Podcasts about CUS

This is a free preview of a paid episode. To hear more, visit www.wethefifth.com* ABBA's Vietnam* Barnen i Nicaragua* Mike Tyson, Ratso, and Cus the Communist* Burning down the house / sort of scolded by a firefighter * The rent is too damn free* Everyone is contemptuous of everyone * Is Trump the Bernie Goetz of Harvard?* Rebutting “higher ed is just fine” revisionism* From YAF to Students for Liberty to Turning Point…* Dating apps, height discrimina…

In this eye-opening episode of the Wild Health Podcast, Dr. Carl Seeger talks with Dr. Julie Siemers—a nurse leader, patient safety consultant, and bestselling author of Surviving Your Hospital Stay. Drawing on 40+ years in healthcare, Dr. Siemers discusses how communication breakdowns, misdiagnoses, medication errors, and lack of patient advocacy continue to threaten safety in hospitals. Listeners will learn crucial, actionable tips: from checking hospital safety scores to speaking up using her "Three P's" (Be Present, Be Polite, Be Persistent) and “CUS” words (Concerned, Uncomfortable, Scared, Safety). Whether you're a patient, caregiver, or clinician, this conversation reveals how being informed and assertive can save lives.

Glen connects with Paylume's Andrew Gomez to unpack the burgeoning pay by bank model, explore lessons learned from other countries' rollouts, and consider the pros and cons facing banks and credit unions. Also- a possible open banking do-over, more stadium naming rights, and resisting the urge to spike the ball before the goal line.    Links related to this episode:   Andrew Gomez/Paylume: https://www.linkedin.com/in/r-andrew-gomez/    Nacha's Remote Connect, June 6-9: https://payments.nacha.org/remote-connect    Part One of our Nacha Payments conference coverage: https://www.big-fintech.com/getting-direct-about-ach/    CU Daily's coverage of a positive sign for CUs' tax exemption: https://thecudaily.com/in-victory-for-credit-unions-cu-tax-exemption-not-targeted-in-committees-bill    The recent CU Town Hall on which we debated implications of the tax exemption: https://www.cutownhall.com/    Bloomberg Law's coverage of potential Open Banking (Section 1033) reconsideration: https://news.bloomberglaw.com/banking-law/cfpb-plans-to-revisit-open-banking-rule-despite-workforce-cuts    BECU's partnership with the WNBA's Seattle Storm, one of several recent naming rights deals: https://storm.wnba.com/news/storm-announce-becu-as-partner-for-performance-center   Join us for our next CU Town Hall- Wednesday May 21 at 3pm ET/Noon PT- for a live and lively interactive conversation tackling the major issues facing credit unions today. This session will feature a round robin on the countless recent regulatory twists and turns. The Town Hall is free to attend, but advance registration is required:  https://www.cutownhall.com/   Join us on Bluesky!  @bigfintech.bsky.social;  @154advisors.bsky.social (Glen); @jbfintech.bsky.social (John) And connect on LinkedIn for insights like the Friday Fintech Five: https://www.linkedin.com/company/best-innovation-group/  https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Exploring CU-specific fintech solutions, with a preview of the CU Spotlight session at FinovateSpring. Detailed Summary: In this episode of the Finovate Podcast, host Greg Palmer interviews Nick Evens, President and CEO of Curql, ahead of FinovateSpring. Nick shares his journey from working within credit unions to leading Curql, a strategic investment fund focused on credit union innovation. He explains how Curql was born from a need to support credit unions in staying competitive with big banks by pooling resources to invest in transformative financial technology. With its roots in the credit union community, Curql helps these institutions gain access to tech solutions they otherwise couldn't afford on their own. Nick then elaborates on Curql's mission to connect credit unions with fintechs and vice versa, underscoring its role in helping credit unions adopt cutting-edge technology. He discusses the company's current and upcoming funds and how they support a growing portfolio of tech firms. Curql not only invests in startups but also fosters an ecosystem where over 130 credit unions collaborate and share resources. Additionally, Curql emphasizes regulatory modernization and strategic partnerships, often co-investing in companies that serve both banks and credit unions. Looking ahead to FinovateSpring, Nick and Greg discuss the special Credit Union Spotlight session, designed to highlight fintechs that cater specifically to CUs. This curated environment ensures that attendees from various roles—whether in lending, compliance, or cybersecurity—can discover relevant solutions. With a diverse lineup of presenting companies, including those focused on AI and member-facing technologies, the session aims to meet the broad needs of credit union professionals and further Curql's mission of bridging the gap between fintech and credit unions. More info: Curql: https://www.curql.com/ ; https://www.linkedin.com/company/curql/ Nick Evens: https://www.linkedin.com/in/nick-evens-76b75316/ Greg Palmer: https://www.linkedin.com/in/gregbpalmer/ Finovate: https://www.finovate.com ; https://www.linkedin.com/company/finovate-conference-series/ FinovateSpring: https://informaconnect.com/finovatespring/ #fintech #CU #creditunions #financialservices #innovation #digitaltransformation #finovate #finovatespring

How and why was the Concordia University System established? The Rev. Dr. Jamison Hardy (President, Concordia University System) and the Rev. Dr. Douglas Spittel (Vice President, Concordia University System) join Andy and Sarah to talk about how and why the Concordia University System was established, some of the long history of higher education in the LCMS, the relationship of the Concordias to the LCMS, challenges and benefits to this relationship, and how the Concordias serve the Church. Learn more and sign up for the CUS newsletter at cus.edu, and follow on Facebook here. Today's episode of The Coffee Hour is underwritten in part by Concordia University Nebraska. You can learn more about Concordia University Nebraska at cune.edu. As you grab your morning coffee (and pastry, let's be honest), join hosts Andy Bates and Sarah Gulseth as they bring you stories of the intersection of Lutheran life and a secular world. Catch real-life stories of mercy work of the LCMS and partners, updates from missionaries across the ocean, and practical talk about how to live boldly Lutheran. Have a topic you'd like to hear about on The Coffee Hour? Contact us at: listener@kfuo.org.

Send us a textI'd expected this to be an AI free show but, let's face it, that just isn't likely in 2025 but the good news is that in the show Pete Major,  vice president of fintech services at CUSO MDT, offers concrete AI use cases at work in MDT and he also, importantly, offers cautions about security and the leading AI tools.In a rush to stay abreast of the fast moving AI universe are some credit unions losing sight of the need to be very sure of the security of the tools they use? Maybe.Major provides tips on how to stay secure while still using AI tools..But there's a lot more in this show.We talk for instance about the need of CUs to keep security in mind when using any technology tools.  If there are flaws - and there have been some doozies in recent years - it's the credit union that will be saddled with the bulk of the blame.On a happier note Major discusses a suite of tools for small business members at credit unions - and, he says, demand for the tools is very hot.  Is offering good tools a path to winning more business members? Just maybe.We close the show pondering what the developments in Washington DC - anything from an end to credit union tax exemption to an end to NCUA - might mean for credit unions and also the rising CU interest in merging.There's a lot to unpack in this show.  Listen up.Like what you are hearing? Find out how you can help sponsor this podcast here. Very affordable sponsorship packages are available. Email rjmcgarvey@gmail.com  And like this podcast on whatever service you use to stream it. That matters.  Find out more about CU2.0 and the digital transformation of credit unions here. It's a journey every credit union needs to take. Pronto

El biólogo español Òscar Cusó y el cámara Sebastián Guzmán nos trasladan al rodaje de 'The Americas' (BBC Studios y NBC Universal), el documental de naturaleza narrado por Tom Hanks, con música de Hans Zimmer, que muestra la biodiversidad del continente americano y que ya está disponible en Movistar+.

El biólogo español Òscar Cusó y el cámara Sebastián Guzmán nos trasladan al rodaje de 'The Americas' (BBC Studios y NBC Universal), el documental de naturaleza narrado por Tom Hanks, con música de Hans Zimmer, que muestra la biodiversidad del continente americano y que ya está disponible en Movistar+.

Diving into the early life of Mike Tyson and how legendary trainer, Cus D'Amato, help Mike become the youngest boxing heavyweight champion.-----SourcesIron Ambition - Mike TysonThe Turbulent True Story of Mike Tyson-----1:55 - Poverty and crime6:50 - The turning point12:10 - Meeting Cus D'Amato 13:30 - Cus's training techniques/journey to becoming champion35:15 - Lessons/takeaways-----You can check stay connected below:WebsiteBook: Chasing Greatness: Timeless Stories on the Pursuit of Excellence  ApparelInstagramX

In this episode of Firing the Man, we sit down with Kurt Elster, founder of EtherCycle and host of The Unofficial Shopify Podcast. Kurt shares his journey from flipping Beanie Babies and Furbies on eBay to becoming one of the most trusted Shopify experts. He discusses key strategies for building and scaling a successful Shopify store, including the importance of branding, storytelling, and optimizing your website for conversions. Kurt also highlights the biggest mistakes store owners make—like neglecting their checkout page and cluttering their navigation menu—and offers practical solutions to fix them. Whether you're just starting out or looking to scale, this episode is packed with actionable insights to help you grow your e-commerce business.We also dive into customer acquisition strategies, including the role of Amazon vs. direct-to-consumer sales, how to drive traffic beyond Facebook and Google ads, and why content marketing is a game-changer. Kurt shares his take on the value of trying things yourself before hiring experts, the importance of understanding your unit economics, and how to build trust with potential customers. Plus, in our signature Fire Round, Kurt talks about his favorite book, his passion for e-biking and restoring vintage cars, and what sets successful entrepreneurs apart from those who struggle. Don't miss this conversation filled with expert advice and behind-the-scenes insights from one of Shopify's top consultants!How to connect with Kurt?Website: https://kurtelster.com/               https://ethercycle.com/Podcast: https://unofficialshopifypodcast.com/Twitter: https://twitter.com/kurtincLinkedin: https://www.linkedin.com/in/kurtelsterYouTube: https://www.youtube.com/user/ethercycle Support the show

The prior approval process for LCMS leaders lacks transparency and is creating distrust and division when qualified candidates are removed without explanation. Family dysfunction in the church is exacerbated when decisions are made without clarity.Pat Ferry, Bill Cario, and Tim Ahlman discuss the topic at length:• Two distinct processes exist for presidents versus theology faculty appointments• Presidential approval requires sign-off from two of three key leaders: LCMS President, District President, and CUS board chair• Theology faculty approvals follow a different, increasingly unclear process• Concordia Wisconsin's presidential search illustrates the challenges when preferred candidates are rejected without explanation• Leaders advocate for transparency while maintaining appropriate church oversight• Relational trust is broken when decisions are made without discussing rationales• Worship practices and associations may impact eligibility without explicit guidelines• The process has evolved over decades with decreasing clarity in recent yearsWe need to continue working together for greater transparency. If we're going to break down walls between us, even little ones, we have to work at it together.Support the showJoin the Lead Time Newsletter! (Weekly Updates and Upcoming Episodes)https://www.uniteleadership.org/lead-time-podcast#newsletterVisit uniteleadership.org

“Member experience is everybody's responsibility because every employee has an impact on member experience.” - Laura LoyThank you for tuning in to The CUInsight Network, with your host, Robbie Young, Vice President of Strategic Growth at CUInsight. In The CUInsight Network, we take a deeper dive with the thought leaders who support the credit union community. We discuss issues and challenges facing credit unions and identify best practices to learn and grow together.My guest on today's show is Laura Loy, Chief Experience Officer at On the Mark Strategies. Laura helps credit unions sharpen their strategies and marketing in order to build stronger, more resilient organizations. She takes us inside On the Mark's approach to creating consistency in the member journey.In our conversation, Laura explains how On the Mark Strategies helps credit unions create consistency in every member interaction and breaks down what she calls the “four success markers”. We also talk about staying ahead of industry shifts, what's changing for credit unions right now, and how CUs can adapt in advance rather than play catch-up later on.As we wrap up the episode, Laura talks about her great boss, her love of the book “The Let Them Theory” by Mel Robbins, and talks about the importance of manifesting work/life balance. Enjoy my conversation with Laura Loy!Find the full show notes on cuinsight.com.Connect with Laura:Laura Loy, Chief Experience Officer at On the Mark Strategiesmarkarnold.comLaura: LinkedInOn the Mark Strategies:: LinkedIn | YouTubeWant to learn more about On the Mark Strategies? Click here.

Why do we have a Concordia University System? The Rev. Dr. Jamison Hardy (President, Concordia University System) and the Rev. Dr. Douglas Spittel (Vice President, Concordia University System) join Andy and Sarah to talk about what the Concordia University System (CUS) is, where each of the Concordias are and how this has changed over the long history of CUS, their visits to campuses and what happens on an official visit, the incredible things going on at our Concordia Universities, and where you can find both of them at upcoming conventions this year. Subscribe to the CUS newsletter and learn more about CUS at cus.edu. As you grab your morning coffee (and pastry, let's be honest), join hosts Andy Bates and Sarah Gulseth as they bring you stories of the intersection of Lutheran life and a secular world. Catch real-life stories of mercy work of the LCMS and partners, updates from missionaries across the ocean, and practical talk about how to live boldly Lutheran. Have a topic you'd like to hear about on The Coffee Hour? Contact us at: listener@kfuo.org.

“When done responsibly, student loans can be one of the most important and empowering investments someone can make in themselves.” - Scott PattersonThank you for tuning in to The CUInsight Network, with your host, Robbie Young, Vice President of Strategic Growth at CUInsight. In The CUInsight Network, we take a deeper dive with the thought leaders who support the credit union community. We discuss issues and challenges facing credit unions and identify best practices to learn and grow together.My guest on today's show is Scott Patterson, President and CEO of CU Student Choice. He joins me to discuss a wide range of topics from his eighth-grade adventures in China to pioneering the early virtual presence of credit unions via Callahan & Associates, as well as the innovation that he has cultivated via his current position at Student Choice.During our conversation, Scott discusses the origins of CU Student Choice, we explore the increasing importance of gap financing, and we talk about potential policy changes under the current administration and how CU Student Choice is positioning itself to support CUs through whatever comes next. Scott also gives us a behind-the-scenes look at OPAL, their newly launched $8 million loan origination platform that's changing the game for student lending.As we wrap up the episode, Scott gives us an inside look at his love for pinball machines, San Antonio, and a certain sci-fi novel from the '90s. Enjoy my conversation with Scott Patterson!Find the full show notes on cuinsight.com.Connect with Scott:Scott Patterson, President & CEO of CU Student Choicestudentchoice.orgScott: LinkedInCU Student Choice:: LinkedIn | Facebook | Instagram | XWant to learn more about CU Student Choice? Click here.

Send us a textIf I say a temp worker, probably you think of a fill in receptionist and that's true as far as it goes.  But talk with O2 Consulting Group and it's a plunge into a whole new world - especially impacting smaller credit unions, ones under perhaps $500 million in assets.  Where exactly does that CU find the talent to, say, implement an AI program? Just maybe a fractional e CTO - shared by two or more CUs - or a temporary exec is exactly the cure.Enter Bonnie Ortiz,  CEO of O2 and longtime COO at the Partnership Credit Union, She's worked inside at credit unions  - she knows the terrain - but now she also has assembled a team of seasoned credit union talents who are available for fractional and temporary roles at credit unions, to help solve anything from tech issues to compliance matters.It's a fact: credit union operations have become increasingly complex. The day of the shoebox credit union is long gone.  Real talent is needed but that talent may be too  costly for a smaller CU.  The O2 solution is  a potential lifesaver.Also on the show is David Martinez, CIO at $500 million  Arlington Federal Credit Union, a credit union that  has used O2 talent many times.  Martinez is a happy customer.He's also a past guest on this show. There a link in the show notes and the topic is about how mid sized CUs can survive, indeed thrive.Keep listening to this episode and Ortiz offers keen insights into the nuts and bolts of a credit union merger. She's looking at the issue with a COO's eyes: how exactly will this merger work? The concerns she raises are keen.  .  Any CU considering a merger - and who isn't? - needs to give this a close attention.Listen up.Like what you are hearing? Find out how you can help sponsor this podcast here. Very affordable sponsorship packages are available. Email rjmcgarvey@gmail.com  And like this podcast on whatever service you use to stream it. That matters.  Find out more about CU2.0 and the digital transformation of credit unions here. It's a journey every credit union needs to take. Pronto

ASUS ROG ALLY X , LE TEST par Yohann LemoreÀ savoir► Constructeur : Asus► Modèle: Rog Ally X► Prix: 899€► Windows 11► Ecran 7", FHD (1920 x 1080) 16:9, IPS-level, glossy display, Gorilla® Glass Victus™, Touch Screen (10-point multi-touch), 120Hz, Response Time: 7ms, Brightness: 500nits► SSD 1To , 24Go RAM DDR5► GPU: AMD Radeon™ Graphics (AMD RDNA™ 3, 12 CUs, up to 2.7 GHz, up to 8.6 Teraflops)► CPU: AMD Ryzen™ Z1 Extreme Processor ("Zen4" architecture with 4nm process, 8-core /16-threads, 24MB total cache, up to 5.10 Ghz boost)Crédits audio :Countach by Karl Casey @WhiteBatAudio ► https://www.youtube.com/watch?v=vpci3Mt-aUY&t

Glen connects with Payfinia CUSO General Manager Keith Riddle and Star One Credit Union's EVP of Operations Minal Gupta about the newly minted CUSO aiming to streamline CUs' provision of instant payment services. Also, newly released FedNow data- plus reporting from the more mature RTP network- reveals some unexpected twists.   Links related to this episode:   Payfinia: https://tyfone.com/payfinia/ (or contact Keith Riddle: keith.riddle@tyfone.com) Star One Credit Union: https://www.starone.org/   FedNow volume statistics through September 2024: https://www.frbservices.org/resources/financial-services/fednow/quarterly-volume-value-stats Glen's 2023 article featuring Minal Gupta/Star One (as well as other early FedNow Adopters) in Credit Union Magazine: https://media.americascreditunions.org/articles/123351-real-time-relevance   Join us for our final CU Town Hall of 2024- Wednesday December 11 at 3pm ET/Noon PT- for a live and lively interactive conversation tackling the major issues facing CUs today. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on BlueSky at @bigfintech, @jbfintech and @154Advisors Follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Insightful conversations with three founders whose startups stood out at VentureTech: Joe Gracia of Pitch Competition winner Nickels/CardFit, Blesson Abraham of Aviary AI and Danial Jameel of Saris AI. Also, the Kelce brothers and Joe Montana unexpectedly find their way into the discussion.   Links related to this episode:   CardFit, the new offering from Nickels: https://nickels.us/acquire Saris AI: https://www.saris.ai/ Aviary AI: https://www.helloaviary.ai/ Our previous VentureTech episode, featuring interviews with Ribbon and Wysh: https://www.big-fintech.com/Media?p=good-ideas-good-investments Glen's blog recapping VentureTech highlights: https://www.big-fintech.com/Media?p=going-deep-hitting-the-gaps-at-venturetech VentureTech: https://myventuretech.com/   Join us for our final CU Town Hall of 2024- Wednesday December 11 at 3pm ET/Noon PT- for a live and lively interactive conversation tackling the major issues facing CUs today. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on BlueSky at @bigfintech, @jbfintech and @154Advisors Follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Continuing our annual tradition, John and Glen glide through a fintech wonderland with Anne Legg (Thrive Strategic Services) and John Janclaes (Nymbus CUSO), sharing thoughts on things they're thankful for across our collaborative community- from the expected (AI, the innovative spirit) to the counter-intuitive (fraud levels, fintech funding).      Links related to this episode:   THRIVE Strategic Services: https://www.anneleggthrive.com/ Nymbus CUSO: https://www.nymbus.com/cuso/ BIG's Innovation Club: https://www.big-fintech.com/Innovation-Club/Technology Open AI's Sam Altman discusses the prospects for Artificial General Intelligence (AGI) in 2025: https://www.youtube.com/watch?v=xXCBz_8hM9w After our podcast discussion of real time payments, the Fed issued its first data on FedNow volumes: https://www.frbservices.org/resources/financial-services/fednow/quarterly-volume-value-stats   Join us for the next CU Town Hall on Wednesday December 11 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on X at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

"You never know where a podcast can lead you." Reena Friedman Watts welcomes Dick Frost, the host of the "On the Throne" podcast, to the Better Call Daddy Show. Dick, a dedicated father and industry professional, shares his journey from the oil and gas sector to becoming a podcast host. Discover how his experiences in the blue-collar world have shaped his views on family, work, and personal growth. From the challenges of balancing a demanding career with fatherhood to the unexpected twists of podcasting, Dick's story is a testament to resilience and adaptability. He opens up about the evolution of his podcast, expanding from oil and gas topics to include diverse stories from the trades and beyond. Dick also shares his insights on the changing dynamics of the industry, the integration of technology, and the importance of maintaining strong family ties. Join Reena and Dick for an engaging conversation that highlights the significance of storytelling, the power of connection, and the value of learning from one another. This episode is a reminder that life is a series of unexpected moments, and sometimes the best stories are the ones we least expect. (00:00) Each week I interview a guest, share the stories with my dad (03:50) You first started out interviewing oil and gas workers, then you pivoted (07:44) I miss a lot of things when I'm away from home, right (11:20) I try not to miss important things, right? Like, with birthdays (12:50) How did you get involved in the industry? Is it in your family (16:25) I'm curious how has the industry changed from the time you were 18 (18:04) You talk about cheating and the drugs and stuff. You said that that is common, right? (19:46) You make a segment called the morning dookie for your podcast (24:29) If you want to know how things work, oil and gas shows would be huge (26:40) Robotization in oil and gas is actually adding jobs, right (29:52) Cus says he always wanted kids, but had trouble conceiving (33:41) A girl needs her dad. Right. So I hope that you get that with your daughters (35:29) Better Call Daddy is a podcast that helps fathers connect with their daughters Connect with Dick Frost: - TikTok: On the Throne Podcast - YouTube: @DickFrost - Listen on: Amazon, Spotify, Apple, Good Pods Connect with Reena Friedman Watts: - Website: bettercalldaddy.com - LinkedIn: Reena Friedman Watts - Twitter: @reenareena - Instagram: @Reena Friedman Watts - Instagram Podcast: @bettercalldaddypodcast We love hearing your feedback. Leave us a review, share your thoughts, and spread the word about this enriching episode. Share it with someone who values community, generosity, and the power of storytelling.

Freshly back from the VentureTech conference, Glen shares interviews with Launch Party winner Ribbon and main event standout Wysh- plus plenty of key takeaways from investors, regulators, entrepreneurs and their prospective credit union partners.     Links related to this episode:   Ribbon: https://www.trustribbon.com/ Wysh: https://www.wysh.com/ VentureTech: https://myventuretech.com/ Our recent interview with Further/Union Credit: https://www.big-fintech.com/Media?p=digging-further-at-finovatefall Glen's blog on Money 20/20 key takeaways: https://www.big-fintech.com/Media?p=money-2020-takeaways-gen-ai-open-data-and-a-cloud-of-dust   Join us for the next CU Town Hall on Wednesday November 20 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. In this session we'll explore likely impacts for credit unions and fintechs from the recent election outcome, including shifts in the regulatory environment. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on X at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Round 2 of our Money 20/20 highlights includes Glen's interviews with a trio of founders- Andre Vellozo of DrumWave and Brittany Kaiser of the Own Your Data Foundation about a model allowing consumers to control and monetize the data they generate, and Eli Wachs of Footprint about combating fraud by whitelisting the good guys. Also- Bitcoin blows up and Cap One/Discover makes a comeback.    Links related to this episode:   Footprint: https://onefootprint.com/ DrumWave: https://drumwave.com/ Glen's blog on Money 20/20 key takeaways: Part 1 of our Money 20/20 coverage, including interviews with Paze and Eisen: https://www.big-fintech.com/Media?p=onboarding-and-offboarding-at-money-2020 Part 2 of our Money 20/20 coverage,Gen AI, Open Data and a Cloud of Dust: https://www.big-fintech.com/Media?p=money-2020-takeaways-gen-ai-open-data-and-a-cloud-of-dust McKinsey's Digital Payments Survey: https://www.mckinsey.com/industries/financial-services/our-insights/banking-matters/state-of-consumer-digital-payments-in-2024 “The Great Hack” documentary, featuring whistleblower Brittany Kaiser (now of DrumWave): https://www.youtube.com/watch?v=iX8GxLP1FHo The Innovation Club, curated by John Best of BIG: https://www.big-fintech.com/Innovation-Club/Technology   Join us for the next CU Town Hall on Wednesday November 20 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on X at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Glen checks in with Money 20/20 President Tracey Davies for a preview of the upcoming four-day Las Vegas extravaganza. Also- a slew of updates on Illinois' interchange fiasco, a countdown to the CFPB's open banking rule, and a desperate attempt to tie 1990s funky divas to 2024 payment headlines.        Links related to this episode:   Money 20/20 USA, October 27-30 in Las Vegas: https://www.money2020.com/ Last week's CU Town Hall- featuring insights from the Illinois Credit Union League's Tom Kane- on the Interchange Fee Prohibition Act: https://www.big-fintech.com/Media?p=cu-town-hall-episode-123 Glen's blog on the IFPA: https://www.big-fintech.com/Media?p=battle-lines-being-drawn-on-illinois-interchange The OCC's amicus brief to the IFPA: https://bankingjournal.aba.com/wp-content/uploads/2024/10/OCC-Amicus-Brief-IFPA.pdf The OCC's amicus brief to the IFPA: https://restaurant.org/getmedia/d5f460e3-3cb6-4d77-9e82-2bf4ae3dc972/2024-10-04-Exhibit-A-to-Corrected-Unooposed-Mtn-of-RLC-IRA-RLC.pdf Glen's History of Money 20/20 in three t-shirts: https://www.big-fintech.com/Media?p=the-history-of-money-2020-in-three-t-shirts   Join us for the next CU Town Hall on Wednesday October 23 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. For this session John Best will lead Fraud-a-Palooza!  It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/   And contribute info to our fraud survey here: https://forms.monday.com/forms/d76e9b3df9f4f42cec6c16d74b581be2?r=use1   Find us on X and BlueSky at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Glen speaks with key players at TruStage Ventures' Fintech Summit: Discovery Fund Managing Director Elizabeth McCluskey on the state of early stage investing, founder Gwyneth Borden on Remynt's journey to startup funding, and Maxwell's co-founder John Paasonen on addressing the housing affordability gap. Also, surprising battle lines forming in the Illinois interchange showdown.      Links related to this episode:   TruStage Ventures: https://www.trustage.com/ventures/portfolio TruStage Discovery Fund: https://www.trustage.com/ventures/discovery-fund Maxwell: https://himaxwell.com/ Remynt: https://getremynt.com/ Glen's update on the Illinois' Interchange Fee Prohibition Act: https://www.big-fintech.com/Media?p=a-state-of-confusion-interchange-battles-move-closer-to-home Our 2022 interviews with Money 20/20 America's Got Access winners Dennis Cail (Zirtue) and Gwyneth Borden (Remynt): https://www.big-fintech.com/Media?p=americas-got-access-vegas-has-crowds   Finovate's demo archive: https://finovate.com/videos   Join us for the next CU Town Hall on Wednesday October 9 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. This session will focus on the latest developments in Illinois interchange legislation, and why it's a national issue. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/    Find us on X and BlueSky at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Glen speaks with two of his favorite fintechs he saw at the recently completed and highly engaging FinovateFall conference: Best of Show winner CardLift and fraud/dispute management platform Quavo. Also- an overview of the eight Best of Show winners, the inevitable artificial intelligence parade, and a pronounced shift in favor of credit unions.       Links related to this episode:   CardLift: https://withcardlift.com/ Quavo: https://www.quavo.com/ Illuma: https://illuma.cx/ FinovateFall: https://informaconnect.com/finovatefall/ Our recent interview with Finovate's Greg Palmer: https://www.big-fintech.com/Media?p=big-startup-energy Best of Show winners: https://finovate.com/finovatefall-2024-best-of-show-winners-announced/   Join us for the next CU Town Hall on Wednesday September 18 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. This session will focus on whether the notion of a Primary Financial Institution is myth or reality. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on X and BlueSky at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/  https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Financial crimes expert Allen Eaves discusses the latest threats facing CUs, including the role of AI in the cybercrime game. Also, we're discussing personal iPhone lists. If you've ever been curious about how often Michael sneezed in July 2021 or how many potential pet names Natasha likes that are related to food, you're in luck! Hint, both answers are far too high.

Glen speaks with Managing Director Deidre Campbell about the Edelman Trust Barometer and its insights on consumer attitudes, with impact for financial institutions and beyond. We then detour into regenerative farming as Fintech South Innovation Challenge winner Alex Edquist discusses how her startup Good Agriculture empowers small farms. Also- banking's version of the Tide Pod Challenge?   Links related to this episode:   The Edelman Trust Barometer: https://www.edelman.com/trust/2024/trust-barometer   Trust at Work: https://www.edelman.com/trust/2024/trust-barometer/special-report-trust-at-work  Good Agriculture: https://goodagriculture.com/  Fintech South: https://www.fintechsouth.com/ Hypepotamus' overview of the ten Innovation Challenge participants: https://hypepotamus.com/companies/b2b/meet-the-10-semifinalist-startups-for-the-fintech-south-innovation-challenge/   The Chase ATM TikTok fiasco (a/k/a Check Fraud): https://www.cnn.com/2024/09/03/business/chase-tiktok-trend/index.html  Consolidation of the Virginia Credit Union League and League of Southeastern Credit Unions: https://www.vacul.org/news/lscu-and-vacul-announce-intent-to-consolidate  Join us for the next CU Town Hall on Wednesday September 18 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. This session will focus on whether the notion of a Primary Financial Institution is myth or reality. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/   Find us on X and BlueSky at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn:  https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/  https://www.linkedin.com/in/glensarvady/

VP of Strategic Growth Marketing and Relationship Management at PSECU Adam Stewart shares solid digital strategy and investment ideas CUs should consider.  And Michael holds an infant and feels the effects of baby fever, symptoms include listening to Amy Grant and Peter Frampton songs and temporary feelings of slight euphoria.

John and Glen riff on the role Bitcoin is suddenly playing in the presidential election, and the thorny issue of how the US government should “manage” its crypto holdings. Also- assessing the prospects beyond the bluster for productive crypto legislation, and the bizarre backstory of HODL.   Links related to this episode:   In his own words, Mark Cuban's take on Donald Trump's crypto conversion: https://x.com/mcuban/status/1813591281970348264 The House's approved crypto bill (the ball's in your court, Senate): https://www.coindesk.com/policy/2024/05/22/us-house-approves-crypto-fit21-bill-with-wave-of-democratic-support/ Analysis of Bitcoin's mid-August price decline coinciding with movement of government holdings: https://www.fxempire.com/forecasts/article/bitcoin-price-prediction-btc-down-as-u-s-govt-transfers-btc-worth-600m-1454167 Coindesk's take on the same: https://www.coindesk.com/markets/2024/08/14/nearly-600m-of-silk-road-bitcoin-hits-coinbase-prime-but-not-necessarily-to-sell/ The history of HODL: https://www.investopedia.com/terms/h/hodl.asp   Join us for the next CU Town Hall on Wednesday September 11 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. It's free to attend (credit union employees might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on X and BlueSky at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/  https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

Velera's Principal of Emerging Services, Chris Corse chats with us about how CUs can build strong fintech strategies for future success. Also, it's quiz time again. Only this time, it's Natasha asking the questions! How will Michael do with the tables turned?

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

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

The Illinois Credit Union League's Tom Kane and Ashley Sharp go deep on the turmoil surrounding Illinois' problematic new interchange law and the steps being taken to course correct. Also- Sam Altman's Worldcoin moves fast and scans (personal) things, and…Backpedaling as a Service (BaaS)?    Links related to this episode:   Our continuing coverage of Illinois' Interchange Fee Prohibition Act:  https://www.big-fintech.com/Media?p=a-state-of-confusion-interchange-battles-move-closer-to-home The ICUL's press release explaining the recently filed lawsuit: https://www.icul.com/news/icul-news/bank-and-credit-union-groups-join-forces-to-challenge-new-illinois-law-restricting-interchange-fees/ The “Guard Your Card” website: https://guardyourcard.com/illinois/ The Chicago Tribune's editorial opposing the Illinois law: https://www.chicagotribune.com/2024/06/03/editorial-retailers-credit-cards-interchange-pritzker-springfield/ The Wall Street Journal's front page article on Sam Altman's Worldcoin/retinal scanning efforts: https://www.wsj.com/tech/sam-altman-openai-humanness-iris-scanning-4d0e1dab   Join us for the next CU Town Hall on Wednesday August 28 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. It's free to attend (you might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on X and BlueSky at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/  https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/

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

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

Cybersecurity expert Roger Grimes demystifies the changing ransomware landscape- how much money do criminals usually demand? How often are they paid, and how much? What is “dwell time,” how do ransomware and wiperware differ, and what constitutes offline backup? Also- the first HODL President?   Links related to this episode:   Our full CU Town Hall session with Roger Grimes: https://www.big-fintech.com/Media?p=cu-town-hall-episode-120 Roger's Ransomware Protection Playbook: https://www.amazon.com/Ransomware-Protection-Playbook-Roger-Grimes/dp/1119849128 KnowBe4: https://www.knowbe4.com/ CU Today's continuing coverage of the Patelco ransomware incident: https://www.cutoday.info/Fresh-Today/Following-Ransomware-Attack-Patelco-Has-Restored-Many-Services-But-Others-Remain-Unavailable Forbes' onsite coverage of Bitcoin 2024: https://www.forbes.com/sites/digital-assets/2024/07/31/bitcoin-2024-when-rage-became-the-machine/  Reuters' comments on Trump's crypto conversion: https://www.reuters.com/business/finance/trump-cites-china-competition-vowing-create-bitcoin-stockpile-2024-07-27/  Our October interview with Doug Brown, President of Digital Banking for NCR Voyix: https://www.big-fintech.com/Media?p=a-digital-first-twin-takes-flight Join us for the next CU Town Hall on Wednesday August 7 at 3pm ET/Noon PT for a live and lively interactive conversation tackling the major issues facing CUs today. This session will focus on whether the notion of a Primary Financial Institution is myth or reality. It's free to attend (you might even win a door prize!), but advance registration is required:  https://www.cutownhall.com/  Find us on X and BlueSky at @bigfintech, @jbfintech and @154Advisors You can also follow us on LinkedIn: https://www.linkedin.com/company/best-innovation-group/   https://www.linkedin.com/in/jbfintech/ https://www.linkedin.com/in/glensarvady/  

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

Nineteenth season! Let that sink in. 19 seasons most of you have been listenning to this guff. Will you never learn? There are listeners to this podcast who weren't born when it started. Goodness - there's even a football club playing in the top flight that didn't exist when this podcast started. (You can pick up this podcast for free on this Substack app, apple, amazon, google, spotify or wherever you get your podcast listening.)The Celtic Underground podcast gets up in the morning, looks in the mirror and thinks “who's that old bugger looking back at me?” It looks on with a paternal smile as some of the whippersnapper podcasts trumpet their new guest providing “exclusive insight” into an event of days gone by knowing that we interviewed that guy years ago when we both had all our hair and all our marbles. Enough of this maudlin meandering, we've got a new season to discuss!On Sunday 4th August at 4:30pm the proper football returns with Celtic hosting Kilmarnock in our defence of the SPFL Premiership title and as we bid for our 4th title in a row and our 14th in 15 seasons (there's a gap there but no-one went and no-one witnessed it. If no-one saw it can we even say it happened?). Having already bagged the pre-season cup (first time in decades) we start our campaign with the possibility of winning up to 4 major trophies. The podcast features Hullbhoy, Ross Hall, Eddie Pearson and Harry Brady. There are obvious concerns about the lack of transfer activity in and the possibility of transfers out, but in general the bhoys are in fine fettle, predicting great days ahead.Oh and for our brand new listener in Cambodia…can't wait to hear of your tales of advanture!It's season 2024-25. It's CUs 19th. Enjoy… This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thecelticunderground.substack.com/subscribe

Straight from Bitcoin Conference 2024, I sit down with Austin Arnold, host of one of the world's most-watched crypto shows Altcoin Daily. From financial literacy to politicians gone Bitcoin and crypto bros to c*ck-blocking gatekeepers, this is one you won't want to miss. ‘Cus, well, Bitcoin. That's hot. --- Support this podcast: https://podcasters.spotify.com/pod/show/taylor-ferber/support

In the 7th episode of the season, Vin and Zach are joined by the dynamic Jesse Schwamb of Members 1st FCU in Pennsylvania, which is one of the top 50 CUs by asset size in the United States.   The three embark on an energetic discussion regarding how Jesse and his team are Improving the ancient business of financial intermediation, diving into topics such as: his passion for utilizing data and technology to personalize the money experience, jumping from first to second level thinking, the ubiquity of fintech, and much more.  For more insights and ideas, visit DCG at DarlingConsulting.com or follow us on LinkedIn.

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses the ins & outs of daily life as an acute care physical therapist. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JULIE BRAUERWelcome to the PT on ICE Show brought to you by the Institute of Clinical Excellence. My name is Julie. I am a member of the older adult division. Thank you for spending some time on your Wednesday morning with me. Let's dive right in. So one of the most common questions that I receive from students and clinicians is is asking me about acute care. Should I go into acute care? Should I choose home health over acute care? And I'm having a lot of conversations with folks about pros and cons. and sharing my reflections from having been in acute care and home health and inpatient rehab and outpatient and private and home with older adults. So I figured I would do a podcast and bring all these thoughts that I've been having in these individual discussions to all of you. Okay, so what I'm going to do is I'm gonna go through a list of five to seven things that I believe are the most important characteristics of acute care and will help you decide if acute care is the right setting for you and if you are going to thrive in that setting. Okay, so number one, this is what I believe is the most important characteristic that sets acute care apart and will be the biggest factor in helping you determine if you are going to thrive in this setting. All right, number one is that in acute care you have complete autonomy over your day. You have complete autonomy over your schedule. This ended up being The reason why I feel like I thrived the most in acute care is because I wanted full autonomy over how I structured my day. So let me explain what that means. So when I was working in the hospital, I would walk into work, you clock in, and you are more than likely going to be given a list of patients. It is then up to you to decide which of those patients you're going to see. Are they appropriate to be seen? So you're doing some triaging there and you have autonomy to make that choice. And then you get to decide, most importantly, what your day looks like. When do you go see those patients? And this was so key for me. I don't like to be in a box. I don't like to be back to back all day. I like to create my own day. And so I would look at my list and depending on how intense or complex the patients were, depending on my energy levels for the day, I would decide, like, okay, I'm going to knock out a bunch of my patients in the morning. Back to back to back, get it done, and then go eat lunch, and then in the afternoon when my energy stores are down, that's when I do the majority of my documentation. So my afternoon, I wouldn't really have to see any patients, maybe one, and the majority of it was documenting. Or if sitting around and documenting for a long time is something that fatigues you, you can do a system where you go see a patient, then you document. You see a patient, then you document. So if you are someone who really needs that energy reset after pouring into a human, typically one that's very sick and there's lots of complexities and you need a little bit of a break and a breather, you can set your day up so that you get that break after every single patient or perhaps after two patients. So you really have a lot of flexibility there. I remember I was the type of person who I would love to knock everyone out in the morning. I would go find a quiet room or a room that was near some natural light. I would put my music on and I would just sit there and document. So you have full flexibility there. When you look at other settings like inpatient rehab, you are back to back to back to back. It's one of the things that I liked the least about the setting is that I did not feel like I had autonomy over my day. And I realized that that was professionally a big core value of mine. And then if we think about home health, you do have a lot of flexibility. You schedule all of your patients yourself. However, I learned my experience was that that was a big burden for me and I never really knew what I was walking into. I didn't get the choice of who was on my schedule. Scheduling patients was typically fairly time-consuming and frustrating when you're trying to reach out to all these people and they may not be answering and you're trying to very efficiently, Tetris them into your schedule so that you're not driving all around your region. Trying to schedule patients became just this extra task that really stole a lot of my energy. So after having been in multiple settings, I think that was the biggest plus to acute care. And if you are someone who likes to have that flexibility and you feel you can be efficient and effective and productive by making your own schedule, then acute care may be the setting for you over other settings. Okay, that's the biggest one. Number two, When you work in acute care, you learn how to be a master of scale. You have to learn how to come up with unique and creative loading strategies because you are in an environment where you don't have weights. You are in an environment where maybe you are just stationed to the edge of the bed because your patient is, they have tons of lines and tubes attached to them. So you have to figure out how to do a lot with a little. And that skill right there has become, it became my superpower going forward into every other setting. I never encounter a time where I'm with a challenging patient, they're complex, or we are in a less than ideal setting, for example, someone's home, and I have never felt I'm stumped. I don't know how to bring a fitness forward approach to this person. I can't come up with an idea. I don't have weights, and so I just don't know what to do. That has never happened. And the reason for that is because over several years, I learned how to get incredibly creative. So in the acute care setting, that could be as easy. I carry around dumbbells in my backpack. and I'm like rucking through the hospital, I bring my own equipment. We paused, we paused, we're back. That could also look like the, this is my favorite hack, the toiletry buckets that are typically filled with shampoos and soaps. I dump those out, roll up towels, soak them in water, put them in the toiletry bucket, and now that becomes a little bit of load, I would have folks deadlift that toiletry bucket, press it over their head. That was one of my favorites. I would use the tray table for a sled push. I would turn the hospital bed into a total gym and put it at an incline and have them reach at the bar above their head and they're doing pull-ups or I'm having them basically do a leg press with the hospital bed. I just was able to always find a way to bring that fitness forward approach and the acute care setting really forces you to get creative. And that was just such an amazing skill that has carried me through every single setting with every single patient that I've had throughout my career. So that's number two. Okay, number three. You do not, for the most part, have to take any work home with you. Yes. How nice does that sound? So for a lot of you who are in other settings and you typically at night, you get home from work, you maybe go to the gym, you eat your dinner and then you're like, well, here's my glass of wine and I'm going to sit down and I have one to two hours of documentation to do. That is not something that is typically happening when you are in acute care. Now in the very beginning as a new grad, a hundred percent, I was taking documentation home for me. But the vast majority after that learning curve, you know, after I got through that steep learning curve, I was not taking any work home from me. With me. You actually get to leave work at work. The administrative burden is very, very low. The EMR is very easy. It's a very low, low, low documentation burden. Something that I didn't know and I learned when I went into home health is that my god, documentation burden was enough for me to, was a big reason why I quit home health. I truly was so frustrated and cognitively overloaded by how extensive the documentation was that I could not even be present or enjoy the time with my patients. And for me, that was enough to say this setting is absolutely not for me. So if you are someone who you're really trying to create a barrier of when I'm at work, I do my work and I do a fantastic job. And then when I'm out, I'm off, I'm done. You go home and your energy stores go to your partner, they go to your friends, they go to your family. Acute care is definitely a setting where you can more easily create those boundaries. Okay, documentation burden low, that's number three. Number four, you are gonna do a lot of things in acute care that don't look like traditional therapy. Okay, so what I mean by this is that your role beyond improving someone's mobility and getting those sick patients, those, you know, individuals who need to get out of that bed and trying to start to get them stronger. Beyond that, I would say The majority of my time was actually spent being a fierce patient advocate, a fierce patient advocate. That is truly what my role became. And I actually evolved to loving that part of the role even more sometimes than going in and doing the functional mobility strengthening stuff. I thought it was such a beautiful opportunity to be able to advocate hard for my patients. So in MMOA, we call that significance over sexiness. You're not always going to get this patient doing squats or deadlifts or bringing in weights, but what you can do is you can fight to the end so that your patient can get over to inpatient rehab. I will never forget one of my first patients that I experienced working on the trauma floor was an individual who had a spinal cord injury. He fell down the stairs, ended up in the hospital. He did not have insurance. And he worked hard every single day with us. I worked with him for months. But because he didn't have insurance, acute rehab was saying, no, no, no, we're not going to take him. Even though everything else made him the perfect candidate to go to rehab. And we know that his outcomes were going to be so much better if he was able to go over and get that intensive rehab. So me and my colleagues were able to just hammer on that goal and we brought it up to the physicians and we got them to do an appeal and face-to-face peer review and we worked closely with case management and we were able to get him over to rehab because we went after that so hard. and that was more beneficial than probably anything we could have done in a more traditional therapy sense. So you have this awesome ability to really dictate the outcome of these folks and it doesn't look anything like PT. Another example is if you have an interest in working in the ICU you have an amazing role there to advocate. Meaning you're going around with the physicians and case management and the nurse manager and sometimes higher up execs in the hospital and you're looking at these folks who are on sedation and on the vent and you know that you want to get that sedation down so you can get these people up and start that early mobility. and you get to look at their settings and look at what's going on and say, look, can we get this person off Propofol and put them on Propofol? Or sorry, the opposite, take them off Propofol and put them on Procedix so that we can try and decrease the sedation burden that's going on with our patients and get them mobilizing faster. That is so cool. I thought that was amazing. I loved feeling like I was like this mama bear trying to protect all of my patients and get them to the next best. setting and really improve their outcomes. And much of that did not look like teaching them how to do sit to stands or deadlifts. So if that's something that you feel you would love to do, acute care is a really wonderful setting for that. Conversely, if you are an individual who, you know, I talk to a lot of clinicians and students who love the fitness part, like their core values when it comes to their professional career are that They want to be able to work with someone when they are in the stage of being able to load them up. That's what brings them value. They want to work more from a sports performance perspective. And they want them to be at a level where they're able to do all the exercise. Like that's what you love to treat. And so I give them the, you know, I let them know, acute care may not be the setting for you. You really may belong more in outpatient instead. So something to think about just the how dynamic of the role can be in acute care. Okay next you learn how to communicate and you learn how to be on a team. All right you will hear all the time that in acute care you have to have really solid interprofessional communication. 100%, you've heard that word over and over again. But what does interprofessional collaboration actually mean? You learn very quickly that the world does not revolve around you and your therapy plans. These patients are so complex. They have so much going on with them. You are one small piece of the puzzle that actually helps them move on to the next level of care, or helps them get home and be safe. You learn it really quick. You cannot operate in a silo. You start to learn what the nurse's roles are, what the nurse tech's role are, truly what your OT partners and your speech partners can do. And you learn how to work with case management. You learn how to have conversations with physicians. They're all right there, and you have to figure out You have your patient's health and mobility, and you want them to get stronger. That's the forefront of your mind. But you've got to deal with all of these other individuals who have their own priorities when it comes to the patient. the physicians or the surgeons, like I'm trying to keep the lungs and the heart alive, or I'm just trying to keep that brain alive. Like that's what their focus is. You know, the nurses are, Hey, I got to get these meds into my patients and they're overloaded. And you start to learn to have grace for people when maybe they're not fitting the idea of what you think should be done for the patient because you're thinking about your bias of mobilization and strengthening. So you start to understand, how to create allies with individuals who have various priorities when it comes to your patient case. You learn how to argue, you learn how to be direct, but you learn how to respect everyone else's role and everyone else's time. And that can become a really beautiful collaborative effort where you can work together and move people forward. And you just don't get that opportunity in other settings. When I went into home health, I really missed the fact that I could easily collaborate with my OT partners or my speech partners, or I could easily, you know, talk to a physician. In home health, a lot of the time it feels a lot more siloed and My goodness, if I was able to get even just a PA on the phone to tell them about a concern I had with a patient, that was a big win. So if you are someone who values and loves the fact that you're surrounded by a team constantly, acute care may be the setting for you there. Okay, only a few more, I promise. Let's do two more. Okay, next, the emotional toll slash connection is very high in acute care. Now, every single setting you are going to be emotionally connected to your patients, right? You could be in very vulnerable situations with the patient. However, I do believe acute care has the highest amount of emotional connection and along with that emotional toll because you are with folks that are dying, that have been through catastrophic accidents, that are, you know, I will never forget the day where I was working in trauma and a patient came in, terrible car accident. That individual lived, but her spouse died. And you are pouring into this human, they don't even know that their spouse is dead yet. I mean, you are going to face these situations so often, especially if you work more in the ICUs. You are surrounded by death quite frequently, and you're surrounded by a lot of sadness and loss and grief. And that can take a significant toll on you. I think it's beautiful that you are able to be someone who can support your patient, your patient's family during an incredibly tough time. But that can also be something if you are, um, if you are an empathetic person to a fault, sometimes like I am, that you can take on a lot of that grief and that can end up being incredibly heavy for you. So something to consider if you love to be in those vulnerable positions with your patient and you want to help them through dying and sickness and grief and loss, it may be a great setting for you. And that's not to say you don't experience intense joy as well. You can. see folks who were minimally conscious after a stroke or traumatic brain injury, and you can see them, you know, spontaneously start to recover. And that's absolutely incredible as well. But the emotional roller coaster is incredibly high. So if you are prone to taking on a lot of energy and emotion, and that's something that you know is not necessarily a positive for you, then maybe acute care isn't the place for you. Okay, last one here, last one. you do not get to see the sexy outcome. You do not get to see the sexy outcome. In acute care, you truly have to be okay with being the person who sees this person once, you plant a seed and you hope that that grows and that ends up changing this person's trajectory. But you don't get to see that outcome most of the time. And that's really hard for individuals. Many clinicians, they want to build that relationship and go along that journey with someone and see discharge day, see how far they've come from the amount of effort and work and progress that you've been making together. That longer term relationship is so important. This is one of the, um, this is definitely one thing that I didn't like about acute care as much is that I didn't have the ability to see this see this outcome. On the flip side of that, I definitely adopted the perspective that, hey, I've got maybe one or two chances to work with this patient. I'm going to do everything possible to set them down the right path. I'm going to pour into this human 200% to try and make sure that I can hand off the baton to the next person and it's a fitness forward individual and I can continue to keep them in that lane. And I was okay with that. I loved knowing that as a fitness forward professional, when I walked in those doors of my patients' hospital rooms, I knew, I just felt that their outcome was going to be different because I was coming into their room. And I loved being able, I loved being able to have that impact with them, even if it's for a very short amount of time. If that is something that you feel like you can get on board with and you can really learn to value and you can be okay with planting the seed and not seeing the outcome, acute care could be a really wonderful setting for you. If you are someone who knows that they want to go along the journey over a long period of time, they want to see discharge day and know what those efforts look like at the end and what the outcome was, probably not the setting for you. Okay, all, that's my list. It's not an exhaustive list by any means. I would love for you all to add to this list to kind of let more folks know some pros, some cons, some other considerations. Please add to this. Put it in the comments. Send me a message. I'd love to post other thoughts about all the things that go into acute care and whether it is going to be the right setting for you. Okay. So I will end with talking to you all about what we have coming up in the older adult division. So in August we, Oh, first let's talk about July. My goodness. So this coming weekend, we, uh, the whole team is in Littleton, Colorado. And then once we go into August, we are in California, Salt Lake city. in Alaska, as well as our Level 1 online course, that starts August 14th as well. PTINice.com, that's where you can find all of that info. If you're not on the app already, make sure you get on there and get into our community. We're on the app so much more now, so if you have questions or comments, find us in there. All right, team, have a wonderful rest of your Wednesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

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

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

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty member Jeff Musgrave discusses how to help older adults understand the value in practicing falling as well as tips for increasing confidence & helping older adults set positive expectations for a meaningful experience. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONWelcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. Proudly serving as part of the older adult division and super excited to be bringing you some more conversations, some more topics regarding older adults. In particular, I think a big swing and a miss oftentimes for older adults when we're thinking about balance and falls training. So much of our time is focused on falls prevention, preparing someone for falls prevention and trying to keep someone from having a fall, which is awesome. We need to do that. It's very important. There's a lot at stake for older adults and we want to prevent as many falls as possible. but we really should not stop our falls training there. So there is a lot of great research to show that we can help improve confidence and reduce injury risk if we can actually prepare someone to fall. And there are two big steps there. So if we're going to go beyond this falls prevention into falls preparedness, there's two pieces. One is getting someone up and down from the ground is a key thing for building confidence and something we need to do if we're planning to do any falls landing with anyone. So just so we're clear, I'm not gonna be covering floor transfers today. I am gonna be talking about strategies. If maybe you've learned how to do these things and you're not sure how to create a successful session regarding falls landing. So I did mention that there is some literature showing benefits for falls landing, because maybe that's new for you. You're like, yeah, I'm not so sure about that. There was a study that came out in 2019 by Moon et al, where they took older adults and they taught them a tuck and roll strategy. So the reality is everyone that got exposure to falls landing using a tuck and roll strategy were able to do two things. One, reduce the acceleration speed of their head hitting a cushioned mat, but also the impact force, the ground reaction force is on their hips. So when we're thinking about trying to reduce head injuries, head, neck, spine injuries, as well as reducing fracture risk. We can do that successfully with a tuck and roll strategy. They found that older adults, after only just two sessions of learning a tuck and roll strategy, were able to reduce their head acceleration speed by more than 40%. 40% slower of their head hitting the floor, or in this case, a crash pad. The other thing they were able to do was reduce that hip ground reaction force by 33%. That's huge, and I especially want you to think about, we know that 30% of adults fall each year. We don't wanna say you're older, so we know that you're going to fall, but we do want them to be aware that there are things they can do to reduce their injury risk. We can teach that, and we want to keep in mind that a lot of our older adults, because of deconditioning, have become frail. They've lost muscle mass. They don't bounce back from injuries as quickly as they should because they've lost reserve and don't have that extra beyond what they need to live daily life physically or within their balance, so they are more likely to fall, and they're more likely to get hurt when they fall, causing a catastrophic injury. So we think about the people in our caseload that are the most frail, they probably, in a lot of ways, have the most benefit from these fall landing strategies, because they're the most likely to have a life-altering fall. Because I think most of the time we think, well, this is just for the people who are super healthy, super strong already. But those people are the ones that are more likely to be okay if they have a fall. The people that really probably need this the most and need it most urgently are those who are the most frail, the most weak. They have the most to lose and are the most likely to get injured in a fall. So I really want to advocate that we find the right strategy for the right place to start these strategies for older adults. And I've got a few tips to try to create a successful session for older adults if you're teaching fall landing for the first time. So I'm not going to be going through the mechanics of how to do that. That is something we go through in depth in our in our live course and teaching that, but I do want to help you set the stage for how to make this a successful session, first time teaching fall landing strategies. VALUE IN PRACTICING FALLS So the first thing is value. Your patients are probably gonna need to be sold on the value, like why in the world would we practice falling? Because it sounds risky and you as a provider may be perceiving risk too. And there is some risk involved. We need to have a very calculated mindset of risk versus reward that's also gonna help us dictate at what place do we start these fall landing strategies. So what's the game? We can prevent head, neck, and spine injuries. We can prevent those hip fractures, likely, if we can teach an effective falls landing strategy. So I wanna let them know that they can learn they can reduce their injury risk. They need to know that it's really possible, it's been studied, people have done it, and if you've already been doing this with your clients, you can share success stories of how you've done this with other people, that it went fine, but you also need to keep in mind the individual characteristics of the person in front of you. I'm not saying carte blanche, like take these people, drop it like it's hot, hit the mat, hit the floor with everyone. If you have taken our live course, you know that there are lots of ways to scale this to make it really easy and very non-intimidating, very low risk. And I'll share a couple of those at the end. So first thing you've got to do is you've got, they've got to know the value. Why would I want to learn this? What could be made better? Reducing their injury risk is the biggest sell here. And even if they're not having lots of falls at this point, we do want to keep in mind with populations that have degenerative neurological conditions that we know are progressive in nature, whether it be MS or Parkinson's disease, falls are frequent. They happen very often. And if they've got the motor control and the ability to learn and do those things now, we want to teach them early rather than later. And get those grooves nice and deep. Get those motor patterns. so that they can access them when they need to. So value is the first thing. What's the value to the patient? You're gonna have to sell them on this. Should be a pretty easy sale because our older adults are thinking about falls and the consequences all the time, whether they've had a catastrophic fall or they've had a friend or family member that's had a catastrophic fall. So that should help set the stage. SET POSITIVE EXPECTATIONS FOR A MEANINGFUL EXPERIENCE The second thing is you wanna set positive expectations. They're gonna need to borrow some confidence from you. You have got to come in confident. You've got to know where you're going to start with the person you're planning to teach fall landing. What is going to be a positive experience for them? Where is it reasonable for them to do this? How many reps? How irritable are their symptoms? We gotta think about those things, but we also wanna share the positive experiences we've already had with others. Hey, I've done this with lots of people. I know it sounds scary. Meet them where they are. They probably wanna hear that you know that they're scared. Or they may be a little concerned. Maybe we don't want to say fearful or scared. But, hey, I realize this could sound scary, but I want you to give this a shot. I'm confident you can do this. We can do this without irritating your symptoms. It's not going to be as exciting as you're imagining. I know what you're imagining in your head. We're not going to be just dropping it like it's hot. We're not going to be hitting the floor. We're not going to hit a hard surface. We're going to teach you all the mechanics. We're going to do it nice and slow, and we'll progress as you're ready. So set those positive expectations, let them know kinda how the progression's gonna go, and that you're gonna be starting very simple, very easy, with just learning the positions, and then from there, you can scale it up and make it more challenging. So value first, positive expectations, and then the last piece, which if you've been following the older adult crew for a while, you've probably heard, but is a huge key with older adults for building their confidence, and that is intentional under dosage. You may have someone who's super active. independent, relatively robust, but you still wanna start fall's landing in a scenario that's gonna set them up for success. We want those successful reps early on to build their confidence so we can invite them along on this journey towards more challenge and more challenging options for fall landing. So we can add complexity, we can add more height to these fall landings so that they can really build their confidence, and take this journey with us. So to give you, I think it's gonna make more sense to give you some examples of how to do this. So intentionally underdosing for something like a backwards fall could simply be done from a recliner. You're a home health clinician, you've got a patient who tends towards backwards falling. You can get them at the edge of the recliner and you can have them tuck their chin and then fall back into the recliner. With the recliner up maybe. Maybe it's completely upright, They are seated, chins tucked, and we're gonna have them slowly work on landing from there. From the recliner, you could tilt it back a little bit and do the same thing. You could progress it all the way from an upright position, slowly falling backwards, to 45 degrees, to all the way flat. You could do this in home health in their favorite spot, which for a lot of our clients in the home health setting is in their recliner. Maybe you're in a clinic setting and you want to introduce a backwards fall landing. You can do that from a seated position with a big wedge. So you imagine that 45 degree wedge, their butt is sitting at the edge of it. You're going to have them tuck their chin and then work on landing backwards, sending the arms out. But they're only doing a very small range of motion. They're not in the floor. They're not Worried about being in the floor, you're not having to teach that getting up and getting down, you can do that from a seated position, which is beautiful. I don't know too many of our clients that would not be successful from a seated position, even our older adults who are pretty frail and are medically complex. If they can go from a seated position to a lying position safely, they can work on a backwards fall landing, and they'll be successful. For our clients who are more advanced, say that goes really well. Maybe we have them go from a standing position and just have them sit and then rock back with their chin tucked. That would be a very easy progression. Once again, not getting them in the floor. They may have had a traumatic experience in the floor. They may feel like the floor is lava, just like the game we played as kids. So we wanna keep in mind, we can scale these things and make it very easy, but you should intentionally underdose your fall landing strategy. Give them options that are super easy. I'll give you a couple examples for forward fall landing. So if you're gonna work on forward fall landing, at least the way that we teach it in the older adult division, there are lots of ways to teach fall landings. But a couple of the key things are, dispersing the load across the forearm and turning the head. You can work on just the motor control of tying these two movements together, getting onto the forearms and turning the head, or even just getting in that position from a seated position, just the mechanics. This is what we're gonna do. This is not scary, this is not hard. You can do this with someone who's super fearful, just working on the mechanics. Then from there, you could do it from a standing position to an elevated mat or some type of soft surface. So even just from a standing position, very slowly working on getting the forearms down and turning the head. It's not complicated. It's not scary. There's basically no risk there. And it could be as slow as you're ready for. After that, once you're comfortable with that, you could speed it up a little bit. Let them try to get very, a little faster down to their forearms with a head turn. From there, you could work on a quadruped position. So hands and knees, maybe on a mat table, super soft mat table, firm enough that they're not having difficulty with their wrist being in that fully extended position. But a mat table could be a great spot, or if you're in the home health setting, You could do this onto a countertop. You could put your Airex pad on top of the countertop and work on that forward fall landing. Once they're good there, you could move this to a bed. And we've not even talked about going from standing all the way down to the floor. So just keep in mind, fall landings are very scalable. Our older adults need to know how to fall, especially if they're frail. It's our job to figure out what's a correct scaling option. They need to know we need to do three things. They need to understand the value. They need to also know that this can be done successfully, that you have been successful doing this with others, that you have maybe practiced yourself based on their specific scenario. And then the third thing is you're gonna intentionally underdose this. You're gonna make sure those first reps are very easy, very easily digestible in small steps, going very slow, and you're gonna progress it gradually as they feel comfortable. And it's really that simple, team. You just have to know all the scaling options and start super simple. I hope that was helpful. I hope you didn't hop on here expecting that I was going to show you step-by-step the fall landing piece. That is something we teach in our live course. I would highly recommend if that's new for you to hop in a live course and we'd love to teach you. But that's an idea of how to set up a session for success. First time someone's learning fall landing techniques, those are the steps you want to take. If you've got experience with this, I would love to hear from you. Are there other strategies that you use that have been helpful for that day one fall landing? SUMMARY Team, if you're interested in what's going on in the older adult world, we've got our next cohort of MMOA level one, our eight-week online courses starting August 14th. We still got some seats there. So if you've not taken online level one, that will be happening soon. Level two course, just want to warn you, it does not come around as often in the last cohort sold out. So if you've taken level one, you're preparing to take level two, you're interested in our next spot, that's going to be October 17th, get your spot. They're probably going to sell out again. If you're trying to catch us on the road, maybe this fall landing thing really struck a chord with you, that's something you would like to add to your toolbox. We'd love to teach you how to do this across a continuum of the spectrum of older adults, their functional ability and whatever setting you're in. We can teach this stuff in any setting and we'll show you how to do that. The next live course is gonna be Virginia Beach. That's gonna be the 13th of this month, and then I'm gonna be in Victor, New York on the 20th, and then after that, the entire older adult team is coming together for MMOA Summit. You'll see almost our entire faculty teach this content, be together to ask us questions, pick our brains. You're gonna have tons of value there because you're gonna have so many people to help you answer your questions and go through these different techniques, and that's gonna be on the 27th in Denver, Colorado. Team, I hope this was helpful. I would love to hear your questions, comments, thoughts on this. And other than that, team, have a wonderful Wednesday and we'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Dry Needling Division faculty member Ellison Melrose discusses the benefits of utilizing dry needling as a treatment for sexual dysfunction in women. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ELLISON MELROSEGood morning PT on ICE Daily Show I am coming to you live from Durango, Colorado this morning in my truck so excuse the background, but we are here to talk about First of all, my name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of ICE. I am coming to you today to talk about dry needling in the pelvic health space, particularly for sexual dysfunction in females or in women. And I wanted to highlight two common diagnoses we have, which is vulvodynia and vaginismus. So let's dive right into that. First, I want to highlight in 2018, there was a joint report done by both the International Urogynecology Association and International Continence Society that overviewed sexual function and dysfunction. They did a deep dive into things like the proper screening, what proper history or physical subjective objective exam would look like. And then they had a huge section on the prevalence of pelvic floor dysfunction in folks that had sexual dysfunction as well. So that's what I wanted to highlight today. We, in the pelvic floor practice or pelvic floor space, we see it often where pelvic floor dysfunction and sexual dysfunction is highly linked and correlated. what I, what this report, um, highlighted is that there's actually 37 different diagnoses of sexual dysfunction that can be attributed to some form of pelvic floor dysfunction. And that's a lot, right? So, um, there granted, I mean, if you look at all of the, the nitty gritty diagnoses, um, we may be thinking maybe we're over medicalizing this, patient population a little bit with specific diagnoses, but it highlights the fact that there's so many people out there that have pelvic floor dysfunction that is contributing to a form of sexual dysfunction. 45% of women that have urinary incontinence will complain of sexual dysfunction at some point in their life. Of that 45%, 34% of that is hyposexual desire disorder. Um, and 44% of those are a brand of sexual pain disorder, which is either dyspareunia or a non-coital, so a genital pain that's not associated with intimacy. And that's what I wanted to highlight. Two most common diagnosis that we see in the clinic that can be challenging for us as pelvic floor PTs often are both vulvodynia and vaginismus. And we'll kind of get into potentially why these can be challenging diagnoses for us. DRY NEEDLING FOR VULVODYNIA Um, but for vulvodynia, the clinical definition of this is anyone that has had pain in or around the vulva region for at least three months without a clear ideology of symptoms. So they don't have, They've had negative cultures, so they don't have either fungal or bacterial infection going on here. And so there's this idiopathic pain presentation in the vulva region. And then vaginismus is a recurrent or a persistent muscle spasm of the pelvic floor, which inhibits any form or enables penetration and there's different forms of vaginismus and different diagnosis underneath that umbrella of vaginismus. And we can kind of dive into that when we talk about vaginismus specifically. I wanted to highlight these two diagnoses particularly because without a proper diagnosis, oftentimes the internal assessment can either be very challenging or it can be very non-therapeutic and actually traumatizing to some of these folks. So if we don't have a particular subjective exam that allows us to understand what is going on with our patients, the whole pelvic floor assessment may be not therapeutic. So for both of these diagnoses, everything starts in the subjective exam. Let's start with vulvodynia. So vulvodynia, oftentimes folks may have symptoms similar to that of a yeast infection or a UTI that then kind of snowballs from there. They may have actually had recurrent yeast infections or UTIs in the past and are familiar with those symptoms, but, and so they do their normal treatment with that, which a lot of times is either over-the-counter medication or they might phone up their OBGYN and say, well, let's get some of these either antifungals or antibiotics on board ahead of time while we wait for the culture. Well, culture comes back negative and the symptoms are still persisting. Sometimes they may get taken away with some of the medication a little bit, but the symptoms overall typically will persist past that. Um, and for folks that have this at this point, it is no longer a, um, you know, bacterial or yeast causing these symptoms. There is a brand of neuropathic pain going So a lot of times they have either had this for quite a long time, at least three months, they've seen other providers that have either provided a medical treatment or something that has been ineffective. And so symptoms have continued. When we think about neuropathic pain and the chronicity and the persistent pain or the chronic pain side of things here, this actually heightened symptoms typically. Um, other subjective things that you might see in these folks is that they may have, um, some sensitivity to, uh, like touch in, in the vulva region, right? So wearing specific type of clothing may be uncomfortable where they may have other brands of, uh, nerve related symptoms like itching or burning. Um, which oftentimes are two symptoms that we think about for either a yeast infection or ATI. And so that's why they get mismanaged in their medical treatment. So it all starts in the subjective exam. And while an internal assessment in these folks isn't out of the question, it can definitely be helpful. It doesn't always, it's not the most efficient way to go about treating this pain presentation. when we think about neuropathic pain, we need to think about, okay, why is this nerve so irritated? And a lot of times in vulvodynia, they see that there is either a irritation of the nerve. Sometimes there can even be, you know, some, some changes in the myelin sheath of these nerves. So there's actual nerve damage associated with it. Depending on maybe what the original cause of the, nerve irritation was. And so when we dive into, we've highlighted their subjective complaints, we know what's going on here, where do we go from there, the internal assessment may be valuable in order to see is this maybe a hypertonicity issue. So if we have tight pelvic floor musculature, can we teach them to relax their pelvic floor and allow for improved blood flow to the pudendal nerve that could be contributing to some of these symptoms. So there is a lot, there is value in that. And I believe that there is, um, oftentimes in the pelvic health space, we are so used to, um, you know, trying to treat, the patient's symptoms ourselves, whereas we can teach our patients to help themselves with learning how to relax their pelvic floor. So there is a benefit in the vulvodynia patient population to utilize the internal assessment. But when we think about efficiency, so how can we treat a neuropathic pain presentation the most efficiently in our in our clinical setting? I am in the dry needling space, and so we use dry needling a ton outside of the pelvic floor world for treating various different brands of pain, one of which is neuropathic pain. So dry needling can be a super efficient tool to improve, to talk to the nervous system and do a nervous system reset to the nerve in question, which oftentimes is the lupudendal nerve. So dry needling is a very efficient tool in order to improve those neuropathic symptoms. With that being said, everything we do physically, manually, we need to highlight that this is a persistent pain diagnosis at this point. And so we need to be utilizing our pain neuroscience education. um, educating these folks about, um, what, what happens to our nervous system when we have had pain for a long period of time. Um, and, and that pain doesn't necessarily equal damage at this point or else everything that we do with our, our manual skills or dry needling, uh, will only get us so far. Right. So, um, vulvodynia again a lot of times these patients come in to us with chronic symptoms so they've been going at this for a very long time they've had typically a medical mismanagement where they've been having some medications on board that weren't helping their symptoms they have a lot of sensitized nervous system and so we want to make sure that we are using the most clinically efficient tool to treat these symptoms. Oftentimes as well, you might actually get some reproduction of symptoms with dry needling when we're approximating the pudendal nerve or getting close to that pudendal nerve, which can be helpful in almost diagnosing, right? So using our tools to help with localizing their symptoms. So that is how we would use dry needling in a case for vulvodynia and in a patient population where we would still likely be able to utilize the internal assessment. DRY NEEDLING FOR VAGINISMUS Now let's pivot to vaginismus. Let's talk a little bit more about different diagnoses under the umbrella of vaginismus and then how we would and why we would use dry needling in this patient population. So, Vaginismus, there's two different diagnoses and underneath that we have two other subdivisions. So we have both primary and secondary vaginismus. So again, a reminder vaginismus is either a persistent muscle spasm of the pelvic floor. It's either persistent or it's associated with something and we'll get into that. Primary means that this has been forever. So this has always been an issue. Um, sometimes there may be a congenital malformation of the genital track on board with this patient population as well. Um, and if that is the case, even things like typically their first, um, like, uh, association with any form of penetration, uh, is oftentimes a, when they get their menstrual cycle. So, um, having a tampon and they're unable to actually insert a tampon into their vagina. Um, from there, then they, they often with this congenital, um, malformation or having it be a primary diagnosis is they, they often are treated fairly medicalized in that state and, and they may require some form of surgical procedure to, widen the vaginal canal. So that's primary vaginismus. Secondary vaginismus is acquired. So it wasn't always an issue, but it could be acquired from a form of trauma. So either an emotional or a physical trauma that then caused muscles in the pelvic floor to spasm. And this can be either global. So what I mean by global is that it's every time anything is enters the vaginal canal, there is a muscle spasm associated with that or it's situational, meaning that things like inserting a tampon may be possible, but physical intimacy with, um, or sexual intimacy is not possible. So there's no, uh, penetration available during, uh, sexual intimacy. Um, so those are the different kind of clinical or, diagnosis we find under the umbrella of vaginismus. Oftentimes in pelvic floor PT, we will see, um, a lot more probably of the secondary vaginismus in that they've, you know, they've never had, they hadn't always had issues, but then something caused or something triggered an issue, which causes the pelvic floor muscles to, um, to spasm, right? And that could be a traumatic birth of vaginal delivery. It could be a sexual trauma. So a, um, yeah, a sexual assault or something of the sort. It could be a, uh, traumatic pelvic exam by their OBGYN, uh, which we've, I see a ton in the clinic and, um, so it could be, a natural physical trauma with that. And then it could also be heightened with a, um, an emotional trauma as well. So a lot of times, I mean, this is a very intimate part of our body. And so there's a lot of times a very, uh, pertinent, uh, or very prevalent emotional, well, um, 70%, I would say probably about 70% of your initial evaluation evaluation, is going to be a subjective exam. Understanding the why behind these patient symptoms is crucial to dictate the course of your treatment or even the course of your assessment in that initial evaluation, right? Like, are we going to be doing an internal assessment on these folks? And a lot of times, probably, probably not, right? So what does day one look like or our initial evaluation look like with folks that have vaginismus? and how and what does our course of treatment look like for them. So typically education goes a long way with folks that have had either a physical or an emotional trauma that has caused muscle spasms here, right? So teaching folks about the anatomy of the pelvic floor musculature uh, why they feel like there's a brick wall when they try to insert a tampon. Right. Um, how, uh, what a Kegel is. Right. So anytime people have any association with the pelvic floor, they are often just think, Oh, I should be doing Kegels. Right. Um, and teaching them what, what a Kegel or what a pelvic floor muscular muscle contraction is and educating like the benefits of relaxing the pelvic floor. And this is just all done through education. So no even physical touch or assessment has been done at this point, but just educating folks around the anatomy of the pelvic floor. Anatomy and physiology of the pelvic floor can go a long way here. We also want to educate about vaginismus itself. So vaginismus is another brand of chronic pain, right? So these folks have typically had pain for an extended period of time, Um, there's not a diagnostic criteria for, for duration of symptoms like there is for vulvodynia. Um, but there is a pain cycle on board here, right? So it all starts in the brain. So it, it either the, the brain perceives an emotional trauma due to either a physical trauma or, or purely emotional that registers discomfort or, or fear associated with, uh, penetration either from a previous, uh, you know, exam with a speculum from a previous sexual encounter, um, from a trauma traumatic birth, right? So the brain remembers those things, which is then going to be causing, it causes muscle guarding. So public for guards, the tight muscles in the public for cause the penetration to be painful. or impossible at sometimes. And then this difficulty in pain reinforces that alarm, the amygdala alarm that's going on up in the brain, right? That reinforces that this is a threat, right? The nervous system then remembers this pain, and so every time our brain is their, their brain is thinking about, you know, either having to go to the OBGYN or having a sexual encounter, anything like that. Um, it is going to remember that and we are going to get the same physical symptoms as the, the tight muscles, um, which is often going to lead to, you know, decrease blood flow to the nervous system, which is going to cause potentially, you know, perceived as pain by these folks. And so they're going to avoid those, uh, you know, avoid whatever is causing this pain cycle, right? And those folks, which ultimately, especially if this is a sexual nature is going to, um, reduce the desire to either have sexual intimacy with their partner or, um, and it's, it's going to reduce that, that overall desire, which is then going to, again, any thought of that intimacy is going to be threatening. So discussing that, that pain cycle with these patients can be very therapeutic and, and helpful in that this isn't their fault, you know? So the nervous system, I like to say it's smart, but dumb, right? It remembers things and not always for the right reasons. And so education about anatomy, physiology, about the vaginismus pain cycle, can take up a majority of your initial assessment with these folks. I also like to do, again, a guided pelvic floor relaxation series with my folks, even if we're not doing an internal assessment. So on day one, these folks, we may not be getting into an internal assessment. We may never get into an internal assessment, but we do want to teach them how to um, feel their pelvic floor muscles and, and learn how to relax them. And so sometimes, um, I will educate them on how to do some self biofeedback either with tactile cueing, um, just medial to their ischial tuberosities sitting on, um, you know, a yoga ball or something like that, where we have some, uh, tactile cueing to the, um, perineal region or the pelvic floor area. Um, and, and teaching them about, again, the anatomy and that when, We're breathing. We're trying to make some of these muscles move. Increasing movement in these tissues is going to increase blood flow to the tissues, which is going to reduce irritation to the nervous system. So teaching them how to relax their pelvic floor without even doing any physical touch yourself can also be helpful. This is a patient population where after we kind of break down and help them understand the why, I like to highlight other tools we have in our toolbox as physical therapists, right? A lot of times when these folks, um, come to pelvic floor PT, they, they've done their research. So they know often that pelvic floor PT equals an internal assessment, which they've had done by their OBGYN and it's maybe been traumatic in the past or Um, they know any form of penetration is, is traumatic. And so, um, right out the gate, I'll say, you know what, that is a tool we have in our toolbox. The internal assessment's a tool. It is gold standard for assessing how the pelvic floor muscles function, but is not everything that we do here at pelvic floor PT. And I introduced dry needling. And I know that seems like for folks that have, don't have vaginismus or don't have trauma associated with penetration, they're like, Isn't dry needling more of a threat than an internal assessment? And for folks that have vaginismus, oftentimes it's not, right? So dry needling the pelvic floor muscles can be an amazing tool as we don't necessarily need to do an internal assessment. on these folks, we know there's likely not going to be anything therapeutic initially with that initial internal assessment. So if we can utilize dry needling in the earlier stages of our pelvic floor PT with these folks, it can be an amazing tool to talk to the nervous system, you know, put a break in that pain cycle associated with the muscle spasms or the tight pelvic floor musculature. It's a beautiful kind of what I like to say control or delete to the nervous system and so it can really help with Retraining that cycle of you know, these muscles Have more control other than just muscle spasm, right? and so if we can take some of the the heightened neuropath or the heightened symptoms down with a tool like dry needling, it may allow us to either ourselves or them do a form of stretching or manual therapy where they can improve the tissue's mobility as well, right? SUMMARY So I could probably talk about this stuff all day. I've already been on here for almost 25 minutes, so I'm going to stop it here, but I want to kind of summarize everything we talked about today. Um, I, we kind of went into a recent report done in 2018 that dove into some pelvic floor dysfunction in, um, sexual function and sexual dysfunction. And we dove into two specific diagnoses today. We looked at vulvodynia and vaginismus clinically and how we can utilize things like dry needling for either treatment or even, um, diving into a little bit of some diagnostic, uh, with, utilize with dry needling as well. Um, and so, uh, while we're, you know, dry needling, the pelvic floor is a fairly unique, um, skill. Uh, there's a lot we can do with dry needling outside of the pelvic floor as well for these folks. And so, um, for those that are in this space, I highly recommend taking our lower body dry needling course if you haven't already, We go into needling for the lumbar spine, the glutes, muscles that surround the sciatic nerve. And so again, taking those principles and utilizing them in the pelvic floor space can be really helpful as well. So we have some courses upcoming this fall. We have, let me pull it up right here. We have a lower body course, I believe in Scottsdale, Arizona, in the beginning of September. We, for those that have taken lower body or upper body, we have two advanced courses coming to you this August. So we have our, our juggling summit up in Seattle and the second weekend in August. And then we have one down in Longmont, Colorado at the second to last weekend in August, um, right before Labor Day. Uh, we have a ton of lower body courses coming to you this fall. So hop onto ptlnice.com and check out what courses we have, um, coming to you. Um, if you guys don't see something in your area, feel free to reach out to us and, um, we can look at getting something booked near you as well. Well, hopefully you guys have a great rest of your Tuesday and enjoy the holiday this week. Bye. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones shares tips to make HIIT more objective, being diligent with monitoring vital signs, and underdosing high-intensity with medically complex patients when needed. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. DUSTIN JONES Alright folks, welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the older adult faculty within the MMOA division. Today we are talking about the top tips to apply high-intensity interval training amongst medical complexity. So I think many of us have been there, right? We're working with that individual that has a whole laundry list of different diagnoses, different medications on board, maybe in a more acute setting. And we know that high intensity interval training is helpful for people. We've seen some literature, we've read some of the research, but what does it actually mean to apply this amongst a very complex situation? All right. So we're going to cover, some key takeaways from a super helpful article that was published last year in 2023 in the Cardiopulmonary Physical Therapy Journal titled, Putting It All Together, An Evidence-Based Guide to High-Intensity Interval Exercise Prescription for Patients with Complex Comorbidities. And I really appreciated the team that wrote this article because it is difficult to navigate, right? Like, we will see some of these headlines of high-intensity interval training proven to be effective in the ICU, for example, or HIT being effective with folks that have recently suffered from a stroke. Some of these things we typically wouldn't associate high-intensity interval training with, but it's been shown to be effective. Now, when we go to apply that, it can be rather intimidating, right? I can speak to this mainly from the home health setting where The trend in home health is that people are getting discharged from more acute settings like the hospital a little too soon, right? So you have these very medically complex individuals in their home with very limited monitoring, medical support if something goes awry, and all the negative thoughts and what coulds, right? What could happen starts to creep into your head, and that can dramatically influence our intervention. Let's talk about three, I've got three main tips for y'all, things that I have learned through mainly mistakes in my career, but then also what this article talks about. One is objectify, two is monitor, three is, I'm gonna save that one for last. BE OBJECTIVE WITH HIGH-INTENSITY TRAINING All right, so the first one, we go to apply high intensity interval training. We need to be objective. Here's what can typically happen. You read an article, you maybe hear a PT on Ice daily show podcast, see a social media post like, all right, I'm going to use this with Betty tomorrow. All right, Betty, we're going to do high intensity interval training. And you're already working on gait training, for example. with Betty and so you're going to be like all right Betty I want you to go fast for 30 seconds and then I want you to walk slow for 30 seconds we're going to do that for a total of 10 minutes right great start I love what you're doing there you got a one-to-one work rest ratio it's already a goal that Betty has to improve her ambulation ability, maybe even distance endurance. Awesome. But what typically happens, right? She goes to do her fast walk. What does that actually look like? Is it fast? Or is it just slightly faster than her normal or a slower walking speed? All that I'm saying here is when, say ambulation, when we aren't objectifying it, when we aren't giving people a number to hit, to look to, to get that real-time feedback loop, they will often undershoot their intensity. This is where the ergometers that many of us have access to can be very, very helpful. A lot of these things are, they're collecting a lot of dust in a lot of clinics, to be honest, right? Like the new step. It's either collecting dust or we're throwing people on there for 20 minutes while you finish your notes or they take a nap, right? We got our recumbent bike. Maybe you have a rower, maybe you have an echo bike, maybe you have a ski in your clinic, but these are functionally all ergometers that are measuring work, they're measuring speed, they're measuring distance traveled. Those are objective metrics that we can use for dosage, that we can use to give people that target to try and hit to make sure you're reaching an intensity. Right, RJ, outpatient, has an Echobike. Echobike, you look at that screen, you've got calories, you've got watts, you've got your revolutions, right? You've got your distance. These are all things that we can use to set a goal to achieve appropriate intensity while we're performing our intervals. So RJ, for example, with the Echobike, it may be watts, right? You may say, pick a number of watts that you're trying to hit. during that 30-second interval and then it's going to be 30 seconds easier, 30 seconds rest for maybe like a total of 10 minutes with someone. Giving them that objective thing to look at is going to be so much more effective than just quote-unquote saying go faster, all right? NuSTEP has the same thing, right? Many of you all have already, I shouldn't say wasted the money, the NuSTEP can be helpful with certain patient populations But my gosh, the price per square foot of a NuStep is absolutely ridiculous. But if you already sunk the money and have one, freaking use it, man. That thing has all kinds of data and information that we can use to really redeem the NuStep, redeem that piece of equipment and achieve a higher intensity. All right? That's the first one. We need to objectify what that high intensity actually looks like. Use ergometers. If you don't have the ergometer, maybe use something like a percentage of a heart rate, for example, some other metrics that we can use to objectify. MONITOR VITALS Speaking of heart rate, number two is going to be monitor. Now, this is what really allows us to apply higher intensity intervals with medically complex individuals, is when we are monitoring Vital signs and signs or symptoms. Vital signs are absolutely huge especially in so many acute settings. Hopefully many of you all are getting them at rest initially, hopefully at least bare minimum at the initial evaluation, right? But when you're working with more acute individuals, you have these complex comorbidities. We need to be checking vitals every visit, but then when we're applying these high intensity intervals, it can be very helpful and advantageous for you to check vitals before, during exercise, and then after to gauge their response. Now I'm not saying check every single vital sign, right? But there's gonna be some pertinent ones based on who you're working with, right? So like if I have someone that is constantly cruising, you know, in the 150s over 90s blood pressure, they're pretty hypertensive. It's not managed terribly well. They sometimes have some symptoms, but a lot of times it's asymptomatic. I'm going to be checking blood pressure pretty regularly. I'll also be checking their heart rate as well. And I can do that during, and before, during, and after an interval. That's where these ergometers can be really helpful. Like a new step, for example, when I program that interval, they're working hard, but then they have that rest. That rest is when we check our vitals. I'll support their arm, get a manual blood pressure reading, and you're going to be able to gauge their response and make sure that you're in a safe zone, right? And the way we like to think about these zones is we like to think about them as traffic lights. So there's a red light in terms of things that you may see where we're going to stop exercise and a yellow light where we're going to be cautious but proceed and then green is just full send. We go into those in our Level 2 course, related to resting vitals, exercise vitals, signs and symptoms as well, related to high-intensity interval training. But for our purposes here, we want to monitor during, so you'll have a good idea of how they're responding. Another one is if someone has some type of cardiopulmonary issue, then a pulse ox can be really helpful, looking at oxygen saturation. We can see their response, make sure we're good to go, and we can adjust our dosage based on that. when we're able to monitor those vital signs it's going to give you an objective view of what's actually happening and I don't know about y'all but here's what typically happens with me is I may throw someone on a new step for example a recumbent bike and we're doing high intensity interval training and I know they've got some cardiopulmonary issues on board, some things that I'm somewhat concerned about, and I literally tell them to go hard. I may give them, you know, hit this number of watts during these hard intervals, and I literally am closing my eyes, crossing my fingers, praying to the rehabilitation gods that something bad doesn't happen. But if we're able to monitor and get that objective information, you can rest assured that you're giving that person exactly what they need, and it is safe. UNDERDOSE THE HIGH-INTENSITY FOR MEDICALLY COMPLEX PATIENTS Alright, so first we need to objectify it, second we need to be able to monitor it, and then third and the counterintuitive one, but it's the reality when we're going to apply high-intensity interval training amongst medical complexity, is that we need to underdose. I hate to say it y'all, but we need to underdose. Oftentimes, I'm not gonna say always, but oftentimes these folks are have a lot on board, right? And from the medical side, but then also from the psychological side, you take someone that has been given the diagnosis of heart failure and imagine what that feels like, right? You may have some perspective of what that actually means, a prognosis of that and what people can continue to do with a diagnosis like that. But there's so many individuals that will get these seven syllable medical diagnoses and they literally view it as a death sentence and they're actively falling apart right in front of your eyes. And that is not necessarily the case. There's a lot of psychological damage as well as physical damage along with these medical complexities. And it can be very advantageous when you introduce something novel and new like high intensity interval training to do it in a very approachable manner. This is where I am typically when I'm introducing I may use something like a subjective report, like an RPE, a rating of perceived exertion. That goes against the first thing I said, right? I told you you need to objectify it, but maybe initially, we want them to be a little bit more in the driver's seat and give them that RPE. You may say, I want you to go hard, I want you to go fast, I want you to go at a seven out of 10, RPE of 10 is your all-out effort, right? Initially, I think that is helpful. But we don't want to stay there because most of the time, people's true high intensity doesn't necessarily match up with their perception of high intensity. And that's where we need to be objective to calibrate that. But initially, I think under dosage, self-report can be very, very helpful. We also need to consider what these high-intensity intervals can do to people outside of our session, right? I learned this the hard way way too many times in home health, where we'd have this epic session. We'd be gone for about 20, 25 minutes, high-intensity intervals, you know, doing steps or ambulation, and then we do some transfer training. I'd take them, walk them out to their mailbox and back. They haven't seen the sunshine in weeks. Man, it was an epic session. And then I come back in a few days. What has that person done since that session? Nothing, right? They weren't able to do their laundry. They weren't able to do any tasks around their home. they were laid up because I absolutely gas them. And so we want to be able to leave gas in the tank for many of these individuals to be able to do things that are really important to them like ADLs, like IADLs, maybe a certain social function, right? And so when we start with that under dosage, you will be able to tweak and progress without impacting the rest of their life too much. which is really important. Many of you all may not have experienced that, right? I think many of you all probably did MRF, right? Memorial Day, high volume, you're working real hard for, you know, 40, 50, 60 minutes, maybe more if you're me, right? How'd you feel after that, right? Many of you all, myself included, were absolutely wiped and that's what a 10-minute session can do for some of these individuals. SUMMARY So, We may want to introduce it in an underdosed manner, see how they respond, make it approachable, and then gradually progress it from there. Then we start to objectify it, give them that target for, I want you to hit this many watts, for example, or this many revolutions per minute. And then we continue to monitor their vitals before, during and after those intervals, and you've got a potent cocktail that can really influence people's functional capacity, but then also the disease process that they are suffering from, and most importantly, it can be safe. All right, let me know your thoughts. Let me know any tips that you have from applying high-intensity interval training amongst medical complexity. I would love to hear from the folks in the ICU, in acute care, in skilled nursing facilities, in acute rehab, where you're dealing with a lot of medical complexity. Love to hear from you all. Drop in the chat on this Instagram video, or if you're watching on YouTube, if you're listening on the podcast, we're grateful for you listening. Hop on social media, and I'd love to hear your take as well. Hope this was helpful. I'll also put the citation for the article, the really helpful article, in the comments on Instagram as well. All right, hope you all have a lovely rest of your Wednesday. Go crush it, and I'll talk to you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses addressing shoulder mobility in wrist pain patients.  Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. CODY GINGERICH Good morning everybody. My name is Cody Gingrich. I'm one of the lead faculty with the extremity division and I am coming with you today on a clinical Tuesday and we're going to be talking about treating wrist pain at the shoulder. All right we're going to be tackling shoulder but treating the wrist. Okay. So wrist pain going after the shoulder to deal with wrist pain. This is a big deal when we're talking specifically about, um, a fitness athletes. Okay. So The reason being, the fitness athletes, people who are lifting in the front rack position, so think our Olympic weightlifters, our crossfitters, people who are just really working a lot of front rack position or overhead movements in general, are going to really benefit from these type of things, okay? So, couple things that I wanna start with and why it is important to look at the shoulder when someone is coming in with wrist pain. In the extremity division we talk about wrist pain a lot of times and most most of the time a lot of different presentations of wrist pain are going to be due to or need more wrist extension. It is going to be a wrist extension intolerance and that is largely going to be the case when we're talking about what we are today as well. With these barbell athletes or overhead athletes that need a good amount of wrist extension to get into good front rack position, or if we were thinking about handstand walking or handstand push-ups or pressing weight overhead, we also need a good amount of wrist extension tolerance to support our body weight overhead. Okay. And a lot of times when these people can come in, we can get pigeonholed into just looking at the wrist and be like, okay, well we're lacking some wrist extension and we need to treat that and we need to calm that down. And we, we stay in our lane right there at the wrist. But what I want to talk about today specifically is going to be really addressing shoulder mobility. in order to free up some space at the wrist. So I have a couple of, uh, I have a PVC that hopefully y'all can see, and we're going to try to show you, um, why in a non-adequate shoulder mobility can end up putting way more stress at the wrist with these athletes, even if they have a pretty good amount of wrist extension. Okay. So when we're talking specifically about the front rack position, I've got a PVC pipe here. So one thing is going to be where we're starting with is going to be if we have a lack of lap mobility, a lack of lap mobility is going to not allow our elbows to come forward and up as much. Okay. And so what that leads to is that barbell then sits way more on our wrist and hand than it does on our shoulders. PVC, I got to kind of tuck my chin down and get it there. But the more that we can drive our elbows up, the more that weight then is supported by our shoulders in that good front rack position. If we don't have the ability to really turn our elbows up high and we keep them low because we don't have that mobility, then most of that weight then comes through our wrists. And even if we have good wrist mobility, that is still a ton of pressure there coming through the wrist joint. The other side of things is we also need shoulder external rotation in that front rack position to distribute the weight that's going through our wrist more evenly. So the other front rack position that I see where if we can't get our wrists and our hands out here, we end up with our wrists right over our shoulders and maybe our elbows even just outside, just like this. And what that does is it forces extension and rotation at the wrist and ends up putting a ton, a ton of stress through that radial side at the wrist. Whereas if we can then open up that shoulder external rotation, that then can distribute the weight more evenly. We can have a flat palm. and a flat wrist into extension. So the other thing when we're talking about getting overhead, I mentioned handstand walking. If we don't have adequate shoulder flexion and we are overhead, that leads us to be here and we still are trying to get our feet up and over our body to walk forward. And that then requires a significantly amount more wrist extension if we don't have all of that shoulder flexion. If we can gain more shoulder flexion then at the top we don't need to roll over our wrist extension quite as much. So a couple different ways and that could also be a lat mobility problem as well. So what I want to encourage you is we have several tests If someone comes in and they're saying they've got pain with these particular movements, right? First, make sure that they have that adequate wrist extension. And the best test we've got for that is really going to be have them place their hand on a table and then see if they can get their elbow beyond 90 degrees at the wrist. Even right at 90, they probably have enough wrist extension to be able to calm those symptoms down, even without gaining wrist extension. So you can still make gains in their pain and treat their wrist pain, even if that wrist extension is a little slower to come. It is typically easier to treat soft tissue mobility restrictions than it is joint restrictions, typically. So a lot of times in our athletes in this population, those shoulder mobility limitations are oftentimes going to be soft tissue related. So we want to then check shoulder mobility. The best test for that, to check lat mobility, is going to be the seated wall test. So if you have the person sit up against the wall, back as flat as they possibly can, PVC pipe then in their hands, palms down, and reach up can they get their knuckles to the wall? If they can, have them then turn those palms up and reach again. And if they come up short of the wall, we can be confident that there is some lap mobility restrictions on board. Okay, that is going to be a situation where treating the shoulder and the lats are going to be a really great way to address the wrist pain, because that will then allow those elbows to come up higher, take stress off of what the wrist is going to have to take on. So if we can decrease stress at the wrist by increasing shoulder mobility, we are doing a good job bumping that wrist pain forward. That's going to address both the elbows high in the front rack position and oftentimes the stacked overhead position when people are going handstand pushups, handstand walking. So we can kind of knock out two birds with one stone by really looking at the lat mobility. Secondarily, we can also look at shoulder external rotation. Okay. Now this could be a mobility issue. This could also be an external rotator strength issue. Okay. But to check the rotation can have them in supine, bring them to this position and then passively rotate and see if they have that mobility to get into that external rotation. If they don't, if they can't access that external rotation in that 90-90 position, we are going to want to start working into that external rotation. That can be with some contract relax. We can do the classic PVC stretch where we work this way and try to warm that up ahead of time before they get into that front rack position. we can also work some like band work in this position working out again contract relax or have the band pulling here stretching out some of those internal rotators and then we can go x internal rotation and then we do eccentrics into external rotation with a band moving that direction that will help to open up some of that external rotation specifically in that front rack position. Okay, so what that will do then is again in that front rack, get us from instead of this position, it will get us more that position and more evenly distribute that weight across the wrist as opposed to it digging into one side or the other. SUMMARY So overall, If someone comes in with wrist pain, and specifically that wrist pain is happening when they're in a front rack position, when they're putting a bunch of weight on their hands from doing handstand walking, handstand pushups, go after and look at the wrist absolutely, but absolutely don't neglect looking up the chain and looking at shoulder mobility, shoulder strength. If they don't have adequate lat mobility to get their elbows through in a front rack position or full shoulder flexion in that position, look first at the lats. See if we can't gain some shoulder mobility from that soft tissue, really be able to get in and through that elbow, take off some of the stress from the wrist. If they have a hard time getting their hands outside of their shoulders and big chest there, start looking at do they have adequate shoulder external rotation, either mobility or strength to be able to maintain that position and again, decrease the stress from the wrist. If you don't hit that and they don't have that ability, you can treat the wrist all day long, but they are going to continue to just keep pissing that off because they don't have any way to overall decrease the stress that that wrist is taking on. Once we can find that root cause of why that wrist is taking on so much weight, then we can start increasing the tolerance to that wrist extension. So we can start mobilizing there, we can start adding back like a plate carry where we're working here, we can spin that in different ways, all of that, and we can then start working at the wrist. But if we don't clear the shoulder first, you're going to be fighting a losing battle overall, because we haven't addressed why that wrist is taking on so much weight and getting irritated in the first place. Okay, so I just want to keep keep y'all's heads involved as far as don't always get tunnel vision onto one joint, right? We always want to look up the chain and seeing if there is something going on that we might be missing. That's all I got for you for today. So again, just as a quick recap, someone coming in with wrist pain, specifically our barbell athletes going overhead, we really want to clear lap mobility and external rotation mobility at the shoulder and make sure that those things are clean so that we can decrease the stress being put on the wrist. If you want to catch extremity man My last minute plans that you can make it to there. Otherwise, we will be in Kent, Washington on July 13th and 14th or Hendersonville, Tennessee on July 20th and 21st. We hope to catch you out there. We have a ton of different, all of those exercises and techniques that I just talked about are in that extremity course and we go into them in much more depth. So we'd love to catch you out on the road. All right. Hope everyone had a great day. Thanks for listening. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett as she discusses experiencing loss, processing grief, and its impact on being a geriatric clinician. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. CHRISTINA PREVETT Hello everyone and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty within our geriatric division and today I want to talk a little bit about grief. This is kind of a personal conversation, but it's also one that I think is really important when we are working with older adults. So personally, I've kind of been speaking a little bit on my social media. I lost somebody very close to me very recently. So I lost my godmother. She was my aunt. She was in my top 10 list of favorite people and she was somebody who had battled cancer a long time ago. They found out a couple of weeks ago that she had a metastasis in her brain and her first radiation she didn't do very well and she passed away like very very suddenly. And to say that this rocked me, like, I don't know if I'm going to keep it together on this podcast. I'm going to try. But to say that this rocked me was like an understatement of the world. And it was devastating. I'm still not OK. And it made me think a lot about grief. So I am 34 years old. And over the last two and a half years, I have lost three people that are really close to me. I lost an uncle that was my dad's best friend, my aunt who was my mom's best friend, which means that they were around us all the time, and I lost my grandmother who I was really close to. And as I was reflecting on this most recent loss, which my aunt was probably the closest person that I have ever lost, I reflected a lot on the process of grief and I thought a lot about how my older adults must feel. And so it reminded me of a conversation that I had with my grandmother. So my grandmother passed away just shy, a month shy of her 98th birthday. She lived a very long life. Her husband was alive until he was 93. And she was just this incredible role model of successful aging. somebody who was able to keep cognitive capacities, physical capacities in the realm of what she wanted for a very long time. And I was having a heart-to-heart with her one time, and I'm sure many of you have had similar conversations with loved ones that have lived a long life. And I said, you know, Grandma, I want to be like you and live to 100, because at that time I was certain she was going to be a centurion. And she turned to me and she said, you don't really want to live to 100. And I asked her why, and she's like, because everybody around you is dead. And to be somebody at, I'm 34 years old, to have had this feeling of accumulated loss, I'm only starting to potentially scratch the surface of what she could possibly mean and what all of our or so many of our older adults may be experiencing in their life. And so while I feel the acute sting of losing somebody really close to me, what I'm also like really recognizing is that there's also a accumulation effect that weighs heavily on my heart around having multiple people that I've been really close to that have passed away. And if I am feeling that at 34, I can only imagine how many of my older adults are feeling when it comes to, you know, they've lost parents, all parents, both parents, their in-laws' parents. They may have lost siblings or, God forbid, kids. Like there's friends and family, like you know, there's jokes around how our older adults are one of their social calls is going to funerals because they experience loss around them so frequently. And I never truly appreciated, I think, how much of a toll that would take on an individual's soul and their experience in some of their zest for life until I felt like some of the accumulated effects over a relatively short amount of time of experiencing a significant amount of loss. what this got me to think about is the way that we interact with grief with our older adults. And when we, really as a culture, how we interact with grief. And so I had one of our TAs, Rachel Moore, she's one of our lead faculty for Pelvic. We were having conversations about this and she said, you know, it's so interesting because everything else just keeps going and you feel like you're stuck in this loop of, oh my gosh, this person has left. And it's true, right? We are with individuals in that short amount of time where we're doing funeral preparations and all those types of things, but that grief weighs heavily on a person's soul and on a person's mind. And we don't really teach individuals how to deal with grief. And when it comes to older adults, we oftentimes think that this is such a normal part of the aging process that I don't think we ever truly hold space for individuals when they are dealing with grief. And so when I was reading a book called Breaking the Age Code, this really came front of mind. So we talk at an MMOA about the psychosocial considerations of working with older adults, about how it can be so great for us to put a heavy deadlift in their hand or get them getting up off the floor for the first time in a decade. And all of those things are really wonderful. But if there are other buckets that are just leaking because they do not have the financial resources, the mental resources, or the skills in order to help with these big buckets that are truly just hemorrhaging, then we're not really gonna give them the best type of care. And when I was reading a book called Breaking the Age Code, it really came front of mind for me about this. where when we look at mental health disorders, and not to say that grief is not a very healthy expression of sadness, but Becca Levy, who wrote The Code Breaking the Age Code, she's the one that we talk about with all of our ageism literature. She wrote a section in this book, her book on mental health, and she talks a lot about how the knee-jerk reaction with our older adults is to give them anxiolytics and antidepressants, without truly leaning into grief and leaning into talk therapies and conservative cognitive behavioral therapies that can just be so, so beneficial when we're working with our older adults. And she described some literature where she actually said, you know, many of our older adults may do even better with talk therapies than some of our younger individuals do because they're creating that connection so intensely. are craving those skill sets that they need in order to make it through their day because their grief is so heavy and your grief doesn't just last for two weeks. And so I was reading, kind of thinking about all this and the weight of grief and the thoughts around grief and how this relates to our older adults and how personally this is relating to me. I started reading a book called The Collected Regrets of Clover and there was a couple of things that they really talked about that I think is helpful for the way that I'm approaching now or thinking about approaching conversations with some of my older adults that I am working with who are experiencing loss or who have disclosed to me that they have lost a lot of people that are close to them. This book is it's fiction. It is so beautiful. It talks about a woman who is a death doula who basically comes and supports individuals through the end of their life. Similar to how a postpartum doula would help a new baby come into the world or a pregnancy postpartum doula, a death doula helps people end their life and end their life on their terms. And they talk about how when we're thinking about grief, First, it's this large weight that is on their frame. And as time passes, that big backpack turns into a purse. And what she's saying is that your grief is always carried with you, but the weight of it becomes easier to carry with time. It never goes away, but we start to be able to function in some ways with it. And I think that's really such a powerful thing to speak to. And when we are working with our older adults, they may be holding a lot of purses. They may be carrying a lot of bags of loss in the non-literal sense that can create this expression of apathy or a lack of engagement, which can sometimes create this space where it may be hard for individuals to engage with us in rehab. sometimes being able to dig deep into some of those considerations and create resources for them can be one of the best things that we can do. And so in this book, she had this quote and I read it on my Instagram a couple of weeks ago, but I'm going to read it to you now. And then we're going to finish off this podcast with a couple of things that I'm thinking about as a geriatric clinician to recognize that there is a lot of grief with our people that we are working with that we cannot see that are influencing who they are and how they show up in the world. And so in this book, this was literally the fifth page in. So if you're a fiction reader, this is such a beautiful book, but they said the most important thing is never to look away from someone's pain, not just the physical pain of their body shutting down, which we see all the time in rehab, right? But the emotional pain of watching their life end while knowing they could have lived it better. Giving someone the chance to be seen at their most vulnerable is much more healing than any words. And it was my honor to do that, to look them in the eye and acknowledge their hurt, to let it exist undiluted, even when the sadness was overwhelming. And so to put this into the context of rehab, I think there's a couple of things that I can think of as a clinician. And the first is that physical vulnerability and emotional grief, they are challenging to navigate. And we want to recognize that not only are we working with individuals who have low physical reserve, but there is an emotional piece of recognizing the loss of physical capacities and the emotional load of the loss of people that love them and they loved. as they get older. So my dad is 67. He has lost his mom, his brother, his best friend, and another friend from school in the last two years. And he's like, this might be it for me. All these people that I planned my retirement with are no longer with me. And I don't want to go to the golf courses anymore. I don't want to engage in physical activity because the people that I wanted to engage in physical activity with are no longer there. diving deep into some of those conversations, we say at MMOA to get truly curious, but not only physically curious about the things that drive individuals, but emotionally curious about maybe some of the things that are holding them back. And I think that can be a really, really wonderful way to get into some of the barriers and recognize that it's a little bit more complicated than them just not wanting to engage in doing squats with us, right? And so that's kind of number one. Number two is it's heavy for us to be able to listen to things that are really sad, but we can have a very big role in trying to mend and heal some individuals who do not have somebody to talk to. We have a loneliness epidemic in our older adult spaces, really all over our generations, but that is compounded, that loneliness is compounded when the people that you are not lonely with have passed away. And so recognizing trying to create resources, whether that is resources within the community like seniors associations or gyms where individuals can connect and have new kinships, especially in the face of loss when they are ready to. is one way for us to create resources and networks. But additionally, having a person that you can refer that is a psychologist, a talk therapist, a psychiatrist too, but where the knee-jerk reaction isn't just prescribing medications. And I am not anti-medication, do not mishear me, but I think that the addition of, you know, our conservative side, we talk about how we are not anti-surgery, we are conservative management forward. Why are we not applying this same mindset when we are working with our older adults who are dealing with really heavy emotions and maybe have never been taught how to deal with grief? I am a parent who is trying to not hide, but make appropriate the work that, you know, of grief and grief processing with my five-year-old. And I am acutely aware of trying to teach her skills to manage sad emotions. But so many of our older adults don't, they don't have those skills. And so it's important for us to recognize some of those resources. And so where I'm going to challenge you all today is one, to lean into these conversations if you have them with some of your older adults. But two, is to do a quick Google search to see if you can find a talk therapist in your area that you could have in your referral network when these conversations do come up. And inevitably, if you're working in geriatrics, the concept of grief and loss will come up. I recognize that in the United States and in Canada, one of the hardest things is finding someone who's in network or taking Medicare and finding somebody who doesn't have a super long wait list. I totally recognize that. It may require a little bit of digging deeper and that can oftentimes be one of the biggest barriers for individuals seeking care through talk therapy and why our primary care physicians are leaning into med management. But sometimes, you know, the best thing we can do is try and find some providers, find individuals who work with older adults on the regular, and try and create those bridges and those connections when appropriate. All right, I hope you found that helpful. I kept it together pretty good, I think, considering all things considered. If you are looking to get into some of our older adult live courses for the summer, we have a couple of opportunities coming up. Our last opportunity in June is in Charlotte, North Carolina with Julie. That is June 22nd and 23rd. In July, we have three courses going. We have Virginia Beach, July 13th, 14th. Jeff Musgrave is up in Victor, New York, July 20th and 21st. And if you truly want the full experience of all of our MMOA faculty and staff, we have our MMOA Summit where Dustin and I are going to be teaching the course, but all of our teaching assistants and other lead faculty are going to be there. That is going to be in Littleton, Colorado, July 27th, 28th. That is going to be a super fun time if you are interested in hanging out with all of us and geeking out about older adult care, like that is the time to take MMOA Live. So if you have any other thoughts, questions, concerns, let me know. If you want to share some of your grief journey, I am all ears because It has been quite the couple weeks that I know that I'm just at the front end of this journey and I'm not gonna shy away from it. And it's definitely given me some new perspective as a geriatric clinician. Even when I thought I kind of had done my research and I've been in a lot of experiences talking about grief, it is so different when you're experiencing it yourself. All right, hope you all have a wonderful week. Signing off now, bye. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Lindsey Hughey // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses when, why, and how to perform cupping to the deltoid muscle. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How is it going? Welcome to Technique Thursday. My name is Dr. Lindsay Hughey. I am division lead of extremity management along with Dr. Mark Gallant, and I am here to talk to you about a deltoid myofascial decompression technique. So in honor of deltoid week, I want to share just a common technique we'll use. First, I will kind of give a little context of why we would use this technique, and then I'm literally going to show you how we'll do cup placement, and then how we'll follow that up with active movement. So we do passive, and then we actually do a little neuroreeducation to that area. WHY CUP THE DELTOID? So why we might choose this technique is someone that literally has pain with palpation at that deltoid, baby with abduction, they have a painful arc, and or when you manually muscle test into abduction and or flexion, they have some pain symptoms. So this would lead us to want to do this treatment. In our extremity management course, we usually call this the weak shoulder bucket. A lot of these folks fall under that umbrella. So I actually have an assistant with me today. So Paul is going to come and sit, and I'm actually going to have him sit like this. I usually have the patient either lay in supine, side lying, or prone to do this technique. But for ease of you all to view the deltoid, I want to have him sit, and then we'll have him lay on his side. So we want so just to orient us to the deltoid and I'm going to move this camera just a little bit right so the deltoid actually gets its name because it looks like an upside down delta so if these points all the way down to that deltoid tuberosity by the way to dive deep into the anatomy of the deltoid check out Clinical Tuesday with Ellison Melrose because we are doing all things deltoid this week. And she did a fabulous episode on not only the anatomy, but the function. So take a look at that. But here we're going to target, we want to target the anterior, the medial, and that posterior region. So some people think of this as like clavicle, acromion, or spinal. So what we're going to do is attach our cups to each of those regions and then all the way to that deltoid tuberosity. So I'm going to grab my gadgets. So practical things we need are some kind of lubricant. I'm going to use Free Up today, but it doesn't really matter, kind of your favorite lotion oil that'll help this stick. So I'm going to put a little lotion anterior, medial, and then that posterior, right? Because we have three main parts here. And then we'll go down to this deltoid tuberosity area. So I'm going to use these nice curved cups. These are actually the newest cups from our colleague and friend, Cup Therapy. So Chris DiPrato just came out with these and his team, and they are awesome for suction. We really, by the way, love myofascial decompression because it's really the only thing we have that really offloads tissue versus like our dry needling, our exercise, our massage, our wonderful treatment adjuncts. but they're compressive in nature. So sometimes this decompressive technique is just a novel stimulus to help that muscle relax and move better and activate better. CUPPING THE DELTOID So I'm going to start with that middle portion and I want For muscle, we usually want about 300 to 600 millimeters of mercury or pressure taken off. And there are gauges that pumps that actually show you that pressure. This is just a standard pump today, but just to keep that knowledge in your back pocket. And then we're going to go posteriorly. So again, I want to make sure lotion is there. I'm going to attach here. How are we doing, Paul? Such a good patient. Such a good model. And then we're going to go anterior. So I'll just kind of shift my body so that you all can see that. Again, we're pumping up. We try to get enough besides that 300 to 600 millimeters or mercury, but enough that they don't pop off. And if this do pop off during this demo, we'll just reattach. And then finally, down here, a little bit more lotion. And then we'll pump. We're getting a little slidey there, doing OK. Sometimes you're doing OK. Sometimes hair gets us, and we might. User error is always fun, too, when your hands are sliding. I'm just going to change this out. Here we go. That one, we needed to go, I think, a little bit smaller. That one was a little too big for the surface. That's why there's different size cups. OK. To visualize, we have anterior, medial, posterior, so we're hitting all parts of that deltoid. And then we're trying to sink into that deltoid tuberosity. For our treatment, I'm going to have Paul lay in sideline, so that shoulder is up. First part of this, and I'll just adjust the Instagram camera a little bit, is we're going to do some passive movement. So we're never just having the patient sit with the cups and doing nothing. It's very rare that we would just let this be a static treatment. So I'm going to take Paul's arm, and then I'm going to move him into all the motions that the deltoid produced. So that anterior is more flexion, internal rotation, abduction for that medial and then posterior contributes to extension and external rotation. So I'm gonna move in and out of all those positions. So I'll demo just a couple of those and then the next part is let's let the patient own this movement with some neural re-education. So then Paul will do those movements and I'll show you our favorite sideline trio for that. So I'm going to flex him and I'm moving my body with this. And then I might mess with a little bit of internal external rotation. And when you're up close to the cups, what you see is some pumping on off of that tissue. And I'll do just a couple more of these. And then I can even abduct. A little bit for Paul on off, and I would spend like a minute or so kind of going off on off and deflection, internal external rotation. I might even go into a little bit of extension. And then I want him to do some of these movements. So I'm going to go from behind to direct Paul and get out of your way. But one of our favorite things for the weak shoulder and to really light up that deltoid and even the cuff, because we know they work together in upward elevation, is we're going to do external rotation. Elbow straight, do flexion, come down, and then go to 90 and do horizontal abduction. So we're hitting all parts of that deltoid and the cuff with this movement. And we'll have Paul do a few of these reps unloaded, but then I'm going to give him a change plate, and I'm actually going to have him load this up. And probably the hardest part is just remembering all the movements. It doesn't quite matter what order you do it in, but what matters is kind of targeting all the different areas of that beautiful deltoid muscle. So go back to external rotation, and this is just like a real patient, right? There's going to be some error in each movement. Again, it doesn't matter necessarily the order. And then horizontal abduction. To make it a little harder, we're going to go ahead and give him a weight. So he's going to go ahead externally rotate. I'll just guide him through those first reps, elbow straight, go ahead and flex. Meanwhile, the pods are still attached, offloading that tissue. He'll come back to 90 and then horizontally AB duct, right? And then we'd give him a sweet spot. You can go ahead and relax. A sweet spot, what we call an extremity management, the rehab dose because we are targeting local tissue. So our rehab dose is anywhere from 8 to 20 reps, 3 to 4 sets, and we're taking a rest break of about 60 to 90 seconds. And our intensity varies from 30% to 80% depending on tissue irritability. But we've done this out. SUMMARY So some key things, we apply the cups, right? But then we actually move the human passively. Then we have them actively do the thing, neuroreeducation. And then finally, we take the cups off. And what we would do is reassess one of those things that blipped an exam, whether it was palpation, whether it was that presence of a painful arc, and or our manual muscle testing to see, did NPRS change with our palpation? Did painful arc, was quality of movement improved, and or NPRS, less pain associated with that elevation? The other thing, one little other pearl I want to share with the cups. So we remove the cups and then we'll massage that area a little bit. But what's neat is you can even take some pressure off. I'm taking this last cup off, but I can reduce the pressure a tiny bit and I can end with like a sliding technique where there's a little bit of offloading still present, but we're sliding along that tissue. for overall treatment dur be more than like 3 to 5 technique. And what's neat asterix very quickly. And pain. The motor bands tha immediately are a little and then they're able to elevate their arm better. And so this quick and efficient technique is one that I would really encourage you to use with your folks that have any deltoid and or cuff issues. You've heard me throw out some terms today regarding weak shoulder, the rehab dose, and the sideline trio. These are all terms that are really common to our extremity management course. So if you haven't taken it yet, Mark and Cody and I and our team to see you on the road an offerings. If you check u dot com in the summer. So in Salt Lake City with Ja and 14th will be in Kent, Washington again. And then July 20th, 21st will be in Hendersonville. So Cody will be there. That is bound to be a blast with that Hendersonville crew. And then it keeps on coming. We have another course in July, Bend, Oregon. So a lot of West Coast opportunities. So my West Coasters join me. I will be doing all those West Coast courses. And then we have more offerings in August. So you can't miss us. Thank you for joining me on Technique Thursday to learn a little bit more about the deltoid. And thanks to Paul, my patient who always looks like he's sleeping, but he's actually awake and with it. I hope you all have a beautiful day. Take care. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.