. They're going from practice to speed and agility camps to to sport positional specific camps. They're constantly engaged in the demands and the domains of their sport and they're doing way too much in that arena and they're not doing enough either other sports or general physical preparedness. The GPP work that we know is the foundation for all athletic endeavors to be built upon. DEVELOP GENERAL PHYSICAL PREPAREDNESS So our pitch, our recommendation for our fitness forward clinics out there, and there are so many now that are branding themselves as being fitness forward, when you're going out and you want to reach this next population, you want to get ahead of these injuries. You want to do something for that youth athlete. You treat their parents already in the clinic. You know that their son or daughter is engaged in travel volleyball, travel baseball, their competitive wrestler, football, whatever that may be. You know their kids, you know their families, and you want to put a program together that gets as many of those kids as possible in your clinic, in your gym, and really helps to teach the fundamentals of strength training. Right? Because if we can get these kids in and start to help educate their motor control patterns, help to instruct them on strength training, under the supervision of a doctor of PT who's trained in the barbell, who's trained in the dumbbell, in the strength and conditioning community like many of you are, and taking our courses now, there is no better instructor to take these kids under your wing and really lead them to where they need to go, which is learning the fundamentals of how to move their body in space, how to get stronger, and therefore how to be more protective against injury. Stronger athletes get hurt less on the field. And if we can start teaching these movement patterns at a younger age, that gives us such a better upslide for being able to instruct and progressively overload these movements over time. So what we need to be doing as Fitness Forward clinicians is setting up some sort of camp, setting up some sort of program. Maybe you have the resources to do it year long, that's great. Maybe you don't. Maybe you can just divide six or eight weeks of your schedule out to fitting in these youth sport performance camps. And you can do them at various times throughout the year. What we have found to be successful is doing a camp in the summer because they're about to lead into whatever their fall sport is. That could be volleyball, that could be Football, I'm not even sure what sports going at that time if I'm being honest, but but getting them into that late summer Is a great time to run some sort of eight-week camp where you teach the fundamentals of strength and conditioning Keep it very simple. OPTIMAL CLASS LENGTH My first point here is to keep it brief 30 to 60 minute classes are gonna be perfect 30 minute class if you're just looking to instruct the strength component closer to a 60 minute class if you're looking to do strength and conditioning together and Okay, so your choice 30-minute class is about what you're gonna need if you're wanting to instruct at least a strength movement Maybe a 60-minute window if you're looking to add some conditioning in there, okay? Keep these programs at two to three days per week Keep in mind how much these kids are already training right how many times they're already doing their sport specific work their speed and agility work there and They're engaged in a lot of things already. If you can keep your program very precise during days of the week, maybe a Tuesday, Thursday, or we have tried like a Monday, Wednesday, Friday, whatever works for you and your schedule, two to three days per week, 30 to 60 minutes is gonna be ideal for these kids, okay? GROUPING BY AGE Now, what age groups? You can't just, we have had not great success by throwing kids anywhere from six to 14 in the same room together, right? The development of those athletes at various milestones throughout their development is so wide and so different that you're not gonna have a successful class with that many different types of athletes. What I would recommend doing is grabbing kids from the nine to 12 group When they hit about eight, nine years old, they're really development enough, they're cognizant enough, they're engaged in the sport, they like what's going on. So if you can grab a group of nine to 12 year olds, and then maybe have another segment of like 13 to 16 year olds. I think those are two really good spaces where you're getting kids at various ends of development, and you're teaching them very different things. At the nine to 12, our strength work for them is really motor control. The stronger they get is really just more repetitions they've had doing that movement. And so we don't really need progressive overload for that group, we don't need barbell training precisely, but really bodyweight and dumbbell or kettlebell loads are going to be perfect for them. and use the load as the reward. So the key here is that, good job, Timmy. Your air squat is looking really good. Because it's looking really good, I want to give you this dumbbell. Hold this at your chest. You're one of the leaders in the class right now. Hold this dumbbell. Keep your squats looking good. So you're rewarding good movement mechanics with load. In that 9-12 year old range, using dumbbells, using kettlebells to instruct your major fundamental movements, your hinge like a deadlift, your squat like a goblet squat, and a press, a dumbbell push press, overhead press, PVC pipe if they need a lighter load. You're instructing that overhead full lockout position, you're instructing a squat pattern, you're instructing a hinge pattern. And for your older kids, your 13 to 16, if they have been with you and they've shown you some good movement patterns now, now we can start to add the barbell in here. Now we can say, good job on your air squat. Let's go barbell front squat. Let's go barbell back squat. Let's go barbell deadlift. Let's go barbell overhead press, strict, or push press. Team, if you don't feel confident teaching those movements, please take a class with us this year. In two days, Saturday, Sunday, eight to five on Saturday, eight to five on Sunday, you're gonna walk away being very confident in your ability to walk right back into the clinic, whether that's with one person or 10 people, and instruct these movements that need coaching. Okay, so if you feel like that's a gap in your game, it is so easy to sure it up. Just join me in a class, join Zach, join Joe, find one of the fitness athlete courses that's in your area, and we'll help you close that gap very quickly, okay? So that's kind of your range of strength movements that you want to focus your energy on. If you've only got a class that's two days a week, do one day squatting, one day hinging, or one day squatting, one day pressing, and just kind of flip-flop your order that you're programming those in. For the younger kids, using load as the reward. And the last thing that I would, well, excuse me, I got two more things. TEACH THE FUNDAMENTALS OF BODY WEIGHT MOVEMENT Teach the fundamentals of body weight movement. You've got to have these kids doing more push-ups. You've got to have these kids doing bodyweight lunging. You've got to have these kids doing some form of a pull-up. And that can be in the form of a ring roll if they're not strong enough, or an assisted vertical pull. But these kids need to develop upper body strength and core strength, do more planks, do more lunging, do more push-ups, do more pull-ups. do a lot of them. It is so easy to teach them really well and give them to them for homework. Like not enough kids are doing that. And I run into this problem year after year with my teens program is that their ability to do a really sound pushup is lacking. And we can have the debate on generation after generation of how bad that's gotten year after year. Ultimately, I don't care. I don't care to engage in that debate. What I care to engage is that what are we going to do with it now? And right now I'm seeing kids that can't do a pushup. So add the push-up, add the pull-up, add a bodyweight lunge, a bodyweight plank. We need to develop some core strength and some solid bodyweight resisted movements. So keep them as a really good accessory movement to the foundational movement that you're teaching that day. ADD CARDIOVASCULAR FATIGUE TO MAKE LIGHT LOADS CHALLENGING And then the last thing, here we go, is adding your conditioning to make the lighter loads you're using more challenging. If all you're giving little Timmy is a light dumbbell or a PVC pipe, by the time I get them done with a 100 meter sprint and then they go back and do this movement, you're going to see some more variability in their movement. By adding that little bit of conditioning, that little bit of metabolic or heart rate duress to the system, you're going to start to see some changes in movement pattern that allows you to coach and improve. Which, guess what team, you can argue this all you want, but that's exactly what they're doing in their sport too. They're getting their heart rate up, they're running around, they're crashing into their friends on the field or on the sport. Their heart rate is going to be elevated and we still need them to move well. So that's what we're doing in the gym as well. Get them on the rower, have them bang out a 30 second sprint on the rower and then get off and do their squats. Send them on a 100 meter sprint, come back in, let's do some deadlifting now. right? Utilize that assault bike. Hammer out 10 calories as fast as you can. Get off. Let me see your vertical overhead press now. Utilizing the conditioning component first to make the load and the weight training that's coming second even more Exposed even bring to light some of the deficits that they have in their movement And that's really where they start to learn how to move soundly under the duress of the environmental constraints and in sport, right? SUMMARY So teaching the foundational movements the squat the hinge the press and using them with lighter loads, dumbbells, kettlebells, with your younger group for motor control, repetition, and with your older group, emphasizing and adding in the barbell. Utilizing a 30-minute session of all you're doing is strength work, stretching it out to a 60-minute session if you're going to add some conditioning work in there, which I recommend you do. And then recognizing that, hey, when I add the conditioning component into the strength component, that's going to really expose a lot of areas that I can coach and develop these athletes in. And through that process, whether you're doing a couple eight week camps throughout the year, you're getting them in maybe right after school, you've blocked off an hour for this at an after school hour or in the evening at the end of your clinical day, you've got this little camp. that you can run this. You're gonna make a couple hundred bucks per kid, and you're gonna get a room full of 20 or 30 kids in there. It's gonna be lucrative for your business and for your staff that you're getting in there to run that. So I really would highly encourage that these PT clinics that have the means, that you have the equipment, that you have the shared gym space, that you're partnered up with a CrossFit gym right next to you, that you can talk to them about utilizing and running this camp through. I highly recommend that you start getting out there in the community. and helping these youth athletes prevent injuries, getting them stronger, and then getting them excited about working out. I mean, these kids are so stoked. The kids that we have in our youth programs, they can't wait to come back to CrossFit. Their parents tell me all the time about how much fun they're having. So, getting them excited about working out might be the biggest win overall. Yeah, if we can prevent a few ACL injuries, that's great. But if we can get these kids excited at a young age about exercise and working out and not seeing it as punishment or something that they have to do, I think we're starting to build a generation of kids that really look at exercise a much different way than maybe our generation has. So that's the key points that I have for you today, guys. Thank you so much for joining. If you're on the Instagram Live, I saw a few comments. I'm gonna circle back and read through those later. Thank you so much. But think about how you can implement that in the clinic. And again, if you have some weaknesses, if you have some gaps that you need shared up, jump into a Fitness Athlete Live course, and let's teach those fundamentals that we need, and then get you right back out there to make a change in the community. Have a great Friday, have a great weekend, and go kick some ass in the clinic. See you guys.  OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the role of the lat and its importance in functional fitness as well as his top three exercises to strengthen the lats. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. GUILLERMO CONTRERAS Good morning, PT on Ice, Daily Show. Welcome to the Best Day of the Week Fitness Athlete Friday. I am Guillermo Contreras on the teaching team within the fitness athlete division of the Institute of Clinical Excellence. My basement gym here. Today's topic at hand is lighting up the lats. One topic that we see most often discussed or looked at within the fitness athlete division, whether it be in the live course or the online course, is the idea of lat weakness. And also, right, we talk about very heavily how to cue engagement of the lats, right? We never wanna say engage the lats, but squeeze oranges between your armpits, pretend I'm not gonna tickle you, don't let me tickle you. And in essence, we want to be able to teach individuals how to better utilize, use, and strengthen their latissimus muscles. The best way we can do that is not only using the pull-up, which we teach in the live and online courses, but also giving some accessory movements. And the accessory movements are where most people tend to have the greatest amount of questions. What movements do we do? What can we actually use to strengthen it besides a standard lat pull-down machine or a seated row machine? Especially when in the fitness athlete realm, we don't have those pulley systems. We don't have a giant cable pulley machine. We don't have a big lat pulldown, seated lat pulldown, or a seated row machine. So being able to give really good accessory movements that individuals can utilize in the gym to improve that lat strength, that awareness of what their lats are doing, is really pivotal. in helping improve the quality of movement, the strength of movement, and the ability for our fitness athletes to complete what they want to be doing in and out of the CrossFit box. STRAIGHT ARM LAT PULLDOWNS So, quick anatomy review for you all, right? We know the lat originates right here on the front side of the shoulder, wraps down around into the low back, and then attaches itself through to the lumbar spine via the thoracolumbar fascia, which is why the pelvis can play a part in the position of the length of the latissimus as well. So with that, I'm gonna give three of my favorite or three of the best movements or exercises that I give, that I prescribe out for a home exercise program or within the clinic to help improve individual's lat strength and lat activation. Number one is a direct strengthener of the lat. It's just gonna target it, it's gonna help people feel it really, really well, and that is right here. It's a straight arm lat pulldown. And I'm gonna show two variations that this one can be performed, depending on, I would say like the level or the strength of the individual you're working with. We start simply by anchoring that band onto a pull-up bar or anything just above head height. We then take that band, we can hold it in both hands here, back away there so there's some tension. We get a nice forward lean, keeping that nice neutral spine. And then I simply keep my elbow straight and pull that band down to my hips. By keeping the arms straight, we ensure we are hitting that lat muscle by performing that shoulder flexion all the way to end range. And in this upward position, we are hitting that end range position of the lat overhead when it's fully lengthened like we would see at the bottom of a pull-up. A way that I progress this for individuals is by adding hip movement or combining that shoulder flexion with hip extension. Because as we extend the hips, we change the length of latissimus by letting the thoracolumbar fascia can relax a little bit more, contract a little bit more, and we get up to the top. This movement is called a lat prayer. Again, I don't know who named it, who comes up with the names of it. It's simply what I know it as, a lat prayer. And what that looks like is a very similar setup. I am here in this forward flexed position, hips back, arms at that end range. As I pull down on that band, I am bringing my hips up towards that band and come into a full contracted position of the lats. as I descend back down, I'm going to that fully lengthened position once again. So it's just a combination of movements. We can do this both as a smooth kind of movement, all occurring at once, or we can segment it as a pull to the hips with that straight arm pull down, and then a stand, return to the hinge, and then come back up. So that is your straight arm lat pull down. dosing that with some good amount of volume right this is just a a rogue blue band i think it's like a half inch or a quarter inch band, but it's got a nice amount of tension on it. I can do anywhere between like 15 to 20 reps, really feel that nice active muscular pump as I'm doing it, and it creates a lot of awareness in that shoulder. The lat is huge when we think of pull-ups. When we're doing kipping pull-ups, chest-to-bar pull-ups, butterfly pull-ups, whatever it is, we wanna have proficient strength in the lats to be able to maintain a stable shoulder and protect us from injury when we're dropping down to the bottom. So number one, again, straight arm pull down or lat prayer. However you want to do that, you can dose it out in different ways. BANDED KETTLEBELL ROW Number two is a unique one in which we use a kettlebell and then a band anchored to the rack or a rig. Here, we take that band and we put it around the handle of the kettlebell. It can also be around our wrist or something like that, or you can actually like attach it onto the kettlebell itself. Easiest way for me to set this up for my athletes is just to have it right around the handle there. And then we set up in the same way we would do a bent over row or a single arm row. So it can either be supported on a bench or a box. It can be in this kind of double leg hinge position here, or we can be in just our standard staggered stance position here. From here, forearm goes on the knee, take a hold of that kettlebell, pick it up. We then row back towards our hip. So I'm here and I'm pulling back to my hip and then letting it pull me forward. So the motion is more of a J. So I like to think of it that way. It's a J back up to the hip and then bringing it back down. So more of a curved motion of that row versus the standard kind of straight vertical row. or I guess you could say horizontal row. What this does is because it is now anchored, as I do that row, it's not a simple horizontal row where I'm just doing a little bit of an upright motion there. I am now getting a bit of a vertical pull force as well, where I have to actually pull against that band, up to my hip, and then back down. Up to my hip, and then back down. This is a really nice one because you can load it different ways. You can load it with a heavier kettlebell going 35, 45, 53, whatever weight you want to use for that weight. Or you can make it much tougher by going with a much heavier band. This is like the Rogue quarter inch band. This is I think like 15 pounds, 20 pounds of force, stress. But you can go much heavier attention on that band, make it much tougher. There, maybe you probably are bracing on something so you don't get pulled over. But this one, if you've never done it before, if you've never prescribed this for your athletes before, this works wonders. It hits that so much better than anything else you've seen. And it feels great. I think it feels really good. It's a very strong movement there. So that is a banded kettlebell row. Again, think of a curved pull towards the hip rather than a straight vertical row. And you're going to get much more of that lat activation as you come back. BANDED LAT SWEEPS The final movement, because we know that the lat is responsible for much more than just doing vertical pulling, It's also responsible for maintaining tension on the bar when we're doing deadlifts, Olympic lifts like the snatch and the clean. We want to make sure we're also training it to do those things. So this here is my favorite exercise for those athletes who struggle to find their lats, to find that armpit squeeze, that pinch, and we can cue it with something called a sweeping deadlift. This here is just a five pound kids bar, it's my daughter's, but we can also use a PVC pipe or a dowel, anything works fine. we take that bar or that PVC pipe, it goes in the band as well. So again, once again, it's anchored on a rack or a rig, something that's not gonna fall over on top of you. We move back away from that anchor point, so now we have some tension on that band. We then pull that bar towards our hips, and then we begin our movement. So here I'm going to bring my hips back, maintaining tension the whole time, bend at the knees, down to the bottom, And then as I come back up, I am maintaining tension, so I'm scraping my shins to my thighs, pulling through, and maintaining that tension there. And back up. We can obviously do this with different grips, right? So this would be more of like my deadlift or clean grip. I can go much wider, as wide as this bar lets me go, and go with more of a snatch grip, and then really focus on more of a snatch setup, or more upright torso, and really think, of going through that first and second pull as I come there, as I come here, getting tall with it, and continuing to use that tension to train how that should feel when I'm pulling that bar towards my body. So there it is, right? A nice recap. Three movements that I love to give my athletes who are struggling either with getting pull-ups or with shoulder pain because the lats might be weak and they're kind of dropping and crashing down in their kipping pull-ups or their butterfly pull-ups. One here, that straight arm pull-down, pulling down to the hips, keeping the elbow straight. Can I add in some hip motion to just really increase that tension and that full range of motion for it? that banded kettlebell row with a vertical and horizontal pull that's working together at the same time to really hit that lat musculature there. And then that sweeping deadlift for maybe my athlete that just really struggles to understand what it means to use their lat to be able to hold that bar close to their body to create more tension through their spine, through the thoracolumbar fascia to maintain a neutral spine when deadlifting, Olympic lifting with the clean, the snatch, et cetera. So there again, three movements that I love to prescribe out to my athletes for that there. SUMMARY If that was good, if you enjoyed learning those, or you're like, oh my gosh, I've never seen those before, never heard of those before, and you want to learn more, please join us on the road, please join us online. We have a number of courses coming up. We have our next course of Clinical Management with a Fitness Athlete, Level 1 course, or what used to be known as the Ascendant Foundations. That kicks off on January 29th. We would love to have you join us there. We do all things squat, front squat, back squat, deadlift, press, pull-ups. We learn how to program for CrossFit. We understand what it looks like to do a Metcon. It's a great experience, great course, especially if you're new to this area and you want to get more involved in the fitness athlete realm. And then our live courses, we have a handful coming up. Next week, we're going to be in Portland, Oregon, January 10th and 11th. We're going to be in Richmond, Virginia, February, I said February 10th and 11th, February 24th and 25th down in Charlotte, North Carolina, so hitting that East Coast. And then in March 23rd and 24th, we're going to be out West in Meridian, Idaho. So if any of those are near you, if you've been looking to take a live course, please head to PTOnIce.com, go to our live courses, check that out. And if you have taken these courses, and you're interested more in kind of just the exercise prescription realm, what do movements look like, these ones right here, there's a resource we have in our self-study courses section of the PT Honors website called the Clinical Management of the Fitness Athlete Exercise Library, over 150 exercises all different realms for deadlift, for squat, for pressing, for pull-ups, for gymnastics. Myself and Kelly Benfinger, the TA, worked really hard to send that out. We just came up with a new version 5.0, fully updated, that we'd love for you to use to help your athletes and have a really great resource for you. So gang, thank you so much for joining this Friday morning. Hope you have a wonderful weekend. And again, thank you for tuning in. We will catch you next week on the PT on ICE Daily Show. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty discusses treating the subscapularis muscle for the fitness athlete. Zach discusses modifications for pressing, pulling, and Olympic weightlifting. In addition, Zach discusses go-to exercises to use for HEP with these individuals. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show, where it is not only the PT on Ice Daily Show, but it is the best day of the week here on the PT on Ice Daily Show, and that is Fitness Athlete Friday. I'm excited to be with you all this week. My name is Dr. Zach Long. I'm a faculty member inside of the Fitness Athlete Division, teaching both our live and advanced concepts course with the rest of the team there. Today, we are going to talk about subscapularis treatment with the fitness athlete. So the subscapularis muscle, I think, gets commonly overlooked in the fitness athlete's shoulder. Alan talked about it last week, so I'm going to follow up his discussion last week with a few other things. But like Alan said last week, this is the largest and strongest of the rotator cuff muscles, and I think it commonly gets overlooked when people are dealing with shoulder pain. And so we're gonna jump into kind of some of the different modifications and treatment strategies that I use when patients have subscapularis pain. Make sure you listen to last week's episode as well. A little quick recap of last week's for you just to set the stage here. SUBJECTIVE EXAM FOR THE SUBSCAPULARIS Subjectively, what I hear most frequently when people are dealing with subscapularis strains are that they have pain with dips, pushups, and the bench press, so with shoulder extension-based pushing motions. And then things like snatches, overhead squats, and kipping pull-ups, where their arms being really stretched overhead in that position. OBJECTIVE EXAM FOR THE SUBSCAPULARIS Alan talked quite a bit last week about testing positions for the subscapularis, and those were absolute gold for ruling in and out the subscapularis. I'm going to throw one more test at you before I move on to more of the treatment stuff. And I like this test because As Alan talked about last week, when you do like IR at neutral, the pecs are such a big muscle working right there that it's not going to be sensitive enough on your subscap. So that's why he talked about like the liftoff test in your arm. The one kind of issue that I have with the liftoff test, I use it with all my subscap people, is for those that are highly sensitive and you know that they're already really irritable, I find at times that just getting into that position really lights them up. So the test that I prefer to start with is that internal rotation at neutral, but we get rid of the pec involvement a little bit. So imagine somebody standing with their elbow right at their side, elbow bent to 90 degrees. You then put one of your hands outside of their lateral elbow and you have them push out like they're doing a lateral raise. You don't let them actually push away from their body, but they're trying to. And then you test internal rotation resistance with the other hand. And you'll find that that little lateral raise push gets rid of a lot of the peck involvement in there and will let you get a positive test for a lot of people that have a subscap strain that your standard IR at neutral would not. SUBSCAPULARIS TREATMENT So let's jump into treatment a little bit and modification. I'm going to say number one, from a manual perspective, like if you made me choose only one area of the body to needle for the rest of my life, and you said you can only needle one thing for forever, choose what muscle. Now this might just be because I treat primarily shoulders, hips, and knees in the clinic, but I would choose subscapularis dry needling over every other area of the body. It has just been the area that I find most frequently gets huge improvements in their symptoms after a quick dry needling session. So if you're not familiar with that, look up Paul iDryNeedle. Paul runs our dry needling division along with Ellie. and the great faculty that we're building over there, but check out their coursework. That is just a money technique to have. From a treatment perspective, so much of my treatment with this comes down to the combination of wanting to build the subscap up, but also wanting to make sure we're not continually overloading the subscap. So I have a lot of conversation with my patients on what sort of modifications they need to be making to their training to not further aggravate the subscapularis. And so, All of these are obviously based on somebody's irritability. So when they strain their subscap, if it's very, very minor, I'm not pulling all of these levers, but if it's very major, I might be. And as y'all know, our goal with the fitness athletes and all of our people in general is to keep them active. We don't want to tell them, stop benching, stop doing pushups, stop doing dips. We want to find ways for them to do those movements or similar movement patterns with less pain. So that's breakout kind of where I kind of go with modifications. MODIFYING HORIZONTAL PRESSING So if we start with like our horizontal pressing motions, which I think are the most common things that I hear people with subscap strains discuss subjectively, that's the dips, pushups, and bench press. I think the reason why those hurt so much is as we take the shoulder into extension, I think you can appreciate as your shoulder goes into extension that you're gonna create a little bit of compression on that anterior shoulder. And as we know, tendons don't like compression. So I think that's why extension is so irritable for these individuals. So one thing that I find myself doing more than anything else in people with subscapularis strains is I actually have them stop doing dips. And we end up replacing dips with, with push-ups or banded push-ups or some variation that doesn't take the shoulder into quite as much extension. When push-ups are pain-free, then we start moving back to dips. But generally, I find that dips are going to be really painful if the push-ups still hurt at all. So that's kind of a general rule of thumb for progression there on the dips. In terms of the pushup and bench press, I find that the most valuable thing we can do for people in terms of modifying is to just adjust the range of motion a little bit. So for the pushup, kind of the two modification, three modifications I make there are a lot of times I have individuals do a pushup down to an ab mat. So that ab mat's just gonna, they touch their chest to the ab mat instead of the floor. We reduce that range of motion, maybe an inch and a half or so with the ab mat there. And so frequently that is enough that we can now still do the prescribed workout with just that slight modification to the range of motion. Other times I find that having them really torque their hands into the ground or keep those elbows close to their side and making it a little bit more like a close grip pushup can help them out quite a bit. From a bench press perspective, very similar. So maybe instead of bench pressing, we do a floor press or a board press. So a floor press is simply a bench press where we're laying on the ground. So when the elbows get to our side, they hit the ground and you can't actually take the arm into extension. That can usually be enough that people can still press really heavy. The floor press is one of the best exercises you can do by far to improve your bench press strength, so it's a great modification in this time period. We can also do a board press where they're on a bench, but they go down and they touch one, two, or three 2x4 boards that are placed on their chest to reduce the range of motion. And then very frequently I also have, especially with more like my power lifters or people that care about bench pressing a lot, I'll use accommodating resistance. So maybe with a lightweight, they can touch their chest and not have that much pain, but if it's really heavy and they touch your chest, they get pain. So that's resist the bench press with bands so that at the bottom, those bands are unloaded a little bit, and then that weight increases as they go towards lockout. So that's a great way to really challenge the lockout, still train full range of motion, but not irritate that already irritated subscapularis. So the big key there is to probably reduce the range of motion a little bit and play with some of those variations to see if you can get people to not continually aggravate the subscapularis but still get in that horizontal pressing stimulus. MODIFYING KIPPING When it comes to kipping-based movements, so toes-to-bars are one that really tend to aggravate the subscapularis, I see quite a bit. I will Usually prefer to just get people to do a really tight kip where they maintain a lot of tension and they don't go into as aggressive an arch position. That is actually a performance advantage in the toes to bar. People will cycle their toes to bar reps a lot faster. So this is a great time to make people do smaller sets because a lot of times they'll fatigue more rapidly with this. but to actually work on a technique improvement that will help them out long-term. So those quick cycled reps with a little bit more tension. If it's more irritated, then we might just do an active hang, knee raise of some sort so that we're still getting the hanging stimulus. We're still getting the ab stimulus, but we're just reducing a little bit of the shoulder demands. And then when it comes to things like kipping pull-ups, if it's highly irritable and I don't feel like kipping is in their best benefit right now, we just turn that into strict band-assisted pull-ups that we maintain that high volume of the vertical pulling stimulus. We maintain those fast reps that keep our cardiovascular system up if we're talking about prescribing kipping pull-ups in a Metcon, but it will unload the shoulder just a little bit to do a strict band-assisted pull-ups versus kipping when somebody has a subscapularis strain. MODIFYING OLYMPIC LIFTING And then the final thing that I often modify is their snatches. So frequently, it's the turnover and the catch of the snatch that really irritate these individual symptoms. So at times, that just means we move to variations where we're not doing the turnover or the catch. So we're doing snatch grip deadlifts, snatch grip high pulls, snatch grip pulls, exercises like that. So we're still building their technique. and working on things that will help their snatch overall. But again, we're just not adding more fuel to the fire there. So that's the main modifications that I make when somebody has subscapularis pain. TREATING THE SUBSCAPULARIS: LESS IS MORE Let's jump now into treatment. And I think from a home exercise perspective, one thing that I'm really big on is that less for your HEP is more. We don't want to overload our patients. So a huge percentage of my patient population at this time are people that are seeing me for a second opinion. And I kind of see three things most commonly pop up when people see me as a second opinion. Number one, they were just underloaded. They didn't get a sufficient enough stimulus, their therapist was on the right diagnosis, but they didn't challenge them enough to actually build tissue strength up. Number two is they're on the wrong diagnosis, which we all see all the time. Somebody thought, you know, that because this person's pain was on the back of their shoulder radiating down to the tricep, they assumed that it was a posterior rotator cuff pain and they didn't do a great job screening out the subscapularis with the tests that Alan talked about last week and I talked about earlier. And so they're treating posterior rotator cuff when it's really the subscapularis instead. And then the third thing is people come in and they have an HEP list of eight exercises that they're doing for three sets. And I look at that and I'm like, man, that's going to take 40 minutes to get done. Less is more here, folks. So the rule of thumb I have here is that my goal, sort of like your post-op ACL that needs a full strength program, My goal with most of my individuals is to try to limit their HEP to 10 or 15 minutes or less, four-ish days a week. I think that that's pretty manageable for most of our people. It gets really crazy when you're asking people to do 30 minutes of work every single day. So to get this done in 10 minutes or less, that usually means that I'm trying to stick to three exercises, maybe four. So in the subscapularis, maybe they do some soft tissue work on their subscapularis. That's one minute. And then we do a nine minute EMOP. So that's 10 total minutes of work. We add in grabbing equipment. They get this done in less than 15 minutes. Less is more with these individuals. Try to really stick to that. And I think you'll see your HEP compliance go up quite a bit. So three exercises, less than 15 minutes, preferably less than 10 minutes is my goal. When I'm looking for exercises, I kind of have four different exercises that we might have in those three of their HEP. Number one is going to be obvious. Like if they have a subscapular strain, we're doing something to try to build that muscle and tendon backup. It would be way too hard for me to really describe these exercises here on the podcast, but if you go to my YouTube channel, Barbell Physio, you can search for all of these exercises. But kind of my general progression here, highly irritable. I'm doing internal rotation at neutral, but I'm going to do it similar to how I did the testing. So I take one band and I'll put it around their arms. So one big resistance band going around both arms. So they have to do that little lateral raise before they do the internal rotation. I'll find that that again isolates the subscap a little bit more than the pecs. Progress that to an IR punch. Progress that to an IR diagonal. Progress that to IR at 90 degrees. That's my general philosophies there. So number one, load the subscap. Number two thing to have in that HEP is to look at any mobility limitations that they might have. Like is their overhead positioning stiff? Is their Tyler test for that posterior shoulder capsule stiff? Do they lack shoulder extension? Does their thoracic spine suck? Does something as far away as their ankle mobility suck? And that's putting them in suboptimal positions for things like overhead squats or snatches. So the second component there is to dial in their mobility, The third component is lat strength. So the subscap and lats have a lot of similarities in terms of their function, but I'd say overall for the athlete doing rig-based gymnastic skills, when they have lat weakness on board, the rotator cuff ends up taking on more of the stress of those movements. I call the lats the glutes of the upper extremity. What happens when somebody has weak glutes in athletic performance? They strain their hamstrings more. They tweak their back a little bit more. Their performance overall goes down. Strong lats are so important to the fitness athlete population. So make sure you're thinking of that with individuals. That's number three on people with subscap strains is to load their lats up. 4. Something to pump a ton of blood into the shoulder tendinopathy, whatever you want to call it. And lateral raises don't bother their shoulders. So we do something like an internal rotation diagonal to directly load the subscapularis. Now lateral raises don't hurt, but we know lateral raises are going to challenge the deltoid quite a bit. They're going to challenge the supraspinatus. Those muscles are all around the subscapularis. So if I then have them do a set of 15 to 20 lateral raises, I'm going to pump a bunch of blood to the shoulder. What happens when we pump blood to an area that's currently injured? We help with inflammatory chemicals that are sitting out in that area. We help with, you know, an overall endorphin release. We just make everything feel better when we add a little bit of blood pump to an irritated area. So that's make that be our final exercise in that little EMOM for them. So I hope those modifications and HEP discussion help you out a little bit more when you see subscaps. Again, make sure you go back and check out Alan's episode. He did a great job discussing internal rotation and shoulder extension and why that's so important in this population as well. Hope y'all have a great Friday and a great weekend, and we'll see you here next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses assessing & treating for issues related to shoulder internal rotation & extension limitation with overhead movement in the fitness athlete. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning's off to a great start. We're here at Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently, I have the pleasure of serving as the Chief Operating Officer here at ICE and the Division Leader in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things fitness athlete, CrossFit, Olympic weightlifting, powerlifting, endurance athletes, and any recreationally active person. we talk about how to address those concerns. I have Dr. Haley with me here today. She's going to be my demo for some hands-on stuff. If you are listening to the podcast right now, I don't know why I pointed to my ear. If you're listening, you can't see me anyway. If you're listening, please switch over to our YouTube channel and watch the video because about halfway through, I'm going to show a lot of hands-on assessments and techniques, and you're not going to be able to see that if you are just listening on the podcast. SHOULDER INTERNAL ROTATION & EXTENSION: ANATOMY Today, what are we talking about? We're talking about the combined motions of shoulder internal rotation and extension in the shoulder, especially its relevance to the fitness athlete. So when we talk about these motions, we're primarily talking about the subscapularis muscle of the rotator cuff and the shoulder blade. So this muscle gets neglected a lot, mainly because most human beings no longer exercise, which means they are no longer vertically pulling and pushing above their head. So they're often not needing to use a lot of internal rotation and extension of the shoulder because they live their life with their arms relatively neutral. But if we look at the actual anatomy specifically of the subscap muscle, we know it is actually the largest and strongest rotator cuff muscle. It takes up the whole anterior portion of the shoulder blade on the anterior side of the scapula and is primarily responsible, yes, for internal rotation, but when the arm is elevated or out in front of the body, It also performs some combined motions of adduction and extension. It functions very similar to our lat muscle. So we have our subscapularis and our lat muscle counteracting all the other muscles of the shoulder and the rotator cuff that elevate our arm above and overhead. Most importantly, from the anatomy is knowing the attachment points. It attaches right on the anterior capsule of the shoulder. And when we see referral pattern, we can see anterior shoulder pain, folks point directly to a spot right on their anterior shoulder. But it also has referral into the posterior rotator cuff and into the medial scapular border. So a lot of times we can chase treating the posterior rotator cuff, especially in the fitness athlete when we actually need to be treating subscapularis. SHOULDER INTERNAL ROTATION & EXTENSION: ASSESSMENT Now how do we know this is a target for treatment? Well that's going to be revealed in our subjective and objective exam. So when someone comes in and I'm gauging their symptom behavior and I'm getting a list of their eggs and eases, especially with a fitness athlete, I'm looking to hear things like pain with dips, pain with bench, especially in the bottom position of a bench press, things like pain in the turnover, or what we call the catch of a bar or a ring muscle up, handstand push ups, again, especially the lowering the eccentric phase, where we're now going from an overhead, flexion, abduction, external rotation. And now we're lowering eccentrically into extension and internal rotation, very similar to the bottom position of a bench press. And then in that pull, that high pull motion that we have in our cleans and snatches with Olympic weightlifting. So when I hear aggs like that, my hypothesis list subscapularis jumps up. I'm looking to assess internal rotation and extension in that athlete, much more so than that sedentary person who comes in and complains of shoulder pain. I'm really not thinking this person is probably having a lot of issues with loaded internal rotation extension in the gym. because they don't go to the gym, right? That is a person where I'm probably going to look to the posterior rotator cuff and maybe the lats for strengthening and the delts for strengthening and just basically get that person's shoulders stronger versus specifically addressing a specific muscle like the subscapularis, which I would with a fitness athlete. So let's talk about how to actually assess the shoulder. So I have Haley here. We're going to demonstrate on her shoulder. You're all probably very familiar with this seated screen. It's something you learned in school. We're going to go through it really quickly. So having Haley lift her arm up and overhead and sitting to look at flexion, coming out to 90 degrees to look at abduction. We can meet in the middle and look at scaption at that 45 degree angle like that. We can put our arm at our side and now we can look at extension. And then we can hold our arm at a side and we can go across the stomach, internal rotation, and then out away to look at external rotation. Now what do we like about that screen? It's a screen, that's it. I hate almost all of that for the fitness athlete. Why? It's really not challenging a lot of true end range positions, especially of extension and internal rotation. The main thing to remember about internal rotation is if Haley's arm is at her side and she's internally rotating, she can palpate on herself. When the arm is at the side, the pec is the main mover there. It's not actually subscap or the deltoid at all. So when the arm is at the side, we're not even challenging actual internal rotation. We're using nothing about the subscap at all. Likewise, if we're seated and we're going through extension, I need to know how can I challenge sheer force to the shoulder like it might encounter in a bench press, a muscle up, a handstand pushup. I can't do that in sitting. SHOULDER INTERNAL ROTATION & EXTENSION: DITCH THE SEATED EXAM So for fitness athletes, we need to ditch the sitting exam and we need to go prone for the shoulder. So I'm gonna have Haley lay on her stomach here. We're gonna look at her left shoulder. We're going to look at internal rotation first. So I want her arm out at 90 degrees, about parallel with her shoulder, and I'm going to instruct her to bring her palm up towards the ceiling. And I want to look at that internal rotation. So we're cheating a little bit here, a little bit of abduction, but we have a really good assessment of internal rotation here. I can overpressure this as well. Haley, don't let me put your hand down. And I can look to see if that's symptom-provoking. So that is how I will assess internal rotation. Is the motion full? Is it provocative with an overpressure test? We can also look at extensions. I'm going to have her scooch a little bit to her right. She's going to bring her arm up at the table next to her side, and then she's going to lift her arm up in the air. And I'm looking to see, again, does she actually have full straight plane extension, or does she drift out into a lot of abduction? Good motion here. Same thing. I'm going to overpressure this. Don't let me push you down. And I'm going to see, is that symptom-provoking? So I'm going to challenge extension in a manner where gravity is providing sheer force through the labrum for me to see if that's provocative. And then I'm also going to overpressure the arm to see if I can overpressure and get any symptom provocation out of the shoulder. The last test that I will do is I'll have Haley stand up and then she's going to turn her back to the camera. We call this the liftoff test. It's also called Gerber's test. Very old test, almost 30 years old now. Tons of great research on it. So I'm going to ask her to pick a hand and I'm going to have her put it in the small of her back. And really I'm going to see how far up her back she can go with that hand. So can she go any higher? Good. Some of you might measure range of motion this way. That's great. I usually see what level of the spine can the thumb get to. Very functional for women, right? Somebody that can't even put their hand in the small of their back is probably going to have a lot of trouble with something like taking a bra on and off. But we get a good measure of range of motion. We know that if she can reach the small of her back, we're primarily now looking at subscap. A really good study by Greece and colleagues way back in 1996 found that if someone can get their hand in the small of their back versus down at their glutes, that just by getting it higher to the low back, we can get 33% more subscap activation. So I know if a person can achieve this position, they have really good range of motion out of that subscap muscle and that we're primarily now looking at subscap in isolation. What do we do now? We do the actual lift off. So I'm going to have Haley lift her hand away. She can lift her hand away and keep it approximately in the small of her back. And then if that's not pain provoking, at this point I am confident in ruling out subscap. Why? This test has 99% sensitivity. If that is negative, I can cross subscap off my hypothesis list and now I can look a little bit deeper into the shoulder. All of that has only taken us eight and a half minutes with a lot of talking. This is something you could probably do in a minute or less in the clinic and immediately rule out the subscap and be really confident that it's not the subscap. So, Haley, go ahead and have a seat. SHOULDER INTERNAL ROTATION & EXTENSION: TREATMENT So, what if it is a subscap, right? What if somebody like me walks in, my left shoulder looks okay, my right does not, Immediately I'm thinking I know which side I'm going to treat. I know which muscle I'm going to treat. We're going to talk about treatment next week. Zach Long is going to get on here. But the main thing is we need to restore that internal rotation range of motion, especially under load. Why? These folks are using this range of motion in the gym or they're trying to use it, which is maybe why they're bumping into symptoms with things like handstand pushups and Olympic lifting and muscle ups and that sort of thing. So we need to restore that full internal rotation range of motion. we need to increase its load tolerance, and we need to, in general, get the shoulders stronger, both delts and lats. But specifically, working on the subscap is going to give a lot of benefit to that athlete. So someone like me, I would needle my own right subscap, try to improve some of that range of motion, and then try to load that internal rotation. We'll talk more about treatment next week with Zach. He's gonna do a follow-up episode specifically on how to treat the subscap for the fitness athlete. So make sure you tune in next Friday. That's all we have for you today. I hope you have a fantastic weekend. Courses coming your way. Head on over to ptinex.com. Remember, all of our courses priced at $6.50 will become $6.95 on Monday. So if you have a course on your list, make sure you buy it over the next couple days and avoid that price increase. All of our courses from the fitness athlete division are on PTONICE.com. Hope you have a fantastic weekend. Have a wonderful new year. See you next week. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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 to adapt the @concept2inc rower for patients & athletes who cannot use both legs, both arms, or seated athletes. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALLAlright, good morning everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Fitness Athlete Friday. We talk all things CrossFit, Powerlifting, Olympic Weightlifting, Endurance Sports, Triathlons, Marathon Runners, Cyclists, figure skating, all that wonderful stuff. If you are working with a person who is recreationally active in the gym, on the road, whatever, Fitness Athlete Friday is for you. Today, we're going to build upon an episode from three weeks ago, introducing you all to the Concept2 Rowing Machine. We're going to build and show you how to adapt this machine for a lot of different folks who might show up in the gym or in the clinic, post-op, adaptive athletes, all that sort of thing. Before we get started, just a heads up about courses coming your way from the fitness athlete division. Your next chance to catch us online for our level one course, online course, eight weeks, entry level course previously called Essential Foundations will be January 29th. So our Clinical Management Fitness Athlete Certification, Level 1 online, prerequisite for Level 2 online, that class begins February 5th. And then our live seminar is its own standalone event. Those are all over the country this coming year, so check out PTENICE.com and look for Fitness Athlete Live for courses coming near you. And then check out our two online courses beginning in January and February. Just a reminder, all of our courses currently priced at $6.50 will jump to $6.95 on January 1st. And really, we don't want to pressure you, but most of our quarter one courses, live and online, are selling out. Our pelvic level one online course just sold out yesterday, about a month in advance. So we're seeing about a three to six month sell out window currently. So if you had an eye on a course, we'd recommend grabbing it sooner rather than later, especially if you can take advantage of saving some money on that price increase. So that's courses coming your way from the fitness athlete division. ROWING 102 So before we get started, I'm going to show a lot of stuff today. So if you are listening on the podcast, and you are a visual person, or you're not very familiar with the rower, I would recommend you stop the podcast, you jump over to our YouTube channel, and continue watching this episode here on YouTube so you can actually see what I am doing. So I'm going to reference two previous episodes as we talk about today's topic. So we're going to get into some advanced mechanics of the rower, how to adapt the rower with different equipment. Go back three weeks, episode 1606, where we talked about the very basics of the Concept 2 rower, how rowing works mechanically, how to put yourself in the best mechanics to row, how the rower itself too works as far as what are the different pieces of equipment, how to clean them to make this machine last you, 10, 15, 20 years, and then also how to use very basic things on the rower like drag factor to understand where you should place your damper on the flywheel, again, to optimize the very basics of rowing. I want you to go back two weeks to Guillermo's episode, episode 1611, to learn a little bit about how intervals, he specifically talked about research on assault bikes, but how intervals on earth machines in a very small time window, two to three times a week, for eight to 20 minutes of work can have a significant increase on VO2max. So never forget, when we're working with patients, working with athletes, especially those folks already active, at the very least, we can help them maintain their current level of fitness, being intelligent with how we use machines, how we adapt the machines, and that's the point of today's episode, of how to adapt these machines. So folks coming in, they can only use one arm, they can only use one leg, they're pregnant, they're postpartum, whatever, how can they get on this machine and at least maintain their fitness as we work through their rehab. 1-LEGGED ROWING So I want to talk about how to set up the rower to row with just one leg. I want to set up the rower and show you how to row with just one arm. And then I want to show you what many people don't know is that the rower actually breaks down in half. Yes, to make it easy to store, but also to get rid of the rail so that seated athletes in a wheelchair can roll up to the rower and row on a Concept2 rower. So the first thing I want to show is very simple, one-legged rowing. So what you're going to want is one of these little things. If you've ever changed your own oil on your car, you know what these are. These are little caddies that roll underneath your car. So they have wheels, six axis, they move in any direction, and they're mainly designed to hold tools and stuff if you're working underneath in your car. So you can get these at an auto parts store for 10 or 20 bucks. You just need one of them and they'll last forever. Alternatively, you can also use a skateboard or something like that. But what we want is we want something that we can place someone's foot inside of that moves, ideally moves what we call six axis, right? Forward, backwards, side to side, and then each diagonal, right? It can potentially move 360 degrees so that as a person rows, their foot can move alongside the rower. So let's set that up. So for example, let's say I can't use my left leg, maybe my left leg is locked in a knee brace, I'm locked in full extension, maybe after ACL reconstruction or something, I can still get on the rower and row with one leg. So I'm going to get on my rower, I'm going to strap in, grab the handle, Until my wife was on the rower last, she cinched the straps all the way down. And now, instead of putting two feet in, because I can't bend this knee, right, it's locked in extension, I'm going to kick it out to the side of the rower, and I'm just going to let it rest in this whale caddy. Now, I can still more or less perform all of my normal rowing mechanics. I can still drive with my right leg, I can still lean back, and I can still pull with my upper body. So this is fantastic, folks maybe working with an amputation, folks locked in a brace, maybe folks that just can't tolerate that loaded knee bend, knee extension with that leg for whatever reason, we can have them still row using something like an oil caddy or a skateboard. So that's one leg rowing. 1-ARM ROWING Now, one arm rowing is totally possible. You're going to want a device like this. This essentially just looks like a hook. You can get this from Adaptive Training Academy. So if you don't know Adaptive Training Academy, we highly recommend them. They have a wonderful course on basically adapting all things fitness for adaptive athletes. So it's a course that has its origins with CrossFit, but now has expanded into the rehab community as well. How rehab providers and fitness professionals can work with adaptive athletes to get them moving, keep them moving. They have a wonderful store full of all sorts of really, really, really cool things to help you work with adaptive athletes. And this is one of the tools they sell. So these hooks are going to latch on to the handle of the rower, and they're going to allow me to row with one hand. If you'll notice on the rower handle, in the middle, it has places technically to row with one hand, but they're not very comfortable. you need to essentially weave your fingers through and then you have the metal chain kind of bashing against your knuckles the whole time you're rowing with one arm. It's also very wide, so you'll sometimes see people row with a neutral grip and that's just not very mechanically advantageous. This is designed to improve that. To bring the handle in so that I can grab it with one hand, I can technically even hook grip this to really get the most out of my grip on my right arm or left arm and row to my chest and maintain my normal rowing mechanics. This is also fantastic for pregnant women who maybe don't tolerate the flexion on the rower anymore because of their stomach or the extension because of the stress it places when they lean back. What's great about these is you can build them on each other and you can essentially reduce the range of motion needed to reach towards that handle. So this can even be great for kids to get them on a rower at a younger age or maybe they literally don't have arms long enough to reach the handle, we can bring the handle to them. So I'll show you what that looks like with one arm rowing. So sitting in the rower, taking the hooks, latching it onto the handle, and now it's reduced the range of motion by about six inches towards me. And now with one arm or the other, I can pull and I can maintain all of the same mechanics of rowing. with one arm. I'm still able to drive with my legs, lean back, and pull the handle to my chest. Again, if needed, I can put another one of these on here and continuously bring that handle closer to me. So this hook is available again from the Adaptive Training Academy store if you want to pick that up for your rowing. DISASSEMBLING THE ROWER FOR SEATED ATHLETES/PATIENTS The final piece is breaking the rower in half. Again, a lot of folks don't know that the rower actually disassembles into two pieces. That's to make it easy to store. It's totally possible to break this rower in half, and if you have a larger car, an SUV, certainly a truck, you could take the rower with you, maybe if you're a home health clinician, and bring it into people's living rooms. it is made to break in half and all things considered once it's broken into half it's not very cumbersome and it's not very heavy. So let's talk about how to do that and then adapt that for the seated athlete. So right here at the base of the foot plates you're going to see a black piece and you're going to see a little handle to lift up. If I lift this handle up you'll see that the rail of the rower is just sitting on metal rod that's connected to the flywheel and the computer portion of the rower. So if I lift this up, I can now disassemble the rower into two pieces. So now the rails here, this weighs almost nothing. This weighs a couple of pounds. Again, this would be very easy to throw in the back of an SUV or a truck. The heavier part, of course, is going to have the damper and the flywheel, and all of the computer parts, but now I have the front part of the rower. Now I can have somebody in a wheelchair roll up to this. We can play with different variables. In the gym, we like to lift it up a little bit, and we like to put sandbags or plates to anchor it down, and we like to sit it on some sandbags or plates. So depending on the type of wheelchair that your patient or athlete has, you may need to bring the rower up a little bit so they can roll up, get into a good position and row. And then definitely, because it's no longer as heavy as it once was, you're going to want to make sure you weigh it down so that as they begin to pull the handle, this thing doesn't move around. But with a little bit of ingenuity, this is something you could even bring into someone's home, maybe wheelchair bound, where they're able to row, maybe do some intervals on the rower. So make sure you understand that the rower breaks down. This also makes it really easy to store rogue fitness. So you can see one over here in the corner, my bench is hanging on it. They make hangers that can be mounted to a wall that can hang either benches or it's designed to hang the front part of your rower off of. If you're thinking you're in the clinic and you don't have room on the ground for a rower, that's okay, you don't need it. You can break the rower in half at the end of the day and you can hang it on the wall. So make sure you understand that the rower breaks in half. That's made for storage, for travel, but also really important to make sure that we can get seated athletes using a rowing machine. So rowing, this is a very versatile piece of equipment. Make sure you understand how to use it. Make sure you understand that you know how to adapt it for different patients and athletes that present to you in the clinic in the gym and get more people rowing, get more people working on or maintaining their current level of fitness as you help them through the rehab process. I hope this was helpful. I hope you have a fantastic weekend. Our very last live course of the year is this weekend. It's happening right now in Salt Lake City. It's a dry needling course with Ellis and Melrose. So if you're there, I hope you have a fantastic time. Other than that, I hope you all have a wonderful Christmas, a very happy new year. 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.

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long discusses Testosterone Replacement Therapy, including research supporting its use, side effects, understanding dosing, and common clinical presentations related to TRT use. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show. It is Fitness Athlete Friday, the best day of the week here on the podcast. I'm excited to be with you as your host, Dr. Zach Long. And today we're going to talk about a topic that's a little out there, like it's not something we talk about a whole lot in the profession, and that is testosterone replacement therapy. And we're going to discuss four or five things that I really believe that those of us in outpatient orthopedics need to understand about testosterone replacement therapy because you are for sure seeing these patients in your clinic with certain conditions and being aware of a few things will help you out clinically. Before we jump into that topic, upcoming courses that we have inside the fitness athlete division. Our live course is, we have one more for the end of the year. That's Colorado Springs, Colorado this weekend. Mitch will be teaching that. If you can't make it to that in quarter one, we will be in Portland, Oregon, Richmond, Virginia, Charlotte, North Carolina, and Boise, Idaho. So check out those courses, pglnice.com. We also have our advanced concepts course. We'll be going live at the beginning of the year. That course always sells out. If you've already taken level one, you can jump into the online level two, but that sells out. So you want to look at jumping in and booking your spot as quickly as possible. TESTOSTERONE REPLACEMENT THERAPY Let's jump into testosterone replacement therapy and what physical therapists need to know about that. Testosterone replacement therapy is injecting testosterone into your body, which is the male sex hormone, prescribed by doctors at times to treat hypogonadism. We've seen a giant increase in the number of people and the acceptance of people being on TRT in the past few years and I think that's why it's so important for us to understand that because so many individuals are now when they you know get into that 35 40 50 year old age range where their libido goes down a little bit. They stop improving quite as much in the gym as they used to. They start to have a little bit more general fatigue, anxiety, et cetera. We're seeing more and more men jump on TRT. I found a research study from 2017 looking at the rates in the US population of people being on TRT. And in 2017, they estimated that between 1% to 3% of men were on testosterone replacement therapy. which that number was a threefold increase in the number of prescriptions of TRT from 2007 to 2017. So threefold increase in those 10 years. And I would even say since then, in my opinion, it has become more popular or at the very least more accepted. Back in 2017, you wouldn't hear a whole lot of people talk about being on TRT. And now I feel like I see it all the time. I see big time influencers talking about being on TRT. all the time on social media, when I'm talking to people at the gym, they're regularly talking about their doctor just put them on TRT, whatever. So there's a lot less stigma around it and there's a lot more people getting on it. And I think that's really important for us to understand because there are gonna be a few things that we see in the clinic in people that are on TRT. And so asking this question more frequently to your male patients, especially that are between the ages of say 30 and 50 years old, is going to change a few things that you might be thinking of clinically. So three-fold increase in those 10 years and probably a little bit more than that. Another really interesting study that I found with testosterone replacement therapy was this study called Testosterone Dose Response Relationships in Healthy Young Men. So this was a really cool study where they took individuals that had previous resistance training experience and they told them that they weren't allowed to exercise during this six-month study. So If they've done previous resistance training, we kind of know that they're going to be through their beginner gains, their newbie gains in the gym where they would have really easily put on several pounds of muscle. So these aren't people that you're going to expect to see drastic increases in muscle mass in a short period of time. especially when they're not working out. But what they did in this study was for six months, they put these men on testosterone replacement therapy at different dosages. So the dosages were 25, 50, 125, 300, and 600 milligrams of testosterone for 20 weeks. So a wide range of doses from 25 milligrams a week to 600 milligrams a week. And they looked at a number of different things, such as their fat-free mass and their leg press strength, and then a number of other different physiological factors. But I'm gonna focus on those two, mostly muscle mass here. So again, we wouldn't expect these individuals when they're not resistance training, but having had previous resistance training experience to gain a lot of muscle mass in this time period. But what they found was that the group on 125 milligrams a week during those six months gained six pounds of muscle on average. The group at 300 a week gained 12 pounds of muscle mass on average and the group at 600 milligrams a week gained on average 19.5 pounds. So a lot of increase in muscle mass during that time period, especially when people aren't doing any resistance training. UNDERSTANDING TRT DOSAGE And so I bring those dosages up because I think that's one really important thing when you have a patient on testosterone replacement therapy, I want to know what that dosage is. So when you're treating hypogonadism, less of this like people getting on TRT to try to improve their sports performance, their aesthetics, their strength, et cetera. What you tend to see is much lower doses in terms of testosterone replacement therapy. Like getting on those low doses under typically 200 milligrams a week is what you'll see a lot of doctors prescribe here. And that's going to do a lot to help improve libido and anxiety and other symptoms like that of hypogonadism. But when you get to that 125 milligrams a week, that's when we start to see a large increase in muscle mass. And what you'll often hear referenced by doctors prescribing TRT is sports TRT dosages versus hypogonadism dosages. And the cutoff there that you'll hear most people discuss will be 200 milligrams a week. So when you're taking 200 milligrams or more, that's when you're getting into a bit more of the sports performance arena than just purely addressing hypogonadism. And I think that's important because of the next studies that we'll talk about in a second here. But 200 milligrams a week, when people are on that, I'm thinking, all right, we're on a pretty good dosage. And if we go back to that study where the milligrams per week range from 25 to 600. It's important to note that testosterone is obviously a performance-enhancing drug. It can be used for medical reasons. It can be used for recreational and sports performance reasons. And when people typically do like a steroid cycle, not TRT, like trying to put on as much strength, muscle mass, sports performance as possible, the dosages that people will typically be at will be at 300 or more. Typical dosage that you'll hear a lot of people talk about doing a starter steroid cycle is like 500 milligrams a week So this study was really aggressive in the dosages that they did there like especially the group that was doing 600 milligrams a week for six months like they were doing a full-blown steroid cycle, but remember 200 milligrams a week is kind of your cutoff there in terms of sports TRT versus just standard TRT. THE RELATIONSHIP BETWEEN TRT DOSAGE AND TENDINOPATHY Why that's important and why I want to know the dosage that my patients are on if they're on TRT is because One thing that I clinically see quite a bit is that those individuals on TRT, I'm frequently finding them showing up to the clinic with tendinopathies more than any other injury out there. In fact, when I see a male between the ages of 30 and 50 years old that's coming to me with a tendinopathy and I know that they're exercising and they look relatively fit, this is a question that I will just straight up ask them. because I think it's valuable information to know. And the reason why it's valuable is that there are actually two research studies out there that have found, one of them found an increased risk of rotator cuff tears in men on testosterone replacement therapy, and another one found an increased risk of distal bicep tendon tears and increased risk of needing surgical intervention to repair that distal bicep tendon tear. And so if we know from these two research studies that these men on TRT are at increased risk of a tendon tear, that would suggest that there's likely some degeneration already happening to some tendons in men that are on TRT. Now, why that is? Can't for sure say though. One theory could be here when we go back to that dose-response relationship study where men taking 125 milligrams or more per week are putting on significant amounts of muscle mass in a six-month period. It could be. those muscles are responding really fast, and those tendons are responding a little bit lower. It could be that maybe these men had low energy, anxiety, depression, they get on TRT, now they're feeling better, and they go from a low amount of activity to getting more aggressive in the gym, so they see training load spikes that challenges those tendons more than they're able to recover from. Whatever reason that is, it happens. We're probably seeing degenerative changes in tendons of men on TRT. TENDON HEALTH ON TRT And we need to be aware of that because that might lead us to want to have more discussions with individuals. on taking care of their tendons if they're on TRT. Like maybe they need to spend a period of time every few months doing heavy, slow tempo work on their spots. Like if you're in CrossFit, maybe not always bouncing out of the bottom of the hole as aggressively as possible. Maybe they have to spend a period of one month every six months where that tempo's going really slow. Maybe we need to be prescribing some extra rotator cuff loading, tendon work, or maybe even different supplements that might have a positive effect on their tendons, such as taking Collagen and vitamin C. There's some research by Keith Barr on that potentially having some positive effects on our tendon health. But that's definitely something worth discussing and having in the back of your mind when you see men taking testosterone replacement therapy is what can you do to help improve their tendon health? INJECTION SITE MATTERS WITH TRT And then the final thing that I think is important for us to understand with TRT, I would have never thought of this unless Jordan Berry, my business partner at Onward Charlotte, also a faculty member for ice in our spine division, hadn't treated somebody that was on TRT and came into the clinic with incredibly debilitating neural tension. So this guy had previously been a bodybuilder that had abused performance enhancing drugs and now was on TRT, but the guy could barely walk, couldn't pick anything up off the ground, had a 10 degree straight leg raise. As Jordan evaluated the guy's lumbar spine, the lumbar spine was completely clear. And Jordan kind of recognizing in this guy's body type that he looked like somebody that may have previously or currently was on performance-enhancing drugs, Jordan went ahead and kind of broke out that with the individual, started talking to him about his previous performance-enhancing drug history. It turns out the guy was still injecting testosterone regularly. He was on TRT after years of being on more performance-enhancing drug dosages of that. And Jordan asked him where he was injecting. And the guy was injecting his TRT dead center in the middle of his… to inject TRT or the place that's safest to inject it is actually going to be glute med. So if I'm looking at your butt from behind, if I drew a line straight down the middle of your glute, both horizontally and vertically, we want to be in that upper outer quadrant or in the vastus lateralis. Those tend to be the safest areas to needle. When he was going dead center in the glute, he was constantly hitting his sciatic with his injections. And so hitting his sciatic nerve as he was giving himself TRT injections resulted in some scarring on that nerve. And that was what was leading to his intense sciatic and neural tension. So I hope that gives you some ideas and things to think of clinically when you see guys on TRT, or at least makes you more aware of the prevalence of this, and that when you see people with it, you might want to be thinking of some different strategies and different questions if they're coming in with things like tendinopathy or weird neural tension. Hope that helps. Hope we see you on the road at a future Fitness Athlete Live course. Have a great day, 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. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses one of the most effective and efficient ways to improve VO2max/fitness/endurance/conditioning both in the gym as well as in the clinic for your fitness athletes (and all clients). Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. GUILLERMO CONTRERAS Okay, live on YouTube and live on Instagram. Good morning, everybody. Welcome to the PTI Daily Show. My name is Guillermo Contreras. Happy to be here with you on the best day of the week, Fitness Athlete Friday, talking all things fitness athlete and improving overall fitness in the individuals that we work with on a daily basis, in our clinics, in our gym settings, et cetera. Before we dive into the topic at hand, Let's go ahead and talk a little bit about the fitness athlete courses coming to your area as well as online. Fitness Athlete Live is going to be on the road over the next three months, quite a bit. Next weekend, we're going to be in Colorado Springs, Colorado, the weekend of December 9th and 10th. The weekend, and that's it for 2023, right? But 2024, we jump in right back onto the road. January 27th and 28th, we're going to be in Portland, Oregon. February 10th and 11th, Richmond, Virginia. And then February 24th and 25th, we will be in Charlotte, North Carolina. So plenty of options, whether you're in the mountains on the West Coast or on the East Coast, we're going to be traveling throughout those areas in the next three months or so. So feel free to check out the website, ptinex.com to find out how you can sign up for those. As a reminder, courses in price at the end of this year. So if any of these courses look like something you can get to, you want to get to, you can travel to, you're going to make a plan to get to. Snatch that course up now because right now courses are $650 and they're going to be bumped up to $695 in 2024. So take advantage of the lower price now. Get yourself signed up for those courses and then find a way to get to these courses but just check those out on the website for where those are going to be. And then fitness athlete level one online. The next cohort is going to start up on January 29th. Currently in the middle of a cohort right now. Started finishing up week four right now. So four more weeks there, a little short break, and then we kick back up on January 29th. And then fitness athlete level two, or what is formerly known as advanced concepts, that kicks off on February 4th. Those courses always sell out. We rarely have anyone that wants to get into it that can't get into it after they sell out. So if it's something you've been looking to do, if you're looking to become certified in clinical management fitness athlete through that certification process, then you need to be able to take a one, take the L2, take the live course. And again, that L2 only comes twice a year. So if it's been on your bucket list, something you want to take, sign up now sooner rather than later, because as I mentioned, those courses, All right. Um, so that is the introduction there. That is what we have on the docket. Um, as I mentioned, again, my name is Guillermo Contreras. I'm a physical therapist, uh, over here in Milwaukee, Wisconsin, and a part of the fitness athlete team here with the Institute of Clinical Excellence. THE ASSAULT BIKE FOR VO2MAX DEVELOPMENT The topic today, uh, the title, uh, is VO2 assault or assault on your VO2. I don't know why I wasn't too creative today, but there's there's a reason we're talking about it is The assault bike or the echo bike or like any air bike right we're talking about like this this beast This beautiful thing we have back here the assault bike I have here in my office Is one of the best tools that we can use to work with individuals in the clinic out of the clinic in the gym trying to improve overall cardiovascular conditioning, fitness, metabolic stress, like all these different factors that we can improve upon using a simple piece of machinery. This piece of machinery costs anywhere between $700 for the Assault bike, the standard or the original, I believe is what it's called, up to $840, $850 for the Echo bike, which you can get through Rogue, the Rogue Echo bike. It can go as low as, if you're really just kind of want to pinch pennies there, a couple hundred dollars, maybe $100, $150, or a Schwinn Airdyne. And those Schwinn Airdyne bikes, right, those are, like we used to have one of those from like the 90s that still worked like it was new. They last forever. they work forever, easy maintenance if you just take care of the chain with the rope echo bike a little more expensive because it's belt driven and again that lasts forever very little maintenance so they're just really really nice pieces of equipment to have. The weight limit then on them is around 300 for the soft bike 330 pounds for the echo bike and probably sure a little bit less for just your standard twin airdyne but they make like the airdyne pro that i'm sure has a 300 pound weight limit as well. last and survive through the apocalypse. That's how good these things are. Not only that, but in the clinic space, they are fantastic for working three limb conditioning. If you have any a knee injury, a hip injury, something that does not allow them to do something like running or standard biking or skiing or rowing, right? They have a limb that they cannot use. You can rest that limb and work the other three in a very effective way that increases conditioning overall. And the reason I'm saying all this, and the reason I'm touting up the Assault Bike, the Echo Bike, right, is because there is no reason that we should not have a piece of equipment like this within our clinics. And if we have something like this, there's no excuse for us not using it with our patients. Especially if you work with an athletic population. When you look at the NFL right now, how many people are getting injured? How many injuries are you seeing on a weekly basis? You've seen an excessive amount of Achilles tears, knee injuries, high ankle sprains, all those things. And one of the biggest things you hear when an athlete comes off of what they call the injured reserve is that, are they in game shape? Like they have the strength back, they have their motion back, they can handle the stress on whatever was injured, but are they truly in game shape? Do they have the ability to withstand rep after rep after rep on the field? And honestly, when it comes to conditioning, there is no better device. in a more efficient way than this behemoth, this beast right here, this monster, this thing we love to hate in the fitness athlete realm, in the CrossFit sphere, and in pretty much anywhere you see this bike. EFFICIENT RESULTS WITH THE ASSAULT BIKE This is proven in a wonderful study where it took 32 individuals and it put them in three different groups. The control group was given moderate intensity cardiovascular training. 30 minutes of 75% heart rate max, cardiovascular cycling, 30 minutes rate of 70, 75% of heart rate max. Group number two was given what we know as a Tabata or a half Tabata. They had to do 10 seconds sprints, five seconds of rest for eight sets. They then rested for two and a half minutes and repeated that whole cycle three total times. Group number three was given a standard Tabata, three sets, of eight repetitions of 20 seconds of work at 10 seconds rest. That is your standard Tabata 20 on 10 off eight rounds. They had to do that three sets with a five minute rest between each uh three set round you call it there or each eight set round I'm sorry eight round set. All in all the modern intensity cardiovascular training group did around three The 10-on-5-off group did around 72 minutes of work per week, so around an hour, a little over an hour. And the standard Tavada group, that three, or the eight rounds of 20-on-10-off, did around 144 minutes of work, or just over two and a half hours, sorry, around two and a half hours of work per week. What they found at the end of the study was that there was no significant difference in improvement across all three of them. All three showed improved time to fatigue, improved VO2 max, improved conditioning, and improved ability to create force, improved MET, M-E-T-S, M-E-T-S. But the big picture here, gang, right? Like what we see there is like, okay, like that means we can pick any of those and get someone more cardiovascularly fit. Yes, that is true. You can kind of pick your poison whichever way you want to do it. What we're talking about here is that the short group, the 10 on, five off, 72 minutes of work per week, one hour of work per week, that group was 250% more efficient in the use of their time to improve their cardiovascular fitness, to improve their conditioning, to improve their power output, to improve their time to fatigue than the other two groups that doubled and six times the amount of work. And how we can apply that is like when we're looking at individuals in the clinic, we probably don't have six hours of week to add to their program, to their plan of care, to get their conditioning up. They might not have six hours additional per week to jump on a bike and do 30 minutes of work three times a week as well. And if we want to get someone more conditioning, better shape, better heart health, improve health markers, blood markers, all those things, while also improving pain, reducing pain, improving function, increase in range of motion, whatever our plan is or whatever our goals are for them in the clinic, this device, the AssaultBike, the EchoBike, a nice quality Schwinn Airdyne bike, that is the way we can do it in a very effective, efficient manner. If you can do the same If you can have the same results in less time, people are going to buy in. If you can show somebody, hey, we're just going to do 8 sets of 10 on, 5 off before we start the session. I'm going to jack your heart rate up. I'm going to get your blood flowing. We're going to not only improve your overall cardiovascular fitness, we're not just going to improve your overall health markers. We're not going to just improve your conditioning, which again, if you're looking at working with athletes, whether it be in professional sports, amateur sports, high school sports, whatever it is, you need to build up their conditioning space or their conditioning ability. SHORTS BOUTS; GREAT RESULTS But across all populations, we can all benefit from this. We can all benefit from having better heart abilities, better cardiovascular fitness, better VO2 mass to be able to stand and do things for longer with less fatigue. So by using this device, using short sprint intervals, things like you see behind me, things like 10 on, five off, or eight rounds, three sets, two and a half minutes rest, or simply one set, one set of eight repetitions of 10 on, five off, right? We can have these small things that can affect individuals. It's also something they can easily do for a home program. if conditioning is an aspect they need to work on. If we're trying to get their VO2 max up, we can give them, hey, I want you to jump on the assault bike, jump on the echo bike. I want you to do 10 rounds. Just go as hard as you can. Rest five seconds. Do that eight times. Do that a few times a week. When you're looking at individuals who have Achilles tears, knee injuries, something where they cannot use that limb or it's uncomfortable to use that limb, they can still get after it with three limbs. They can use left leg and both arms and get after it on a soft bike. Again, effort is what matters here. Intensity is what matters. And when we're talking about working with individuals, trying to give them the most effective, efficient way to get better, get stronger, get healthier, and we're thinking of a fitness-forward approach to everything we do, this device, these tools, these strategies, these techniques, in doing that. and nauseam about getting people fit or getting people strong, using intensity as the way to do that. And if you're curious how it works and if it works for you, simply get on an assault bike, get on an airdyne bike, push yourself hard for 10 seconds, work a five seconds rest, repeat, rinse and repeat for eight rounds and see how you feel after that. See how the improvement comes upon there. Hope to see you on the road, gang. Hope to see you online. Thank you for tuning in. Have a wonderful weekend and we'll see you next time 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.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the Concept 2 rower, including each key component & how to perform basic maintenance on it. Alan also coaches rowing technique, including how to use the monitor to establish the ideal "drag factor" so that patients & athletes understand their optimal damper setting as well as strokes-per-minute (spm). Finally, Alan discusses how to improve rowing performance, including testing & retesting established benchmarks on the rower. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL Hey, what's up? Good morning. Welcome to the PT on ICE Daily Show. I hope your morning is off to a great start. We're here early on Fitness Athlete Friday out in the garage to talk about rowing. Fitness Athlete Friday, if you're not sure, we talk all things related to CrossFit, Olympic weightlifting, powerlifting, running, biking, swimming, today, rowing, everything related to the recreational athlete, that patient or client who is getting after it on a daily basis. Before we get started today, let's talk about a couple of quick announcements. Courses coming your way from the fitness athlete division, we have no more courses that you can take in 2023 unfortunately. All of our live courses between now and the end of the year are either done or sold out and all of our online courses are finished or have already started towards the end of the year. Your next chance to catch us is going to be in January on the road for our live seminar Your next chance to catch us online is going to be January 29th for Fitness Athlete Essential Foundations, or February 5th. We also call that course Level 1 Online Now. Your next chance for our Level 2 Online course, previously called Advanced Concepts, will be on February 5th. What are those courses? Those three courses compose the Certification and the Clinical Management of the Fitness Athlete, or known as CERT CMFA. Our level one online course is all of the basics. It is a lecture-heavy course. It is a course heavy on clinical application, not only to the fitness athlete but also taking the principles that we teach, how to properly dose and prescribe load, how to increase the intensity of your physical therapy sessions, taking concepts, not only applying them to the fitness athlete but all of your populations, everybody that could potentially come into your physical therapy clinic. Our level two online course, previously called Advanced Concepts, gets a lot deeper into the weeds with a fitness athlete. So if you're looking to learn about advanced Olympic weightlifting, advanced gymnastics, such as those found at CrossFit, muscle ups, handstand walking, pistol squats, all that sort of stuff, and then a super incredible thorough deep dive into programming, then the level two online course is for you. That is for the person who is looking to regularly work with fitness athletes in the community and be the provider of choice in their region. And then our live seminar is focused almost entirely on moving, about understanding what it means to perform a one rep max or a sub max test to predict a one rep max, what that feels like for you to do it so that you better know how to apply that to your patient population, but also how to program based off of that, how to work different therapeutic exercises together to facilitate both intensity as well as recovery during physical therapy. So those three courses compose the CERT CMFA. So p10ice.com, click on our courses to find the next live or online courses coming your way. And I will say this morning ahead of an announcement that you're going to see via email and social media that our prices will be going up per ticket on January 1st. So you heard it here first. Our ticket price will be going from $650 for the majority of our courses live and online to $695 on January 1st. If you were looking to grab one of our courses in 2024, I would do it now. Save yourself the 50 bucks. So that's what's coming your way from the fitness athlete division. ROWING 101 Today we're talking about rowing. We're here with the rower. I love this piece of equipment. I think it's a very versatile piece of equipment. I've had the chance to spend a lot of time on the rower when I first began CrossFit. Was not really able to run. I was so overweight. Spent a lot of time on the assault bike, and a lot of time on the rower. I've done a lot of endurance stuff on the rower, a lot of different programming on the rower. I've rowed two full marathons. So I want to share today the very basics of a rowing machine, what it is, how it works, and how to take care of it. If you're really thorough with your maintenance, even a couple of minutes per month, this is a machine that could last you your entire career without really needing to purchase any repairs or even possibly replace it. And then we're also going to get into the basics of rowing technique and how to get a little bit better at rowing. COMPONENTS OF A ROWING MACHINE So let's start from the top. and describe the rowing machine and all of the different parts, and also some tips and tricks for maintenance. So first things first, the question that most people have about the rower is how does it work? It works with sensors in the damper, which is a flywheel, with a computer monitor here, and then calculations are performed by the computer every pull to give you outputs of a pace of meters or calories, some sort of output of your work. So there are sensors in the chain and sensors in the flywheel. Starting from the front of the rower and working our way out, we have the damper. This houses the flywheel. This is where the resistance from the rower comes from. This handle on the side toggles between 1 and 10. What that does, is the higher the setting, as you approach 10, you're allowing more and more and more air to flow into the damper and create resistance against the flywheel as you row. So you are in charge of a combination of letting more or less air into the damper and pulling the chain you kind of control how the rower feels. A lighter damper is going to feel like a smooth row on really smooth water and a high damper is going to feel like in a really aggressive row maybe through really rough water or something like that. Far and away the majority of people are going to want to row somewhere with a damper setting between four and six. Now you do get more work awarded for a higher damper setting. That being said, it is much more challenging and fatiguing to pull. So the higher the damper goes, you need to be a stronger human being in general, especially with your pulling capacity, and you need to be a more experienced rower. You'll see folks trying to break world records, row at a 10. That's not the majority of human beings who are using a rower. Most folks sitting down on the rower, especially a longer effort, are going to be somewhere between a four and a six. We can calculate the exact damper setting that is best for each individual using a setting on a monitor called the drag factor, and we'll talk about that in a little bit. Taking care of the damper and the flywheel housing is really simple. Take a vacuum, suck the dust out, blow the dust out of there some way to clear the dust so that the flywheel does not get a bunch of gunk accumulated in there. Very easy to maintain the flywheel. Next is the chain. Pretty simple. When you are storing a rower, even if you're storing it horizontally, Always place the monitor down and release the chain. That takes tension off the chain. That's going to let your chain last a lot longer, and it's going to let the screws that hold your monitor upright last a lot longer as well. The chain is pretty simple. It's a handle attached to a metal chain that again pulls on the flywheel. So normally when we're using it in class, we have it out and racked in the handle, but when we're storing it, put it away and take the tension off that chain. Very easy to maintain the chain. Just keep it away as a solvent, not a lubricant. Find an actual lubricant, something like white lithium grease, to grease up that handle, keep it moving nice and smooth, and keep it from rusting as well, especially if your rower is stored somewhere that's not climate-controlled. A CrossFit gym that doesn't have air conditioning, in your garage or something, where it's gonna be subjected to humidity, keep that thing lubricated so it does not rust. Very easy to maintain otherwise. Our footplates, this is where our feet go, pretty simple. We're going to adjust the foot plane based on the length of our foot such that the strap, we want the strap somewhere about mid-foot. We don't want it jammed up in our ankle crease and we don't want it out on our toes either. We want to be able to plantarflex and dorsiflex our ankles and not be restricted by the straps. Taking care of the straps is pretty easy, they're just fabric, use some sort of fabric conditioner. Maybe in the winter, some fabric conditioner so they don't crack and fray. Once a month, again, a few minutes of maintenance and the machine is going to maintain it. And then just clean the footplates. Keep the footplates clean of junk, dog poop, whatever. Otherwise, very easy to maintain the straps and the footplates. The seat, the biggest thing here is that the cleaner you keep the track, the smoother the seat is going to go back and forth on the track. You can coat this with a little bit of grease as well, but the main thing is, especially if you've jumped on here and you've rowed for a longer distance, the pressure of your butt on the seat is going to kind of grind against the track a little bit. It's going to leave little black particles, and a little bit of residue. If you clean that up, it's going to keep the seat moving nice and smooth. And again, maybe once a month, add just a little touch of grease and work it into the metal of the track. Pretty easy to maintain the seat and track. And then the most important component of the rower, the component that is the most expensive when stuff goes wrong, is the monitor. So the monitor is where we keep track of our work. It is battery-powered. It works a lot like a car. It's got C batteries in the back. As you row, you are transferring a little bit of energy from the battery to the rower, kind of like an alternator in a car. And then just like a car, over time, the batteries will decay. These are C batteries. They will decay a lot faster than a car battery. And you may need to replace the batteries every few months. That's far and away going to be your largest expense with a rower. making sure if you're running low on batteries, that you change the batteries out. Now the rower will run without batteries, but it will only run as long as you are actively rowing. So if you stop rowing at any moment, the monitor will shut off. So not something you want to happen in the middle of a workout, especially a longer row. The biggest thing with maintaining the monitor, do not directly spray any sort of cleaning solvent on the monitor. Just like you would not spray it directly onto a laptop computer, You would maybe put it on a little rag and just kind of wipe it. Make sure that you're not putting a lot of chemicals inside of this. Again, it is a computer. So that's taking care of the monitor. So those are the key components of the rower. MECHANICS OF ROWING Now let's talk about the mechanics of rowing. So I'm going to turn sideways here so you can see my side profile. putting our feet in. We want to have tight straps, but we don't want them to be excessively tight on our feet. Again, we want to have the strap somewhere, maybe midway between our ankle crease and our toes. We want to be able to plantarflex and dorsiflex our toes. Tighten it enough so that if you lift your shoe up, you can easily transition on and off the rower. That's how tight the strap should be. Now the mechanics of rowing are very simple, however, they require knowing that rowing is a leg press primarily. Your legs are doing the majority of work on the rower, not your arms. A lot of folks get on here and they do really short strokes and they really do an arm-heavy stroke. and they find that their arms get fatigued, their grip gets fatigued, that should not happen on the rower, even if you jump on here and you commit to rowing three to four hours to get a marathon. You should not feel like your grip strength is a limiting factor on the rower because your legs are doing the majority of the work. So how we like to coach rowing is we like to say legs, lean, and pull. So as I have the handle, I'm thinking about a big leg press, almost like I'm going to deadlift. Legs, then I'm going to carry that momentum forward, lean, and then I pull with my arms. So full speed it looks like this. Legs, lean, pull. Legs, lean, pull. And that should allow a nice smooth rowing pattern. I'm going to let the damper stop for a second so you can hear me. If you hear a lot of slapping, When someone is rowing, that means that their handle is not moving smoothly back and forth. Something is probably wrong with their rowing form. For some reason, their rowing handle is going in an elliptical pattern instead of a straight line. Just like anything else in physics, Straight lines are astronomized. So we need to fix what's going on. We should be using legs, lean and pull. We should be moving as one continuous unit and that handle should be moving smoothly in and out of the rower. So that's the basics of rowing mechanics. A lot of folks can use a lot of simple peeling or more of a lean- back. We're not excessively extending the spine. However, we do want to use the momentum generated by our legs to transfer into a little bit more posterior chain activation to get a little bit more out of the handle. The longer the handle, the more credit you're going to get meters or calories on that rower. DRAG FACTOR Now let's talk about the drag factor. I'm going to turn this rower around again. Drag factor is a calculation of an imitation of what it would feel like if you were actually in a rowing boat on the water. How much drag would you perceive rowing through the water? An ideal drag factor is going to be 115 to 135. How is that calculated? It's going to be different for every person based on how hard they pull the rower and the setting of the damper. How we get to it, it's going to be in the menu on our rower. We're going to go to more options once the rower is turned on. We're going to go to utilities and it's the setting under display drag factor. So it's going to say row to display drag factor. Now what you're going to do, this is again, this is individual to every person. Every person, based on their specific damper setting, based on their rowing mechanics, based on how strong of a rower they are, it's going to be different, but we're shooting for 115 to 135. So if I get on the rower, I'm just going to start rowing, and it's going to tell me my drag factor. So right now, after a couple of pulls, it's telling me 99. I'm at a dip or a 4. I'm going to bump up to 5. I'm going to do a few more pulls. And now I'm at 121. So I'm between 115 and 135. What does that mean? A damper setting of 5 for me is going to get me right where I want. So the most important thing, especially if somebody's going to be using a rower a lot, for our CrossFitters who are probably going to be rowing every week, For maybe a patient who has a rower at home in the basement, working on drag factor can really help them know when they sit down, no more mystery about where to put the damper setting. You're going to be able to say, you know what? For you, damper four, damper five, damper six. Maybe for a very tall, very strong, very experienced rower, maybe they are at damper seven or damper eight. That's going to be rare, but also not impossible. So drag factor is really going to help folks know when I get on the rower, where should I put that damper based on my mechanics, based on my experience and strength with rowing. MAKING PROGRESS ON THE ROWER The final point I want to talk about aside from the components, maintaining it, mechanics, and drag factor is making progress on the rower. A lot of folks want to get better at the rower. The unfortunate truth is to get better at the rower, much like anything else in life, you should do more rowing. So, rowing is a great accessory thing to add in, especially for our CrossFitters. It's unloaded. It's not going to be as tough on the body as maybe adding in an extra session of Olympic weightlifting or running per week. Very easy to add in an extra maybe 30 minutes of rowing a week to try to get better at rowing. A lot like anything else with monostructural work, with cardio, with running, rowing, biking, The answer to the question how do I get better is where are you weak at on the rower? Are you weak under fatigue in the middle of a CrossFit workout? Are you weak at very short sprint efforts about getting on a rower and rowing 500 meters? Are you weak as the fatigue fall-off factor sets in and you row maybe a 2k or a 5k row as you get into longer endurance rowing? Where is your weakness? If folks say, I don't know, that's a great time to establish some benchmarks. A lot like wanting to know somebody's 400-meter run time, Their mile run time, their 5k run time, we can do the same thing on the rower. We have established benchmarks on the rower. A lot of them are pre-programmed in the computer. What is your 500-meter row time? What is your 2k row time? Your 2k row is going to be equivalent to a mile run. What is your 5k row time? that's going to be fairly equivalent to a 5k run. A lot of folks are going to be faster on the rower than running, but that's about equivalent as well. So establishing some benchmarks, looking and seeing how far speed falls off going from 500 to 2k, from 2k to 5k is going to let you help that patient or athlete better program that accessory rowing to get specifically better at the energy system they need to work at. Getting better at rowing too is recognizing where my paces at. Pacing on the rower is per 500 meters. That's the pace that you usually see pop up on the screen, two minutes per 500, two minutes and 20 seconds per 500, and so on and so forth, and understanding each person needs to learn what is a fast, maybe a PR pace for my 500-meter row pace. If there's a workout that has maybe three rounds of deadlifts, pull-ups, and a 750-meter row, what pace should I look to establish if I want to hit that fast? What pace should I establish if I want to hit a sustainable pace that I can hold for maybe a longer effort, like a 750, and then what does a recovery pace look like? If we have a longer workout that maybe has some 1000-meter rows, we had a workout this week that was 50 burpees, 2000 meter row, a one-mile run, and a much longer endurance-focused workout, what should my 500-meter pace look like on the rower for a longer effort, a 2000 meter effort, and understanding when you get on the rower you settle in what pace am I hoping to hold here based on the outcome that I want. Do I want to get on and off this rower as fast as possible, treat it like a sprint effort, Do I want to get on here and sustain a longer effort, or is this maybe a very long effort, a 2,000 meter row in the middle of a workout, and I'm thinking about primarily using this as recovery until I recover a little bit, and then I can begin to pick up the pace again. So understanding where your benchmarks are at, where your paces are at, and what the goal of the goal we're at. where it is in the workout, it's very important to get on here and not go too slow and give up the workout, but also not jump on here and just burn out and be that person on here that looks totally miserable because you started off way too fast and now you've wrecked yourself and you still have a long way to go. So the rower, the damper, the chain, the seat, the foot plates, the monitor, what they do, how to take care of them. Rowing mechanics, it's a leg press, not an arm pull. Legs, lean, and then pull. Drag factor, different for everybody. Very important to understand to get on there and play with drag factors so that you understand for each person, and they understand for themselves, why and how I'm choosing the damper setting that I am, and then how to make progress. Test benchmarks, train rowing, get more comfortable being on the rower, especially for long distances, and then reassess those benchmarks. So I hope this was helpful. Join us in a couple weeks, we're going to go over some more advanced rowing, how to turn the rowing machine into a skier, and then how to use the rower for adaptive purposes for adaptive athletes, or just for folks who come in the clinic, who maybe can't row because they're only able to use one leg or one arm or both, how to use a bunch of different equipment that you probably already have around the house or the clinic to get those people rowing. So hope you have a fantastic Friday. Thanks for joining us. We'll see you next time. 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 // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad". Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALL All right. Good morning, folks. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. We're here a little bit early in the garage. We're going to be talking about some double unders today. Welcome to Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at the company, as well as the Division Leader in our Fitness Athlete Division. We love Fitness Athlete Friday. We would argue it's the best day of the week. On Fitness Athlete Friday, we talk all things relevant to the CrossFit athlete, Olympic weightlifting, powerlifting, bodybuilding, anybody that's recreationally active in the gym. We also talk about our endurance athletes, whether you're running, rowing, biking, swimming, triathletes, If you have a person that's getting after on a regular basis, Fitness Athlete Friday has a topic for you. Some courses coming your way from the Fitness Athlete Division. We have a couple live courses before the end of the year as we get ready to close out 2023. This weekend, as in tomorrow and Sunday, November 4th and 5th, both Mitch Babcock and Zach Long will be on the road teaching. Mitch will be down in San Antonio, Texas, and Zach will be in Hoover, Alabama. Even though it's last minute, both of those courses still have some seats. And then your final chance to catch Fitness Athlete Live will be the weekend of December 9th and 10th. That's gonna be out in Colorado Springs, Colorado, and that will be with Mitch as well. Online from the Fitness Athlete Division, our entry-level course, Clinical Management Fitness Athlete Level 1 Online, previously called Essential Foundations. The next cohort of that class begins November 6th. We love that class. That is a great entry-level experience into all of this stuff if you have not taken it yet. We take you through the very basics, back squats, front squats, deadlifts, presses. We get into some basic gymnastics with the pull-up and introduce you to Olympic weightlifting with the overhead squat. Along the way, we have case studies relevant to athletes with those particular issues that we discuss with those movements. We talk a lot about loading and we get you introduced to basic programming, both for injured athletes and also how to recognize CrossFit style programming, strength style programming to better prepare you for those folks who want to continue on to our level two online course, previously called Advanced Concepts, who really want to drill down into programming, advanced gymnastics, advanced Olympic weightlifting, and truly become the provider of choice for athletes in their region through the clinical management fitness athlete certification. So that's what's coming your way course-wise from us in the CMFA division. WHAT ARE WE DOING WITH THE DOUBLE UNDER? Today we're going to talk about double-unders. This is personally an issue I've struggled with for a long time and probably maybe aside from pull-ups and handstand push-ups, one of the more basic movements we see in the gym that still a lot of your membership base will struggle with, maybe you personally struggle with, and I want to talk about what are we actually trying to do with the Double Wonder, some tips and tricks and cues to think inside your mind as you're going through them. I want to spend some time talking about the equipment involved in jumping rope because I think there's two sides of the equation, people with very basic equipment and people with maybe equipment that they don't need that's maybe too expensive, too advanced, And then I also just want to talk about how to begin to better practice double unders so that you can work towards achieving them and being able to complete them during a workout, in large sets, when the CrossFit Open comes up, or just in your regular workouts at the gym. So first things first, with double-unders. When I ask a lot of athletes in the gym when I'm coaching, when they say, oh my gosh, I just did five double-unders in a row, I say, great, great, what were you thinking about? And overwhelmingly, the majority of the people say, I don't know. I couldn't tell you what I was thinking about. And that strikes me as very different from a lot of stuff that we do in the gym. People usually have maybe one cue or maybe even a couple cues in their mind when they're setting up for a heavy deadlift, when they're setting up for a clean and jerk or a snatch or a handstand pushup. They often don't kick up upside down or go to max out their snatch and tell you that they had nothing going on in your brain. But something about the double under, people think it's just magic, how you learn these and how you get better at them. And unfortunately, it's not magic. Fortunately, it's just physics. So I want to talk about really at a base level, at a nerdy physics mathematical level, what are we doing with the double under? We are translating linear force. We are creating force across the lever that then transforms into rotational force where your jump rope handle meets the bearing. FIX THE SET-UP If your jump rope is nice enough to have a bearing. So a lot of times the setup, even with just the handles is wrong of looking at a jump rope. Again, it's quite a basic piece of equipment. It's got some handles. you to hang on to in a rope. Even a cheap moderate jump rope of $20 should have some sort of bearing set up so that it spins a little bit. We are trying to create force at the end of the handle that as we flip that jump rope it turns into rotation through the rope and that by doing it both hands at a time with that flicking motion we spin the jump rope. What we're not trying to do is physically spin the rope ourselves with our shoulders, right? We're trying to create rotational force through a flick. So the first thing is making sure that you are even handling your jump rope appropriately. If you are cinched down with a full grip, right where the handles meet the bearing, first of all, you can physically block the bearing if you're not careful. If you hold right here with a depth grip, that bearing cannot spin anymore, right? It's going to be extraordinarily difficult to easily create rotational force here and you're going to naturally be that person who has to spin your arms to spin the jump rope. That's exhausting. It's not a great way to do single unders and it's an even worse way to do double unders. So first things first, where are you grabbing the handle? You should be grabbing further down the handle, ideally with a loose grip, as low on the handle as you can get, right? The longer the lever, the more force amplification we have, right? The more force is going to be transferred and transformed into rotation down here versus the higher we grab up towards that bearing. So a nice loose grip, thinking about flicking, creating linear force at the bottom of the handle that creates a spinning force for me up at the bearing. So that's number one of making sure that you're even using the jump rope correctly. The next thing is making sure it's sized correctly. I always laugh when I see people in the gym who I know are taller than me, which is not very useful because most human beings are taller than me, but I know someone is a couple inches taller than me and I see them using a rope shorter than a rope I would use and I think What the heck, why are they using such a short rope? It makes sense why trying to do double unders, they're bringing their knees up to their chest and bending their knee to try to clear the rope because the rope is so short. How do we sign the jump rope? We take the jump rope, we hold both handles, we step one foot, we try to even it out as much as possible, bring it towards our body, and the length of that rope should be at our nipple or maybe a little bit higher. If it's down at our stomach, it's too short. You're gonna have to do some really unnatural jumping things, like piking your hip, or kicking your legs back, or both, just to be able to clear that short rope. Likewise, being a little bit longer is okay, but this thing up to my chin or above my head, I have a lot of slack behind me now. I'm moving a lot of extra weight I don't need to, and that's all the more drag factor on the rope that's gonna mess up my timing as I try to learn double unders. So making sure we're holding the handles in the appropriate place and making sure that we understand how to measure our jump rope. A really nice jump rope will have maybe a nut or a screw here to adjust. This is a typical, what we call a class rope. This is just a $20 rope from Rogue. You'll often see these in the wall at a gym for everybody in class to use. These can't be adjusted. They go based on your height. There should be a table or a chart or the coach should know what color you should be using based on your height, assuming that you know what your own height is, to make sure that you're using a jump rope that is long enough with maybe a little bit of extra slack, but is not extraordinarily short or long. So that's first things first, using linear force to create rotational force, making sure the rope is sized to us correctly, and making sure we're holding the handles in the right spot so that we're not hampering ourselves from creating that rotational force. SOMETIMES IT'S THE WRENCH We have a saying, with jump rope, with most things in life, it's usually not the wrench, right? It's not the equipment, it's the mechanic. But sometimes it is the wrench. A lot of folks start trying double-unders with maybe the class rope they have, and I think that's a great place to start. Now the issue is a lot of folks will start trying double-unders, they'll look at people in the gym who are really great at double-unders, and not recognize that that person probably started with the class rope, and they'll immediately go out and buy a $200 competitive CrossFit game speed rope. There's a couple issues with the wrench itself of making sure you have the right wrench. We've already talked about length. A really nice jump rope, again, will have a way to adjust the length that you can undo a screw or a nut and make it longer or shorter and get it really dialed in. These ropes, again, are a fixed length but making sure the length is exactly correct. The next thing that most people don't consider is that this jump rope has some weight. Yes, the handles have weight, but that's going to be relatively fixed based on the brand that you have. So not considering the weight of the handles, what is the weight of this rope? This is a class rope. This is about 2.5 ounces or so, which I would call a medium weight rope. When we are doing jump rope, In learning double-unders, the best thing you can do is use a rope that's a little bit heavier. null: Why? Two reasons. SPEAKER_01: When you spin a heavier rope, you can hear it slapping on the ground in the gym, even over the loud music. That helps your brain learn the timing. A heavier rope also forces you to develop wrist speed. When we're doing double-unders, it's not about how fast you jump, it's about wrists. And a really light rope doesn't force you to learn that speed because it costs you almost no energy to go through that movement pattern. So for a lot of folks, they're trying to purchase the most lightweight rope ever, and I'm going to show you some different ropes here in a second, when in reality they should probably be working with a heavier rope. Again, this is a class rope. This is maybe two and a half to three and a half ounces, somewhere in the middle. What's going to help a lot of folks Smartgear brand rope. You can buy this from Rogue or from RX Smartgear directly. You can see just by looking at these two ropes, significantly thicker, right? This is a 4.1 ounce rope. The handles are different. Yes, they spin a little bit better. They have a little bit better hand grips. You can see here different spots to put your thumb along the handle. But most importantly, the cable is heavier. This is going to teach hand speed, this is going to build up endurance with the double under, and it's also both the sound and the feeling of this rope is going to help learn timing a lot better for our jump rope. So making sure that we have the right rope. Again, almost everyone trying to get good at double unders immediately goes and buys the $200 speed rope, when in reality they should probably buy this. Now the nice thing about these ropes, as you can see, I'll bring it up really close, is this is just a keychain type carabiner. When I'm ready for a lighter rope, the most expensive part of a jump rope are the handles. The cable is usually cheap or sometimes even free if it gets frayed. If you fray your actual rope, you can email Rogue, you can email RxSmart here, they'll send you a new cable that you can reattach to your handles and you can use the same handles forever. So as you get better, you can detach, put a lighter cable on, make it easier and more energy efficient as you actually start to string together double-unders. But early on, you're going to want a heavier rope, something around four ounces. That's the biggest recommendation I can make to folks who are trying to learn double-unders, and especially to those folks who have 19 different speed ropes at home. They've got a second mortgage on their house full of jump ropes just to pay for them all. and they're going lighter, lighter, lighter, thinking they need a lighter rope, a faster rope, lighter handles, diamond grip handles, when in reality they just need a heavier cable. So when in doubt, go heavier. Again, four ounce rope compared to maybe a two and a half or three ounce rope. Once you can start to turn over bigger sets of double unders, 25, 30, 50, you're able to start doing them in workouts, your efficiency, your endurance with them improves, now you're ready for a cable itself is basically non-existent. This is aircraft grade aluminum. This is about eight tenths of an ounce. So almost 500% lighter than that heavy rope I just showed you. This weighs almost nothing. It is very hard to feel when you jump rope with this cable and it's very hard to hear as well, especially if you're in a CrossFit style gym in the middle of workout with loud music playing. What's different about this besides the cable weight? The handles are so much nicer. They are diamond grip. My thumbs can lock on. I can hold very low on the rope. Again, I want to have as much time for that force to build up and transfer along the length of the handle as I can. I can hold just my index finger and my thumb and really develop that flicking motion. What's also very nice is look at the spin on this handle. right? That thing spins forever. Very, very, very efficient for large sets of double-unders, but only once you can actually do them. So this is kind of the in-stage progression of somebody who looks at a workout that has a couple rounds of 30 or 50 or maybe even 100 double-unders and says, no problem, I got These ropes are about $200. And again, the most expensive part arguably is the handle. If the cable frays, you can replace it. But a very, very, very high quality jump rope intended for folks who have already learned how to do big sets of double unders, ideally using a heavier, cheaper rope. So that is what we would call a speed rope. So that's the wrench. BUT IT'S USUALLY THE MECHANIC Now let's talk about the mechanics. because there are a lot of things we can do, a lot of cues we can give that can very quickly make double unders a lot better. The first thing is understanding, again, in a double under, what changes is my hand speed. Jump, spin, spin, jump, spin, spin. It is a double spin of the rope. It is not an increase in my jump rate. A lot of folks, off the ball of their foot. Because in a single-under, we're only clearing the rope once, we can get away with a very small jump and just clear that rope once. We see a lot of boxers do this. You see a lot of people in the gym who have jumped rope a lot in the past do this with single-unders. They can crank out 150 single-unders in one minute with that very fast, low jump. That's not gonna cut it for a double-under. Why? The rope has to pass twice. A lot of athletes in the gym will ask me, I have no problem getting it over the first time, but it gets caught the second time. The answer is yes. The rope has to come back around again twice and you have to be in the air the whole time. That's why it's called a double under. You're trapping the rope on the second time through, which is why you're not getting your double under. How and why are we trapping the rope? Most commonly, is we do not increase our jump height, we just now try to jump even faster. All we're gonna do there is trap the second pass of the rope that much more quickly. We're just getting more efficient at bad double-unders. We need to consider a smaller, taller, slower jump. We should practice single-unders on the ball of our foot, and we should practice a little bit taller jump, but not try to pick up our legs not jump speed. If you correspondingly increase your jump speed, you're going to trip because you're now trying to basically get in rhythm and jump twice for two rope swings. That doesn't make sense. Keep your jump speed the same. Stay tall, vertical on the ball of your foot, and jump a little bit higher. Practice single-unders that way. When you can begin to turn over 50 or 100 single-unders like that, now you know you have the jump height, the jump speed, to be able to begin to turn over double unders. Remember, wrist speed, not jump speed, and stay on the ball of your foot. A lot of folks will do some really dramatic stuff to get that rope over twice, and they will land on their heel. Again, the rope has to pass twice. If you land on your heel, there is no physical way that rope can pass under your foot for its second time through. You're going to track the rope underneath your foot. So small, short, sorry, tall, vertical jump. PRACTICING & DRILLING DOUBLE-UNDERS Make sure we're practicing wrist speed. A penguin drill is a great drill to give people, to have them practice maybe what's a new jump height and cadence for them. And at the top of their jump, have them slap their thighs twice to imitate the double flick of the jump rope. You'll find a lot of athletes who think they should be able to do double-unders, struggle a lot with that drill. They're used to that short, very fast jump cadence for single-unders. Asking them to slow down and jump a little bit higher wrecks them. It also messes them up mentally when now they have to focus on actually doing something with their hands. You'll find they're probably not as ready for double-unders as they thought they were. So double-unders, not magic, just physics. We are creating force across a lever, the handle of the jump rope. We're holding it as low as possible. We're trying to create rotational force where the rope meets the handle at the bearing. We're holding it as low with as loose of a grip as we can. We're thinking about flicking the wrist, not spinning the shoulders. Sometimes it is the wrench. Make sure the rope is the correct length. Make sure newer athletes who are beginning to experiment with double unders use a heavier rope, something three, four, maybe five ounces, and that we reserve those speed ropes for once we're actually able to string together bigger sets of double unders with a heavier rope. PROGRESSIVELY OVERLOADING DOUBLE UNDERS The final thing is how to progress these. A lot of folks want to be able to do more unbroken sets, Can you just practice more sets of double unders? Yes. The key thing though is that we practice that. We don't try to do it in the middle of the workout under an extreme amount of cardiovascular fatigue and that we consider double unders no different than a back squat or a clean and jerk or a deadlift. That we take principles of progressive overload and we carry it over to our body weight, cardiovascular stuff, especially higher scale, like double unders. How do we do that? Things like a Zeus Rope. or a drag rope are great. A drag rope is literally climbing rope with handles. It has, you can see the same handles as some of the other jump ropes I've shown you. The only difference now, there is no handle spin. The only way I'm going to rotate this rope is by being really aggressive and really fast with my hands. This is a nine ounce, I guess you'd call it cable. Again, it's technically just a length of climbing rope. This is nine ounces. So this is 900% heavier than the speed rope. So if I want to get better at double unders where I can look at a workout that has a couple rounds of maybe a hundred double unders and it has some other stuff in there too that's also going to make me tired from a cardiovascular perspective, how do I know when that workout shows up that I can blast through those with my speed rope? Well, when I go back and take class workouts that maybe have small sets of double unders 20 or 30 at a time, I bring my drag rope to class. And I do smaller sets with a heavier, slower rope that continues to progressively overload my double-unders so that when big sets do show up in different workouts, I can handle those no problem with my speed rope. So it takes practice, intentional practice. Folks are always disappointed that they don't magically learn double-unders 18 minutes into a 20-minute AMRAP. That's not how it works. Sometimes it does, but it usually doesn't. Practicing this stuff at home with a cheap jump rope from Rogue that's 20 bucks, practicing 10 minutes a couple times a week is really going to go a long way. I always tell folks when they're practicing double-unders the same way I tell them when they're practicing things like pull-ups. When you're learning to kip, when you're learning that motion, forget about getting your head over the bar. Just learn the rhythm. That's the most important thing you can do. I say the same thing to folks who are going to be going home and practicing double-unders. Don't focus on actually getting the double under. Focus on doing the mechanics correctly. Use a timer so that you're not just in your garage for an hour and you're breaking stuff because you're so frustrated or the neighbors are worried because you threw your jump rope into the street. Set a timer, do as many as you can, and then take a break for two minutes and do a couple sets of that. Make sure that you aren't treating it as a workout, but that you're treating it as practice and that you use different methods once you actually can do double unders. to continue to progressively overload your double unders. So double unders, not magic, physics, make sure your wrench is set up, but make sure your mechanics are dialed in as well. And make sure if you want to get better at these, that you actually spend diligent time to practice and make sure that it's actually practiced and it doesn't turn into a second workout that day. I hope this was helpful. I hope you have a fantastic Friday. If you're going to be at a live course this weekend, we have 10 of them going on, I believe. So I hope you have a fantastic weekend. We'll see you all next time. 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. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock discusses how to approach setting up at a competitive event, including looking the part, preparing to capture leads, and knowing what is possible in the context of a short session with a potential patient. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - MITCH BABCOCK All right, here we are. Good morning, everyone. Welcome to the PT on ICE Daily Show. I'm your host on Fitness Athlete Friday. I'm Mitch Babcock, lead faculty in the online Essential Foundations Level 1, Level 2 courses and our live Fitness Athlete course on the road where we do all things barbell in your hands all weekend long. I'm pleased to be joining you guys this beautiful Friday before Halloween here, October 27th. And my apologies for nine minutes behind the clock as our CrossFit hour this morning was jamming and ran a little bit long. Today's topic is something that we derived off the ICE Students page. So shout out to all of you that are active on the ICE Students Facebook page. We always appreciate the engagement, the questions, the comments, the thought. It spurs topics like these. You don't even know what kind of good info may come from a question that you pose on the ICE Students Facebook page. So thanks for being a part of that to everyone. 01:18 - THE ART OF THE 10 MINUTE EXPOSURE The topic today is the art of the 10 minute exposure. We're talking about, hey, someone posted a question of, I have an opportunity to set up at a local CrossFit gym or a CrossFit competition that's going on. And I want to know what should I do? Should I treat for free? What should I be doing? How long should I be doing it? And so we want to talk around that concept today of like, let's say you have 10 minutes with a free prospective client and you're trying to win them over in that fitness athlete space. What are some things that you need to be doing and doing well? And so that's going to be our topic of discussion today. And just before I dive into that, I do want to let you know that next weekend November 4th and 5th. Both Zach and myself are gonna be out on the road. Zach's gonna be in Hoover, Alabama, and I'm gonna be in San Antonio, Texas. Team, we are running out of dates to catch the live course at the end of 2023, so if you were hoping to wrap up that cert, or you wanted to hit that course and get dialed in on all your barbell dosage, treatment, refinement, everything, there's like a total of three weekends left at the end of the year. Anna Marie Island just sold out, so that one's off the map now in Florida. Shout out to everyone that's gonna be in Florida. We got Colorado Springs, we got Hoover, Alabama, and we got San Antonio, Texas. So if you want to catch us next weekend, we've got two dates. Check the PT Online's website and we will see you there at those courses. Okay, let's paint the picture. You are a newly minted business owner of your own. You've started your own practice, maybe in a CrossFit gym or near one. And you're looking to do this fitness athlete thing on the out of network side of things. And you want to anchor your ship tight to a CrossFit community in your town, which is smart. And you have an opportunity now to go to a CrossFit competition, market yourself, get your name out there, your business exposure, all of that. What should you focus on? I wanna start with looking the part. 05:07 - PHYSICALLY LOOKING THE PART Aesthetically, physically, from a business perspective, from a clothing perspective, all of the above. That if you're gonna go into this environment, that you need to pull up on the right horse. I don't want you showing up to a biker rally on a scooter and thinking like, I don't know why I didn't blend in with this culture, this community, right? Humans still operate on that first impression basis. That is still a key component. Those first three seconds that someone looks at you, sees you, makes all these internal assessments on what your business is like, what kind of information they can gather from you, what kind of expert you are. We have to respect that first impression and we have to bring our best foot forward. So let's start with your setup. your nice pop-up table, right? Whatever that is, they're cheap on Amazon, you can get a nice brand new table for 100 bucks, it's black top, looks good. Go on Vistaprint or Banner Buzz or one of these websites that will print out a nice custom fit tablecloth that will stretch over an eight foot pop-up table that has your business logo branded across the front of it. So you've got your treatment table and you've got a nice table up front that's going to hold all your brochures or anything else that you have on it. Marketing materials wise, that's a very nice printed stretch fit cover. You're going to invest a couple hundred dollars into having those things ready at any event you go to and market. 5k races, CrossFit events, whatever, right? Tent or not, really doesn't matter. Indoor comp, outdoor comp, you may wanna invest in a little pop-up tent, but let's just assume you're set up inside and you don't need to worry about that. You've got your treatment table, you've got a table up front. You need to personally look the part as well. And I don't just mean the clothes you wear, and yes, I do mean the clothes you wear, but I also mean physically. You need to physically look the part. If you're going in here and working with fitness-forward athletes, you should look the part like you train from a fitness-forward approach yourself. If you're not there yet, and you're trying to inject yourself into that community, anticipate a hard ramp up, right? You need to look like you work out, you train, you've exercised, you do CrossFit, you have some calluses on your hands, that you can speak to the expertise that these athletes are expecting you to have. That is just a cold truth that no one really wants to admit and talk about. If you can't tell the person in front of you how many burpees you do in seven minutes, you're probably not ready to set up at a CrossFit comp yet. Your personal expertise probably has some developmental work to be done on the back end prior to you setting up and going out there and being like, yeah, I can solve all your problems for you. I know exactly what you're going through. So get yourself dialed in from a physical perspective. Two, get your wardrobe updated, right? Do not roll into a CrossFit comp rocking that same polo that worked in the in-network setting and the khaki pants that you wore Monday through Friday. We're not in that setting anymore, right? So invest a few hundred bucks into a nice clinic wardrobe that looks good. Some nice athletic pants, joggers, whatever. Black always goes well. And get yourself a nice top and take it to your local screen printing place and have your business logo screened on the top of it. everyone's wearing the cotton freaking t-shirts with their low company logo on it but not everybody's wearing that that next level nice t-shirt whether that's lulu or whatever you go and you buy your stuff from you get that nice t-shirt you get your company logo on it it just stands out it just looks a little bit better a little bit more professional and a leg up on the competition you're going to business suspense that stuff anyways you might as well get a shirt you like you feel good you look good in and go get your company branded on the front of it So step one, looking the part. Both your setup, your table, your banner, your clothing, right? And physically looking like you train and you exercise and you know what you're talking about when it comes to this stuff. Two, Treat for free. Everyone's talking about should I charge people at these comps. I say that you're there to gain exposure. You're there to convert people back to your clinic. You want them to come to your operation. So you need to funnel everything through that filter. Everything needs to be geared around how do I get in front of people, show them I know what I'm talking about, and then get them to schedule an eval and come see me at my clinic. It's not about a transactional thing here. It's about giving things to the consumer in that environment where you're in front of hundreds of them, over delivering for free, and then converting on that at the end of the sale. 09:49 - CONVERTING LEADS And that's a key part. You need some way to capture leads and convert leads. The best way to do this is having some sort of QR code available. Everybody's scanning QR codes these days. Having a flyer printed out on a little plastic flyer holder that when they walk up and it says right there, free 10 minute session with Dr. So-and-so. Scan here. Boom, that's easy. Boom, pull out my phone, scan it. It takes them to something, a lead generation on your website. That could be sign up for my newsletter, name, email, phone number, city, whatever. That could be put in your contact information. We're going to reach out after today and kind of be in touch with you. Whatever that is, whatever lead funnel that you want people to go to, that's where that QR code directs them to on your website. So they scan the QR code. Boom. That holds their place in line. And then you're calling the next person up 10 minutes at a time. Hey, I got 10 minutes. What's going on here? In that 10 minutes, your goal is to address the areas that most need addressing, to over deliver the best you can, and then to convert that individual after the sale. Give, give, give, and then ask. Give, give, give in that 10 minutes. Here's what I think is going on. This is common. These get blown up. This gets overworked. This is out of position. This is stiff. We need to mobilize this. Here's some things that I like to do. Let's get some needles in that area. Let's do some cupping. And at the end of it, say, hey, I would love to earn your business. If you would, please take my card. I'd love to have you call and set up an appointment. I can actually get you scheduled right now. This looks like something that needs some work. Would you like to schedule right now while I got a few minutes? Don't be afraid of the ask. You're giving free content, you're giving free knowledge, you're giving free experience, and you're giving your time and service to that individual. Do not be afraid for the ask at the end of it, right? Can I earn your business? I'd love the opportunity to work with you, get you in the clinic. My e-mail rate is this. Can I get you scheduled for next week? Convert those leads. We stink at this as a profession and something we definitely have a lot of work to do on getting better when that conversion, that sales conversion process kicks in, right? 10:43 - TRIAGE & TREAT And then the last thing I have, if we're looking the part, if we are converting our leads is to know what works and deliver on that. Team, if they're at a CrossFit comp, they don't need pain science information right now. Okay? I'm not saying there's not a time and a place for that. What they need is something to help them recover. Their back is likely blown up. It feels like there's a hundred gallons of blood shoved right in their erectors right now. They want their back to loosen up and feel better. Their legs are probably imploded. They want their legs to feel better. Their shoulders are probably imploded. They want them to feel better. Right? Understand what these comps and these things are going to ask people to do. Lots of pull-ups, lots of squats, lots of deadlifts. Know what works for those things so that you're efficient in your clinical approach in those 10 minutes you have with someone. We're not trying to solve all their pain and all their problems in 10 minutes. We want to show them that we have tools that can help them. And if you give me more time, if you give me an eval, if you give me a couple sessions, I can get to the root of your problem. So you're having things at the disposal, ready to go for shoulder, like high-volume pull-ups, what am I gonna do to address the lats and the biceps? High-volume squats, what am I gonna do to address the legs and the quads? High-volume deadlifts, what am I gonna do to address the low back? Are you gonna bring needles and stim and hook people up and get them stimming? Cool, maybe get two treatment tables so you can get one person started on that and you get the other person on the table right after that. Are you gonna do some cupping on there, try to increase some blood flow? Great, get it set up, get it rocking, take a bunch of pictures. Another good thing to ask someone for is to have them take a picture and post about your company on social media. Remember, they're getting this for free. They're willing to do something in exchange. Scan your QR code? Sure. Post a picture? Sure, I can do that. Tag my business? I would really appreciate the exposure. We're just getting started. I love working in this community. I love working out in CrossFit. I'd love to be able to help athletes like you down the road. If you could post about my business, that would help me a ton. Thank you so much. They're thankful for your time, your service, and your free delivery of something to them, and they're willing to exchange that in terms of something else for your business. So there's some things for you guys to think about. The art of the 10-minute exposure. You've got 10 minutes in front of somebody. Treat them for free. Have some way of funneling and converting those leads. And don't forget to ask for the sale. Can I get your schedule? Can I get your book? Can I get your e-mail? Look the part. clothing, wardrobe, physically, and then your environment that you're set up, your tables, and your banners, and your marketing materials. And don't forget to ask for something on the tail end. Let's take a picture. Let's post about it on social media. Convert those leads, team. Get those people that you're there, you're giving your time for, for free. Convert those people into prospective clients that are on your books for the next week's following. I hope this was helpful. I hope you took something from it. that you know what works and that you're going to deliver on what works in that 10 minutes for that patient. Team, thank you so much. Shout out to anyone that's going to be at our courses to the end of the year. We're looking forward to wrapping up 2023 with a bang. Next weekend, we're in Hoover, Alabama and San Antonio, Texas. And still some spots for you to join us if you want to. And have a happy Halloween. I know we're rolling into it this weekend. Our gym has a Halloween WOD planned for tomorrow. So a costume WOD for tomorrow and then Halloween on Tuesday. So let me be the first to wish you a happy Halloween weekend, team. Thanks so much. Go kill it in clinic today. Have a great one, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Part 1 Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. If you snore loudly and feel tired even after a full night's sleep, you might have sleep apnea. Guest:  Dr. David Neubauer MD  Dr. David Neubauer is Associate Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University and an expert in sleep medicine. David Neubauer is a Fellow of the American Academy of Sleep Medicine and Life Fellow of the American Psychiatric Association, as well as a member of the Sleep Research Society, European Sleep Research Society, and the World Sleep Society, where he serves on the International Scientific Committee. He has served on the Board of Directors and Executive Committee of the National Sleep Foundation. David is the author of Understanding Sleeplessness: Perspectives on Insomnia published by the Johns Hopkins University Press, as well as numerous articles and book chapters on sleep-related topics. He is coauthor of the American Academy of Sleep Medicine Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults and the current Wolters Kluwer UpToDate section on “Pharmacotherapy for Insomnia in Adults.”   Part 2 Special Guests: Tara (Schmidt) Pfund, PharmD Product Manager at AssureCare LLC   Parth Shah  VP of Product at AssureCare, LLC Tara is the lead development, design, and strategy for various clinical services solutions supporting pharmacist providers.  The successful expansion of pharmacy roles during COVID-19 lead many pharmacists to want the temporary shift to become permanent. Dr. Tara Pfund, PharmD talks about the shifting scope of practice from being a medication dispenser to taking on a clinician role as an integral member of patient care. Pharmacists are playing a vital role in improving health outcomes and studies have shown positive impacts on health outcomes when pharmacists are involved in the patient care. Medication adherence, outcomes in chronic conditions, and preventing hospitalizations have all seen improvement with pharmacists' expanded scope of care. AssureCare's innovative, patient-centered, connected care platform increases access to care, reduces cost of care, improves quality of care, and accelerates patient engagement.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  https://journals.lww.com/nsca-jscr/fulltext/2019/12000/validity_and_reliability_of_the_rear_foot_elevated.9.aspx https://journals.lww.com/nsca-jscr/pages/articleviewer.aspx?year=9900&issue=00000&article=00300&type=Fulltext  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad". Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ALAN FREDENDALL Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today here on Fitness Athlete Friday, the best darn day of the week. I currently have the pleasure of serving as our Chief Operating Officer at Ice and a lead faculty member here in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things CrossFit, power limping, Olympic weight lifting. recreational bodybuilding, running, rowing, biking, swimming, triathletes, marathoners, anybody who's out there getting after it on a regular basis, we address all things relevant to that population. Some courses coming your way really quick from the Fitness Athlete Division. Your last chance to catch us online for our eight-week online entry-level course, Clinical Management Fitness Athlete Level 1 Online will begin November 6th. So that's just two weeks away. That'll be our last cohort of the year. That class will take us right through the holidays. and then we'll take a little break. The next cohort after that will be available sometime in the spring. So if you've been hoping to join us for that class, November 6th is your last chance for the next couple months. Live courses coming your way between now and the end of the year as we get into the back half here of quarter four. You can catch Zach Long down in Birmingham, Alabama. That'll be the weekend of November 4th and 5th. That same weekend, Mitch Babcock will be in San Antonio, Texas. The weekend of November 18th and 19th, Mitch will be in Holmes Beach, Florida. Beautiful place, just actually took a vacation there a couple weeks ago. Wonderful place to get to, especially in mid-November if you're from the Northeast or the Midwest, Florida's a great spot that time of year. That class just has one seat left, so if you've been looking to get baby both to Florida and to fitness athlete, that is your chance. And then our very last live course of the year from the fitness athlete division will be December 9th and 10th. That will be out in Colorado Springs, Colorado. That course will also be with Mitch Babcock. So check us out online, check us out live. We'd love to have you here at the end of the year before we get into the holidays. 02:16 - DOES FORM MATTER? Today's topic, we're going to take a deep dive into form and mechanics. Does form matter? How much does it matter? We hear this question a lot in our courses as we're introducing movements, instructing the basics of how to perform some of the most basic movements, your squats, your deadlifts, your presses. This may be a question that you get from athletes or patients in the clinic and for a long time and even right now this is kind of a very dogmatic campy approach to this topic of yes form is the most important thing or no form has no application at all we've even heard things like Sheer force is an artificial construct created by physical therapists to scare people away from moving. Physics doesn't matter as much as we thought it did. That movement, however it happens, is normal, natural, and that's how the human chooses to move, and there is no right or wrong way to move. So, where's the magic lie? Where's the evidence lie? What actually works in practice in the gym with real human beings? And what are some pearls to take away from the discussion on form? So often we get questions of does it really matter if the low back rounds during a squat or a deadlift? Does it really matter if the back hyper extends with overhead lifting? Who cares if someone catches a snatch with a bent elbow or they never reach full extension of the elbow at the bottom of maybe a pull-up? If someone presses their jerks or snatches out, is it really that big of a deal? So today I want to approach this topic from a couple different directions. I want you to go back and watch last Thursday's episode or listen to it on evidence-based medicine about making sure we're addressing all of the facets of evidence-based medicine when we approach a really hot topic like this that also has a room for a lot of interpretation one way or the other. We need to look at what does the evidence say, we need to look at what does our friend physics say, what does our clinical experience say as far as What is our anecdotal experience with clinical pattern recognition with actual patients and athletes? And then what does the patient say? What matters to the patient? Patient expectation and input matters. So let's start from the top. 04:42 - WHAT DOES THE EVIDENCE SAY? What does the evidence say? As much as we don't want to hear this, we don't have a lot of strong evidence either way in this discussion about form. When we talk about what does the evidence say, we have nothing concrete or strong for or against poor mechanics and lifting. We have a ton of research out of the functional movement screen space that looks at movement quality and its association to injury. And time and time again, I have to declare my bias. I hate that test. I think that test is total garbage. I think the research supports that that test is total garbage. And when we look at does particularly unweighted movement transfer to predicting injury, we have stacks and stacks and stacks of research across a wide variety of populations, recreational athletes, tactical athletes, first responders, professional athletes, that shows the association between quality and injury prediction or injury risk reduction is simply not there. We do have some research that looks at the effects of lifting, and I'll put lifting in air quotes here for those of you listening on the podcast, that lifting with a rounded back does not seem to cause low back pain or make current low back pain worse with the caveat of when we look at that systematic review and meta-analysis from O'Sullivan and colleagues a couple years ago, that the papers they included did not have any patient lifting more than 25 reps across the span of a day at a weight heavier than 25 pounds. It's really hard to take research like that and extrapolate it to our population who might be deadlifting two or three times their body weight, cleaning or snatching their body weight, doing dozens or hundreds of things like pull-ups and handstand push-ups and double-unders, really getting a lot of load through their body, running, crossfit, lifting, whatever. That research really has no application. It's really hard to even call that lifting, right? Those are just kind of activities of daily living. We can't take research like that and extrapolate it to somebody dead lifting with a low back and say these are the same. They are just simply not. We also need to be mindful of the research that we do have. When you look at papers on deadlifts with low back pain, on the effects of lumbar reversal with lifting, what you'll find in those studies is that one of the variables that the research authors always control for is the lifting mechanics themselves. You'll often see, if you actually read the full paper, not to harp on that, but when you read the full paper, when you read the methodology, what you will find is that very often those folks are instructed how we would instruct a movement in the gym, which is to try to maintain a brace-neutral spine, modifying the load or modifying the range of motion to maintain that, to therefore reduce that as a variable in the research study. That if we cannot control mechanics, that's one more variable that maybe takes a little bit away from our conclusion when we look at the data. Of trying to standardize the mechanics as much as possible is how we can narrow down the focus of that research study on whatever the intervention is and whatever the outcome and feel really confident that the association there is direct and that other variables aren't at play. If we can't say deadlifts are safe, deadlifts increase low back strength, deadlifts improve low back pain, if we look at a study and there was no control on how the deadlift was performed or how the mechanics were performed through those deadlifts. One study does sumo deadlifts, another does conventional, one does trap bar, one allows back rounding, one does not. You'll see when you read those studies that controlling for those variables, controlling for those mechanics, is one of the ways that variables are reduced. And so it's hard to look at those studies as well and extrapolate to altered mechanics, what we might call a movement fault, and translate that to the population that we're working with. It's hard to take research and say, you know what? I'm gonna do everything this study did except change everything about it, right? That doesn't mean you're implementing that research and practice. You're taking the general idea and you're kind of going your own way with it. You no longer have that evidence base to stand on. From the research, we do know that symmetry can be objectively quantified, we can assess it, and we can intervene on it. Very often, physical therapists are very comfortable at calling out and identifying qualitative faults without really understanding what might be going on, how to assess it, how to measure it, how to track it, or how to change it. But if we look at some really nice research papers, a great one came out this year, I'm gonna butcher this name, I'm so sorry, Yuja Kovic and Sarah Bond came out this year, looking specifically at asymmetries and change of direction in basketball athletes and finding that there are ways that we can objectively quantify things like asymmetries, strength, speed, motion, quality, asymmetries, that we can also intervene on them. This study in particular sought to reduce the change of direction asymmetry by overloading the slower slash weaker limb with three times as much training volume compared to the stronger or faster side. That looking at an 11% or so difference in change of direction speed, able to reduce that down to just 4% simply by overloading the volume on the weaker, slower, basically problem area. In this case, it was the lower extremity. A very simple study, just using some lower extremity strengthening, three times as much volume as the contralateral limb. We know we don't need a biodex or some other form of fancy isokinetic testing or force plates in our clinic to have ways to objectively identify and assess maybe quality that is associated with asymmetry that is maybe the cause of pain, aggravating current pain, aggravating past pain and or limiting performance. Great study by Helm and colleagues 2019. wanted to validate the five rep max rear foot elevated split squat. Maybe you have heard of this as the Bulgarian split squat, but essentially kicking up that back leg, doing a five rep max on each leg. In this study, they used a barbell. In the clinic, you can use dumbbells as well, trying to find a five rep max per side, and then quantifying and objectifying the asymmetry side to side. Finding it's a very reliable, very valid way as compared to things like Biodex, and force plates to develop an idea of asymmetry from side to side. I would argue a paper like that we can extrapolate to the upper extremity, we can do something like a landmine press, we can do something with our lats or back with something like a bent over row and really start to think if we're seeing movement faults that we think are the cause of symptoms or some sort of performance issue to start getting more objective in how we assess, reassess, and intervene on these things. So that's what the evidence says. It doesn't say a lot. Besides that, we need to help people get stronger and we need to quantify where their strength is at as they're starting their rehab program and then reassess it as they're finishing in order to be sure that person actually got stronger and actually closed the gap on any sort of perceived or actual asymmetries that we found. 11:38 - WHAT DOES PHYSICS SAY? What does physics say? This is something that we tend to ignore a lot, that we exist as human beings on a planet with things like gravity, and that we are subject to certain physical characteristics that we can't avoid. Physics would say that the shortest route between two points is a straight line, and anything else, any other extraneous movement is a force leak. Any amount of force leak doesn't matter what your sport is. If you're an Olympic weightlifter, a powerlifter, a crossfitter, a gymnast, a swimmer, a runner, The more inefficient your mechanics, the more extraneous movement, the more your leg kicks out into circumduction in your run, the more your lower back rounds and extends back and forth as you go through deadlift reps, the more you bend your knees or bend your elbow in your pull-ups, it doesn't matter. The more extraneous movement you have, the more you're leaking force out of your system, the more you're limiting your top end performance. I have yet to this day see anybody break the deadlift world record by doing a Jefferson Curl. Yes, under extreme loads we might see a little bit of low back rounding, but we don't see people intentionally initiating a 1500-pound deadlift with a Jefferson curl mechanic. They tend to approach the barbell over and over again in a similar fashion, either setting up in a conventional or sumo deadlift and really doing everything they can, again, to minimize extraneous movement, put the maximum amount of weight through the ground to lift the highest load up in the air. That is performance, that is physics. We have to remember, unless we can invent some sort of technology or better understand physics, we can't get around that. So that's the evidence, that's the math. What does our personal experience say? Our clinical experience, maybe some of you would say this is anecdotal, but remember, part of evidence-based medicine is our clinical experience. 13:59 - WHAT DOES CLINICAL EXPERIENCE SAY? Our clinical experience would say that those folks in the gym that we see performing pull-ups, overhead movements with things like a constantly bent elbow, tend to be the people that we most often see over in the PT clinic for stuff like elbow pain. That the folks who rock up on their toes, catching their cleans, their snatches, because they lack ankle dorsiflexion, are the folks that we tend to see coming into the clinic with things like knee pain. That those folks who always quarter squats, no matter how much we try to help them get to a deeper range of motion, a greater range of motion, whether it's working on their mobility, elevating their heels, giving them a squat to target, whatever our coaching cues corrections are, those tend to be the folks in the clinic with things like knee pain and hip pain. And those folks who show up with lumbar rounding in the bottom of their deadlifts, as they're pulling the deadlift off the floor, the bottom of their squat, catching a clean, catching a snatch, those tend to be the people who come to see us for low back pain and hip pain in the clinic. 18:01 - WHAT DOES THE PATIENT SAY? And that connects really well to the third part of evidence based medicine of what matters to the patient. We have to understand these folks are often aware of their faults, especially the more they've been training, the less faults they tend to have, and they're more acutely aware of the ones they have left, and they also know the association between the faults they have and maybe aggravation of symptoms, re-aggravation of symptoms with maybe a previous injury. Understanding as well that we don't just always work with the lead athletes, that our goal is to introduce movement to everybody who comes into our clinic. How hard is it to introduce movements, even basic movements like the squat or deadlift, to patients who maybe never done this in their life before? Not even with a barbell. Maybe we just hand Doris a kettlebell for a goblet squat, or we have Frank just deadlifting a kettlebell off the ground. How tough is it for that person who is a complete novice to this If our instruction is, hey, Frank, you know what? Mechanics don't matter. Points of performance are arbitrary constructs created by rehab providers and fitness professionals to scare people like you into purchasing more care than you need. How helpful is that to teach movement to somebody new? What are they going to say? Uh, okay. So like, is there a way I should do this? Is there a best way? Well, Frank, it doesn't matter. All human movement is good and natural movement. Just do whatever feels good. That's not very helpful, right? And you would never do that in the clinic with a patient. You would never do that in the gym with an athlete. If you do actually do that, I challenge you to film that and send it to me because my gut tells me that nobody actually does that because you know how stupid you would sound and how likely it is for the patient to be successful if that's your approach to instructing movement. Likewise, if we do have that more experienced athlete, what good does it do to tell that person who has extreme low back pain, when their spine rounds in the bottom of the squat, there may be somebody who's filming their lifts to try to figure out why do my squats bother me? And our answer is, hey, there's no evidence to support that your spine flexing is a source of your pain. Same issue, right? Same outcome, entirely different patient population, but same outcome. Okay, that's not very helpful. I can see my tail tucking here, and I notice that when that happens, that's when I feel my extreme low back pain. That person has already associated that in their mind. What good does it do to tell them that there's no evidence to support that that's what's happening? They're experiencing it firsthand, right? We need to be mindful of the way that we instruct this, both with new and experienced athletes, patients in the gym and the clinic, that mechanics do seem to matter. People seem to have a natural awareness that at least some sort of standardization of performing a movement seems natural and that some sort of association exists between maybe symptoms and faults. We always acknowledge the resiliency of the human body, that yes, it can develop tolerance in different positions, such as lifting with a rounded back, but we can also still do stuff at the same time to limit pain with lifting. We can modify the range of motion. We can modify the load, the volume, whatever, to a more tolerable level. We need to get a lot more comfortable living in the gray area. Yes, we can recognize injuries multifactorial. Yes, the body's capacity can be temporarily reduced by things like sleep, stress, illness, nutrition, but we can also still manipulate movement to be more comfortable and enjoyable and also help that person work on strengthening in a manner that we know is very evidence supported that's going to reduce the likelihood of future injury. I have an athlete on my caseload right now, very, very impressive athlete, been doing CrossFit a long time. every time she's under an extreme amount of cardiovascular fatigue, or she's doing something like a 10 rep max with a back squat or a three rep max clean or something like that. Usually under a high amount of fatigue, she demonstrates some lumbar reversal associated with that lumbar reversal is always extreme low back pain. She is aware of that. She's somebody that films her lifts. She knows every time she rounds her low back in the bottom of her squat, that is what usually will kick up an episode of low back pain that could last short term, a couple of days, or could really set her back weeks or maybe months. So she's very aware of her spine rounding, the association of form with the development of symptoms, and aware of how bad those symptoms can get. So what are solutions with that in regards to does form matter or not? Well, the first thing we can always do is help reduce that pain acutely, right? Of that person is an extraordinary pain in our clinic, regardless of what we're going to do with them in the gym, regardless of how we're going to address their form, we have ways to reduce their acute pain. We can modify those squats, we can do things like belt squats, we can do lightweight, high tempo squats, tempo squats at maybe 30 or 40% of her max where she's maybe taking three, five, seven seconds to sit down to that squat to maintain or continue to build strength in a way that doesn't aggravate her symptoms. We can do alternate movements if a squat pattern is not tolerable at all, hip thrusts, deadlifts, et cetera, to train lower extremity general strengthening. Yes, we can build up general strength and endurance of the low back, the legs, the posterior chain as we're getting more comfortable, but we can also spend some time working with that athlete on their mechanics of what's going to probably help you the most is that under extreme fatigue, you know how to breathe embrace, you know when to call it for the day when you know you're extremely fatigued, so you don't find yourself in this position again and again. And yes, the final step there is probably to layer in some intentional lifting in that what we would say poor mechanical position, right? Let's also add in some rounded back lifting so that we expose ourselves to the movement so the only time we encounter it is not under a 10 rep max on the 10th rep where we tend to encounter our symptoms. So let's do things like sandbag cleans and sandbag squats and yes, Jefferson curls and other things like reverse hyper extensions. Let's do all the things. We don't have to focus just on form but also form matters. We need to train in that position so that when we get into that compromised form position, it is going to have a less likelihood to be symptomatic and set that athlete back. 21:09 - MECHANICS & PERFORMANCE And finally, we need to go beyond pain into performance. What does the evidence say? What does physics say? What do we say? What does the patient say? What does performance say? What can you possibly help an athlete with who comes into your clinic, who wants to pay you $150 an hour to improve their snatch, and you say there are no optimal mechanics to complete the snatch. We know that's not true, right? People who win gold medals in clean and jerks and snatches tend to lift a certain way. They tend to all show relatively the same mechanics. That tells us that mechanics seems to matter a lot in regards to high level performance. There's a reason those Olympic weightlifters tend to initiate their pull off the floor in the same fashion, going through their first pull, their second pull, their receiving position, the jerk overhead or the catching of the snatch. There's a reason that it looks pretty much textbook no matter who the athlete is, how tall or short or big or small they are or what their race or gender is. They all tend to show the same mechanics time and time again. It seems like it's physics at the end of the day. We don't see anybody breaking the snatch world record with a rounded back deadlift to a muscle snatch, do we? And I think that tells us a lot of now beginning to shift towards using mechanics to push performance. And again, as long as we can be objective about it, I think that is the way to go. 24:41 - SUMMARY So what does the evidence say? We have nothing strongly for or against poor mechanics and lifting. is it relates to people actually performing resistance training not just picking up pins off the floor with a rounded back. We need to be mindful that research studies tend to standardize points performance for lifts such that everyone is performing the same thing the same way every time. What does physics tell us? It will always tell us unless something miracle happens with a change in physics that the shortest route between two points is a straight line Mechanics matter in performance. Straight lines are strong lines. What does our clinical experience tell us? That people who tend to move like crap, especially under increasing amounts of load and or volume, whether it's due to poor mobility, going too heavy, going too fast, those tend to also be the people who need a lot of healthcare treatment, right? Those folks who tend to move quite well tend to have maybe one particular fault, that they're usually aware of, and that they're usually also aware of being associated with their symptoms, and we need to be mindful of that. And what do those patients say? People who are already active are usually aware of that fault, they're usually aware of when and how they demonstrate it, and they are usually aware of that it's associated with some sort of symptom, development of a new symptom, re-aggravation of a previous injury, that sort of thing. We know the group of people we probably need to help the most are inactive patients. The other 90% of the population, right? The majority of the people in our caseload. Inactive patients, people who are complete novices to movement, can't learn things in a structured manner that they're going to be able to repeat them on their own in the gym or at home in the garage or whatever. if our approach is that physics, points of performance, faults, are just artificial constructs that we create to scare them and somehow fleece the general public out of their money. And then also finally, something to remember is that you'll be stuck on a hamster wheel in your clinic forever just treating people in pain if you're not able to transition people to the lifelong fitness and performance side of what we can offer them. At a certain point, mechanics do matter as it relates to top end performance, as it relates to goal setting. And you're crazy if you think, quote unquote, normal people don't want to increase the amount of weight they can snatch, or how fast they can run their mile. We need to be mindful that with top end performance, when people want to see their 5K time come down, or their one rep max back squat go up, that mechanics really, really, really do matter. So mechanics, do they matter? It depends, but there's probably more to be said for mechanics mattering for a performance aspect, for instruction aspect, and for overall higher quality and the ability to perform more movement more often, which is the goal. If we are aware of mechanics, but also being mindful that sometimes they don't matter, especially if we're not being objective about assessing them, reassessing them, and what we're doing to intervene on maybe trying to improve mechanics. Tough discussion, but I think it's worth one having. I hope you all have a fantastic Friday. If you're gonna be at a live course this weekend, I hope you have a great time. We'll see you all next week. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses hip shifting in the squat. Zach emphasizes the need to ensure first and foremost, pain is in the hip or elsewhere in the body is not the cause of the shift. Second, Zach urges listeners to determine if the shift occurs under increasing loads or not. Finally, Zach discusses that if the squat is pain-free and that the movement pattern does not change under load, hip or ankle mobility is the final culprit. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ZACH LONG Hey everybody, welcome to the PT on Ice daily show. It is the best day of the week here on the podcast, and that is Fitness Athlete Friday. I am your host today, Dr. Zach Long. I'm lead faculty inside of the clinical management of the fitness athlete curriculum, teaching in our live weekend seminar, as well as our advanced concepts course. And today we're going to be chatting about assessing the individual that has a hip shift when they squat. what are the questions you should be asking, and what are the things that you should be looking at and programming for them to help address that hip shift in the squat before we dive into that topic. Upcoming courses that we have in the Fitness Athlete Live arena here. November 4th and 5th, I'll be in Hoover, Alabama, and Mitch will be in San Antonio, Texas. November 18th and 19th, we'll be in Holmes Beach, Florida, and in December, Colorado Springs, Colorado. If you can't make it to any of those courses, we are already filling up the 2024 calendar as well. And we have Portland, Charlotte, North Carolina, Boise, Idaho, Renton, Washington, Raleigh, North Carolina, and Fenton, Michigan on the map. So check out all of those courses, as always, at PTOnIce.com. If you want to get registered, learn how to better assess, treat, and help fitness athletes do the movements that they love, as well as how do we get those people that are not already getting their daily dose of physical activity, how do we start to get them involved in that sort of stuff as part of their plan of care when they come to see us for pain? So PTONICE.com there. 02:32 - ASSESSING THE HIP SHIFT All right, today's topic, the hip shift in the squat. What I mean by that is you watch somebody squat, and instead of their weight staying even side to side, you see them shift some of their weight more towards one side than the other. Why does that happen? What are the questions you need to be asking? And then what are the things that you need to be doing as part of their treatment? So I think there are two big questions to ask subjectively when somebody comes to see you for a hip shift or you notice that when you're watching videos or watching somebody actually lift in the clinic. Question number one is, does that individual currently have pain in regions of the body that are impacted by the squat? Question number two is, does that change under load? When you ask and answer those two questions, you'll have a much better idea of what interventions you need to do to help improve that squat pattern. 3 Different Pieces to That 1. If someone is having pain, That's kind of the end of the discussion on the hip shift in the squat. So if somebody comes in and they're dealing with really nasty patellar tendinopathy or they're dealing with an ankle that was just sprained and is very, very sensitive as we dorsiflex the ankle. or someone has really irritable hip impingement. As they squat down and those tissues start to get loaded more as we go through range of motion, if those tissues are really sensitive, the body is understandably going to want to unload those tissues and try to avoid further aggravating them. So, when pain is on board and I notice a hip shift, I don't really worry too much about the hip shift right now in terms of trying to correct that. Instead, my main focus is on doing everything I can to calm down that irritability, because until we calm down that pain, we're probably not gonna make a whole lot of progress on the hip shift. So if pain's on board, take care of the pain. Now, there are definitely things that you can do that might assist this a little bit, but to me, those are secondary to the pain portion of this. So you could have somebody do box squats where they limit their depth to where they don't hip shift. or some other variations of lifts that maybe load that tissue a little bit less so that they demonstrate less of that hip shift. I think that's a fine intervention to do so that maybe that hip shift doesn't become, you know, as much of an ingrained movement pattern to them. But overall, when pain's on board, just take care of the pain and don't worry quite as much about the hip shift. 04:29 - HIP SHIFTING UNDER LOAD The second component to that, the second question was, does this change under load? And this is the big one that I see missed quite a bit. So I've had a couple of these show up in the last few months in the clinic, which is why I decided to do this podcast. And of those that I've seen lately, most of them, I was a second opinion. So they'd already seen another physical therapist or a chiropractor. And they had already had a lot of mobility drills that they were working on to try to improve the hip shift but they weren't noticing a change with the mobility drills. And what was missed by that previous practitioner was the fact that the hip shift worsened with load. And if we think about like the mobility demands of a squat, those demands don't change drastically when they go from an air squat to a 45-pound barbell squat up to a 400-pound squat. What does change is the demands that we're putting on the muscles. And actually, it's a little different than that. It's a little opposite. When you put load on a bar, if you're a little stiff, that load will often help you move a little bit better. It'll help push you through a little bit of that stiffness. So the key thing here is that if you notice the hip shift gets worse under fatigue or under load, then it is probably not a mobility issue. It is much more likely to be a tissue capacity issue, a strength issue. That's the big turning point here. So two examples of this that I've seen lately. Number one, super high level power lifter. He started noticing when he looked at videos of his squat that his bar would get uneven, but that wouldn't happen until he got to weight over 400 pounds. Prior to that, it didn't happen. And if you watch a set of him squatting over 400 pounds for say a set of five, what you notice is rep one was a little bad, rep two a little worse, rep three worse, rep five was really, really bad in terms of that bar being uneven. And what I noticed when I started analyzing that was that as he came out of the bottom of the hole, you would see his one side of his leg, if you're watching that Instagram, I have no idea why fireworks just popped up on my background, but You saw one of his legs really extend rapidly and the other one slowly extend. And what that's called is a good morning squat fault. If you've taken the Fitness Athlete Live course, you've heard us discuss that squat fault, but he was doing it only on one leg. And that leg had previously had an ACL reconstruction. And when we went and measured his limb circumference on that leg, he had a significant quad muscle mass difference on that side compared to the other side. So it was a strength deficit. And what we ended up doing with him was we loaded up his quads, doing a lot of unilateral work. We'll talk about a few drills for that in just a second. And what we noticed is the more we built up that unilateral quad strength, the less that hip shift was present. Another example I saw was recently in a… very high level CrossFit athlete, like top 200 in the world. When he deadlifted, he lost a major competition because his deadlift was relatively weak compared to his level of fitness. And when we watched his deadlift, he kind of did the same thing. So he starts pressing off the ground and the side that he had previously had an ACL reconstruction on about a year and a half prior to this, he hyper extended that knee as soon as he started pressing off the ground because he was still had a little bit of top end quad weakness relative to the other side. So he locked that knee out and he tried to, on that surgical side, make it almost a straight leg deadlift and rely on his posterior chain rather than his quads. So if it changes under load, it is a strength issue, not a mobility issue. 09:26 - ANKLE & HIP MOBILITY If it doesn't change under load, then you're gonna shift your thinking towards it possibly being more likely to be a mobility issue. And so from a mobility perspective, a few things that we like to look at, Number one, I'd say the most common are ankle and foot limitations. So lack of ankle dorsiflexion, lateral tibial glide, or the ability of the midfoot to move as somebody drops down into a squat. In our Fitness Athlete Live course, we talk you through a couple different tests that we think really help you screen out the foot and ankle, and if that's the impacting factor on somebody's squat technique. The second one to that is going to be somebody's hip mobility. And then the third to that is sometimes you'll see knee flexion limitations, but typically you don't see knee flexion limitations unless somebody's had some really significant trauma to that knee or a recent surgery. Outside of that, it's typically the ankle or the hip from a mobility perspective that will be impacting somebody's squat, causing them to have a hip shift in the squat. So once you answer that, you kind of know what to do. If it's pain, take care of the pain. If it's mobility, work on mobility. If it's strength, then let's do some unilateral strength loading of whatever tissue it is that you identified was a little weaker on one side versus the other. Take care of that. But I also think that it's worthwhile to spend a little bit of time working on some drills that might help reinforce a better movement pattern. So that as you build up maybe that unilateral strength or as you open up that ankle mobility, now you start teaching them a little bit more of where they want to go. And there are two drills that I really frequently use for that. My favorite to use is what's called a sit squat. So what I do there is I get an individual sitting on a box, a bench, a chair, a medicine ball, whatever the lowest surface they can perform this drill on, and they're sitting on it. We pull their feet back underneath them. We lean over. I get them positioned exactly how I think they should look in the bottom of the squat. And then they're sitting there, and I've got everything lined up so that it's symmetrical or as close to symmetrical as I feel like we're gonna get or we need to get. And then what I do is I tell them, imagine that there's a scale underneath your butt. Right now it says 100% of your weight. I want you to make it say 50% of your weight. So they just unload that medicine ball a little bit. Now I say, I want you to lift up one inch and only one inch. So they barely lift off the medicine ball or chair. They go back down to 50% weight and they just cycle up and down. And if you do a set of five to 10 reps of that, it is gonna actually burn really, really good because most people don't spend a whole lot of time under tension down the bottom of the squat. because there's no load on it. It's not going to be very fatiguing or really eating to their recovery a lot. So I use this a ton as a warmup drill, but that is deceptively hard and is really good for getting people to evenly drive and press into the ground and get an even lift off. And then when they sit back down, what they should feel if they're on something like a medicine ball is that they have the same amount of butt cheek touching the ball. Like if they sit down and it's only left butt on the medicine ball and right butt is floating off the side, then they're not squatting evenly. They're demonstrating that hip shift so they also get some tactile feedback in terms of their positioning. The other thing that I really like to do at times with individuals is get them to do some tempo box squats. So we squat down to a medicine ball, a bench, a low box, whatever it is, and we're basically doing the same thing there. We're going down nice and slow and we're making sure when we touch that surface that we're squatting to that we feel an even amount of weight on both butts. so that we, again, know if we're hip shifting or not. Those can be two good drills to drill in moving a little bit away from that hip shift. So, again, your two questions to ask when you see a hip shift. Are they having pain? Does it change under load? When you answer those two questions, you'll have a much better idea of what to go to to get rid of the squat hip shift a little bit faster. So, hope that helps. Look forward to being back on here again in a few weeks with you all. Hope you all have a great Friday and a great weekend, and we'll see you on the road. 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. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock takes a deep dive into the jerk, discussing the importance of learning a strong leg drive, improving shoulder mobility, and committing to a strong finish with the movement. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app.physicaltherapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. Good morning, everybody. Welcome to PT on ice Daily Show. I'm your host, Mitch Babcock from the Fitness Athlete Division. That means it's Fitness Athlete Friday, and I'm stoked to be back on the podcast, bringing to you another episode, this time going into some nuanced stuff around the jerk. So stay tuned for some more details around how to make your jerk a little bit better. Today's topic, don't be a jerk with your jerks. Before we get into that team, first of all, I'm wearing my Lions shirt. Did you watch the game last night? Of course you did. Thursday night football. Let's go Lions. It's been a long, hard existence being a Lions fan. So we're out here stoked that we got t01:27 MITCH BABCOCK hree wins already on the season. Other news, non-football related, is that the fitness athlete team is going to be around the country coming up real fast here next weekend. Joe and myself are going to be out in Linwood, Washington, and we're rocking a big course out there. So if there's still time, if you want to slide in just under the cap of that course out in Linwood, if you're in the Seattle or greater Seattle area, we'd love to have you out at that course. We also have some courses coming up in the southern region. We've got San Antonio, Texas. And we've got Anna Maria Island in Florida. So if you're looking at Florida or a Texas course, we've got two of those in store for you coming up in the month of November. So otherwise, welcoming in the fall season here today. 01:43 MAKING YOUR JERK BETTER And today's topic around don't be a jerk with your jerks. We just finished up a nice May cycle where we did a lot of snatching and clean and jerking for the last eight weeks. and giving my members of the gym as many helpful tools as I can as a coach and an athlete of what's helped me with my shoulder overhead, specifically the push jerk in this cycle, but all of these principles also apply for the split jerk as well. And I see this done wrong or at least thought about wrong a lot. I figured it was helpful to share with you guys, whether that's from a personal standpoint as an athlete, you're out there training in the gym yourself and you're like, hey, This is sweet. I hate jerks. I hate split jerks or push jerks. And I want to get better at those. Or if you want to be able to pass that on to your clients or members, hopefully this will be helpful. So the first thing I want to talk about is what not to do. Don't press your jerks. 03:37 THE JERK HAS LITTLE TO DO WITH ACTUAL PRESSING The push jerk and the split jerk is not about how much you can press vertically. It has little to anything to do with actually pressing the bar vertically over your head. Think about what your one rep max strict press is. Ladies is usually somewhere in the ballpark of 60 to 100 pounds. Men, somewhere in the ballpark of 100 to 200 pounds of a strict press. And yet people are able to do almost twice as much as that when it comes to a jerk movement. It is not about your strength to move the bar off of your shoulder and press. So stop thinking of it like you need to push the bar up. The jerk is about pushing yourself under. That requires a couple things. One, specifically the legs. You need to start thinking about your legs way more than your shoulders on your jerks. It is all about your legs' ability to launch the bar off of your shoulders enough that you can then press your way under the jerk. Again, goes for the push jerk or the split jerk. So when you're in setup position, you've stood up that heavy clean and you're ready to make the jerk. Hopefully make the jerk. You need to be thinking about how much leg drive can I create vertically on this bar right now to launch this thing as far off my shoulders as possible. That means I need strong legs. I need to be better at my front squat. Specifically, when I stand up out of a heavy front squat, I need to be powerful in the finish as I'm standing and finishing that lift. So that's something that you can be training on days that you're not jerking at all, but be thinking about that last little third of the squat. Standing it up with a little power, with a little speed, and learning how to create really rapid short triple extension. Power cleans, same thing. Rapid triple extension at the top, but all we're trying to create here is more powerful legs. You can work on just dip and drives. It's a very common drill for Olympic lifters to work on. Get a bar in the front rack position. You just dip, hold, and just create a slight little bit of triple extension coming out. Dip, hold, create triple extension coming out. The focus point on the jerk needs to be on a strong leg drive. Now, once you get that to occur, then the press is actually you pushing your body under. It's just pushing myself down to a supported arm position. The shoulder is strong if it can meet the load in its locked out position. It's significantly less strong when it has to do any sort of motion to try to press out that kind of weight. So the quicker you are to press yourself down and support, the heavier of a jerk you'll be able to have, because it's just about supporting the load, not about pressing the load. 07:01 SHOULDER MOBILITY & THE JERK That requires shoulder mobility. And this is the big downfall to your split jerk is likely either A, you've been thinking about trying to press it over your head this whole time instead of jumping over your head. And B, your shoulders are too dang tight to really get into that full 180 degrees of flexion lockout arm position. You're trying to press it out in front and that's killing you, right? So you gotta open up that shoulder mobility. And you guys are the experts at doing this. Mitch, what do you like to do to open up your shoulders right before I'm weightlifting. I'm not talking about a PT session. I'm talking about something members can do out in the gym, boom, in real time to open up that double arm overhead position. I want to use a green band, but I don't want to do a single arm. I want to do double arm. And so rather than looping the band and attaching it to the pull-up bar like we normally do, I want to drape the band around the bar in this fashion. This is a poor example, but you get what I'm trying to say. I just, I don't want to half hitch it at all. I want to just loop it over the bar and have the band hanging down. I'm going to put both my hands through the band and I'm going to spin around. If you're watching this, this is a great I hope you're having fun with this because I'm spinning right now. I'm going to do like three circles and what that's going to do is wind up that band. So I've got it looped over the bar and I wound it up by doing three circles in it. My hands are now held in this double overhead position and I'm going to kneel down on the ground from that position. I'm going to start to have the band pulling my shoulders, essentially both arms, right near my ears at this point. When I'm down there kneeling on the ground, hands overhead and hooked to the band, now I can start to add some side bending into this position, which really starts to peel on this lateral seam of my arm, coming down to thoracolumbar fascia, up into the tricep area. I can side bend left, side bend right, and even add in a little upper back T-spine extension to that drill. It is the best opener I have found recently to get my shoulders ready to push jerk. because I'm hanging out in the exact position, an exaggerated version of it, but the exact position I want to finish my jerk in, which is the head through, the T-spine up and extended, and the arms behind my ears. So when you're thinking about pushing yourself under the bar, make sure your shoulder mobility is opened up so that you can do that. Okay, so what do we got so far? Strong leg drive, Don't press your jerks. Instead, push yourself under your jerks and make sure your shoulder mobility is on board for you to do that really well. 10:47 IMPROVING JERK TECHNIQUE And the last thing you need to think about, the only really cue I'm thinking after I think jump is I think head through. I think jump and I think head through. Too many people are scared to put their head through on a heavy jerk. They're committing to failing it and therefore they're committing to self-preservation. And so what they do is they jerk and they leave their head back behind the bar and they're like, if it works, cool, then I'll bring my head through. But if it doesn't, I can bail quickly and easy. That is just committing to failing the rep right from the start. You have to know that if this goes bad and I'm still pushing my head through and I can quickly get out and underneath the bar if I fail it. You're, trust me, you're athletic enough to move out of the way of the bar. I've seen it a number of hundreds and hundreds of times of athletes trying to get the head through, fail the rep and are still getting out from underneath the bar. You've got to commit to that head coming under and through the window. Because if not, the bar is going to be out in front of your center of mass. And it's way too heavy for you to hang on to out there. My max jerk is 350. There's no way if I don't get my head through that, that I can hold that kind of load overhead. I've got to bring the head through and I've got to bring the arms behind my head. And that's when I close my eyes and say a little prayer. Oh, I hope this goes good. But the head is forward. I'm not looking at the bar. The head's got to be forward and through. So the only two cues, if you're thinking about anything, it's jump as hard as I can and push my head through that window and pray for the best. Shoulder mobility needs to be on board. It's all about the legs. It's not about the shoulders. And it's about getting your head through the bar. And if you do those three things, you go out in the gym today, right now, and you start practicing those three things, I promise your jerks are going to feel faster, snappier. You're going to reach lockout a lot quicker, and you'll be able to PR that push jerk or that split jerk, whatever you're doing. And hopefully add 10 pounds on it. Don't forget to tip your caddy when you do. All right. I'll open, I'll share my Venmo below. Don't worry. That's how to not be a jerk with your jerks. I hope that stuff helps you. I hope that gives you some things to think about maybe for your athletes you're working with or cues that can help them and restore that overhead position. I think I should probably film a video of that shoulder mobility opener. I got a feeling I'm going to get some comments or questions about, Hey Mitch, I had no idea what you were trying to explain. Can you drop a video? So I'll walk right out in the gym. I'll film that and I'll do my best to drop a link to that video in the best place possible. Maybe over on my Instagram. Head over to my Instagram, Dr. Mitch TPT, follow that. And then, uh, I'll drop that video there for you guys, man. So glad you guys are here. Happy Friday. Go lions three and one and one and O in the NFC North. It's a good time to be a lion's fan for the first time in about seven years. Team. I hope you have a great weekend. If you're taking a nice course, let us know if you're taking a nice course next weekend, we'll see you out there. And if you want us to head down South, come find us in San Antonio or find us in Florida. and we'll be hanging out down there in the month of November. Have a great weekend, everybody. 01:27 MITCH BABCOCK Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko stresses the need to maximize preparation and recovery for a successful competition. He emphasizes the importance of preparing for the week before the competition, the competition day itself, and even the week after the competition. Joe encourages individuals to focus on their game plan, proper nutrition (including carbs, protein, and electrolytes), fluids, and electrolytes. Additionally, He highlights the importance of keeping the body moving between events to avoid stiffness and stagnation. The ability to warm up, maintain a good heart rate, and perform at a fast 100% effort is crucial for success. On the day of the competition, Joe advises sticking to one's game plan and not letting others dictate it. He mentions that CrossFit is about being able to adapt on the fly, but it's important to trust one's strategy and see where it takes them. Joe also emphasizes the importance of nutrition during competition day, stating that eating is necessary and what one eats matters. He provides the example of an elite athlete who consumed multiple Snickers bars for fast carb and glucose intake to replenish muscles, but notes that this strategy may not be applicable to everyone. After the competition, Joe discusses the importance of the follow-up week. He suggests focusing on recovery during this time and allowing the nervous system to recover and do what it needs to do. He highlights the significance of giving oneself time to recover, as it is an important part of the overall competition process. Overall, the episode emphasizes the importance of preparation, execution, and recovery in the context of a competition. It highlights the need to have a game plan, trust one's strategy, focus on proper nutrition, and prioritize recovery to maximize success. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app.physicaltherapy. Thanks, everybody. Enjoy today's episode of the PT on ICE Daily Show. 01:26 JOE HANISKO Good morning, everybody. It's PT on Ice, daily show live. It's Friday, I would say September 22nd, getting close to October already. It is Fitness Athlete Friday. I'm Joe Hanisko. I'll be your host today. One of the lead faculty of the clinical management of the Fitness Athlete crew. Today we want to chat about competition. So CrossFit competition prep 101. Just the basics. We get either personally ourselves or some of our clients who are signing up for local or online competitions and we want to make sure that we're preparing them and that they understand what their expectations are for getting into that competition. the week before, the actual date of, and then even that week after, like making sure they maximize their preparation and their recovery for a successful event, especially when really all that we typically have to see in comparison is these elite athletes who are going to be doing things similarly, but also different because of the amount of training they've put in and just the fortitude that they've built up in terms of an athlete and the resilience that they've earned in an athlete. We'll talk about that CrossFit Competition Prep 101. Before we get going, I want to make a couple of call outs to the CMFA Live agenda that's coming up for the rest of the year. Both of our Essentials and Advanced Concepts course took off online in the last week or so. So those are going to be going through until the end of the year and we'll get those going again at the beginning of 2024. But in terms of live courses, we have a handful coming up in the next few months to close out the year. So if you're looking to get into any Con Ed courses, we are going to be in California. Washington, Alabama, the state of Texas, down in Florida, New Orleans, and Colorado, all before Christmas. So from now until Christmas, we have six or seven CMFA Live courses that will be out there. So grab a seat if you're looking for that. Hop on to theptnis.com and you can find all of our courses there. All right, CrossFit Competition Prep 101. 03:45 PREPPING FOR COMPETITION WEEK  Let's talk about the week of. So you're going into this weekend of competition. What do we do that week before? I would say that at this point, We're not talking about the prior weeks and months of training. That's a whole other conversation. But at this point, whatever you've done to earn your right to sign up for this competition, you've done it, you've earned it. You can't really gain a whole lot more in one week of training, but you can lose a lot in that one week. So we want to make sure that we take that week leading into competition pretty seriously. If we're assuming maybe competition day is on Saturday, which is most common for a lot of local events, I would say that those first two to three days of that week, Monday, Tuesday, Wednesday, per se, I would focus on training as normal. Keep things consistent. If you guys have specialized programming through your gym and or you're using some sort of online platform like Mayhem, Days one, two, and three can stay pretty consistent. We don't have to change a whole lot about that. It allows us to stay moving, feel good, test some things out, and it's not until day four and day five that we really start to maybe change some things there. Day four, I would say, is a great opportunity to just take a complete rest day, figure out how the body is feeling, let things calm down. Maybe we focus on just a nice walk outside, maybe we do some mobility work and some soft tissue work to kind of prep the body but I'm cool with day four-ish in that time frame being a complete rest day if that works out into your calendar. It gives us time for the body recover for the nervous system to recover and then it gets us to day five the day before competition. I would suggest that the day before competition you don't do absolute rest. I think it's kind of nice to low level prime the body for movement especially when you're about to do something at a pretty high intensity the following day. So this could be super easy, like moderate EMOM style work, where you're doing a lot of body weight or simple movements. This could be just a zone two kind of monostructural day where we hop on the erg, sorry about that light there, hop on the erg, get some of our heart rate into that zone two level and just do a nice 20, 30, 40 minute cruise control type of workout. But I like the idea of the day before competition, moving the body and taking that rest day, maybe a day or two before competition. opposed to resting right up until that point there. So in terms of our basic agenda, days 1, 2, and 3, you can stay pretty consistent. Day 4-ish, probably 3 or 4-ish, we're going to take a complete rest day and let the body completely recover, maybe focus on soft tissue mobility. And then day 5, we want something smooth and easy, get the body feeling good. If you have any you know problem areas we're doing a little bit of accessory work to tune those up but we're not hitting a hardcore CrossFit style event the day before that competition. A couple other things that I would maybe not do in that week before is I would not go above 75 80 percent of your maximum volume in terms of load so if your programming calls for deadlifts, squats, whatever it might be, some heavy loaded exercise, no matter what, keep that in that moderate, upper moderate range there. I feel like being in that 60, 65, 70, maybe 75% range at the most gives you an opportunity to load those tissues, feel like you're getting something out of it, but also not blasting the nervous system. Our nervous system is probably one of the most undervalued parts of our recovery because it's hard to sometimes assess until you go and perform. But when the nervous system is down, our actual performance will be down as well too. And typically what drops the nervous system is high volume training and high loaded training because we only have so much of the tank to give before we need to recover. So I would avoid hitting heavy, heavy weightlifting the week of. Keep those 75-ish percent or lower. That being said, too, another thing I've seen a lot and had a lot of education on is if your event calls for some sort of weightlifting complex, like a hang snatch to overhead squat to hang snatch complex, I'm just making something up, don't go out and test that thing at max capacity over and over and over again. One of the biggest flaws that I see with our novice CrossFit athletes is that it's something new. It's like, oh, I haven't done this exact complex. I don't know exactly what it's going to feel like. Well, go and test it at that 50%, 60%, 70% maybe. but I see so many people the week or two prior doing it three or four times and what they're doing is depleting their nervous system and when it matters on that Saturday when competition is there, you may in fact lose some by having tested that so often before. So I would, I'm not saying don't trial it to see what it feels like, but I'm saying you should have a good understanding now with all the training you've done before to earn your right to be in that competition, roughly what your capabilities are, and then testing that complex at lower to moderate weights will give you a little bit of an insight to where you think you can be, but you are not going to get stronger by practicing that over and over again in a week or two before that event. So get familiar, but don't blast yourself with those complexes. Yeah, and then the other thing I was gonna say is just don't, in terms of testing, going a little farther, don't test all those workouts that you're about to do at max capacity multiple times either. I'm on board for learning, for strategizing with team, if you have a team event, I think that is great, but do those several weeks in advance. Don't go and blast your body the week of testing an event that you're probably gonna do because that's where we'll see decreased performance and potentially injury risk that will increase when we're doing that stuff there so recap of the week of the week of you're going to train as usual for the most part days one two and three Day three and or four, we're going to take a rest day and let that body completely recover. Just focus on mobility, recovery style stuff. Day five, we want to move a little bit. Lightweights, bodyweight style exercises, throw that into an EMOM format. Get yourself on a ERG machine and do some zone two monostructural work. We want to avoid max effort loads throughout the week to keep our nervous system healthy. We don't want to test everything over and over again. Save yourself for Saturday. You will not lose by not training, but you can lose by overtraining in that week before. All right, so now you're in the day of. Day of competition. This looks a little bit different to everybody, but a few little pointers that I have, some of them will be obvious, but just reminders, is that just stick to your game plan. Hopefully you've thought your process through and trust it. You know yourself as an athlete, your team hopefully has connected, or your training partners, and you know each other fairly well. Don't let other people dictate your plan. Stick to your plan. CrossFit's all about being able to adapt on the fly, which you will have to do sometimes, but don't go in constantly thinking that you have to change your strategy. Trust your strategy and see where things take you. 10:37 NUTRITION ON COMPETITION DAY  In terms of nutrition during competition day, I feel like we need to be eating. I think that's an obvious thing to say, but what we eat matters. We see people, Matt Frazier was a good example, who would just slam multiple Snickers bars in a day of competition because he was looking for fast carb glucose intake to replenish those muscles. It's actually not a terrible strategy, but we're not Matt Fraser either. There's got to be probably some moderation to that. I do believe having easily digestible carbohydrates, which may include some sugar and that's fine. A couple little gummy worms here or there, some fruit, maybe some of those protein bars or energy bars that have some carb in it, built in it. things that taste good and that are easy for you to digest are probably best. We need carbs to replenish our muscular glycogen system and just our overall metabolic system. I think getting some protein in is fair, but we don't need to heavily douse protein. We don't need to be eating like multiple burgers that will sluggishly kind of slow you down. So lean proteins, beef jerky, a little bit of pulled chicken, something like that can be a fairly easy type of protein to digest. And then I would say a third thing being fluids and electrolytes. So this is where getting salt waters of some kind, like a element for an example, or your own homemade version of that, getting that electrolyte balance into our body is crucial. You're going to be pumping fluids out, And you can get really scientific with this and weigh yourself before and after an event like some of these higher level athletes do. But I don't think that we have to be at that level. But do replenish your fluids. Be drinking water. Get some sort of electrolyte back into that system. And I think these are going to be two really crucial things in terms of adjusting fluids that are important there. Some of these sports drinks, just read the back. Get smart with these guys. Like read the back of some of these labels and you'll realize that you could make yourself a way better balanced electrolyte style drink than the marketed ones that have virtually nothing inside of them. So get online. figure out how you could dose in some table salt with some other electrolytes and just make something that is gonna help you retain fluids, especially if you're doing this in a hot, humid environment where you know you're gonna be sweating a lot. And then I think the other thing in between events is don't just sit and do absolutely nothing. Take some time, five, 10, 15, 20 minutes at the most to recover and chill, but as you're leading up into that hour before your next event, try to move. walk around, hop on a bike if they have one. This is where I will actually, in some circumstances, support things, simple things like massage guns. There is some anecdotal and potentially actual structural evidence that would say that the vibration and impulse is a good way to just kind of prep that nervous system and keep those tissues a little bit more aware of what they're about to be doing. I'm game for it. Whatever you gotta do to stay agile and feeling like you're at your best is what we need to be focusing on there. So day of, stick to your game plan, proper nutrition, including carbs and protein predominantly, and then electrolytes is big as well, fluids and electrolytes, and then find some way to keep that body moving in between events that you're not stiff, stagnant, going in. The ability to warm up, keep your heart rate at a good level, and then hit a fast 100% effort event is crucial to success. We don't wanna be going in cold. Even if you're feeling a little tired, you gotta find a way to keep that heart rate moving. 14:17 TAKING REST AFTER COMPETITION All right, final thing is our final prep, I should say follow-up week, the week after your event. So you've done your week before, you've completed your event, congratulations. Sunday, Monday, Tuesday, leading into the next week, what do we do? Be okay, I'm gonna say this again, be okay taking more than one day of rest. I have an event coming up this weekend that has for sure three main events that all are at least 18 to 20 plus minutes in domain plus five like mini events. And then if you are lucky and fortunate enough to earn your right into the championship event, that would be four main events. So four main events plus five mini events. I don't train for that. Nope, not many novice athletes do. Elite athletes, yes, they are prepping with four to six hours of training on average per day in a week. We don't do that. Not many of us are doing that. So if we are going to go out and sell our soul in this event on a weekend, be okay taking Sunday, Monday, and maybe Tuesday and doing little to no major physical activity. It doesn't mean you have to be a couch potato. Maybe you are again going for hikes, walks, little bike rides, whatever it might be. Find some enjoyable sport that you like, like golf to get out and just stay active. I'm not asking you to be lazy, but I'm asking you to respect the amount of volume that goes into some of these CrossFit events. I see a lot of people who go and smash it on Saturday and then are at the gym on Sunday working out or Monday doing a, you know, high level, uh, online programming that is consisting of two plus hours of training. to each their own at the end of the day, but it's okay, I'm giving you permission to let your body recover. At the end of the day, for me, I'm reminding myself that this is not about today and tomorrow, this is about 20, 30, and 40 years from now. I am building my fitness to be a better, older adult. So be okay taking some time off. Use the next week to just sort of assess the body. Did anything tweak? Are you sore? Are you stiff? Focus on those areas. This is where getting your clients maybe back into your clinic that following week and just prepare for that. Say, hey Johnny, I know you got an event coming up on Saturday. Why don't we make sure that we have a day to meet on that following week just so we can talk about how it went and be sure that we're doing some good recovery things and I can help you better game plan that following week as well if I can see you early on that week. So take time to assess the body. And I would suggest again, similar to the week before, keeping loads in that 75, 80% or lower before we get back on track with your normal training. Just allow again that nervous system to recover and do what it needs to do, so. Hopefully that was helpful, guys. Again, either for yourself or for clients that you're having, but I love the fact that people are dedicating themselves to fitness and that they're willing to put their body, their soul, their personalities, their mentalities, their identities on the line and go sell it on a weekend or online competition. We are training for a purpose. We have short-term goals. We can go test those out. We have long-term goals. All this is leading to that direction. So preparing yourself for that competition is really important. Executing on the day of is really important and making sure you give yourself time to recover afterwards is also important. Hopefully it's helpful. If you have any questions, comment on the videos. Otherwise, take a look online and see if you have any interest in getting into our CMFA live courses coming up across the country. They are filling up. So let's get on those and enjoy the end of our year together. I will talk to you later. Have a great weekend. 17:46 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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 the role of carbohydrates, the relationship between carbohydrates & performance, carbohydrate loading, and carbohydrate consumption timing. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 02:14 ALAN FREDENDALL Good morning everybody. Welcome to the PT on ICE Daily Show. Glad to be back again. Hope your day is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and elite faculty in our fitness athlete division. It is fitness athlete Friday. We would say it's the best darn day of the week here on Friday, live on Instagram, live up here on YouTube, and wherever you get your podcasts. Thank you for joining us. Some announcements really quick. If you're looking to join us in the fitness athlete division, we have a couple chances online and about a dozen chances live before the end of the year to catch us out on the road. Our online courses, fitness athlete essential foundations, that's our eight week entry level online course. All things relevant to treating the recreational athlete, the cross fitter, the Olympic weight lifter, the power lifter, the orange theory athlete, the boot camper, so on and so forth. That is the course for you. That starts this coming Monday, September 11th. We still have room in that class. And our advanced concepts course, also eight weeks online. Pre-requisite for that class is essential foundations, our entry level course. Advanced concepts is only taught twice per year. It is taught spring and fall. So this is your last chance to catch it this year. That will kick off the week after September 17th. That class has just two seats remaining. So if you're looking to round out your fitness athlete certification, make sure that you get into fitness athlete advanced concepts this fall. Live courses coming your way between now and the end of the year. Your next chance will be September 30th on October 1st. That will be out on the West Coast in the Bay Area with Zach Long. Also on the West Coast, October 7th and 8th, you can catch Mitch up in Linwood, Washington. That's outside of the Seattle area. Also on the West Coast, October 21st and 22nd, Zach will be on the road again, this time up in Vancouver, British Columbia. You have two chances the weekend of November 4th and 5th. You can either catch Mitch down in San Antonio, Texas, or Zach will be down in Birmingham, Alabama. Mitch will again be on the road in November, November 18th and 19th. He'll be in Holmes Beach, Florida. That's right outside of the Tampa area on Anna Maria Island. You can catch Joe Hanisco in New Orleans. That'll be December 9th and 10th. And then our last course of the year will be December 9th and 10th as well. That'll be out in Colorado Springs with Mitch. So that's your chance to catch us on the road in the fitness athlete division. Today's topic, let's talk about carbohydrates. Let's take a deep dive into what a carbohydrate is, how it's relevant to us here in the fitness athlete division as far as exercise, energy and performance goes. And then let's talk a little bit about when and how to kind of dose out your carbohydrates, who needs to be eating them, who maybe needs to think about eating more. And let's talk about timing of getting those in to best suits whenever we're going to be exercising to maximize and optimize our performance. 04:18 WHAT IS A CARBOHYDRATE? So starting very basic, if you know nothing, what is a carbohydrate? It is a sugar, a starch or cellulose plant material. So commonly we know carbs traditionally are things made out of maybe table sugar, candy, soda, that sort of thing, potato chips, things that are maybe less than optimal carbohydrate choices but are overwhelmingly what is often consumed when people eat carbohydrates. We also think of fruit being fructose. We think of the sugar that's in milk, lactose. We also think of carbs as vegetables that we eat when we're primarily eating the cellulose in a vegetable, we're eating that plant matter, we're eating things like green leafy vegetables, broccoli, kale, asparagus, that sort of thing. So different ways we can consume carbohydrates. They're not all equal as far as content goes, but those are all kind of classified as carbohydrates. Why do we care about them? Well, we really care about carbohydrates because eventually they become glucose in our body, which is an energy currency, a way that we metabolize energy reactions and chemical reactions in our body, but we also store glucose as glycogen. We store glucose as glycogen both in our liver and in our muscles. At any given time, we only have about four grams of circulating glucose in our system. So we have a relatively small amount. Our body does not really like to have glucose moving around in our blood system. So when we tend to get beyond that four grams circulating throughout our body, that's when insulin is released, insulin is released, and at the end of the day converts that glucose into glycogen, either stored within our muscles or stored in our liver, or if we do have an incredible excess of glucose in our system, it can be also stored as body fat. 09:13 MUSCLE GLYCOGEN  Aside from the four grams circulating in our body, we have about 400 grams stored inside of our muscles, and we have about another hundred grams stored in our liver. For most people, a total of about 500 grams of muscle glycogen or about 2,000 calories worth of energy. And that's kind of where, if you ever wonder where is the recommendation that I should eat 2,000 calories a day to maintain a healthy weight, where does that recommendation come from? It comes from estimations of how much muscle glycogen we are storing and throughout the day using for regular physical activity, but also for exercise. And that if we deplete that glycogen throughout the day, we will need to eat 2,000 calories of food to replenish that glycogen back into our muscles and back into our liver. We can make glucose and then store muscle glycogen on demand. This is that process you may remember back from middle school or high school biology and chemistry called gluconeogenesis, gluconeogenesis, make new glucose. This is a very, very slow energy intensive process. We can only make about 30 grams of glucose per hour. Now this typically comes from our body fat. It's synthesized, made into glucose, and then is either stored as glycogen or pushed into circulation for energy. So this is kind of where the all day energy you have of being at work, maybe working around the yard, relatively low intensity activity. The energy, the glucose that supports that energy, those metabolic reactions comes from that process of taking body fat, turning into glucose in the liver, about 30 grams per hour. 11:17 GLYCOGEN DEPLETION DURING EXERCISE Now when intensity increases is really our concern in the relationship between carbohydrates, glucose, glycogen, and exercise. That when we start to exceed about 65% of our VO2 max, we start to use more glucose, use more glycogen than our body can produce per hour. So we start to dig into the reserves that are inside of our skeletal muscle and our liver. Now at very high intensities and very long durations, especially if heat, if temperature, is a factor as well, humans can use up to 150 grams or more per hour of that glycogen, which means at any given time, there are only about a couple hours of energy stored in our body for higher intensity activity. So above 65% of that VO2 max, what we call a low oxygen environment, we can no longer make enough glucose and glycogen to replenish what we are burning with that high intensity exercise. We are in a high oxygen environment, relatively low intensity activities. Our body can again make those carbohydrates, make those sugars from the fatty acids from our body fat, but as intensity increases, we start to dig into our reserves. Now that typically happens around the 90 to 120 minute mark. That is going to be a little bit different for every person. Bigger people, people with more muscle can store more muscle glycogen. Those who are better trained, who exercise at all, but especially those who are used to doing long endurance training, can store a little bit more muscle glycogen. And then certainly you've heard of the concept of carb loading, where if we taper our activity for two to three days and we increase our carbohydrate consumption accordingly, we can supersaturate our muscles with glycogen as well. And overall, we may have about 50% more glycogen reserves than the average person. We might have maybe 600 to 700 grams available. So maybe we can kind of flirt with having two hours of energy total for high intensity activity before we need to start thinking about eating, eating food, eating it to not only continue exercise, but feel better after, which is part of what we're going to talk about today. The relationship between carbohydrates and performance, especially if you want to be training multiple times a day or otherwise just not feel terrible the rest of the day after you finish exercise. Now it's not an all or nothing concept. It's not, I have a hundred percent of my muscle glycogen or I've used it all and I need to stop exercising and eat. We certainly know that we can consume food during long endurance activities, but also that as those reserves deplete, we feel a performance shift as we're doing different activities of we can feel maybe speed slow down on a run, maybe power slow down if we're out and we're on the assault bike or something like that. And we know we can run out. That's a concept that's called bonking of where we have depleted almost all of our muscle glycogen and our body is going to take us from that high intensity, low oxygen environment and say, Hey, you need to cool it. We need time to recover some of this energy and your body's going to stop you for you. And that's the concept of bonking of shifting you to a high oxygen environment by lowering your intensity in an uncomfortable manner, maybe even possibly losing consciousness, but definitely not feeling like exercising anymore. It's really important that we never hit that point. If we can avoid it, we've all we've all done it. I have a story of hiking in the smoky mountains of bonking at the top of a mountain, mainly because my wife ate all of our food on the way up and I had nothing to eat. So I had no choice and bonked at the top. But it's important to know that we don't want to get to that point. We never want to use all of our glycogen and hit that wall because there is a compensatory recovery point afterwards where for one to three days after we're going to feel really low energy as our body slowly recuperates and restores all of that glycogen in our body. We're not going to feel like pushing the pace. We may not feel like exercising at all. It's going to impact our training. And what you don't want to get into is kind of this weekend warrior phenomenon. Where maybe you go you go for a really hard run for two to three hours. You hit the wall and then you don't feel like exercising maybe for another week, right? Where you don't feel like you can work out again for a couple of days. That's not very productive training. So we want to avoid that. 13:58 CARBOHYDRATE CONSUMPTION And we'll talk about that now as we talk about when should I eat my carbohydrates. So it's really cool that technically a human being does not need to eat any carbohydrates at all. You may have heard of the keto diet of being low carb, maybe no carb, under 50 grams of carbohydrates, being in a state of ketoacidosis of only utilizing your own body fat as an energy source and the fat and protein that you consume. But it's cool that we don't technically need to eat carbohydrates. Yet almost all of the metabolic and chemical reactions in our body are fueled by carbohydrates. It's very, very interesting how our body operates. So you can go without eating carbs. So again, your body can make carbs about 30 grams per hour, but we need to understand that that takes time as we talked about. And especially if we are doing longer, harder events, we're thinking about maybe training twice a day, something like that. Then we need to understand that that process is slow and we need to give the body either a lot of time or we do need to consume carbohydrates. We also need to recognize at some point that eating carbohydrates is like consuming jet fuel for a mechanical engine. Of it's a very caustic chemical reaction to our body, a lot like burning gas inside of a gasoline engine, that it does create some low grade, low grade inflammation that's kind of always present as we're eating carbs and fueling our chemical reactions with the carbs. And so kind of the longevity side of the research would say, if you want to live as long as possible, avoid that. However, that's in direct conflict with the performance research, especially if you want to be a more competitive athlete. You want to do longer, more intense activities. You want to maybe train multiple times a day. You need to understand that those are two kind of diverging thoughts of longevity versus performance. At some point, those tend to dissect and not reconverge of needing to eat carbs to fuel your activity, especially multiple activities in a day or a busy workday after you exercise or avoiding carbs. Maybe even you may have a longevity physician who recommends you take metformin prophylactically to keep as much glucose out of your system as possible because of the inflammation that's present. But nonetheless, we need to talk about that relationship between eating carbs and performance. So it's that that longevity versus performance question that we have a need to eat carbohydrates if we are a long duration endurance athlete, that when you start to run 10 miles, 15 miles marathon, ultra marathon, when you start to do long trail runs, long bike rides, long hikes, that sort of thing. Again, you are using your reserves faster than your body can make more. And you either need to know that at some point you're going to hit that wall that we talked about or you're going to need to start consuming carbohydrates as you exercise. Higher level elite endurance athletes may eat 90 grams of carbohydrates per hour in the forms of liquid carbohydrates, gels, chews, that sort of thing. Folks who maybe are doing half marathon or marathon training may be eating less, maybe about 30 grams per hour. Our fitness athletes don't necessarily need to eat carbohydrates during exercise. We think about a typical one hour CrossFit class. We're not really at the level of intensity and duration long enough to need to eat carbs during that hour. We can get away with doing that hour of fitness and then worrying about carbohydrates after. But there's also a want, a need versus want. The want for carbohydrates is understanding that performance trade off, but also understanding that your body can only make about 30 grams per hour. So what does that mean? That means if you do go to that one hour CrossFit class, you don't technically need to eat carbohydrates before or during, but that you might want to front load your consumption afterwards, especially depending on the time of day in which you do your exercise. If you're like me and you like to get up and exercise first thing in the morning and then you might be looking at, hey, I have 8, 10, 12, 14, 16 hour day ahead of me. Those subjective feelings that you may feel your patients, your athletes may feel of, I feel tired all day after exercise. I feel like I just need to go home and go to bed. I feel weak. I feel like I can't do my work tasks. I can't take care of my kids. Maybe even feeling lightheaded or some sort of impaired cognitive function. Like my mind just feels cloudy. All of those are good subjective reports to tell you that you should probably eat some more carbohydrates after that exercise session or to recommend that to your patient or athlete. And then we get in now to how to do that of our long duration endurance athletes. We've already talked about they're probably going to be or hopefully should be consuming those carbohydrates as they're exercising, especially once they cross maybe that one hour mark of again, it's not an all or nothing equation of go until I can't anymore of as those reserves of muscle glycogen get depleted, I'm going to feel worse and worse and worse than my performance. And how I get ahead of that is eating, eating those carbohydrates while I'm exercising. So the combination of me eating them and my body making some more keeps them relatively high, keeps my performance, my output higher, keeps me away from feeling kind of that onset of losing power, losing speed, losing energy throughout my workout. 22:08 CARBOHYDRATE CONSUMPTION & TIMING How to eat those? Well, I'm still trying to figure that out. As I get more into long endurance training, I have tried chews and gels and my body doesn't really sit with those. I tend to do better with liquid nutrition like Gatorade. Every person is going to be different, but definitely those people who are going out for longer workouts, especially crossing an hour need to find a way to start to consume that as they're exercising. This is also relevant to our fitness athletes who may be doing a multi event day. Maybe they're doing a local CrossFit competition. Maybe they're a quarterfinals or a semi finals athlete where they have multiple events per day, multiple days in a row. I always laugh now when I go to a CrossFit competition and I see that person after workout eating chicken and salad, right? Just not enough carbohydrates in that meal to replenish what was used in that CrossFit workout in order to have those reserves restored and ready for the next workout, which might be two to three hours after the first one. They might have a third one two to three hours after that, right? Those are athletes who they don't necessarily need to eat carbs during the workout because it's a relatively short event, maybe 10, 20, 30 minutes. But if they have to workout again in three hours, they're definitely somebody who's going to want to eat higher carbohydrate food. That's the case. You see CrossFit Games athletes eating gummy bears and Snickers bars, just getting as much carbohydrates as they can. Again, they're trying to maybe replenish 200, 300, 400, 500 grams of carbohydrates within a two to three hour window to be ready to work out again. So understanding it's important to get those carbs back in if you're wanting to train or you have to exercise again in a relatively short amount of time. I hiked the Grand Canyon last year with Dustin Jones and Jeff Musgrave and we did it. It was about a 12 hour hike up and down about 20 miles and we did it almost exclusively on water, Gatorade and gummy bears, right? Just high carb food that's going to keep our reserves up because we're basically hiking and walking in a hot environment at moderate to high intensity for a very long period of time. I'm thinking I just ran 10, 800s this morning. I have a 12 hour day ahead of me. The first thing I did was eat three bananas, right? The first thing I did was house 100 grams of carbs to give my body that jump start on replenishing that glycogen, which was not entirely gone, but definitely mostly gone at the end of that running workout. And that's really going to determine how you recommend carbohydrate intake to that patient athlete in front of you of what does the rest of your day look like? When do you train and what does the rest of your day look like? If you work out at 5 a.m. and then you have to go to work all day and you're maybe a physical therapist, right? You have a relatively physically active job. You're getting your steps in. You have an eight to maybe 10 hour day in front of you. You'll probably feel a lot better if you eat the majority of your carbs earlier in the day to replenish those reserves. You will find yourself feeling subjectively better. If you work out early in the morning, maybe you run and you want to lift weights at lunch or go to CrossFit after work. How can we fuel our body to be able to do double sessions in a day, two a days, right? The same thing, we need to front load that carbohydrate consumption in the morning, at lunch, in the early afternoon so that by the time we are going to work out again, most of those reserves are back. They're probably not going to be 100% back where I can PR my 5K in the morning and go PR a CrossFit benchmark in the afternoon. It's probably not going to work out that way to be 100% ready to go for a second session in the same day. But you will feel better during the day subjectively and you will definitely perform better objectively in that second session if you eat a lot more carbohydrates in between. Now who is that person that maybe works out in the afternoon or evening and that's their only session of the day and then they go home and they basically watch some TV, get ready for bed and go to bed? That is maybe a person who can get away with maybe a lower carbohydrate or could maybe play with a keto diet, right? Of hey, I work out at 6 p.m. when I'm done with work, I get home around 7.30, take a shower, eat some dinner, go to bed. That is a person that they do not necessarily need to replenish as much of their glycogen as possible because of their schedule, right? They deplete their glycogen in the evening, they are going home consuming some with maybe a dinner meal and then they're going to bed. They're giving their body maybe 8 to 10 hours to replenish hundreds and hundreds and hundreds of grams of muscle glycogen overnight while they're asleep. So that is a person who maybe could get away with lower carbohydrate or no carbohydrate consumption between when they work out and when they wake up again. That's a person who's going to work out, have dinner, sleep, have breakfast and have lunch again before they work out again 24 hours later and they're in a really good position where maybe they don't need to worry about it as much. So carbohydrates, what, when and how? Understanding they're very important for performance, especially for longer duration exercisers, for long endurance athletes. They're definitely linked to performance, especially if you are wanting to train multiple times a day. You are in a competitive environment where maybe you're doing multiple events in a day and then we need to understand timing of when should I eat them. For most people, if they're working out in the morning, they're maybe doing multiple sessions in a day. They're going to work and they want to feel like they have high energy. They should probably eat a good portion of their carbohydrates earlier in the day, but there is that person who maybe trains later in the day who doesn't have a lot going on between when they train and when they're going to train again, who maybe can get away with not eating as much carbohydrates as somebody else. So understanding that food is our friend, food is fuel and understanding how your body creates, consumes and utilizes carbohydrates for energy can be a really big game changer for performance during and after exercise. We all probably have that patient who seems really active, really fit, but complains all the time of being tired, of feeling weak, of not hitting PRs. And that can be a good person, yes, to evaluate their protein consumption, to make sure that their muscles, their musculoskeletal system is recovering appropriately, but also to have a conversation of what their carbohydrate consumption looks like. If we can up our carbohydrate consumption a little bit, we'll often find that that subjective fatigue, weakness that comes after a training session, especially if we're going to train again later or we have a long day of work or whatever ahead of us, we can alleviate a lot of that just by tweaking our diet a little bit. So I hope this was helpful. If you're going to be on an ice course this weekend, I hope you have a fantastic weekend. Have a great Friday. Have a great weekend. Bye, everybody.  24:46 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Mitch Babcock discusses that consistency in the gym, combined with attention to lifestyle factors, can lead to significant rewards in terms of fitness and overall health. By being present and dedicated to regular training, individuals can see improvements in strength, conditioning, and cognitive function. Additionally, by addressing lifestyle habits such as sleep, nutrition, and alcohol consumption, individuals can further enhance their fitness journey and ultimately live longer, healthier lives. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 01:26 MITCH BABCOCK Hey, welcome everybody. Welcome to the PT on ICE Daily Show. Welcome to Friday. Welcome to Fitness Athlete Friday. I'll be your host today. Mitch Babcock, lead faculty in the fitness athlete division, all things online and live course. And it's been a minute since I've been on the podcast. So I'm excited to be back joining all of you this morning. So thank you. First of all, if you're downloading us, listening to us on your way to work, if you're on live with us on Instagram or YouTube, thanks so much for making this part of your morning or your evening, whatever it is for you. And thanks for downloading wherever you download your podcast from. We always appreciate it. Don't forget we're the only daily physical therapy show on the market. So thank you for subscribing and liking and signing up for those automatic downloads. It really means a lot to the whole team here at ICE. Before we jump into today's topic, which is post CrossFit Games for the rest of us. Okay, I want to talk a little bit about some of the courses that we have coming up for the live division. We have a very busy September in October and even leading into November and a couple courses in December. So looking at Q3, Q4, we've got quite a bit on the books. The fitness athlete team as a whole was a little quiet through the summer. As our team, many of us on the lead faculty, not us, but others on the lead faculty, welcomed some new additions to their family or kind of spending some time at home. So the summer months were a little quiet and we're excited to ramp up on the road here in Q3 and Q4. So you can find us all over. Zach's going to be out in the Bay Area here in September. The end of September you can find him out in California. I'm going to be out in Seattle, just north of Seattle in Linwood with Joe as well. We got a course in British Columbia coming up, Alabama, San Antonio, Florida, New Orleans, Colorado Springs. We're hitting some big cities and covering a large part of the map this fall. So if I just named off any cities, your cities or near you, please check those out on the PTA On Ice website. We'd love to see you at one of the live courses. 02:16 POST CROSSFIT GAMES All right, let's get into today's show, shall we? If you didn't tune in last week to Kelly Benfey's episode on her post CrossFit Games Reflections, you should definitely do that. CrossFit fan or not, whether you train this stuff or not, you need to understand the level at which Kelly is at in humbly speaking herself. She's not going to give as much credit as she deserves. Making it to the CrossFit Games is a feat 99.9% of people that participate in CrossFit will never achieve. You can be pretty good at CrossFit. You know, you could be pretty good at pickup basketball, but you're not going to make the squad and play with the Lakers. You know, like that's kind of the comparison of which we're dealing with now in the CrossFit sector. And so for us to have someone like Kelly, who's went there, who's done that, who's trained at the highest level, who's rubbed elbows with the best of the best in the game and to get some reflections from her, it's worth the 10 or 15 minutes about what it's like behind the scenes. So great episode, Kelly. But today I want to talk about after the games, what about the rest of us that just train this stuff because we like it? We want to stay healthy and fit. We enjoy getting stronger, but we also have nine to five jobs. We also have families, husbands, wives, kids. We got to shuttle kids off to soccer practice. Maybe I coach the soccer team, right? What is what does it look like setting and reframing goals after the CrossFit Games for the rest of us? Because we still want to be motivated. We still want to be inspired. We watch the games and we see what's out there and we see what people are capable of and and all of that is fun and it's all a great part of the sport. But when it's our time to take the floor, it's important to reframe those goals and context and the things that matter to us and are achievable to what we can set our sights for over the next six, nine or 12 months. And that's really what I want to focus today on. 04:35 SETTING & REFRAMING GOALS What can you reasonably achieve in the next six to nine months or even set your sights on before the next open rolls around? Because we know we're going to throw the hat in the ring and do the open. You know, what are some realistic goals, realistic goals that are going to turn into real change in your health and fitness and overall well-being? And that's ultimately what we're doing this for. We're not most of us aren't going to make the games. Hat tip to Kelly for putting in a ton of work over the last five to 10 years, probably to get to that point where she was able to make the games. But for the rest of us, we're looking to check that box. We're looking to do it safely and effectively and making sure that when we come out the other end, we come out unharmed and we come out healthier and a better person after doing the training than when we started. So here's some goals that I have for you today for post CrossFit Games goals for the rest of us. What part of your training really behooves you to spend time training? 06:30 INVESTING IN FOUNDATIONAL STRENGTH And what I mean by that is strength and monostructural conditioning work. It's really going to benefit you long term to invest hours weekly daily into getting stronger. So I want you to set a goal to try to put 30 pounds on your deadlift over the next year, to try to put 20 pounds on your back squat and to try to put five to 10 pounds on your strict overhead press. Those are realistic goals that are going to require you to train those movements consistently. And because you're training the foundational strength movements, the squat, the deadlift, all of your other movements will then reap a reward from having done so. Your clean and jerk, your front squat are going to benefit from your back squat being trained regularly. All your Olympic lifts and all your other movements are going to benefit from you training your deadlift frequently. Your shoulders are going to be healthier from having done more strict press. So set some realistic goals. I'm going to put 30 pounds on my deadlift, 20 on my back squat, 10 on my overhead press And that's going to require me to make sure that I'm hitting those boxes week in and week out over the next handful of weeks, months, and the better part of the next year. So it really is helpful that you spend time working on the foundational strength. The other thing that's going to benefit you for your gymnastics movements. So spend time benefiting or getting increased reps or getting your first rep of a strict pull up. Many of you in the CrossFit space are still gung ho about your kipping pull ups, your toes to bar technique, all these other things. I want to bar muscle up, but you haven't laid the foundation with the strict pull up yet. You need to stay there. Over the next six or nine months, can you add one or two reps on your max strict pull up? Can you get your first strict pull up by going through a beginning strict pull up progression and over the next six months, get your first strict pull up. Those are going to be big rewards for your long term health in fitness training. The same thing with your push ups. We in the CrossFit space, those of us that coach a bunch, boy, we're used to seeing a lot of crappy push ups, right? Poor midline stability, we can't hold a good plank position, we don't have a strong shoulder position to be able to press out of the end range of extension, and we have athletes wanting to bang out a lot of reps and not even one of them looks solid. So spend time mastering your strict pull up and your strict push up. You're going to be a better athlete and your fitness will reflect that if you do. Master a skill over the next six to nine months. Get better at double unders. Figure out how to climb a rope, right? Finally take some coaching advice from your team at your gym and figure out how to put down a new skill. There's a lot of reward that goes into the neural motor, the coordination, all of the things that come together to allow you to build and develop a new skill. And if there's one that you've been putting off, because let's face it, your ego is kind of getting in the way, you don't like to look like you can't do the thing so you just scale out of it a lot, spend time over the next six months and learn that skill. Just one, pick one. I want to get better at double unders, I want to be able to do 20 unbroken double unders. Cool. Over the next six months you're going to attack that and that's going to be a goal that's going to elevate your fitness long term. You're going to have that skill for a long time and you're going to be able to use that skill in a lot of workouts coming up. So spend a couple of weeks, a couple of months and develop a new skill. And then your model structural work. 10:06 LONG DURATION ZONE TWO WORK Add in one day a week where you're adding in some longer duration zone two, you know, longer duration stuff on the bike or the rower going out for a long paced run. Like we don't do enough of that. And every single expert in the space says from a longevity standpoint, it is so key from a health standpoint, from a fitness standpoint, it is so key that we get more long duration zone two work in. And now some of the research, some of the leading experts are saying 60 to 90 minutes, 120 minutes a week. Look just start easy with one day a week where you stretch it out more than 20 minutes. I mean low hanging fruit one day a week. I need to do a long duration piece that's more than 20 minutes. If we can check that, then we'll start talking about increasing the model structural workload and be able to increase that more. But that's a foundational component to your fitness. That's on the base of the CrossFit hierarchy pyramid that says, hey, we need to be really good at metabolic conditioning. And when we have a better aerobic base, everything else steps up above that. So build that aerobic base. Add in one day a week of model structural work zone two on a bike, on an erg, on a runner and stretch it out more than 20 minutes. So you're prioritizing strength. You're working on a skill. You're getting better at your foundational gymnastics movements and you're adding in some longer aerobic work. 20 minutes one day a week. 13:21 MORE CONSISTENCY IN THE GYM From a class perspective, I would just say it ain't volume. It's not loading that's going to make the difference for you. You don't need to be lifting heavier weights and metcons. You just need to be present more frequently. Just be more consistent. If you normally make it three days a week, try to make it four. If you normally make it four, can you make it five? Can you just add one more day a week making it to the gym? Can you slide in that little Saturday morning class that you typically skip out on? Because you're going to see big rewards coming by just simply the consistency in the gym. You don't have to do anything heroic. You're just more consistent. You're getting five sessions instead of four. And week after week, that aggregates into a lot more training sessions at the end of the year. So bump it one day a week. If you have other skills that are going to make you a much better athlete six, nine, 12 months from now, set a bedtime and actually stick to it. Get the water intake that you need and try to reduce the alcohol. Can we go 30 days with no alcohol and just see what that does for your overall health? See what it does for your sleep, your concentration, see what it does for your overall training, your fitness in the gym? How much sharper am I cognitively when I'm at work? Measure all those things after 30 days of no alcohol. If you make it 30, can you make it 60 days no alcohol? 60, can I go 90 days no alcohol? And just start aggregating these days of optimizing all the little details that you can. And you're going to see such big rewards on your fitness. They're little challenges. They're hard ones. They're not easy, but they're ones that we can bite off and actually stick to for a month, make one month into two months, make two months into three months. The majority of us don't need a new competitors program. We finished watching the CrossFit Games and everybody's selling their hard work pays off, their Matt Frazier program, the new Mayhem Rich Froning style stuff. And while all those are great programs, for most of us, that's not what we need. We don't need additional loading. We don't need more volume or longer duration workouts. What we really need is more consistency in the gym. We need to get stronger at the things that matter and we need a better conditioning, a better engine to be able to do more things. And then the lifestyle stuff comes along with that. We're going to be one hour in the gym and the 23 hours out of the gym. What are we doing with the 23 hours out of the gym? Can I set a bedtime? Can I get better sleep quality? Can I eat better? Can I reduce my alcohol consumption? All of those little details that will stack up and aggregate over a year or six months or nine months into a much fitter version of yourself. The stronger and healthier you get, the longer you're going to live. And ultimately that needs to be all of our game plan. Why are we doing this? The oldest, not the oldest member, the most tenured member of my gym, we call him the Godfather just for that reason, says all the time, I'm just trying to still be doing CrossFit when I'm 70. Like every decision he makes in the gym day by day, he keeps that greater focus. He's not coming into the gym saying this is the year I make it to the games. He's coming into the gym every day saying, I need to make a decision that's right today so that I can still be doing CrossFit when I'm 70. Because I know that if I'm still doing CrossFit when I'm 70, I can be doing all the things in my retirement that I want to be doing. So keep the long term vision in play. We're looking to be able to do this over a lifespan. Stretch out and increase your lifespan, the number of healthy, good years you're living. That's what ultimately this is all about for us. So here's some small actionable goals that people like you and me can really bite off and really set our sights on over the next six or 12 months. Throw our hat in the ring when the Open comes around next year and say, hey, you know what, because I put that work in starting in August, I'm really a much better version of myself now in February. Comment below if one of these, if you've got a goal that we listed off and you're like, look, I need to jump on that. Drop a comment below whether that's YouTube, whether that's Instagram, whether that's on a podcast format. Let us know. Reach out to us. And then as always, if you need help with any of these things, that's what we're here for. So talking about all things lifestyle related in our live course as well. Excited to see those of you that are going to make it for your first time out at one of those courses. We're hitting the road heavy this fall. So looking to see you guys out there. In the meantime, if you're training today, have a great session. Get some caffeine in you and ramp it up. I will see you guys out on the road very soon. Have a great day, everyone. 15:56 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

Dr. Kelly Benfey // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Kelly Benfey discusses her experience competing at the 2023 CrossFit Games, the role of rehabilitation providers in competitive sport, and the capacity of the human body for exercise as it ages. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:33 KELLY BENFEY Good morning and welcome to the PT on ICE Daily Show. It's Fitness Athlete Friday and my name is Kelly Benfey. I just wrapped up an amazing CrossFit season where I got to compete at the CrossFit Games. And so what we're going to get to talk about this Fitness Athlete Friday is going to be a couple takeaways from the CrossFit Games that I think are relevant in the rehab space. Before we jump into that, though, within our Fitness Athlete crew, we have a couple of online courses coming up that I just want to bring to your attention. So we just wrapped up an awesome cohort with our clinical management of the Fitness Athlete Essential Foundations course online. And so our next course is going to be kicking off in a few weeks on September 11th. That course always fills up. So if you're thinking about it, please jump in with us, grab your spot right now. And then if you've already taken that and you're looking to continue developing your skill set, our Advanced Concepts course that's only offered two times a year is also starting September 17th. So rarer opportunity to hop in on that one. So if you've been looking to take this course, that's going to get started quite soon. And then we have a handful of live courses for the remainder of the year. So all of that information is going to be on PTice.com, PTonice.com. So we hope to catch you live on the road. I'd love to see you all. So we'll be getting back on the road for the remainder of this year to finish strong. So let's get into our topic. Of course, I could talk about this stuff all day if you know me. So we're talking CrossFit Games takeaways. A couple of things that I experienced and found were relevant in the rehab space. This is Fitness Athlete Friday, so we get to geek out on all things, CrossFit Games, CrossFit competition, all that good stuff. So number one, I have five different things that we'll kind of work through. 03:35 HUMAN CAPABILITY So number one, I always leave the CrossFit Games feeling absolutely motivated and inspired by what the human is actually capable of doing. So I really it was it was just such an honor to be on the same field as some of these amazing, amazing athletes, be behind the scenes and all that good stuff. So a couple highlights that I saw now just to I competed in the team division. So it actually didn't allow me to watch as much as the individual competition. I'm still working through catching up on that all the live the live coverage that they had. But I got to be within the team division. So one of the athletes in the team division, she clean and jerked 250 pounds and then a couple hours later ran a 5K, 4.5 ish K, 5K in under 20 minutes. So it just always impresses me that people can excel in things that I also excel in the strength events, yet also push their aerobic capacity and monostructural skills to an insane level as well. So it was just absolutely mind blowing to see athletes also just I know how hard we worked on my team and just having other athletes really push the boundaries. I find to be super inspiring as a competitive athlete. And then moving moving towards almost even debatably more inspiring. 04:11 OLDER ADULTS PUSHING BOUNDARIES  The age group divisions are always just such a blast to watch. I wish they had a little bit more coverage because arguably that's more these are more the athletes that are relatable and even more inspiring. For example, the 60 plus division, I believe the 60 60 to 64 division, both men and women had bar muscle ups in their last event. So these are our older adults crushing it, doing high skill level at a very high competitive level. Just absolutely amazing. And like I had the opportunity, my mom came and watch. She's going to watch me and have a blast, obviously, but she's not necessarily going to see like watch me and think, oh, wow, that's something I can do. She's going to see something in her age division and then become inspired of, hey, maybe I'm going to start my barbell class in my gym, for example. So I just think the human capabilities, even in our older adult divisions, is just as important as what the individual and team athletes are doing. The professional athletes, if you will. And then we also have the adaptive visions that are starting to grow and the upper extremity adaptive athletes were performing rope climbs. Rope climbs are hard enough when you have two upper extremities to grip onto the rope with. They were doing it with one and we're also sealing our lower adaptive lower extremity adaptive divisions, doing things like box jumps and maxing out their clean and jerk and snatch and really just taking no opportunity to have an excuse to not push their fitness forward and continue to be athletic and competitive in their sport. So I absolutely love seeing those. I wish I got to see a little bit more of it. I wish we got to view a little bit more of it on the broadcast, so hopefully we'll be able to continue pushing that forward. I just saw a couple posts of highlighting those athletes, so keep keep those in the forefront of your mind. That's what's really inspiring to more people, I think, in this world, in our country. OK, so the next three points that I want to kind of work through all kind of build off of each other. 09:20 INJURY RATES & PROGRAMMING So one thing that I thought was really relevant this year at the Games was the programming. And like I said, I have paid attention a lot to a lot more detail of our team division programming, but I just wanted to bring your attention as a rehab professional, as a movement specialist that's working with athletes all the time. I think it was important to note this. So just a couple examples. So in our competition, we had four days of competition. On day one, we had overhead squats at 135 pounds and 95 pounds. Then day two, we had a one rep, one rep max snatch. And then on day three, we had more snatches at 185 pounds and 135 pounds with running. So that's back to back days that we're seeing a barbell shoulder stability type exercise that is very demanding on the shoulders. In general programming, we would probably look to spread the frequency out of when we're doing things like overhead squat and snatching. Being able to do those back to back days can challenge the shoulder and challenges your ability to recover and perform repeatedly. Another thing that I noticed as on our day two, we had a strict ring muscle up to a front support hold. So going through that pole to deep press and hold at the top of the unstable rings is really challenging for the shoulders. And then right into day three, we had 30 synchro ring muscle ups on the long straps, which are tough. And then 63 more parallet bar dips. So that's a lot of vertical pressing for the shoulder to get through back to back days. And so I've personally experienced issues with pressing with shoulder pain. I've worked with a handful of athletes that recently have been that's a common theme in our clinic that I'm working with. So that is I remember if I was in the middle of having a flare up of that shoulder pain presentation, it would be really hard to be able to do that back to back days because you can always push through one workout. Adrenaline is a really strong drug, I would say that helps you get through it. But the next day when you wake up and things are a little bit inflamed, it's really hard to be able to repeat those motions. So that was just one thing I noticed that was not necessarily what I would have expected in programming, just how frequently the same movement is tested. And it's one thing to test the fitness of it, but it's also one thing to test the tissue capacity. So those are things that the my rehab mind was kind of evaluating while I was going through it, which brings me kind of into that next point I want to bring up was injury rates this year. I'm not sure if I just noticed more injuries and pain happening. A lot of KT tape being thrown on our limbs because I was in the background. But there did seem to be a lot of withdrawals from individual and team, excuse me, team athletes this year. We know the injury rates in CrossFit, the highest injury rates that we're seeing are in the shoulder joint. And based on that programming, it kind of makes sense. It makes sense that we're seeing a lot of shoulder issues. And so just from an athlete's perspective, it's absolutely devastating. It's so upsetting to have to withdraw from an injury, whether it's yourself, whether it's a teammate. We put so much time, money, effort and dedication to an entire long season. This started in February. So working day in and day out, making decisions based on that this specific weekend. It's just an absolute shame to see an athlete have to pull out of competition because of shoulder pain or whatever issue they may have. So I know I got to talk to a couple of the teams that had to withdraw. And the common theme that they were telling me was like, oh, yeah, I had this lingering issue for a while. I just retweaked it about two weeks ago. So they weren't necessarily the Roman Krenikov situation where they just, unfortunately, came down and rolled an ankle and had a new injury. This was a couple of these things were like lingering elbow issues that are really tested in the moment of competition with all the stress on board. Exposing to really deep positions of that dip position. If we have lingering shoulder stuff going on when you're pushing to 150 percent of your capacity, it's not likely that you're going to come out OK sometimes. So as soon as some of the workouts were announced, these athletes were like, well, I'm not feeling too great about this. So I take it's just such a shame because I think as rehab professionals, we need to have the skill set to be able to address these issues that our competitive athletes are experiencing and make sure that we're not just getting them back to be able to do a ring muscle up and take an ibuprofen. That's a whole other issue. We don't want our athletes to be doing that, obviously, but we want to be able to get them back to baseline and then beyond baseline because that originally that shoulder with that skill set got injured. So it's definitely up to us to be able to have the resources and provide rehab for these athletes that they find valuable. Not every single one of these athletes has a team of physical therapists that are top notch, that are traveling with them, that are on like on them 100 percent of the time. And so it is very likely that you may come across a CrossFit Games team athlete that's going to need to go through four days of competition with repetitively dips and butterfly pull ups and pulling, pulling whatever it may be. All these really challenging things for our shoulder girl to be able to tolerate. So that just I walked away being thankful that I came out unscathed, essentially, because if you followed any of my CrossFit career, I've had issues with my shoulder before. And strength always is super protective against injury. And I feel really lucky, essentially, to have all the knowledge that I have to put myself in the best scenario. Even within my teammates, we had a shoulder issue that we had to train around a little bit where we couldn't our best choice wasn't to continuing to do 30 muscle ups the week before, for example. But we rehab the crap out of it and put ourselves in the best situation possible to be able to come away without withdrawing by any means and putting up a pretty good performance over the course of the weekend. So that just brings me to want to plug our courses just one more time. So I mentioned the beginning, we have a couple of online courses coming up. I would say 75% of the clinical decision, clinical decisions I'm making on a daily basis are all things that I learned from these courses. The other 25% is probably all the other stuff I learned from my ice courses. So I know I'm biased, but I promise I'm not lying. If you at any point would feel nervous, nervous if I came into your clinic saying I can't do ring muscle ups, help. Please hop in one of our courses. It's really a fun, fun way to spend your eight weeks online. And so the last point I wanted to make kind of along the same theme was the importance of stress and recovery. So if you are an ice in the ice world, I'm sure you have heard us talk about the importance of stress and stress that the body takes on and how it helps us or doesn't help us recover well. 11:04 COMPETITIVE ATHLETES & REHAB And competing in the CrossFit Games this past weekend really made this become like full picture for me. I prioritize sleep, I prioritize what I'm putting in my body, and I prioritize managing stress as well as I can with all of the training that we were doing. But at the CrossFit Games, I will say I was probably at a peak stress level in my life. I don't live there on a daily basis, but the couple of weeks leading up to it, highly stressed and enduring also highly stressed. For example, day one, the volume wasn't really high. We were coming off of two sessions a day, up to two hours per session. So training heaps, I would say. And day one, all I did was three leg assault climbs, 30 overhead squats and then four laps on the bike track, which was aerobically really challenging, but not high impact. And the next day when I woke up, my fitness tracker is showing me my heart, HRV is plummeting. I felt like I did probably triple that amount of volume at minimum. And I was really surprised because volume wise wasn't crazy, wasn't out of my realm. But I felt the I think what I was feeling was the high level of stress that competition brought on. So and just to circle back a little bit, if you're having lingering shoulder pain, it's probably not going to get better with how much we're ramping up as far as volume in the eight weeks leading up to the CrossFit Games. 15:10 HIGH STRESS IN COMPETITION And then in the high, high stress environment, it's also going to be asking a lot to be able to recover and repeat these highly demanding movements like snatching, overhead squatting into ring muscle ups, to fatigue into dips where we're highly fatigued and moving at 150 percent of our capacity, essentially. So it just really is that's another way that I think bringing like stress and managing our recovery is just too important to ignore as the physical therapist, because we all know that person that's chronically stressed, chronically in that sympathetic state that maybe they are going into the gym and adding more weight. More stress onto their body. It's I absolutely can understand how they probably don't feel well at the end of the day, day in and day out. And so you have the ability as their rehab pro to help change their foundation of what they feel on a daily basis, too. So don't forget those things when you're dealing with any type of person that comes into your clinic. Stress management can really hit hard on so many levels and prevent maybe just set them up to rehab even better with all the good rehab skills you're doing with them in the clinic. And then lastly, I just wanted to share a couple of highlights because I feel like I had so many so much amazing support from our ice community. So just a quick couple personal highlights. Having been a spectator of the CrossFit Games for the five or six years or so has been in Madison. It was just such a cool opportunity to be able to push the Bob to do ring muscle ups with the long, long straps on the Zeus rig to use that four person axle bar for the deadlift. Those are things that you just never would see in a norm or any other CrossFit competition that's really only going to be at the CrossFit Games. So I remember pushing the Bob to the finish line and just reflecting on North Park, like, how cool is this? I've always wondered how it felt. So that was a really cool personal highlight that was really motivating throughout the weekend. Another personal highlight was our one rep max snatch. I have had some issues with shoulder pain and snatching and tweaked my elbow before from kind of poor movement patterns. So all season I was in a bit of a snatch funk. I'm sure you can relate if you are an athlete that tries to snatch frequently. It's sometimes good, it's sometimes not good. And so just about two or three weeks before the CrossFit Games, everything kind of clicked and I was able to hit a PR and perform really well on stage. So as an athlete, it just felt really special to be able to showcase the hard work that I put into that movement all season. And then lastly, I just had the best time with so many friends and family that were there to support at the CrossFit Games. I had my gym community from Milwaukee, my gym community from Chicago when I lived there, my ice community was there, our onward community. We had such a large cheering section, essentially. And trust me, that helped us get through that whole weekend. So thank you so much for everybody that was there, that sent messages, that supported us. It was such an honor to be able to represent this crew and we had a blast doing it. So thank you, thank you, thank you. So those are my takeaways from the CrossFit Games. I would like, like I said, this is stuff I can talk about all day, every day. So if you have any thoughts on programming, injury rates, anything you noticed from your spectating view, I would love to chat about it. So feel free to comment and tag me on this post, send me a message. Other than that, have a wonderful weekend and we will see you next or on Monday with our PT on Ice Daily Show. Have a great weekend. 19:06 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on Ice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

Join Drs Amelia Langston and Jonathan L. Kaufman, MD, as they discuss current CAR–T cell for B-cell lymphomas as leading researchers and practitioners in the field. Relevant disclosures can be found with the episode show notes on Medscape (https://www.medscape.com/viewarticle/987069). The topics and discussions are planned, produced, and reviewed independently of advertisers. This podcast is intended only for US healthcare professionals. Resources Cancer Immunotherapy With Chimeric Antigen Receptor (CAR) T Cells https://emedicine.medscape.com/article/2500108-overview Multiple Myeloma https://emedicine.medscape.com/article/204369-overview CD19 https://www.ncbi.nlm.nih.gov/gene/930 BCMA in Multiple Myeloma - A Promising Key to Therapy https://pubmed.ncbi.nlm.nih.gov/34575199/ Histology, Plasma Cells https://www.ncbi.nlm.nih.gov/books/NBK556082/ Idecabtagene Vicleucel in Relapsed and Refractory Multiple Myeloma https://pubmed.ncbi.nlm.nih.gov/33626253/ Ciltacabtagene Autoleucel, a B-Cell Maturation Antigen-Directed Chimeric Antigen Receptor T-Cell Therapy in Patients With Relapsed or Refractory Multiple Myeloma (CARTITUDE-1): A Phase 1b/2 Open-Label Study https://pubmed.ncbi.nlm.nih.gov/34175021/ Progression-Free Survival: What Does It Mean for Psychological Well-Being or Quality of Life? [Internet] https://www.ncbi.nlm.nih.gov/books/NBK137763/ Ide-Cel or Standard Regimens in Relapsed and Refractory Multiple Myeloma https://pubmed.ncbi.nlm.nih.gov/36762851/ Clinical Management of Triple-Class Refractory Multiple Myeloma: A Review of Current Strategies and Emerging Therapies https://pubmed.ncbi.nlm.nih.gov/35877215/ Bispecific Targeting of CD20 and CD19 Increases Polyfunctionality of Chimeric Antigen Receptor T-Cell Products in B-Cell Malignancies https://pubmed.ncbi.nlm.nih.gov/35597752/ Bridging Chemotherapy: Multiple Myeloma https://www.ncbi.nlm.nih.gov/books/NBK584176/ Autologous Bone Marrow Transplant https://www.cancer.gov/publications/dictionaries/cancer-terms/def/autologous-bone-marrow-transplant Myelodysplastic Syndrome (MDS) https://emedicine.medscape.com/article/207347-overview GPRC5D-Targeted CAR T Cells for Myeloma https://pubmed.ncbi.nlm.nih.gov/36170501/ Talquetamab, a T-Cell–Redirecting GPRC5D Bispecific Antibody for Multiple Myeloma https://pubmed.ncbi.nlm.nih.gov/36507686/ Elotuzumab: The First Approved Monoclonal Antibody for Multiple Myeloma Treatment https://pubmed.ncbi.nlm.nih.gov/27493709/ Natural Killer Cells in the Malignant Niche of Multiple Myeloma https://pubmed.ncbi.nlm.nih.gov/35087536/

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the efficacy of mobility programs to produce meaningful, function change in range of motion for patients & athletes. Take a listen to the episode or read the episode transcription below.  Article referenced If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:32 ALAN FREDENDALL Good morning everybody, welcome to the PT on ICE Daily Show. Happy Friday morning, I hope your day is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and lead faculty here in our fitness athlete division. It is Fitness Athlete Friday, we would argue it's the best start day of the week. We talk all things CrossFit, functional fitness, powerlifting, Olympic weightlifting, endurance athletes, runners, bikers, swimmers, everything related to the person who's regulationally active here on Fridays. Before we get started with today's topic, we're going to be tackling mobility. We're going to define mobility versus flexibility. We're going to discuss a recently published paper showing the effects of long term stretching on mobility changes and address concerns related to that paper. Before we get started, let's talk about a couple of announcements. It is the CrossFit Games individual and team competitions began yesterday. Age group and adaptive athletes began Tuesday. We have a day competition all week long. You can catch it on ESPN. You can catch it on YouTube. Our very own Kelly Benfee here from the fitness athlete division will be competing with her team. Plus 64 CrossFit Army end game in the team division. So you can check her out. She had a couple of events yesterday and she's got events every day the rest of the weekend. Speaking of fitness festivals, the I Got Your Six Fitness Festival will be June 21st and 23rd down in Charleston, South Carolina with our friends at Warrior WOD. We had the virtual competition this year, but next year it's going to be in person. So it's a ways away, but look forward to that calendar if you want to come down to Charleston and join us for a weekend of approachable fitness courses coming away from us here in the fitness athlete division. Your next chance to catch our live course will be September 9th and 10th. That will be in Bismarck, North Dakota with Mitch Babcock or the end of September, September 30th and October 1st. You can catch Zach Long out on the West Coast. He'll be in Newark, California. That's in the Bay Area. Our online courses, Clinical Management Fitness Athlete Essential Foundations, our eight week entry level online course begins again September 11th and Fitness Athlete Advanced Concepts, our level two online course begins September 17th. So mobility, let's talk about it. How much can we really move the needle? My goal today is to define mobility as it's often talked about in kind of common terms with athletes in the gym, patients in the clinic when they talk about mobility, defining mobility versus defining flexibility. Talking about a paper that was published a couple of weeks ago, looking at the effects of long term stretching specifically at ankle mobility, which is a joint we're always after to improve the range of motion within and then really how to approach mobility from a practical clinical standpoint. 2:01 EFINING MOBILITY VS. FLEXIBILITY So let's start first with defining mobility versus flexibility because they're often used interchangeably and that's not the correct way to use them. Then when we talk about flexibility, we're talking about the capacity of soft tissues of muscles, tendons, ligaments to be passively stretched, whether me as the therapist stretches you the patient or whether you stretch yourself using your own body, using stretch straps, things like that. The ability to passively stretch muscle tissue at a specific joint. Now mobility is different. Mobility is the ability of a joint to actively move through a range of motion. And of course, we're always chasing a full range of motion. So the ability, for example, of the need to advance across the toes in active closed chain dorsiflexion, the ability of the hip to externally rotate or flex sitting down into a squat, that would be an assessment of mobility, actively moving the joint through the range of motion. And you, the patient or athlete moving yourself through the range of motion, aka how much motion can you actually access? Because we see some folks have a big difference between their flexibility and their mobility. We may be able to passively move their ankle, passively move their leg into a normal or above average range of motion. But when that person stands up, they re-encounter gravity and they try to actively move that joint. We can sometimes see a big difference between mobility and flexibility. And that brings us to a really important point that a lot of what we see in marketing, in programs, in our own home programs for athletes and patients is that we say we're prescribing mobility. But really, what we are giving for the most part is flexibility, that a lot of passive stretching is what is given out, which can improve flexibility. Yes, but may not always result in any sort of functional change in mobility. We see a ton of programs all over social media, especially in the fitness athlete space, that are marketed at improving mobility. But when we actually look at the content of those programs, things like ROMWOD, things like GOWOD, things like whatever WOD, that we actually see a lot of passive stretching, a lot of flexibility. And so it's no wonder that folks come in and have been doing one of these programs for weeks, months, years, and have not seen any sort of beneficial improvements. In their mobility, their ability to actively move joints through a range of motion, because they have not been doing any sort of mobility work, they have been doing a lot of flexibility work. And we know those two things don't always translate. We don't always see a bunch of flexibility work translate into any sort of improvements in actual meaningful functional mobility. 7:32 THE RESEARCH ON STRETCHING So what does the research say? There's a bunch of research on passive stretching. There's a bunch of research on the benefits specifically of eccentric loading to improve range of motion, to improve active mobility. And we've always kind of wondered the question of what is the dose response relationship with flexibility training, with stretching? We have a great paper that came out last month in the Journal of Strength and Conditioning Research by Wernicke and colleagues. I'll post the link on Instagram and in the show notes on the podcast that sought to answer that question. So this was a study that sought to look at the effects on maximal voluntary muscular contraction, flexibility and muscle thickness of the ankle plantar flexors. Now, the experimental group had a lot of stretching prescribed. Specifically, they stretched six times a day for 10 minutes each session for six weeks. So about 42 total hours of stretching through the calf complex, an hour per day for 42 days. They perform the stretching with a night splint type orthotic of a boot that prepositions the foot into ankle dorsiflexion with the addition of a strap assist to pull their ankle into additional dorsiflexion if able. So essentially stretching the gastric complex 10 minutes, six times a day for six weeks. Now, what did the results show? The results did show an improvement in range of motion of when they remeasured ankle dorsiflexion. There were improvements that reached statistical significance. But really, when we look at the results, when we look at the actual data itself and not the summary of data in the discussion, we look at the raw data. What do we think about the results? We think that the functional improvement here is probably questionable. Then we actually look at the ranges of motion increases experienced by these subjects that most folks experience the change of about 0.25 to 0.5 centimeters or about one tenth to two tenths of an inch of an improvement in ankle dorsiflexion. Now, when we measure functional ankle dorsiflexion in the clinic, we use the closed chain half kneeling knee to wall task to measure the ability of the knee to advance over the toes with a planted heel. We show this assessment in our online essential foundations course, and we show this in our live seminar as well. And what we'd like to see there is that an athlete with the heel flat can advance their knee over their toes about four inches. That ideally they would contact the wall. We know if they can contact the wall, they have about four inches of motion there or possibly more. But that is enough motion, for example, to be able to advance the knees over the toes and sit down into a nice full depth squat. And so when we look at changes of 0.1 inches in a test where we're looking to see four full inches of range of motion, we realize that's not really that much of a functional improvement of yes, the results did reach statistical significance. But the practical application here is very, very, very minimal of that person. If we improve their ankle dorsiflexion and it was, for example, zero inches, somebody like me, somebody with a very stiff ankle, particularly my right ankle that has about zero inches of closed chain dorsiflexion. What good really is 0.1 to 0.2 inches of closed chain dorsiflexion improvement? The answer is not. It's not right. It's not a functional improvement. It's not a meaningful improvement. Yes, it was a statistically significant improvement, but in real life, it would not help that person move any better. It would not improve that person's mobility, even though their flexibility, yes, has technically changed. So we need to be mindful of how to actually interpret results of studies like this. We also need to now talk about what is the practical application of a study like this to practice, because this study came out and a lot of social media posts were made, a lot of podcasts were made that said, look, you're just not stretching enough. If you stretch an hour a day for six weeks, you can see an improvement in joint range of motion. And yes, again, while true, not functional. 10:14 APPLYING RESEARCH TO PRACTICE We also have to step back and really analyze the methodology of this paper and also analyze things like the inclusion and exclusion criteria of this paper. We're probably unlikely to find an actual real person, a patient or athlete who's going to do six hours a week, an hour per day, seven days a week for many, many weeks of flexibility training, essentially, right? We hear time is the biggest barrier to exercise. We hear time is the biggest barrier to home exercise program compliance. So it doesn't really make sense that if we can't get somebody to perform a 12 minute remom for the home exercise program, what's the likelihood that they're going to do an hour a day of home exercise program on top of maybe also trying to exercise an hour or more per day? The answer is unlikely. Right. We know that if we if we dose that out to somebody, there are very few patients who are going to come back and say, yep, I did. I did six sessions a day, 10 minutes per session, and I did it every day, seven days a week, just like you prescribed, doctor. That's a very unlikely result. So we need to be mindful of that when we're talking about applying this to real actual people. We also really need to dig into the inclusion criteria and look at the baseline assessments in a study like this, because this study would portray that some of these folks were stiff and saw improvements. Some of these folks had OK mobility and saw improvements. But really, when we look at the baseline assessments, the quote unquote stiffest person in the study still had three point four inches of closed chain dorsal flexion, right? More than enough ankle mobility to be able to squat to depth, assuming nothing was wrong mobility wise in that person's hip or knee. That person would have all the dorsal flexion needed to be able to, for example, functionally squat to depth. So we have to ask ourselves, is this actually representative of the populations that we treat? Is it representative of somebody who might come to us and say they need help with their mobility? What's the likelihood that they're actually going to do an hour a day of this type of training? And also, this is not the person that's going to present in our clinic, right? Of the person who can close chain dorsal flex at least three point four inches. You're not even going to consider that their ankle is stiff and maybe even prescribe some mobility stuff for their ankle to them, because they already possess all the range of motion needed to squat. On the high end in these subjects, they were beyond three point four inches, right? There were people with four, five, six, some folks close to seven inches of closed chain dorsal flexion. Way above average mobility. And so we need to recognize and ask the question of why are we studying the effects of flexibility and mobility on people who already have adequate, above average, perfect or excellent mobility, right? We see this a lot in medical research of we study the effects of, for example, resistance training on bone loading in older adults, and we exclude people with osteoporosis and osteopenia and folks who have any sort of issue that might throw an extra variable into the study. And what we find ourselves is studying interventions on people who don't need the intervention, right? And this study is exactly that case of we are studying the effects of flexibility training on the mobility of people who don't need any help with their flexibility or mobility. So again, can we generalize studies like this to the general population? Probably not. And for a lot of reasons, the ones we've already discussed here. And what we need to realize when we look at this data and look at a big picture is when we look at the results of studies like this, when we look at all the data aggregated, yes, but also unaggregated on those data tables, what are we looking at? That we tend to find that folks fall into buckets, that we can classify them. We know that, for example, with low back pain, we can find people who are flexion intolerant, extension intolerant, shear intolerant. We know they may or may not respond to directional preference type exercises, but people tend to fall in classification buckets based on what's going on. And we need to recognize that mobility is no different. Even looking at this study, looking at the baseline measurements of folks, we have folks who appear to have great mobility, who improved with intervention. We have folks who have great mobility, who did not improve with interventions. We had folks with poor mobility, who improved with intervention. And then we had the most unfortunate group of all, folks with poor mobility, who did not seem to improve with intervention. So we need to recognize that the person we're working with in the clinic, in the gym, probably fits into one of those buckets. If they are somebody who is interested in working on the mobility, even if we may not need it, right? We have that person who can hinge all the way to the floor with a perfectly flat back and locked out knees and touch their palms to the floor. A very bendy, flexible individual who is asking you for help on their mobility, right? That person does not need mobility help. They do not need flexibility help. But yet they are maybe seeking some extra mobility programming. We have folks with poor mobility, who need mobility training, who we know will not work on it anyways, especially an hour a day. So we see that our patients and athletes fall into these buckets, and we need to recognize which bucket they may fall into. We may not know early on how they're going to respond to interventions, especially if they haven't tried anything previously, but we'll know very quickly across the plan of care of their physical therapy if they're going to be somebody who responds to interventions like these. So what do we actually do with that person in front of us? Well, I think what we don't do enough is ask people a few simple questions of I see that you have some mobility things you could work on. How much time do you actually have for this? I don't think we ask that question enough. I think we give people what we want to see them do, what we hope they will do, and then we're often disappointed when they don't do it because we haven't asked first of all how much time they're willing to dedicate to it. I appreciate over the years how I've started to ask this question, and people have been very honest of I'm never going to do this at home. I'm only going to do this when I come here to physical therapy. Well, I appreciate that honesty, right? Because I'm not going to waste my time writing out a really detailed program that you're not going to do. So I think starting with that, excuse me, that question is very, very important. And then also recognizing and being really, really thorough and methodical in your reassessments along the way so you know if this person appears to be somebody who's going to respond to mobility type interventions. This study in particular has a lot of issues with the methodology, only including people who already possess a lot of nice functional mobility. It did a lot of long-term passive stretching, and we also need to recognize that primarily due to the way the intervention was done in this study, they primarily stretched the gastroc but assessed mobility and range of motion by the closed chain dorsiflexion test, which really looks at soleus muscle flexibility more so than gastroc. So we're stretching the gastroc, but assessing the ability of the knee to advance over the toes in a kneeling position, which is really looking at the soleus muscle complex. So we need to recognize the limitations of this study, and in our own practice of actually making sure we're giving the right mobility to the right person based on the deficits that we're finding in their assessment. We hear often, what are some great shoulder stretches? Well, it depends on what is limiting your shoulder mobility. If I give you a bunch of lat stretches and you seem to be really limited in external rotation because of maybe something going on in your subscap or your internal rotators not related to your lat, if you pass all of the screens we see for the lat, then giving you a bunch of lat stretching, a bunch of shoulder stretching, it's really not going to benefit and improve the mobility we need to work on. So we need to be sure we're working in the right area and addressing the right area with our exercises as well. So mobility, how much can we move the needle? Well, it really depends. It seems to be maybe a genetic component. It seems to be a combination of how well people respond to this type of training, and we also need to recognize that it appears to take a lot of time, possibly more time than the patient or athlete in front of us actually has. So understand the difference between flexibility and mobility. Flexibility, the ability for us to stretch muscles passively or a patient or athlete to stretch themselves passively versus mobility, the ability of the person to actively move their joints through a range of motion under gravity, functional movements, things like a squat, a lot of close chain type movements. We have research that looks at long-term stretching, but we know the quality of the research is not that great and the practical application of the research itself is not that great. Yes, we can reference the study and say if you're willing to stretch six hours a week, you might see changes in your ankle mobility, but again, we don't know that for sure. In practice, we know that our athletes and patients tend to fall in buckets. We need to be able to recognize those folks where they lie in our assessment. And again, always ask the question of how much do you really want to work on this? How much time do you really have to work on this? Somebody who says I have an extra hour a day before bed at night. Okay, that's a person who maybe could try out an hour of flexibility training before bed. Whether you give them a program, whether they sign up for something like ROM WOD, GO WOD, Mobility WOD, whatever WOD, Stretch WOD, the millions of programs out there. Or somebody who goes I'm not going to do this at all. I know myself, I'm not going to do this at night before bed. I'm not going to do it in the morning. I'm not going to do it before I work out and I'm not going to do it after I work out. Okay, that is a person that we probably should not spend our time on trying to give a bunch of mobility homework already knowing that they're pretty intentional and honest that they're not going to do it. So mobility, can we move the needle? Maybe. Jury's still out. We still need to see more research, of course, more impactful research, more functional research, and more practical research. Research that actually looks at what sort of changes can we expect to make in maybe 12 to 15 minutes a day? The range of time that we're probably prescribing to most of our patients and athletes. So I hope this was helpful. I hope you have a fantastic Friday. Hope you have a great weekend. If you're going to be at a live course, enjoy yourself. Enjoy the CrossFit Games. Watch Kelly Benfee and Ruth Huron. Have a great Friday. Have a great weekend. Bye everybody. 20:32 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. You

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses how manipulating reps within a set can alter the intended stimulus of the set to bias towards power, strength, hypertrophy, or endurance gains. Guillermo discusses new research highlighting that depending on population, some individuals may still experience strength gains at lower loads & higher rep counts and that most individuals will improve hypertrophy regardless of rep dosage.   Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one on one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody. Enjoy the show. 01:32 GUILLERMO CONTRERAS Good morning, crew. Welcome to the PT on ICE Daily Show. Welcome to one of the best days of the week, if not the best day of the week, Fitness Athlete Friday. I am with you. My name is Guillermo Contreras, part of the teaching team with the fitness athlete crew of the Institute of Clinical Excellence, talking all things delightful and super interesting, such as the rep continuum. So I'm going to leave you a little bit guessing as to what that means and dive into some fun stuff as in where are we going to be over the next couple of months? Where can you catch us on the road before the year ends? For our live courses, we have more than a handful coming up here in the next several months, starting in September on the weekend of September 9th and 10th. We'll be in Bismarck, North Dakota. In October, we will be technically September, October, September 30th and October 1st. We are going to head out to the West Coast to Newark, California. A couple weeks later, October, a week later, October 7th and 8th, we're going to stay in the West Coast. We'll be in Linwood, Washington. Moving into November, we'll be double, double teaming for, I guess, I don't know if that's the right phrase, but two different locations on November 4th and 5th, San Antonio, Texas and Hoover, Alabama. So moving from the West Coast down to the South. November 18th and 19th, we will be in Holmes Beach, Holmes Beach, Florida. I'm not sure where that is, but Florida. And then lastly, in December, we are going to be in Metair, Louisiana, as well as Colorado Springs on the weekend of December 9th and 10th. So there you go. If you've been looking to take a live course with the Central Foundation, or with fitness athlete courses, one, two, three, four, five, six, seven, eight opportunities for you between now and the end of the year to catch us on the road and be able to take that course and join us. And hopefully we get to meet you out there. If you are looking to do the online courses, Essential Foundations currently is going on their seventh week of this current cohort. So we're finishing up in about a week and a half. That take about a month off. And then we're going to kick off the next Essential Foundations cohort on September 11th. So if you've been looking to get started with the fitness athlete coursework, try to get an idea of what you would do when you work with fitness athletes, get more comfortable with the barbell movements, the squat, the deadlift, the press, what CrossFit is in general, some introduction to programming as well as the gymnastics movements, such as the pull-up. Would love to have you join us on September 11th as we kick off the new Essential Foundations cohort. These courses do tend to sell out online. So signing up sooner rather than later behooves you if you're interested in it and you want to get it in before the end of the year. Advanced Concepts as well. I think that only has two cohorts a year. So only twice a year that you can actually sign up and take Advanced Concepts. That second time right now is going to be on September 17th. Advanced Concepts does always sell out. It's a more high level course. You're going to learn a much deeper dive into programming, into modifications, into the high level gymnastics movements, such as handstand push-ups, muscle ups, high level Olympic weightlifting, breakdown and progressions. A lot of really deep dive stuff. A lot of brain work and physical work you'll be doing for this course. So that one starts up on September 17th. So please be sure to sign up again sooner rather than later for that one because that one does absolutely sell out early. Sometimes a couple months early. So sign up now if you're looking to complete your coursework to get your fitness athlete certification or if it's just something that's been on your bucket list you've been dying to take but you have not and you want to get it in before the end of the year. Fantastic. So that's what we have on the docket for fitness athlete. This morning the topic at hand is the rep continuum or the repetition continuum. For those who are not sure what that entirely means, what we're looking at with the rep continuum is, I just realized my camera is really blurry over here but that's okay. Is what we commonly know as the strength endurance continuum which for the majority of us or anyone who's been in like the strength and conditioning realm what that means is okay what are the optimal rep ranges and loads that you want to use when you're trying to train strength, when you're trying to train hypertrophy and when you're trying to train more like localized muscular endurance. And for the longest time we have had the accepted theory that it is one to five reps at 80 to 100 rep 100 percent run at max. Hypertrophy is going to be eight to 12 reps at 60 to 80 percent one rep max and endurance is going to be 15 or more reps at anything below 60 percent of your one rep max. That's what's been commonly known and so in 2021 Bradshon building company down at the NSCA right they decided to do a lit review look at everything they could out there and got a better understanding of is it truly that is that the only way or are those the only things we know or are there actually other ways to gain strength gain hypertrophy gain gain endurance in our muscles and is that truly the most optimal way that we can do these things or is there other ways that we can kind of build it up can we use lighter loads can we use moderate loads can we use heavy loads and play around and dive into these different realms. So again they did a very very significantly large lit review and their purpose of the paper was to critically scrutinize the research on the repetition continuum highlight gaps in literature and draw practical conclusions for exercise prescription. Based on the evidence they proposed a new paradigm whereby muscular rotation can be obtained and in some cases optimized across a wide spectrum of loading zones. So that is that kind of the basis for the paper and it's a long one it's probably like 11 pages and you have like a bunch of pages of exactly the the the protocols that they use in all these different studies that they reviewed and I'm just going to try and do my very best to summarize what they kind of found in each section and then at the end if you don't want to like listen to this whole thing you're listening later on just jump to the last maybe like minute or so and I'm going to try and kind of concisely conclude everything there. When it came to strength strength as we know it is supposed to be ideally that one to five rep range 80 to 100 percent one rep max heavy heavy loads is how we're going to build strength and what they found in this here is that trained individuals people have been doing it for a while tended to show improvement in strength even with light loads so people who have been doing it for a while people who who already lift heavy and such when they use lighter loads in different variations there actually is an increase in overall strength albeit they they mentioned in a caveat that it is to a lesser extent than the use of heavy loads. Um they also mentioned that typically what they see is as you reach that genetic ceiling like where your where your strength is kind of at its highest or going to be pretty high the greatest benefit is going to be in heavy loads with specific movements that you're trying to get stronger and again that should be something that all of us are probably saying like no duh right that's that's the set principle right you learn that in undergrad kinesiology right specific adaptations to impose demands when you get someone that's a higher level at the very highest level and you're trying to get them stronger the way to get them stronger is to apply specific stressors to elicit a specific progressive improvement in strength that's what they saw there so what we see is with heavy loads or when we want to build strength you can do it with low loads there are ways you're going to build low loads and that practical application the clinical application is that all the studies i guess the majority of studies that found that low loads improved strength their way of testing strength was using isometric dynamometry therefore the isokinetic or isotonic leg extension leg curl hip extension you name it they used single joint mechanisms to test that single joint single movement strength from a practical application that can very easily mean for us in the rehab realm if we are trying to get someone's quad stronger if you're trying to improve specifically quad strength hamstring strength whatever it may be there is a point where we can use lower loads to high intensities right all across the board effort was dependent on improvement maximal or hard efforts with low loads showed improvement when individuals cut off before maximal effort before fatigue before stress there was not the same amount of improvement whether it was strength hypertrophy or muscular endurance so low loads can be used on single joint movements however strength is most often applied in compound movements coordinated multi-joint efforts i.e. squats deadlifts presses lunges all those type of things and so we want to make sure that if we are trying to help someone improve their squat improve their deadlift strength improve their rowing strength we're trying to create these compound movements that are are functional in nature to what they're doing we have to be getting comfortable with the barbell movements we have to be comfortable loading them heavily right so if you're going to be working with athletes who are doing functional movements you better be loading them with functional movements you better be loading them heavy with functional movements if the goal is to do actual strength improvement and that actually is nice because it it shows two things right one yes the one to five rep range eighty one hundred percent max of these movements is where we want to be for strength and two if we're trying to do very specific rotator cuff bicep quad hamstring strengthening then it's okay to use lower loads maximize that intensity range and we're going to see strength improvements there if we're very specific with what we're doing there number two moving on to hypertrophy hypertrophy getting the gains bigger bigger arms shoulders back legs quads hamstrings you name it everything there well we typically see in the realm of like bodybuilding in the realm of anyone who's trying to put on mass is we're going to be doing somewhere around that eight to twelve rep range sixty to eighty percent so submaximal loads add an effort when you get to that mid-range you're creating some sort of mechanical stress that causes that muscle to basically in essence break down a little then build back up and get stronger as long as you know all the fuel and everything is there for it and in the study the meta analysis showed comparing high loads which are greater than 60 percent of one rep max versus low loads which are less than 60 percent one rep max is that there was no real difference in hypertrophy which is kind of interesting right you can again offer an example of you can use low or high loads moderate loads kind of in that range to build hypertrophy the notable effort though again that they mentioned in here is that when individuals were using low loads the effort was much higher so it was a higher level of effort because it is critical for maximizing hypertrophic adaptations so again if our goal is to have someone who has a very very atrophied quad and we are not going to try and pursue something that allows for 60 to 80 percent of that one rep max relatively heavy loads right moderately heavy loads that are challenging and fatiguing and stressful then we'd better be using low loads but eliciting a maximal effort where they are working hard for 15 18 20 reps whatever it may be that kind of ties in a little bit with with anyone who kind of plays around with blood flow restriction training where you're doing 30 15 15 and you're maximizing that effort there it's a very low load somewhere around 20 30 percent of one rep max for a lot of reps there too but that's again there's another topic there right effort is dependent on this are we are we using maximal or high level of effort to maximize hypertrophic gains strength gains etc the one thing this study did show the review did show was cool is that for from an age-related standpoint the light load training appears to be as effective as heavy training so when we're looking at our older adults where we might see more of those joint related conditions when they can't sometimes tolerate heavy loads on their knees on their hips whatever it may be using light loads at this this higher effort level might induce a similar hypertrophic change because it's going to stimulate both type one and type two muscle fibers when we're using lower loads we're in essence what they mentioned in this review is those type one fibers might be stimulated stimulated more because you're doing more of an endurance or long bout of exercise and effort which is going to stimulate those more when you're having it's more type two muscle fibers so either way we're building them both up and we're trying to build hypertrophy in that way so there we go and even in the really said that some researchers propose that you should train both like high level volume with high effort and lower volume with higher effort as well again working in those things there too so minimum threshold though if we have to like throw a number out there is where they're in there it's somewhere in the range of 30 one rep max right we should not be training anything below 30 of our one rep max or if you're using rp like a three out of ten so hopefully that makes sense right low loads are fine high loads are fine they're both good again as i mentioned with strength and now hypertrophy effort is dependent right we need to be working hard we need to be pushing individuals and lastly there's the endurance response right less than uh greater than less than 60 percent of one rep max 15 or more repetitions right lots and lots and lots of reps trying to really fatigue those things out and um in the look review right this is probably the shortest section in there that kind of looked at and it kind of just demonstrated that like there's a lack of dose response relationship right whether you were doing uh high loads or moderate loads light loads there wasn't a significant change in overall muscular endurance and i believe uh the lighter loads for endurance were more beneficial for like lower extremities which would make sense right you're running it's a lot of like impact and going doing a lot of air squats uh things like that's going to help build that muscular endurance uh versus doing like really heavy back squats and hoping that's going to translate to doing a 5k or doing like a really long hike and stuff like that it can there's aspects of it that will help but with resiliency and like injury prevention we're talking like muscular endurance so it's the ability to go longer in that way you can look at a powerlifter who just does powerlifting and know that they ain't doing like a 5k anytime sooner a long cycle right so those those are the main kind of areas we looked at right so again a lot a lot of talk there a lot of like little details about this lit review and what i want to specify again this conclusion right what is what is the grand arching scheme or grand arching topic uh or takeaway from this it is that what we're looking at trying to build strength strength related advantages of heavier load are dose dependent right so if we are going to have someone get stronger at the squat the deadlift or the press they better be doing heavy squats heavy deadlifts and heavy presses if we want someone to specifically improve quad strength we can do squats we can do step ups we can also do isometric leg extensions at lighter loads for higher volume and what matters here is the effort and also if you are trying to train for a specific thing you're trying to help someone improve their squat or increase strength with squat they better be squatting right specific adaptations to impose demand for strength is the greatest area that we see that that has to be specified there strength is going to improve strength hypertrophy we can use high loads we can use low loads we can use moderate loads if you want to build muscle we can use them all the one thing they mentioned though is you have to remember with low loads it's a lot more effort dependent there's going to be a higher amount of metabolic stress which can lead to just general discomfort in the muscle and some people don't like that so the the likelihood of them sticking around to doing for doing like three sets of 18 at maximal effort where they're feeling like an eight or nine out of 10 difficulty is not there the compliance might not be there high loads you need more volumes more more volume right so you can you only do two or three sets two or three reps i'm sorry at 80 90 percent which means you're probably doing seven eight nine sets to get the appropriate amount of volume to elicit the hypertrophy response and what we know is that's not fun if you've ever done 10 sets of three something really really heavy that is a miserable session and it's also hard on your on your joints on your tissues it's a lot of stress so if anything is off in your training continuum whether it be your sleep your recovery your nutrition right you're going to feel that much much more which is why we probably go with that middle moderate range where it's hard enough difficult enough but it's not going to elicit any type of ill feeling or pain discomfort etc and then lastly with endurance as i mentioned already the lighter loads are going to be more beneficial for the lower extremity musculature otherwise it's pretty much equivocal like whether you use heavy loads or lighter loads for endurance you're not going to see too significant of a difference as far as gains go in that area cool i will link the study in the comments for anyone who wants to check it out for themselves that's all i got for you this morning on this fitness athlete friday if you're doing some hypertrophy work today play with some heavy load play some moderate load play some light load if you're doing some strength work get after that barbell get heavy with it and hopefully everyone enjoys their weekend thank you for tuning in and we'll catch you next week on the pt on ice daily show take care again 19:04 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 CEUs from home check out our virtual ice online mentorship program at www.ptonice.com while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to ptonice.com and scroll to the bottom of the page to sign up  

Dr.  Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long. In today's episode, Zach shares his favorite exercises for low back strengthening, including the reverse hyperextension, heavy horizontal rowing, and Jefferson curls. Take a listen to learn how to discuss cold plunging with your patients or athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTROWhat's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show.  01:25 ZACH LONG Welcome to the PT on ICE Daily Show here on the Best Day of the Week on the podcast. It is Fitness Athlete Friday. I'm excited to be with you here today. I'm Zach Long. I'm one of the lead faculty members inside of our fitness athlete division. And today we're going to talk about a few of my favorite exercises for low back strength. Before we do that, two pieces to get out of the way. Number one, congratulations Joe Hanisko, one of our faculty members here inside the fitness athlete division. He and his wife Aubrey just had their first child, so congrats Joe. Second, upcoming courses we have inside the fitness athlete division. Advanced Concepts, eight weeks online, starts up September 17th. That always sells out, so if you've already taken essentials and you want to move on and take advance, you need to go sign up for that really soon because it will sell out several weeks in advance. Upcoming live courses we have September, we're in Bismarck, North Dakota, as well as Newark, California. October, just outside of Seattle. In November, we're in Hoover, so look forward to seeing you on the road. Or in Advanced Concepts. So let's jump into today's topic and that's bulletproof back exercises. So one thing that we talk about a lot in so many of our courses, but especially in Fitness Athlete Live, is that there's just this principle of rehabilitation. Like when a tissue is injured, what do we strengthen? We strengthen that tissue, right? If you're dealing with Achilles tendinopathy, we're doing Achilles tendon loading. If you're dealing with patellofemoral pain, we're getting your quads and your glutes really strong. We strengthen the tissues around what is injured. That's a principle of rehab. But all of a sudden when we start talking about low back pain, that principle like goes out of the window. And so much of our profession then says, no, we're not going to get the back strong. Instead, we're going to worry about the glutes not activating. We're going to worry about psoas tightness. We're going to worry about transversus abdominis activation. And while I'm not saying any of that is not completely irrelevant, I'm just saying that a principle of rehab is that we strengthen the area that is injured. So when somebody has back pain, we should probably make that back a little bit stronger. And so I want to share five of my favorite exercises for doing that today. And number one for back strength is going to be the reverse hyperextension. So this is a piece of equipment that you don't see a lot of physical therapy clinics. So I'm going to describe it for those of you that aren't familiar. Imagine you have a high-low table that goes up about five feet off the ground. And it's got this nice cushiony pad on top of the table. And you lay your torso on that with your legs hanging vertically off of that. And then you lift your legs up. So it's essentially just doing like a Romanian deadlift, except your upper body's horizontal to the ground and locked in place, and you're lifting your legs up. So there's reverse hyper machines, but this can also be done a number of different ways. I have patients doing it off of beds, off of incline benches, over exercise balls, over a barbell in J-cups on a rack, over a glute ham developer. A lot of different ways to do reverse hypers. But they are a phenomenal exercise for building a little bit of low back strength and endurance. And I'd say this is probably one of my most frequently prescribed low back exercises, because it works so well, even on your highly irritable patients, so frequently they can do this and get a huge pump into those muscles around their lower back, which of course is going to help tremendously out with pain and with working through a little bit of inflammation and getting fluids moving a little bit. So really make sure you check out reverse hypers. If you've never done those before, I would highly encourage you to take a look at different reverse hyper variations. You can find some videos of that on my YouTube or my Instagram if you need some ideas on how to do that, or you can just shoot me a message and I'll send you that video. But it is a great exercise to start with. Exercise number two, any form of heavy rows. I think we very frequently think of bent over rows and other movements like that as an upper back or mid back exercise, but they're so underrated in terms of what the low back has to do in terms of holding an isometric contraction. So I love really heavy rows. So bent over rows or really, really, really love pin lay rows. So if you're not familiar with pin lay rows, here's another great exercise for you to go train and explore within your own personal fitness journey. So barbells on the ground with bumper plates on it, you hinge over quite a bit to grab the bar and you're doing a row with every time the bar goes all the way back down to the ground. And what I really focus on with my pin lay rows is that my lumbar spine stays locked in place. I let my thoracic spine round and extend a little bit as I row. And that's just a phenomenal exercise to build total spine strength. So really for sure, check out pin lay rows if you've never done those before. Next movement is a series of movements actually. So that's anything off of a glute ham developer. Not very many physical therapy clinics have a glute ham developer, but a lot of gyms do. And so a glute ham developer is an exercise, a piece of exercise equipment that has a lot of different potential variations that you can do. But really I like to do tons of isometric holds off of the glute ham developer. So the glute ham developer has this little foot plate. So you lock your feet in place and then your thighs into this other pad. And then your upper body is free hanging out here. So you can hold your upper body parallel to the ground and you're now going to do a really good isometric of your low back, your glutes, your hamstrings to hold that global extension position. But you can then do different things like hold some light dumbbells and do rows to make that a little bit more challenging. You could turn it into a hinge movement by doing back or hip extensions, either loaded or unloaded, but so many different variations of exercises that can be done off a glute ham developer to load the post of your chain and the back specifically that you really want to make sure you check those things out. Up next, Jefferson curls. So Jefferson curls tend to get physical therapists a little bit fired up because everybody seems to be on one side of the equation or the other. So Jefferson curls, where we work on segmentally flexing the spine and taking the spine from an upright position, going into global flexion with light load behind it. I love Jefferson curls because so frequently in our culture, people are absolutely terrified of flexing their spine, especially with any load. And so the lightly load that and make people feel more confident that their back can get out of neutral position and not explode. Like we see Instagram infographics happen all the time by unfortunate influencers. The Jefferson curl is a great way to build confidence that the spine can be flexed. I love this to build a little bit of submaximal strength out of positioning. I love it also for my athletes that have some neural tension. We've worked through so much of that neural tension, but I know they're going back to a sport like CrossFit where they're going to be doing a ton of hinging motion. I like to use the Jefferson curl as the in range, make sure we completely clear out any of that stiffness that might be remaining. So that's exercise number four. And you all know exercise number five, last exercise. If you've been to an ice course, whether this is total spine thrust, modern management of older adult, lumbar spine management, or fitness athlete, you know what the next exercise is. And that is the freaking dead left because that is the best exercise that has ever been invented to build low back strength as well as human's confidence in their body. It is shocking and amazing how often somebody pulls a weight off the ground that they didn't know that they could do. They didn't know that they were strong enough to do it, or they didn't know that their back wasn't so fragile that they couldn't pick up that 95 pound bar, that 125 pound bar, that 225 pound bar. They pick it up and all of a sudden, their chest pops up a little bit. They walk out of the clinic a couple inches taller because they're so much more confident in their body when they learn how to pull a heavy weight off the ground. And it's something that they weren't expecting. Dead lifts can be conventional dead lifts, sumo dead lifts. They can be kettlebell dead lifts, so many different options for it, but get your people pulling heavy weights off the ground because that builds a lot of confidence in the human body. One of our favorite research articles from that comes out from Taglia Theory and colleagues in 2020. So they looked at individuals doing low load motor control exercises and manual therapy compared to a group that did heavy loading. So they're doing squats and dead lifts and a ton of other exercises that load the spine heavy. And what they actually found was that the heavy group, the group that were getting after it lifting heavy loads, had significantly reduced levels of kinesiophobia, which when it comes to low back pain, we all know that's the key. Our patients, after they've had an experience of low back pain, are terrified of their backs. And anything we can do that reduces kinesiophobia and makes them feel more confident is really important. And in that Taglia Theory and colleagues article in 2020, low load motor control exercises, your bird dogs, your clam shells, those sorts of movements, they don't make people less fearful of their back, although they do help with their pain. Heavy loading helps with pain and makes people more confident in their body. And that's what it's all about. So five different exercises there. We've got reverse hypers, we've got heavy rows, we've got glute ham developer work, Jefferson curls, and the greatest exercise of all, the dead lift to make your patients stronger in their low back, more confident in their low back, and getting back to doing the things that they love. So I hope you enjoy this episode. As always, reach out to us if you have ideas for future topics you'd love to hear of, and we look forward to seeing you on the road. Have a great weekend, everybody. 11:12 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.    

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  https://pubmed.ncbi.nlm.nih.gov/34852731/ https://pubmed.ncbi.nlm.nih.gov/33630675/ https://pubmed.ncbi.nlm.nih.gov/32023545/ https://pubmed.ncbi.nlm.nih.gov/34770213/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4493260/  https://pubmed.ncbi.nlm.nih.gov/31869820/  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines heat-based recovery including hot tubs, whirlpools, and saunas. Take a listen to learn how to discuss cold plunging with your patients or athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody. Enjoy the show. 01:32 ALAN FREDENDALL All right. Good morning, team. Welcome to the PT on ICE Daily Show. Happy Friday morning. Hope your Friday's off to a great start live here on YouTube and Instagram, everywhere you get your podcasts. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the chief operating officer here at ICE and a lead faculty in our fitness athlete division here on Fitness Athlete Friday. We consider it the best start day of the week. We talk all things CrossFit, Power Lifting, Olympic Weightlifting, endurance athletes, running, swimming, cycling, all that sort of thing. So if you're interested in working with the recreationally active patient or client, Fridays are for you. We're going to talk all things heat based recovery today. We spent two weeks ago talking about cold based recovery. So it'll be a nice change of pace on the opposite side of the spectrum. Before we get started today, first of all, I want to say big thanks to our friends at FIRE, Foraging Youth Resilience for having Jeff, our CEO, and myself out this week to their annual camp outside of Boulder, Colorado. Huge fun getting to know a lot of the kids, the campers, as well as a great network of coaches, games athletes, all sorts of wonderful people from the CrossFit space coming together to help support FIRE. It was great to meet everybody out there. If you want to learn more about FIRE, you can read more on their website. We're big supporters of FIRE here at ICE. So you'll continue to see us have more opportunities to help get involved with FIRE and support FIRE as time goes on. Some courses coming your way from us in the fitness athlete division. If you're looking to catch us out on the road for clinical management in the fitness athlete live, that's our two day live seminar. Your next chance will be September 9th and 10th. That's going to be out in Bismarck, North Dakota with Mitch Babcock. And then you can catch the same month at the end of September, September 30th and October 1st out on the west coast. Zach Long, aka The Barbell Physio, will be out in Newark, California. That's in the Bay Area of California. And then online, our clinical management fitness athlete essential foundations, our eight week online entry level course into the clinical management fitness athlete curriculum. That will start September 11th. That's taught by myself, Mitch Babcock, Kelly Benfee and Guillermo Contreras. And then the next week after our level two online course, clinical management fitness athlete advanced concepts start September 17th. So you can learn all about that at ptenice.com. That's where everything lives that you want to know about ice. So today's topic, heat based recovery. We have talked about cold based recovery, specifically two weeks ago here on fitness athlete Friday. We talked everything regarding cold plunges and cold based recovery. We're going to go to the opposite side of the spectrum now and talk about heat based recovery. So the big summary from if you didn't catch us two weeks ago, the big summary from cold plunging is that we really want to avoid it after exercise. It seems to really have an effect on that post exercise inflammation effect that we want to build strength, build hypertrophy. It does have some benefits, but we mainly want to avoid it after exercise. You're going to see a recurring theme here with heat based recovery. But I do want to start by first of all, defining what is heat based recovery, talking about the differences between things like hot tub or whirlpool. Differences between you may have questions about infrared versus traditional sauna. And then I want to talk about some of the research supporting the use of heat based recovery, but also the application of it both in the clinic. And when you're discussing these topics in the clinic or the gym with your patients or athletes. So let's start first by defining it. What is heat based recovery? We have a couple different types. The first is what we'll call hot water immersion. This is basically the opposite of cold water immersion or cold plunging. This is where you get in a hot tub or a hot bath or a whirlpool machine, some sort of hot water immersion. Now defining temperatures here is really important. We did that two weeks ago with cold water immersion. Really important to note that at least from the research, we have specific temperature ranges that we're discussing with all of these modalities. And we're also assuming that you have your whole body immersed in something like a sauna. Or that if you're in hot water, for example, a hot tub or a hot bath, you're immersed at least up to the level of your neck. A lot of what we're going to talk about doesn't apply to you if you're somebody that just sticks your your foot in the hot tub. Or doesn't otherwise get fully immersed in whatever modality you're using. So two different types of hot water immersion, hot tub or hot bath. When we're at home and we run a bath, when we look at what is the temperature of what the average human being might consider quote-unquote hot. A hot bath is right around 100 degrees Fahrenheit. And that your average hot tub is not too different. A hot tub that you might get into is going to be somewhere between 100 to 110 degrees Fahrenheit. But now when we look at this from a research perspective, it's usually tightly controlled and it's usually tightly controlled a little bit hotter. So when they look at hot tub whirlpool type immersion in the research, they're looking specifically at a temperature range of about 110 to about 120 degrees Fahrenheit. So if you're somebody that really hates a hot bath, if you run a hot bath and you wait for it to cool down a lot, then just know this is going to be on the upper end of your temperature comfort. Why this matters is that when we add that that circulating bubble component to a whirlpool, to a hot tub, it seems with the water continuously moving that it makes that hot water immersion just a little bit more tolerable and therefore they bump the temperature up a little bit. Again, 110 to 120 degrees Fahrenheit. And again, immersion in a hot tub whirlpool up to the level of the neck. Now duration is really important. We talked about that with cold plunging. That if you're somebody that gets in for a minute, you probably don't have to worry about the positive or the negative effects because you're really not doing it. The same is true here. When we look at hot water immersion, when we talked two weeks ago, we talked about humans have a really great tolerance for heat at rest. We can sit outside 70, 80, 90, maybe even 100 degrees, especially if we're in some shade and we can be okay. We don't have a great tolerance for cold at rest. And we see this carry over into hot water immersion that because we're so much more tolerant to heat, we see duration for hot water immersion a lot higher. We often see duration 15 to 30 minutes in a whirlpool in a hot tub. Maybe you've been at a hotel or a resort or something. You've seen that sign. We've all seen that sign on the hot tub. You know, don't stay in here too long. Max time 20 minutes, 30 minutes. That tends to be our tolerance for hot water immersion. So somewhere between 15 to 30 minutes, but definitely longer than what we're used to seeing with cold water exposure where the general recommendation usually never exceeds 10 minutes. Now getting into sauna, temperatures are going to go up. We're no longer actually sitting in water. We're usually sitting in a room that is either steam heated or dry heated. Those also have different temperature parameters when we look specifically at how they're studied in the research. Traditional sauna, whether it's dry or a steam sauna, is a lot hotter. 150 to up to 220 degrees Fahrenheit. Infrared sauna is going to be lower, 120 to 140 degrees Fahrenheit. And again, the duration for sauna is going to be higher, a lot like hot water immersion. Somewhere between 30, maybe even to a 90 minute dose, and that's going to be mostly for infrared sauna. That would be really tough to do in a traditional sauna. So that's how we define hot water immersion and also what we would call just sauna, sauna protocol, traditional or infrared. Now the research. I want to share a couple of different papers with you as we get into talking about what does the research support? What does it not support? Talking back to hot water immersion. So again, our hot tub or our whirlpool protocols. A great paper from 2022, the Journal of Sports Science. More and more Gamino and colleagues, pardon me butchering that, looking at hot water immersion. They took folks and they had them sit in a whirlpool for 15 minutes at 110 degrees Fahrenheit. They also had another group sit in a cold plunge at 50 degrees Fahrenheit and they compared outcomes on the quadriceps muscle. They wanted to look at specifically the contractile properties of the muscle itself and found that the group sitting in the hot water after exercise had increased contract properties of the quadricep muscle compared to the folks who did cold water immersion and compared to the folks who did nothing, who sat at a room temperature room. So the the effects of hot water immersion appear to have a more beneficial effect on our muscle and we'll get more into that as we get more into the research. My next paper, really old. I love some of these old papers that just show how long we've been studying this stuff. Francisco and colleagues back from 1985, so before I was even alive, Journal of Applied Physiology. Looking at the use of hot water immersion and comparing it to basically an active recovery protocol. So two groups of subjects, one group exercising at 60% of their VO2 max. So essentially an active recovery spin on a cycle or a really really really low slow jog, something like that. To a group that did an hour in a whirlpool at 105 to 110 degrees Fahrenheit. And then they did a crossover here. So they took both groups and then flipped them a couple of days later and had them repeat the same thing. What they found in the group who sat in the hot tub for 60 minutes is they had an almost identical cardiovascular change. So they had an increase in their cardiovascular output and their mean arterial pressure, which just kind of tells us that there is a cardiovascular demand on the body when you are exposed to heat that mimics low-level active aerobic recovery type exercise. So what does that tell us? That tells us that first of all if we are looking for a recovery day that a longer hot water immersion or maybe a sauna can be a viable option in place of a recovery workout that we're going to get some increased cardiac output. Our heart rate is going to elevate. We know being exposed to heat we're definitely going to sweat. That's going to come on board no matter what. But we're going to see blood pressure changes as well. That tells us we're kind of getting a flushing pumping effect when we're exposed to heat specifically in this study hot water immersion compared to if we went to the gym and just spun on our bike or went for maybe a really long walk or a really slow jog or just some sort of active recovery exercise that they appear about equal. Which is great if that's what we want. If we're trying to limit cardiovascular load, if we're trying to limit volume on our body then we need to be mindful that a longer duration hot water experience can have that effect on us. So it appears to be about an equal effect, which is nice. The next study here, Borg and colleagues from 2020, the International Journal of Sports Physiology and Performance, looked at hot water immersion versus cold water immersion versus control. Specifically they had these folks do these modalities after cycling in what they called hot weather, 75 degrees Fahrenheit. So they went for a long bike ride in the heat and they came back. They threw one group in cold water immersion in the cold plunge. They threw one group in hot water immersion, a whirlpool, and one group just sat at room temperature. And they found that those exposed to the hot water immersion were more likely to report that the session they had just performed, the cycling session in the heat, was easier. And they also had a lower cardiovascular response to those who had a cold water immersion. So it seems like when we're cooling down we want to choose heat as it's easier on our body, easier on a cardiovascular system than finishing a hot workout in the heat. It sounds great. We've all had those workouts. I just had one two weeks ago where we literally want to stick our head in the sink, which is exactly what I just did, and just cool down our head. That seems like what we want to do, but we know that can have sort of a shocking effect on the body compared to if we ease ourselves out of the heat with maybe not exactly what we just did in the heat, but we choose something that's going to feel temperature neutral compared to what we just did, which was a really tough workout in the heat. Heat exposure after exercise, especially in the heat, seems to have a beneficial effect as we're trying to cool back down to baseline. Now switching gears and looking at the sauna research. So this is just as popular as everybody wants to know about cold plunges. Everybody wants to know about sauna protocols. If you listen to anything about Andrew Huberman, you have been blasted with more information than maybe you've ever wanted to know about the sauna. But I want to pick just a couple papers here looking at sauna exposure, specifically after exercise. So Bezoglav and colleagues 2021 International Journal of Environmental Research and Public Health. This is a great study. This doesn't actually research anything on sauna protocols itself. I love this study. This is basically a patient expectation, an athlete expectation of what athletes expect will help them recover and what they actually choose when they are performing their recovery. And it's just really important to know this paper in the back of your head. That 97% of athletes surveyed use sauna as their number one choice for recovery. So that's really important for us to know. We have to be able to speak intelligently about good, bad pros, cons about sauna with our athletes knowing that 97% of them are thinking I'm not feeling great. I'm feeling banged up. I am going to choose sauna as my number one recovery protocol. And we know this from physical therapy research. Massage is also popular. Not surprising. It's popular with athletes. 87% of athletes choose massage as their secondary recovery protocol. And then 80% choose taking a nap, third. So in that order, sauna, massage, and napping. So that's a really important paper to know. Miro and colleagues from 2015 in Springer Plus. This is an online open access journal. Looked at comparing folks doing infrared sauna, traditional sauna, after performing either hypertrophy focused resistance training for 60 minutes or endurance training. So they basically wanted to create a bunch of muscular damage and then have folks either get in an infrared sauna or traditional sauna. This study also had a crossover design. So the objective outcome here was a counter movement jump test and then also effects on the cardiovascular system. So that traditional sauna was performed at 122 degrees Fahrenheit for 30 minutes. The traditional sauna was performed at 70 degrees Fahrenheit for 30 minutes. And again, both groups exercise really hard for an hour. The traditional sauna group saw a reduction in performance on the counter movement jump after sauna protocol compared to the group using the infrared sauna. The traditional sauna group also had a significant spike in their heart rate. About 30 to 40 more beats per minute resting while sitting in the traditional sauna than the group sitting in the infrared sauna. So again, like we talked about a couple papers ago with environmental exposure, it seems like using sauna, specifically a really hot traditional sauna after exercise, seems to have a negative impact on our system. Of it's just too much heat load, it's too much cardiovascular load. It can lead to both negative performance outcomes, but also negative physiological outcomes. Supporting that, Skorsky and colleagues from 2019 International Journal of Sports Physiology and Performance. This group was looking specifically at performance. They had swimmers perform 4x50 meter sprints. I don't know anything about swimming. I assume that's a tough thing to do to do 4x50 sprints. Afterwards, the swimmers were either put in a group where they sat passively at room temperature. For 25 minutes or they did three eight minute rounds in the sauna, a traditional sauna at 185 degrees Fahrenheit. And then they had those athletes come in the next day and repeat the 4x50 swim performance. All of the subjects who used the traditional sauna after the sauna reported a stressful experience, both physically and mentally. And then the next day all of them had impaired performance when they went to repeat the 4x50 swims compared to the group that sat at control. They obviously did not report sitting at room temperature as a stressful experience. And they all performed better at the 4x50 than the sauna group. So it appears that longer duration, hotter traditional sauna seems to have a more negative impact on recovery. So what does this tell us? What does all this research tell us? How can we apply this with our patients, with our athletes, when they're asking questions about sauna? Maybe they're already using a sauna protocol. So as we talked about two weeks ago, cold water immersion, cold plunging appears to have a really negative impact on performance and recovery when used directly after exercise. Compared to hot water immersion, whirlpool, hot tub used after exercise. And it also really seems to affect our ability to adapt to the heat. So the takeaway here is that if we're just finishing exercise, maybe traditional sauna, especially for a longer duration, especially for a higher heat duration, is maybe not the modality of choice. Just like a cold plunge is maybe not the modality of choice. Which is not to say we can't use heat as recovery modality. But if we're thinking we just finished training, we should look towards that hot tub. We should look towards that whirlpool. We should maybe look towards that active recovery. And we should save a really long, hot traditional sauna or a cold plunge for maybe before training earlier in the day. Or what we don't have research on yet is what is that window? How much time difference between training and using a really hot sauna or using a cold plunge is still going to allow us to feel better recovery wise but not have those negative effects on performance. We don't know that yet. But for now what we can recommend is stay away from that cold plunge. Stay away from that really hot, long duration traditional sauna about right after training. Give yourself a gap. Again, we don't know how long. Or do it earlier in the day sometime before you actually start your exercise protocol. We do know that both hot water immersion and infrared sauna offer cardiovascular effects that are similar to active recovery. So if we really are not feeling like exercising today, if we're really feeling like we need a day off, we can still have some positive health benefits from going and getting in the sauna. Especially something like an infrared sauna or sitting in a hot tub for maybe 10 to 30 minutes. But we really need to consider avoiding that long duration traditional sauna. It appears to have a big effect on our cardiovascular system. It's adding a training load. It's adding a heat load to our body that's going to cause our body to need to adapt to that stress. So big term takeaways. There's no shortcut, right? What we're seeing in the research with both cold water immersion and hot water immersion, there's no shortcut here. We need to allow the body's natural inflammatory response to the exercise that we just did occur if we want to reap the benefits of that occurring. Yes, these things can help us feel less sore. Yes, they can help us feel less fatigued. But if we use them too much, they do seem to have a long-term detrimental effect on our performance. Which kind of defeats the purpose of going in and doing a hard workout, a long run, a long bike, a long CrossFit session, a long weightlifting session, whatever you're doing. If we chronically use these things, yes, we might feel better. But we need to be concerned that maybe we're leaving something on the table as far as strength, as far as hypertrophy when we use these kind of extreme temperature modalities, cold plunging, really really hot sauna. I could imagine that one study that showed a really detrimental effect was only 185 degrees. Some traditional sauna protocols in the 200s. I know Jeff Moore does the sauna at 205 degrees, I think for 15 minutes, which is even more of a heat load than 185 degrees. So just be aware of that and understand how to speak about these things with your patients and athletes because they're going to have questions about it. Remember that paper? 97% of people look to sauna is the first choice for a recovery modality and then massage and then taking a nap. So 97% of people could use probably more education on sauna because we know they're thinking about using it. So I hope this was helpful. We have an entire week in clinical management fitness athlete essential foundations dedicated to this now. We talk all things nutrition, sleep, we talk cold water immersion, hot water immersion. We also talk about compression therapy. So things like massage, massage guns, cupping, all that sort of thing. We discuss all of that research that your athletes, your patients want to know about when they come into the clinic and ask about recovering from exercise. So I hope you have a wonderful Friday. I hope you have a fantastic weekend. Thank you for joining us. Have a good day. Bye everybody. 22:33 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at ptonice.com While you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines cold plunging, discusses the research behind cold plunging, and how to practically approach practicing cold plunging. Take a listen to learn how to discuss cold plunging with your patients or athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:25  ALAN FREDENDALL Alright, good morning PT on ICE Daily Show, happy Friday morning. Hope your morning is off to a great start. My name is Alan, I'm happy to be your host today. Currently, I have the pleasure of serving as a faculty member here in our fitness athlete division and the chief operating officer here at ICE. Fridays, our fitness athlete Fridays, we talk everything related to the recreational athlete, whether that's somebody in the gym doing CrossFit, powerlifting, Olympic weightlifting, bodybuilding, out on the track, the road, running, biking, swimming, whatever, that person who is getting after it. Four to six days per week is the focus here on fitness athlete Friday. We're biased, but we would argue it's the best darn day of the week. Courses coming your way from the fitness athlete division. Taking the summer off, we have some live courses coming up in September. You can catch Mitch Babcock out in Bismarck, North Dakota. That will be the weekend of September 9th and 10th, so the first September of the fall. And then you can catch Zach Long, aka the Barbell Physio out in Newark, California. That's the Bay Area. That's going to be the weekend of September 30th and October 1st. Online courses from us, our Essential Foundations, our eight week entry level online course starts back up September 11th. We're currently halfway through the current cohort. And then our Advanced Concepts course, our level two course that requires Essential Foundations, that drills down deep into things like Olympic weightlifting, gymnastics, programming, both for CrossFit and strength, injured athletes, all that sort of fun stuff. That starts September 17th. So you can find out more about our courses at ptenice.com. So today's topic, let's talk about cold plunging. You can't trip over a rock in public these days without finding somebody trying to get neck deep in some cold water somehow. Everybody's doing it. They're posting about it. There are probably a million ads you've seen on social media for this tub. This thing that looks like a bourbon barrel. This thing that looks like a fancy bathtub. All these different ways to essentially cool down your body. So I want to attack this topic from three different angles. I want to talk about defining a cold plunge and how probably most of the people cold plunging currently or certainly what we see happen on the Internet is not true cold plunging. I want to talk about the research supporting, not supporting the use of cold plunging. And I want to talk about the practical application of what we can recommend to our patients and athletes when they come into the clinic or the gym and ask us what we know about cold plunging. What's the best way to cold plunging and all that sort of thing. So let's start from the beginning. What is a cold plunge? We need to start at the top and understand that humans have a really large tolerance for heat at rest and a very poor tolerance for cold at rest. You can imagine it's much better to sit outside on a 90 degree day than a 30 degree day. So our perception of temperature is a little bit different. It's skewed based on if we're active or if we're resting. It flips entirely when we are active. You can imagine how terrible it would be to run on a 100 degree day versus running on maybe a 50 degree day. We would all probably much choose the 50 degree day because our bodies lose heat tolerance as our activity level increases, which is all that to say of we have a really poor tolerance for cold at rest, which means when we define the parameters of what's used for cold plunging in research, we'll quickly recognize that most of us, most of the people we see aren't doing it cold enough. They aren't doing it long enough and they aren't exposing as much of their body as they need to to the cold plunge. So a cold plunge is defined by the research is going to be exposure up to your neck or possibly your entire body for 10 minutes at 40 to 50 degrees Fahrenheit. That's a large portion of our body. That's a really long duration of cold exposure for a human being at rest. And that is relatively cold. Again, we have a really poor tolerance to cold at rest. Now, imagine we've we've all taken a bath. Imagine you you take a hot bath or sit in a bathtub and then you get that feeling of, oh, I'm getting really cold. Like this water has cooled down significantly. Again, our perception of temperature is really skewed. When we decide it's time to get out of the bath because the bath water has become too cold, we've probably started in bath water of maybe one hundred and five to one hundred and ten degrees. And it has only cooled down to maybe 90 to 95 to the point where we say this is cold, quote unquote, cold. I'm going to get out of the bathtub now. But really, 90 to 95 degree water is remarkably warm compared to what we define as cold plunge in the literature. So most folks are probably simply not getting their water cold enough to even define cold plunging. Again, the duration of support in the research is cold plunging of 10 minutes. So if you are doing it for 30 seconds or one minute, just know you are not anywhere close to reaping the effects or the positive or negative that we've seen in the research. If you're only dipping your toe in for a few minutes or jumping in up to your knees or your waist and hopping back out again in the research, exposure would define itself as being exposed up to the neck, at least. So many folks just putting their legs in a cold plunge, just going up to the level of maybe the knee, going up to maybe the level of the waist or maybe belly button mid chest or something. Again, if you're doing that to slowly gain tolerance, that's OK. But if that's what you're calling normal cold plunging, just know you're probably not reaping as much of the effect. Again, positive or negative that we'll talk about here in a second as you could be. So cold plunging 40 to 50 degrees up to your neck, duration of about 10 minutes. So all that to say, most people are probably not actually cold plunging when we do it ourselves or we watch others do it. Excuse me. Simply not cold enough, not enough for their body to get in effect and not enough for a long duration. I do want to give a special shout out to ICE faculty members Dustin Jones and Jeff Musgrave. They are unashamedly posting their cold plunges every day on social media and they really get after it. You can see that they have a bunch of ICE in their backyard cold plunges and they're sometimes exposing their whole body to the cold plunges. So they are doing it right. That's the way to do it. So let's switch gears and talk about what does the research say. The research in this field is becoming overwhelming of just looking at the trend and volume of research. Eight hundred and seventy articles published on what the research would call cold water immersion since 2008. So an exponential growth in the people studying, the amount of people studying and the volume of research studying this particular area of what we might call athletic recovery. I want to talk about just two journals today, two journal articles. There are literally like we talked about hundreds and hundreds and hundreds and hundreds. But I really want to talk about two. What I like about these two articles I want to share is that they are 30 years apart and they essentially say the same thing. So first, I want to go way back. 1985, I wasn't even alive yet. Journal of Applied Physiology, Peterson and colleagues talking about cold plunging exposure after exercise. These folks did three sessions a week of what the again the research calls cold water immersion or cold plunging. They did do it at 50 degrees Fahrenheit. They did it for 15 minutes instead of 10. So they went up to their neck. They did it for 15 minutes and they did it cold enough. 50 degrees Fahrenheit. They did this three times a week after resistance training. Evaluation here looked at a lot of different things. One rep max leg press, one rep max bench press and some ballistic things, counter movement, jump, squat, jump, ballistic push up. And this article really wanted to focus on what happens to muscular hypertrophy. This journal article, 1985, now 38 years ago, said you can expect to have less muscular hypertrophy if you expose yourself to a cold plunge after resistance exercise as compared to control. Control in this group was people who just sat at room temperature like you might sit on the boxes at CrossFit class or on the curb after a really long hard run. They just sat and kind of cooled down for 15 minutes compared to the cold plunge group. Fast forward 30 years, 2015, Journal of Physiology, Peking Colleagues, very similar parameters. That's why I picked these two papers. They are perfectly 30 years apart. They use almost exactly the same parameters and they found pretty much the same thing. Peking Colleagues in 2015, very similar parameters, twice a week of cold plunge exposure, 10 minutes at a time, also 50 degrees Fahrenheit. They followed folks a little bit longer. Peter Peterson in 1985 followed those athletes for seven weeks. Peak in 2015 followed them for 12 weeks. Almost same exact parameters, though. They looked at almost exactly the same stuff. They looked at leg press strength, knee extension strength, knee flexion strength, both one rep max and eight rep max. So they're looking at maximal strength and they're also beginning to look at kind of what is your ability to produce force over time. So what we call maybe endurance, which really is indicative of hypertrophy. This team also did some muscle biopsies and what they found with the group exposing themselves to the cold plunge after resistance training compared to the control group, in this case, a group doing active recovery. So not even resting, just doing active recovery for 10 minutes after the resistance training session. The control group, who continued to exercise at a low level, had a 17% improvement in hypertrophy, a 19% improvement in isokinetic strength and a 26% improvement in myonuclei per muscle fiber. So the control group blew the cold plunge group out of the water. Now, that is not to say that the cold plunge group got weaker or smaller. They did not get as strong and big as the control group. And it's led to believe because they were the cold water immersion group, that it's the cold plunge, that something about that cold exposure seems to blunt the body's natural response for healing to encourage hypertrophy gains and strength gains. The big takeaway from this study is the myonuclei per muscle fiber. We can think of myonuclei as if one myonuclei per muscle fiber is great, but more is better. It's almost like having a personal assistant for everything in your life. Your life would be a lot easier if you woke up in the morning and someone was there who had your clothes ready for you. If someone was there who had already prepped your shower for you, if someone was there who already made your breakfast for you, right? The more people you have assisting you in your life, the more efficient you will be at running your life because they're doing everything for you. That's a lot of the role of the myonuclei in our muscles. The more the better. The interesting thing about myonuclei is they stick around even during a period of training, whether it's injury, whether we get busy with life, whether we switch training modalities, maybe we start prioritizing endurance training to train for a marathon or something. Those myonuclei stay around and that's kind of what creates that strength across life of that person who comes into the gym who says, I haven't worked out in 10 years and then deadlifts 400 pounds. You're like, where did that come from? That took me years to build to that strength. This person just naturally has it. Yes, they may naturally have some genetic strength, but what they probably had in the past from training was myonuclei that are now living in their body. And so losing those myonuclei or rather not gaining them through cold plunge exposure not only affects strength and hypertrophy in the short term, but affects really long term fitness gains over time. So very interesting study from PEEK and colleagues showing that cold water immersion after resistance training seems to really have a negative effect on strength and hypertrophy. So it doesn't seem to help. It maybe seems to have a negative benefit, at least after resistance training. Most people aren't doing it correctly. What is the actual practical application? What can we recommend to patients and athletes who ask us about cold plunging? The first thing is to make sure that they understand what it actually is and that they're doing it correctly. Of, hey, if you're going to do this, you should have a way to expose yourself up to the neck, your whole body up to your neck. You should build up your tolerance to do it in sessions of 10 minutes at a time. And the water should be really uncomfortably cold, 40 to 50 degrees Fahrenheit. We don't like to see colder than that. That can be a little bit dangerous, but we also don't like to see warmer than that. Right. Remember, cold bath water is technically hot, 90 degrees Fahrenheit. So we need to see somewhere between 40 to 50 degrees Fahrenheit. We need to talk about timing of cold plunging. The research would really suggest we should never do it after training, especially if we're just training once a day. We're training for life. We're training to be strong and be training for life. And we're not training to be competitive athletes. We're not training multiple times per day. If you're somebody that just exercises once a day, you should not finish that exercise session with a cold plunge. Maybe you start your day with a cold plunge or maybe you cold plunge before you exercise to get the effects that cold plunging can have aside from apparently blunting our strength and hypertrophy gains. And then there's a little bit of a caveat there for competitive athletes, folks who are, you know, let's think of a CrossFit Games athlete. Let's think of somebody running multiple races, an Ironman, a long cycle race. Maybe between events is the time for a cold plunge. We need to recognize those events are already really destructive to the body. Nobody goes to the CrossFit Games and comes away fitter. They come away significantly beat up with probably weeks or maybe even months of repair time needed to recover from an event like that. So at that event, we're not as concerned about not gaining as much strength and hypertrophy as possible because of the short duration. It's only a couple of days or maybe even a one day competition is only a couple of hours. So maybe that is the time between events to use cold plunging. But after regular training, we should not use it. We need to recognize the point of exercise is to create a micro injury that your body will repair and heal from. Your tissues get stronger from a tensile strength perspective and your brain more effectively learns how to use those muscles so that we get stronger and bigger over time. We become more adapted to the stress. We have an increase in tensile strength. We have an increase in myonuclide per muscle fiber. And that's what really creates robust lifelong strength. I love the quote from Pique and colleagues. Remember that anything intended to mitigate and improve the body's natural ability to improve resilience to physiological stress with exercise may actually be counterproductive to muscular adaptation. Cold plunging, NSAIDs, antioxidants, anything that can slow the chemical reactions, the natural chemical reactions in our body to respond to that micro injury is going to affect our ability to recover and be more resilient to that stressor in the future. So a lot like discouraging folks from taking a bunch of maybe ibuprofen or injectable steroids, we should say, hey, if you're going to cold plunge, make sure you start your day with it. Make sure you do it before training. You should really try to avoid finishing that workout and jumping right out into that maybe that cold plunge in the in the gym parking lot, because this research is really so profound of you're leaving maybe 20% improvement in strength and hypertrophy on the table when you cold plunge after training if you don't. So cold plunging, what is it? How does it work? Does it have a negative effect? Yes, it seems to. But also, that doesn't mean that we should say just don't do it. If you enjoy it, if it helps you start your day, if it helps you feel less sore, by all means, cold plunge. But let's rearrange when you cold plunge in your day to make sure that we're not doing it after training. And let's make sure we're doing it correctly up to our neck in the water, cold water, 40 to 50 degrees Fahrenheit. And duration should be at least 10 minutes, right? If you're just up to your knees in 60 degree water for two minutes, you're not actually cold plunging. You should feel good. You're probably not going to get a negative effect from that because you're not doing it correctly. But you're also leaving a lot on the table by not doing it correctly. So cold plunging. Hope this was helpful. We just revamped week five of our Central Foundations course to include a whole bunch of different training modalities like cold plunging. We talk about hot tubs now. We talk about saunas, both infrared and traditional saunas. We talk about compression therapy, massage, pneumatic boots, massage guns, everything folks have a question about. So if you've already taken the Central Foundations, head on over, check out week five for that update. If you haven't taken it yet, remember, September 11th is your next chance. So have a fantastic weekend. I hope you all have a lovely long four day weekend for 4th of July. We'll see everybody next time. Bye everybody. 18:00 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 CU's from home, check out our virtual ice online mentorship program at PT on ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ice dot com and scroll to the bottom of the page to sign up.

In this episode, we break down common movement and mobility limitations in crossfit and olympic lifting athletes. We discuss aspects of the clinical management of the fitness athlete with Dr. Zach Long The Barbell Physio If you want to learn more from Zach: https://thebarbellphysio.com/

In this episode, Dillon sits down with Dr. Alexis Morgan and Dr. Christina Prevett to discuss strategies to return back to the gym postpartum. We look to answer questions: What is pelvic organ prolapse? Can you exercise with pelvic organ prolapse? How do you overcome the fear of lifting heavy after delivery? What should you do about leakage or urinary incontinence postpartum? All of this and more are answered in this episode. Hope you enjoy! -Team [P]Rehab The [P]rehab Membership: Trial 7-days for Free! Guest Bio: Dr. Christina Prevett MScPT, PhD (c)  teaches five courses at the Institute of Clinical Excellence, including Clinical Management of the Fitness Athlete: Pregnancy and Postpartum. She speaks internationally on topics such as Lifting in Pregnancy and Postpartum and Pelvic Health for the Female Athlete. Christina is a national-level weightlifter, who competed in powerlifting and Olympic weightlifting meets within 6 months of giving birth to her daughter Mya. Dr. Alexis Morgan, PT, DPT is a women's health physical therapist, internally trained pelvic floor clinician, and CrossFit-L1 trainer located in Hendersonville, TN. She specializes in treating pregnant and postpartum athletes. This is the ultimate anti-barrier solution to keeping your body healthy. Access state-of-the-art physical therapy, fitness programs, and workouts online in the comforts of your own home or gym. Follow [P]rehab: Website Instagram LinkedIn Twitter Facebook TikTok [P]Rehabbers thank you for listening and let us know what to talk about next. We hope to help you take control of your health through education! Did you enjoy this? Please rate, review, share, and subscribe. Every bit of feedback, comments, subscriptions, and sharing helps others to discover this content and find available solutions!