Podcasts about clinical management

What are the most effective ways to prevent kidney stones from recurring? In Part 2, David S. Goldfarb discusses evidence-based prevention strategies, including dietary counselling, hydration, and the role of pharmacological therapies.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/RAU865. CME/MOC/AAPA/IPCE credit will be available until June 30, 2027.Real Talk on Directions and Decisions in the Clinical Management of EGFRm NSCLC: Optimizing the Patient Journey Throughout the Disease Continuum In support of improving patient care, this activity has been planned and implemented by PVI, PeerView Institute for Medical Education, and LUNGevity Foundation. PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by independent educational grants from AstraZeneca, Black Diamond Therapeutics Inc, and Johnson & Johnson.Disclosure information is available at the beginning of the video presentation.

This week's topics include technology to improve stroke outcomes, adult use of social media and health decisions, impact of social media ban on Australian youth, and an LLM to augment clinical management in a low resource setting.

Some people on HIV treatment have a viral load that won't fully suppress. In this episode, we speak with Annemarie Wensing (University Medical Center Utrecht in The Netherlands and Witwatersrand University in South Africa), Aryen Stam (University Medical Center Utrecht) and Tomasso Clemente (IRCCS San Raffaele Scientific Institute in Milan, Itally); authors of an international consensus published in The Lancet HIV, bringing together nearly 100 experts across six continents to tackle one of the least standardized challenges in HIV care: low-level viremia. What does the evidence actually say about risk? When should a clinician act? How to communicate a low-level viremia diagnosis to a patient? And what does this guidance mean for the people being treated in settings where resistance testing and second-line options are out of reach? Click here to read the full article: https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(26)00107-4/fulltext

Dr. Ina Park, Professor at the University of California, San Francisco and Principal Investigator of the California Prevention Training Center discusses the clinical management of Mycoplasma genitalium, including testing and treatment options, with Dr. Meena Ramchandani. View episode transcript at www.std.uw.edu.This podcast is dedicated to an STD [sexually transmitted disease] review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs and STIs. Editor and host Dr. Meena Ramchandani is an Assistant Professor of Medicine at the University of Washington (UW), Program Director of the UW Infectious Diseases Fellowship Program, and Associate Editor of the National STD Curriculum.  

In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat discuss a 15-year-old girl who attempted suicide by ingesting rat poison, acetaminophen, ibuprofen, and amlodipine. The episode focuses on long-acting anticoagulant rodenticides (LAARs), such as brodifacoum, which inhibit vitamin K epoxide reductase, causing delayed coagulopathy. Key topics include clinical presentation, diagnostic evaluation, and management, emphasizing vitamin K1 as the primary antidote and prothrombin complex concentrate or fresh-frozen plasma for major bleeding. The patient stabilized with aggressive supportive care, including vasoactive agents and NAC therapy, alongside psychiatric intervention. Listen to learn more!Show HighlightsClinical case of a 15-year-old girl who attempted suicide through polypharmacy ingestionIngestion of multiple substances, including chewable rat poison, acetaminophen, ibuprofen, and amlodipineDiscussion of toxicology related to long-acting anticoagulant rodenticides (LAARs) like brodifacoumSymptoms and clinical presentation following acute ingestion, including metabolic acidosis and elevated lactateDiagnostic evaluation and laboratory findings, including coagulation studies and liver function testsManagement strategies for LAAR poisoning, including the use of vitamin K and supportive careImportance of monitoring for delayed coagulopathy and serial INR testingConsideration of calcium channel blocker toxicity in the context of the patient's clinical instabilityOverview of the mechanisms of action of LAARs and their impact on vitamin K-dependent clotting factorsKey take-home points regarding the recognition and management of rodenticide ingestion in pediatric patientsReferencesReference: King N, Tran MH. Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management. Transfus Med Rev. 2015 Oct;29(4):250-8.Reference 2: Feinstein DL, Akpa BS, Ayee MA, et al. The emerging threat of superwarfarins: history, detection, mechanisms, and countermeasures. Ann N Y Acad Sci. 2016 Jun;1374(1):111-22.

This accredited continuing education program is supported by an educational grant from Blueprint Medicine. It provides timely and practical education on systemic mastocytosis (SM). To obtain CME credit, visit https://checkrare.com/learning/p-systemic-mastocytosis-recognition-diagnosis-and-clinical-management/SM is a rare, chronic disorder driven by aberrant mast cell accumulation across multiple organ systems. Although diagnostic criteria are well established, a recent natural history study found that the average time to diagnosis is nearly five years. This prolonged delay—largely due to limited awareness of SM and its early symptoms—often results in unnecessary disease progression and inappropriate treatment. To address this clinical gap, this activity, led by Daniel J. DeAngelo, MD, PhD, Chief, Division of Leukemia at the Dana-Farber Cancer Institute, Harvard Medical School, in Boston, MA, provides an overview of the early signs and symptoms of SM, outlines the appropriate diagnostic criteria and tools, and reinforces the importance of timely referral and testing for these patients to be properly managed. Led by a clinical expert with experience diagnosing and treating patients with SM, this 45-minute CME program will highlight early signs of SM, outline diagnostic criteria and tools, and reinforce the importance of timely referral/testing. Target AudienceThis activity has been designed to meet the educational needs of physicians specializing in hematology, dermatology, gastroenterology, immunology, and family practice. Other members of the care team may also participate.Learning ObjectivesAfter participating in the activity, learners should be better able to:Describe the early symptoms of systemic mastocytosis and its clinical relevance.Apply best practices to diagnose systemic mastocytosis more efficiently.FacultyDaniel J. DeAngelo, MD, PhDChief, Division of LeukemiaDana-Farber Cancer Institute,Harvard Medical SchoolBoston, MADisclosure StatementAccording to the disclosure policy of the Academy, all faculty, planning committee members, editors, managers and other individuals who are in a position to control content are required to disclose any relationships with any ineligible company(ies). The existence of these relationships is not viewed as implying bias or decreasing the value of the activity. Clinical content has been reviewed for fair balance and scientific objectivity, and all of the relevant financial relationships listed for these individuals have been mitigated.Disclosure of relevant financial relationships are as follows:Faculty Educator/PlannerDr. DeAngelo discloses the following relevant financial relationships with ineligible companies:Consultant: Amgen, Autolos, Blueprint Medicines, Incyte, Jazz, Novartis, Pfizer, and Takeda Research Support: AbbVie, Glycomimetics, Novartis, and Blueprint MedicinesData Safety Monitoring Board: Daiichi-SankyoOther Planners for this activity have no relevant financial relationships with any ineligible companies.This activity will review off-label or investigational information.The opinions expressed in this educational activity are those of the faculty, and do not represent those of the Academy or CheckRare CE. This activity is intended as a supplement to existing knowledge, published information, and practice guidelines. Learners should appraise the information presented critically, and draw conclusions only after careful consideration of all available scientific information.Accreditation and Credit DesignationIn support of improving patient care, this activity has been planned and implemented by American Academy of CME, Inc. and CheckRare CE. American Academy of CME, Inc. is Jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.PhysiciansAmerican Academy of CME, Inc., designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Other HCPsOther members of the care team will receive a certificate of participation.There are no fees to participate in the activity.  Participants must review the activity information including the learning objectives and disclosure statements, as well as the content of the activity. To receive CME credit for your participation, please complete the pre and post-program assessments. Your certificate will be emailed to you within 30 days.PrivacyFor more information about the American Academy of CME privacy policy, please access http://www.academycme.org/privacy.htm  For more information about CheckRare's privacy policy, please access https://checkrare.com/privacy/ContactFor any questions, please contact: CEServices@academycme.orgCopyright© 2026. This CME-certified activity is held as copyrighted © by American Academy of CME and CheckRare CE. Through this notice, the Academy and CheckRare CE grant permission of its use for educational purposes only. These materials may not be used, in whole or in part, for any commercial purposes without prior permission in writing from the copyright owner(s).

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/UEH865. CME/AAPA/IPCE credit will be available until April 21, 2027.Redefining Precision Oncology in Pancreatic Cancer: Translating Emerging KRAS-Targeted Strategies into Effective Clinical Management In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Revolution Medicines.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/UEH865. CME/AAPA/IPCE credit will be available until April 21, 2027.Redefining Precision Oncology in Pancreatic Cancer: Translating Emerging KRAS-Targeted Strategies into Effective Clinical Management In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Revolution Medicines.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/UEH865. CME/AAPA/IPCE credit will be available until April 21, 2027.Redefining Precision Oncology in Pancreatic Cancer: Translating Emerging KRAS-Targeted Strategies into Effective Clinical Management In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Revolution Medicines.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/UEH865. CME/AAPA/IPCE credit will be available until April 21, 2027.Redefining Precision Oncology in Pancreatic Cancer: Translating Emerging KRAS-Targeted Strategies into Effective Clinical Management In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Revolution Medicines.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/UEH865. CME/AAPA/IPCE credit will be available until April 21, 2027.Redefining Precision Oncology in Pancreatic Cancer: Translating Emerging KRAS-Targeted Strategies into Effective Clinical Management In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Revolution Medicines.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/UEH865. CME/AAPA/IPCE credit will be available until April 21, 2027.Redefining Precision Oncology in Pancreatic Cancer: Translating Emerging KRAS-Targeted Strategies into Effective Clinical Management In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Revolution Medicines.Disclosure information is available at the beginning of the video presentation.

Identification of pancreatic cystic lesions has become increasingly common due to improved resolution and increased utilization of cross-sectional imaging. However, there are many types of pancreatic cysts, each with varying degrees of malignant potential. In this episode from the HPB team at Behind the Knife, listen in as we discuss the clinical presentation, diagnostic work-up, and management strategies for various pancreatic cysts: Pseudocysts, Serous Cystadenomas, Mucinous Cystic Neoplasms, and IPMNs, amongst others. HostsAnish J. Jain MD (@anishjayjain) is a current PGY4 General Surgery resident at Stanford University and a former T32 Research Fellow at the University of Texas MD Anderson Cancer Center.Jon M. Harrison MD is a Hepatobiliary & Pancreatic (HPB) surgeon at the Massachusetts General Hospital in Boston, MA and a former HPB Surgery fellow at Stanford University. Learning Objectives·      Develop an understanding of the clinical presentation, diagnostic work-up, and treatment of benign pancreatic cysts·      Develop an understanding of the clinical presentation, diagnostic work-up, and treatment of pre-malignant pancreatic cysts·      Develop an understanding of when surveillance is appropriate for management of pancreatic cysts, and the criteria involved in making that determination·      Develop an understanding of the prognostic utility of PancSeq for IPMNsReferences: Paniccia A, Polanco PM, Boone BA, et al. Prospective, Multi-Institutional, Real-Time Next-Generation Sequencing of Pancreatic Cyst Fluid Reveals Diverse Genomic Alterations That Improve the Clinical Management of Pancreatic Cysts. Gastroenterology. 2023 Jan;164(1):117-133.e7.PubMed Link: https://pubmed.ncbi.nlm.nih.gov/36209796/ Ohtsuka T, Fernandez-Del Castillo C, Furukawa T, et al. International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas. Pancreatology. 2024 Mar;24(2):255-270.PubMed Link: https://pubmed.ncbi.nlm.nih.gov/38182527/ Zelga P, Hernandez-Barco YG, Qadan M, et al. Number of Worrisome Features and Risk of Malignancy in Intraductal Papillary Mucinous Neoplasm. J Am Coll Surg. 2022 Jun 1;234(6):1021-1030.PubMed Link: https://pubmed.ncbi.nlm.nih.gov/35703792/ Ciprani D, Weniger M, Qadan M, et al. Risk of malignancy in small pancreatic cysts decreases over time. Pancreatology. 2020 Sep;20(6):1213-1217.PubMed Link: https://pubmed.ncbi.nlm.nih.gov/32819844/ ***Fellowship Application Link: https://forms.gle/QSUrR2GWHDZ1MmWC6Sponsor Disclaimer: Visit goremedical.com/btkpod to learn more about GORE® SYNECOR Biomaterial, including supporting references and disclaimers for the presented content.Refer to Instructions for Use at eifu.goremedical.com for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available. Rx only Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listenBehind the Knife Premium:General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-reviewTrauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlasDominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkshipDominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotationVascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-audio-reviewColorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-audio-reviewSurgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-audio-reviewCardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-reviewDownload our App:Apple App Store: https://apps.apple.com/us/app/behind-the-knife/id1672420049Android/Google Play: https://play.google.com/store/apps/details?id=com.btk.app&hl=en_US

In part two of this series, Dr. Justin Abbatemarco, Dr. Marjo S. van der Knaap, and Romy J. van Voorst discuss the patient management card and how patients should use it.  Show citation: and Clinical Management of Vanishing White Matter. Neurology. 2025;105(11):e214320. doi:10.1212/WNL.0000000000214320  Show transcript:  Dr. Justin Abbatemarco: Hello and welcome back. This is Justin Abbatemarco here with Romy J. van Voorst and Dr. Marjo S. van der Knaap. After discussing her article, Published Neurology Consensus Base Expert Recommendation for Diagnosis and Clinical Management of Vanishing White Matter Disease. Romy, I really want to talk with you about the patient management card. What inspired you to create that in this publication, and how should patients use that? Romy J. van Voorst:  So what the main motivation was of the study was actually a previous study that we did before. And in this study, we looked at the impact of any short matter on unaffected family members. And we found out that actually many family members encountered clinicians that were unfamiliar with its disease or disease-specific management. And during interviews, we saw that there was an urgent need for moral harmonization of care and also symptom management because families felt like they are left alone with just their child and no guidance on how to go further. And we wrote these recommendations to help families better understand the diagnostic and care process so they can also participate in informed decision-making. So they can understand what kind of preventive measures they can take and whether or not this interferes, for example, with quality of life goals. So there are a lot of different recommendations families can take home with. Dr. Justin Abbatemarco:  Marjo, anything else you want to add there? Dr. Marjo S. van der Knaap:  Yeah, I think the management card also helps because they have a physical card when they go to consultation or to emergency room that they can hand over. It's an official publication. It's developed by the Finishing WebMetter Expert Consortium in combination with other experts in combination with patient advocates and representatives. And so it's really a sort of a guidance that cannot be denied. So it has some authority to it. Dr. Justin Abbatemarco:  But I think it's a theme that applies to many neurological diseases, and addressing that. You do it really practically. And I agree, giving something more tangible for patients to present, especially to non-neurologists to help them give some guidance. It's an idea that we need to think about in clinic all the time on how we're interacting and supporting caregivers and when they're interfacing with the medical community at large. So I love what you guys have done here and to make us think about this more broadly. Thanks again for all your time and your work on this topic. Dr. Marjo S. van der Knaap:  Thank you for having us. 

In part one of this two-part series, Dr. Justin Abbatemarco, Dr. Marjo S. van der Knaap, and Romy J. van Voorst discuss vanishing white matter disease, focusing on the clinical and MRI findings that would prompt the consideration of genetic testing.  Show citation: van Voorst RJ, Schoenmakers DH, Bonkowsky JL, et al. Consensus-Based Expert Recommendations for Diagnosis and Clinical Management of Vanishing White Matter. Neurology. 2025;105(11):e214320. doi:10.1212/WNL.0000000000214320  Show transcript:  Justin Abbatemarco: Hello and welcome. This is Justin Abbatemarco here with Romy J. van Voorst and Marjo S. van der Knaap. After discussing their article published in Neurology, Consensus-Based Expert Recommendation for Diagnosis and Clinical Management of Vanishing White Matter. They both work for Amsterdam University Medical Center in the Netherlands. And we're going to have a two-part episode dissecting maybe two elements of this paper. Marjo, maybe we could start here and just talking about what vanishing white matter disease is and what in the clinic and MRI findings would make us go towards a genetic testing. Dr. Marjo S. van der Knaap:  There are two things about vanishing white matter that matter most to families, and one is the stress sensitivity. So any type of physical stress, like fever, viral infection, anything may cause a rapid decline and you never know when it comes. And that brings me to the second item that's very difficult and painful for families. And that's the unpredictability. You never know when a disease is going to hit and then your child is going to go down. So you really need the support of neurologists who know about this disease and help you go through this situation. Dr. Justin Abbatemarco: Right. And this paper serves as a great resource for folks that if they have a patient in clinic like this, medications to avoid, how to manage those stress responses. And so it's a really helpful publication to have there. And then I think another message we talked a lot about on the podcast was the importance of genetic testing when patients aren't fitting a typical bucket and this specific disease has unique characteristics. I think the cystic appearance of the MRI, which you do a great job highlighting, would really lead us down that road. So I think it's all really helpful and it gives us some ways to start in clinic with patients and our caregivers. So thank you. Come back and join us for the second part of The Neurology Minute episode where we're going to talk about the patient management. 

How do experienced operators approach the most technically demanding aspects of Distal Venous Arterialization (DVA)? In this episode of BackTable, host Dr. Sabeen Dhand sits down with Dr. Kumar Madassery for a detailed discussion of procedural strategy, technical decision-making, and real-world troubleshooting in DVA. --- SYNPOSIS Dr. Madassery walks through his approach from pre-procedure planning to final scaffolding. The conversation begins with imaging review, patient selection, and anesthesia considerations, emphasizing how preparation influences technical success. They then examine venous mapping and access strategy, with specific attention to femoral and tibial disease patterns and how these anatomic variables shape crossing techniques.This episode also covers wire and catheter selection, techniques for creating the arteriovenous anastomosis, balloon sizing, valve management, and stent scaffolding. Throughout, Dr. Madassery shares practical solutions to common access challenges and highlights decision points that can determine procedural durability. The discussion closes with reflections on clinical management, operator fatigue, and the value of professional networks when navigating complex limb salvage cases. --- TIMESTAMPS 00:00 - Introduction03:08 - Pre-Procedure Imaging and Setup05:01 - Venous Access and Mapping07:27 - Anesthesia and Patient Preparation12:29 - Femoral and Tibial Disease Considerations23:17 - Crossing Techniques and Tools27:16 - Venous Access Challenges and Solutions35:54 - Creating the Anastomosis37:03 - Balloon Sizing and Scaffolding Techniques38:26 - Navigating Venous Access Challenges39:56 - Wire and Catheter Strategies42:08 - Dealing with Valves and Anastomosis44:16 - Proximal vs. Distal DVA Approaches47:01 - Scaffolding and Stent Techniques50:06 - Clinical Management and Case Fatigue01:01:10 - Networking and Seeking Advice01:05:41 - Concluding Thoughts and Future Directions

About the Lecture: The Israeli, a novel by veteran journalist Phil Kurata, is set in the years 1947 to 1965, after the end of World War II, when in the Middle East, newly independent countries were shaking off the colonial powers of Britain and France. It reimagines the life of famed spy Eli Cohen. Beginning in Alexandria, Egypt, it transitions to a nascent Israel and then to Syria, where Cohen spies for the Israelis. Steeped in the food and the culture of the Middle East at that formative period, it takes a hard-eyed view of racism and prejudice on both the Israeli and Arab sides. It takes the reader on a deep dive into the intractable and often vicious conflicts that split the region today. About the Speaker: Phillip Kurata is a novelist and former journalist who grew up in Lawrence, Kansas, and earned a bachelor's degree in French literature and a master's degree in Asian Studies from the University of Kansas. He studied at the University of Tunis in the mid-1960s, and—as a fluent French speaker—he returned to Tunisia as a Peace Corps Volunteer and a public health educator. He got into journalism while studying Chinese in Taiwan, writing for the Far Eastern Economic Review. He later worked for United Press International, Agence France Presse and Voice of America in Japan, Taiwan, Hong Kong, Beijing, France, and Washington, DC. Phil served for many years as a writer with the U.S. Department of State, based in Washington, DC. His first novel, The Reluctant Agent, was published by Washington Writers' Publishing House as the Fiction Prize winner. His most recent novel, The Israeli, published in 2024, is a fictionalized story of the legendary Israeli spy, Eli Cohen, and examines the destructive power of ethnic hatred. Dr. Elspeth Cameron Ritchie is a forensic psychiatrist with special expertise in military and veterans' issues. She has been Chief of Psychiatry at Medstar Washington Hospital Center since 2018. She retired from the Army in 2010, after holding numerous leadership positions within Army Medicine, including Psychiatry Consultant. She trained at Harvard, George Washington, Walter Reed, and the Uniformed Services University of the Health Sciences, and has completed fellowships in both forensic and preventive and disaster psychiatry. She is a Professor of Psychiatry at the Uniformed Services University of the Health Sciences, Georgetown University, and George Washington University School of Medicine. An internationally recognized expert, she brings a unique public health approach to the management of disasters and combating mental health issues. Her assignments and other missions have taken her to Korea, Somalia, Iraq, and Cuba. She has over 250 publications, mainly in the areas of forensic, disaster, suicide, ethics, military combat psychiatry, and women's health issues. Recent volumes include: “Forensic and Ethical Issues in Military Behavioral Health”, “Women at War”, “Post-Traumatic Stress Disorder and Related Diseases in Combat Veterans”, “Intimacy After Injury: Restoring Sexual Health on Return from Combat”; “Psychiatrists in Combat, Clinicians Experience in the War Zone”, “Gay Mental Healthcare Providers and Patients in the Military: Personal Experiences and Clinical Care” and “Clinical Management of the Homeless Patient: Social, Medical and Psychiatric Issues." **Learn more about IWP graduate programs: https://www.iwp.edu/academics/graduate-degree-programs/ ***Make a gift to IWP: https://wl.donorperfect.net/weblink/WebLink.aspx?name=E231090&id=3

Everything you need to know about tubo-ovarian abscesses (TOAs): breaking the stigma, safer treatment, fertility preservation, and better outcomes. This episode of BackTable OBGYN features Dr. Katherine Smith, an assistant professor and MIGS Fellowship Program director at UT Southwestern. With hosts Dr. Amy Park and Dr. Mark Hoffman, Dr. Smith provides an extensive overview of contemporary TOA management, emphasizing the significance of early intervention and the evolving understanding of TOAs beyond traditional STI etiologies. --- SYNPOSIS The conversation delves into the management of TOAs, both non-ruptured and ruptured, and the underexplored connection to the female reproductive tract microbiome. They also touch on the integration of AI in clinical practice, particularly in streamlining administrative tasks. The episode underscores the need for updated guidelines and more research into the microbiological aspects of TOAs to improve patient outcomes. --- TIMESTAMPS 00:00 - Introduction 02:20 - Understanding TOAs: Early Interventions and Challenges04:43 - Clinical Management of TOAs08:06 - Surgical Approaches and Considerations22:25 - Microbiome and Infection Insights32:10 - Discussing Patient Reactions and Education32:47 - Teaching Practices and Medical Education34:18 - Clinical Observations and Data36:55 - Surgical Management of Ruptured TOAs40:50 - Challenges in Treating Infected Endometriomas50:13 - Exploring the Role of AI in Medical Practice54:23 - Concluding Remarks --- RESOURCES ACOG Recommends Concurrent Sexual Partner Treatment for Recurrent Bacterial Vaginosis for the First Timehttps://www.acog.org/news/news-releases/2025/10/acog-recommends-concurrent-sexual-partner-treatment-recurrent-bacterial-vaginosis-first-time Strange Bedfellows, Ina Park MD, MS https://www.inapark.net/the-book

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On this episode, we discuss ulcerative colitis (UC) and describe its clinical presentations, underlying pathophysiology, and common etiologies. We evaluate current clinical guidelines and evidence-based strategies for managing UC. We also compare and contrast the efficacy, safety profiles, and appropriate use of available UC therapies, such as aminosalicylates, corticosteroids, immunomodulators, and biologics.  Cole and I are happy to share that our listeners can claim ACPE-accredited continuing education for listening to this podcast episode! We have continued to partner with freeCE.com to provide listeners with the opportunity to claim 1-hour of continuing education credit for select episodes. For existing Unlimited (Gold) freeCE members, this CE option is included in your membership benefits at no additional cost! A password, which will be given at some point during this episode, is required to access the post-activity test. To earn credit for this episode, visit the following link below to go to freeCE's website: https://www.freece.com/ If you're not currently a freeCE member, we definitely suggest you explore all the benefits of their Unlimited Membership on their website and earn CE for listening to this podcast. Thanks for listening! If you want to support the podcast, check out our Patreon account. Subscribers will have access to all previous and new pharmacotherapy lectures as well as downloadable PowerPoint slides for each lecture. If you purchase an annual membership, you'll also get a free digital copy of High-Powered Medicine 3rd edition by Dr. Alex Poppen, PharmD. HPM is a book/website database of summaries for over 150 landmark clinical trials.You can visit our Patreon page at the website below:  www.patreon.com/corconsultrx We want to give a big thanks to Dr. Alex Poppen, PharmD and High-Powered Medicine for sponsoring the podcast..  You can get a copy of HPM at the links below:  Purchase a subscription or PDF copy - https://highpoweredmedicine.com/ Purchase the paperback and hardcover - Barnes and Noble website We want to say thank you to our sponsor, Pyrls. Try out their drug information app today. Visit the website below for a free trial: www.pyrls.com/corconsultrx We also want to thank our sponsor Freed AI. Freed is an AI scribe that listens, prepares your SOAP notes, and writes patient instructions. Charting is done before your patient walks out of the room. You can try 10 notes for free and after that it only costs $99/month. Visit the website below for more information: https://www.getfreed.ai/  If you have any questions for Cole or me, reach out to us via e-mail: Mike - mcorvino@corconsultrx.com Cole - cswanson@corconsultrx.com

In this educational podcast discussion, Carlos M. De Castro, MD, and David Dingli, MD, PhD, FRCP, FRCPEd, FACP, FRCPath, explore paroxysmal nocturnal hemoglobinuria (PNH). They trace the evolution of treatment from early complement inhibitors to today's expanding therapeutic options, emphasizing how these advances have transformed patient outcomes and quality of life. The conversation blends clinical insights with practical considerations for therapy selection and patient care, including:The pathogenesis of PNH and the role of complement activationLandmark therapies such as eculizumab and ravulizumabAdvances in proximal inhibitors (eg, pegcetacoplan, iptacopan, danicopan)Quality-of-life considerations, treatment personalization, and emerging therapiesPresenters:Carlos M. De Castro, MDProfessor of Medicine, DUMCDivision of Malignant Hematology and Cellular TherapyDepartment of MedicineDuke UniversityDuke Cancer InstituteDurham, North CarolinaDavid Dingli, MD, PhD, FRCP, FRCPEd, FACP, FRCPathConsultant Hematologist and Director of Bone Marrow Transplant ProgramProfessor of MedicineDivision of HematologyMayo Clinic College of Medicine and ScienceRochester, MinnesotaLink to full program:https://bit.ly/3Jtjqgr Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

Episode Description: How can healthcare leaders expand access and improve equity at scale without further burdening overstretched systems? In this Bright Spots in Healthcare episode, senior leaders from leading provider organizations explore how remote-first, tech-enabled primary care models are transforming access for diverse and underserved populations. Through real-world examples, clinical, innovation, and strategy experts will highlight how they're leveraging data, team-based care, and smart technology to: Expand access to historically marginalized communities Improve care continuity and build patient trust Reduce avoidable utilization and enhance system efficiency Deliver sustainable, equitable outcomes at scale Panelists: Michael Cui, MD, Associate Chief Medical Informatics Officer, Rush University Medical Center Amanda Parsons, MD, MBA, Vice President, Clinical Management, Healthfirst Emily Young, MBA, President, Tufts Medicine Integrated Network, Tufts Medicine Gabriella Lawrence, Senior Director, Clinical Solutioning, TytoCare Download the Episode Guide: Summarizing key insights and speaker highlights, this guide is your companion to the discussion. Download it to follow along and take away actionable strategies. Thank you to TytoCare for supporting this episode. TytoCare is transforming primary care with a smart, remote-first approach that connects patients and clinicians to deliver equitable, efficient healthcare, anytime, anywhere. Learn more here: https://www.tytocare.com How to Engage: Chat with Us: Share your thoughts with Producer Jessica Tenzer at jtenzer@brightspotsventures.com  

The incidence of early onset colorectal cancer (EOCRC) has been rising prompting the change in change in screening guidelines to 45 years of age for average risk patients. Join us for an in-depth discussion with guest speakers Dr. Andrea Cercek and Dr. Nancy You, where we provide a comprehensive look at the growing challenge of EOCRC. Hosts: - Dr. Janet Alvarez - General Surgery Resident at New York Medical College/Metropolitan Hospital Center - Dr. Wini Zambare – General Surgery Resident at Weill Cornell Medical Center/New York Presbyterian - Dr. Phil Bauer, Graduating Colorectal Surgical Oncology Fellow at Memorial Sloan Kettering Cancer Center  - Dr. J. Joshua Smith MD, PhD, Chair, Department of Colon and Rectal Surgery at MD Anderson Cancer Center - Dr. Andrea Cercek - Gastrointestinal Medical Oncologist at Memorial Sloan Kettering Cancer Center - Dr. Y. Nancy You, MD MHSc - Professor, Department of Colon and Rectal Surgery at MD Anderson Cancer Center Learning objectives:  - Describe trends in incidence of colorectal cancer, with emphasis on the rise of EOCRC. - Identify age groups and demographics most affected by EOCRC. - Summarize USPSTF recommendations for colorectal cancer screening. - Distinguish between screening methods (e.g., colonoscopy, FIT-DNA) and their sensitivity. - Understand treatment approaches for colon and rectal cancer (CRC) - Understand the role of mismatch repair (MMR) status in guiding treatment. - Outline the importance of genetic counseling and testing in young patients. - Discuss racial, ethnic, and socioeconomic disparities in CRC incidence and outcomes. - Describe the impact of cancer treatment on fertility and sexual health. -  Review fertility preservation options. - Identify the value of integrated care teams for young CRC patients. References: 1.         Siegel, R. L. et al. Colorectal Cancer Incidence Patterns in the United States, 1974–2013. JNCI J. Natl. Cancer Inst. 109, djw322 (2017). https://pubmed.ncbi.nlm.nih.gov/28376186/ 2.         Abboud, Y. et al. Rising Incidence and Mortality of Early-Onset Colorectal Cancer in Young Cohorts Associated with Delayed Diagnosis. Cancers 17, 1500 (2025). https://pubmed.ncbi.nlm.nih.gov/40361427/ 3.         Phang, R. et al. Is the Incidence of Early-Onset Adenocarcinomas in Aotearoa New Zealand Increasing? Asia Pac. J. Clin. Oncol.https://pubmed.ncbi.nlm.nih.gov/40384533/ 4.         Vitaloni, M. et al. Clinical challenges and patient experiences in early-onset colorectal cancer: insights from seven European countries. BMC Gastroenterol. 25, 378 (2025). https://pubmed.ncbi.nlm.nih.gov/40375142/ 5.         Siegel, R. L. et al. Global patterns and trends in colorectal cancer incidence in young adults. (2019) doi:10.1136/gutjnl-2019-319511. https://pubmed.ncbi.nlm.nih.gov/31488504/ 6.         Cercek, A. et al. A Comprehensive Comparison of Early-Onset and Average-Onset Colorectal Cancers. J. Natl. Cancer Inst. 113, 1683–1692 (2021). https://pubmed.ncbi.nlm.nih.gov/34405229/ 7.         Zheng, X. et al. Comprehensive Assessment of Diet Quality and Risk of Precursors of Early-Onset Colorectal Cancer. JNCI J. Natl. Cancer Inst. 113, 543–552 (2021). https://pubmed.ncbi.nlm.nih.gov/33136160/ 8.         Standl, E. & Schnell, O. Increased Risk of Cancer—An Integral Component of the Cardio–Renal–Metabolic Disease Cluster and Its Management. Cells 14, 564 (2025). https://pubmed.ncbi.nlm.nih.gov/40277890/ 9.         Muller, C., Ihionkhan, E., Stoffel, E. M. & Kupfer, S. S. Disparities in Early-Onset Colorectal Cancer. Cells 10, 1018 (2021). https://pubmed.ncbi.nlm.nih.gov/33925893/ 10.       US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 325, 1965–1977 (2021). https://pubmed.ncbi.nlm.nih.gov/34003218/ 11.       Fwelo, P. et al. Differential Colorectal Cancer Mortality Across Racial and Ethnic Groups: Impact of Socioeconomic Status, Clinicopathology, and Treatment-Related Factors. Cancer Med. 14, e70612 (2025). https://pubmed.ncbi.nlm.nih.gov/40040375/ 12.       Lansdorp-Vogelaar, I. et al. Contribution of Screening and Survival Differences to Racial Disparities in Colorectal Cancer Rates. Cancer Epidemiol. Biomarkers Prev. 21, 728–736 (2012). https://pubmed.ncbi.nlm.nih.gov/22514249/ 13.       Ko, T. M. et al. Low neighborhood socioeconomic status is associated with poor outcomes in young adults with colorectal cancer. Surgery 176, 626–632 (2024). https://pubmed.ncbi.nlm.nih.gov/38972769/ 14.       Siegel, R. L., Wagle, N. S., Cercek, A., Smith, R. A. & Jemal, A. Colorectal cancer statistics, 2023. CA. Cancer J. Clin. 73, 233–254 (2023). https://pubmed.ncbi.nlm.nih.gov/36856579/ 15.       Jain, S., Maque, J., Galoosian, A., Osuna-Garcia, A. & May, F. P. Optimal Strategies for Colorectal Cancer Screening. Curr. Treat. Options Oncol. 23, 474–493 (2022). https://pubmed.ncbi.nlm.nih.gov/35316477/ 16.       Zauber, A. G. The Impact of Screening on Colorectal Cancer Mortality and Incidence: Has It Really Made a Difference? Dig. Dis. Sci. 60, 681–691 (2015). https://pubmed.ncbi.nlm.nih.gov/25740556/ 17.       Edwards, B. K. et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 116, 544–573 (2010). https://pubmed.ncbi.nlm.nih.gov/19998273/ 18.       Cercek, A. et al. Nonoperative Management of Mismatch Repair–Deficient Tumors. New England Journal of Medicine 392, 2297–2308 (2025). https://pubmed.ncbi.nlm.nih.gov/40293177/ 19.       Monge, C., Waldrup, B., Carranza, F. G. & Velazquez-Villarreal, E. Molecular Heterogeneity in Early-Onset Colorectal Cancer: Pathway-Specific Insights in High-Risk Populations. Cancers 17, 1325 (2025). https://pubmed.ncbi.nlm.nih.gov/40282501/ 20.       Monge, C., Waldrup, B., Carranza, F. G. & Velazquez-Villarreal, E. Ethnicity-Specific Molecular Alterations in MAPK and JAK/STAT Pathways in Early-Onset Colorectal Cancer. Cancers 17, 1093 (2025). https://pubmed.ncbi.nlm.nih.gov/40227607/ 21.       Benson, A. B. et al. Colon Cancer, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J. Natl. Compr. Cancer Netw. JNCCN 19, 329–359 (2021). https://pubmed.ncbi.nlm.nih.gov/33724754/ 22.       Christenson, E. S. et al. Nivolumab and Relatlimab for the treatment of patients with unresectable or metastatic mismatch repair proficient colorectal cancer. https://pubmed.ncbi.nlm.nih.gov/40388545/ 23.       Dasari, A. et al. Fruquintinib versus placebo in patients with refractory metastatic colorectal cancer (FRESCO-2): an international, multicentre, randomised, double-blind, phase 3 study. The Lancet 402, 41–53 (2023). https://pubmed.ncbi.nlm.nih.gov/37331369/ 24.       Strickler, J. H. et al. Tucatinib plus trastuzumab for chemotherapy-refractory, HER2-positive, RAS wild-type unresectable or metastatic colorectal cancer (MOUNTAINEER): a multicentre, open-label, phase 2 study. Lancet Oncol. 24, 496–508 (2023). https://pubmed.ncbi.nlm.nih.gov/37142372/ 25.       Sauer, R. et al. Preoperative versus Postoperative Chemoradiotherapy for Rectal Cancer. N. Engl. J. Med. 351, 1731–1740 (2004). https://pubmed.ncbi.nlm.nih.gov/15496622/ 26.       Cercek, A. et al. Adoption of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer. JAMA Oncol. 4, e180071 (2018). https://pubmed.ncbi.nlm.nih.gov/29566109/ 27.       Garcia-Aguilar, J. et al. Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy. J. Clin. Oncol. 40, 2546–2556 (2022). https://pubmed.ncbi.nlm.nih.gov/35483010/ 28.       Schrag, D. et al. Preoperative Treatment of Locally Advanced Rectal Cancer. N. Engl. J. Med. 389, 322–334 (2023). https://pubmed.ncbi.nlm.nih.gov/37272534/ 29.       Kunkler, I. H., Williams, L. J., Jack, W. J. L., Cameron, D. A. & Dixon, J. M. Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer. N. Engl. J. Med. 388, 585–594 (2023). https://pubmed.ncbi.nlm.nih.gov/36791159/ 30.       Jacobsen, R. L., Macpherson, C. F., Pflugeisen, B. M. & Johnson, R. H. Care Experience, by Site of Care, for Adolescents and Young Adults With Cancer. JCO Oncol. Pract. (2021) doi:10.1200/OP.20.00840. https://pubmed.ncbi.nlm.nih.gov/33566700/ 31.       Ruddy, K. J. et al. Prospective Study of Fertility Concerns and Preservation Strategies in Young Women With Breast Cancer. J. Clin. Oncol. (2014) doi:10.1200/JCO.2013.52.8877. https://pubmed.ncbi.nlm.nih.gov/24567428/ 32.       Su, H. I. et al. Fertility Preservation in People With Cancer: ASCO Guideline Update. J. Clin. Oncol. 43, 1488–1515 (2025). https://pubmed.ncbi.nlm.nih.gov/40106739/ 33.       Smith, K. L., Gracia, C., Sokalska, A. & Moore, H. Advances in Fertility Preservation for Young Women With Cancer. Am. Soc. Clin. Oncol. Educ. Book 27–37 (2018) doi:10.1200/EDBK_208301. https://pubmed.ncbi.nlm.nih.gov/30231357/ 34.       Blumenfeld, Z. How to Preserve Fertility in Young Women Exposed to Chemotherapy? The Role of GnRH Agonist Cotreatment in Addition to Cryopreservation of Embrya, Oocytes, or Ovaries. The Oncologist 12, 1044–1054 (2007). 35.       Bhagavath, B. The current and future state of surgery in reproductive endocrinology. Curr. Opin. Obstet. Gynecol. 34, 164 (2022). 36.       Ribeiro, R. et al. Uterine transposition: technique and a case report. Fertil. Steril. 108, 320-324.e1 (2017). 37.       Yazdani, A., Sweterlitsch, K. M., Kim, H., Flyckt, R. L. & Christianson, M. S. Surgical Innovations to Protect Fertility from Oncologic Pelvic Radiation Therapy: Ovarian Transposition and Uterine Fixation. J. Clin. Med. 13, 5577 (2024). 38.       Holowatyj, A. N., Eng, C. & Lewis, M. A. Incorporating Reproductive Health in the Clinical Management of Early-Onset Colorectal Cancer. JCO Oncol. Pract. 18, 169–172 (2022). ***Behind the Knife Colorectal Surgery Oral Board Audio Review: https://app.behindtheknife.org/course-details/colorectal-surgery-oral-board-audio-review Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

A New Podcast from Obstetrics & Gynecology, featuring members from the Editorial Team and contributing authors, each month as they highlight the latest research and practice updates in the field. This episode features an interview with Dr. Jen Gunter, author of “Addressing the Challenges of Online Misinformation and Unregulated Products in the Clinical Management of Menopause.”

Please visit answersincme.com/WHF860 to participate, download slides and supporting materials, complete the post test, and obtain credit. In this activity, experts in oncology discuss how the latest therapeutic advances in frontline management of urothelial carcinoma can be integrated into practice to optimize patient care. Upon completion of this activity, participants should be better able to: Review guideline recommendations for the first-line treatment of advanced UC; Identify multidisciplinary strategies to optimize first-line treatment of patients with advanced UC; and Outline current and evolving multidisciplinary approaches to enhance outcomes for patients with UC.

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

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.

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.

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. 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