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It's kinda perfect timing to have Dustin and Brayden, the blood brothers behind Blood Brothers, on the pod the week of our huge event (the GET IT IN YA!™ SpecTAPular) we're throwing in their space on May 31st. Strangely, this is the first time the brothers have graced the pod to give us their story, and they broke it all down in detail. They also chatted about the Ontario scene at the time (2015) and their homebrewing roots, their entrance into the scene and the popularity of their Guilty Remnant White Stout, the optimal packaging size for barrel-aged stouts, how they grew from a homebrew spot to their brewpub to their new facility, the price of big stouts and how adjuncts work, how the event came together, the tariff situation and their current approach to distro in the USA, and the Blood Brothers x BAOS Podcast collaboration pastry stout. They crushed four BB bangers - Yeti Pilsner collab with True History, Friendly Beers Oat Cream IPA with Fine Balance, Emerald Den West Coast IPA, and Boya Barrel-Aged Imperial Stout with Donuts. This was a gem - cheers! GET YOUR TICKETS BEFORE MAY 31st: getitinyafest.com BAOS Podcast Subscribe to the podcast on YouTube | Website | Theme tune: Cee - BrewHeads
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 discusses the concept of "stronger with less," focusing on low dose training for older adults. He highlights a recent publication that challenges traditional biases regarding the dosage needed to elicit a positive response in older adults. Dustin aims to provide hope and practical insights for healthcare professionals, particularly those with limited interaction time with patients. He emphasizes the gap between recommended physical activity guidelines—such as 150 minutes of vigorous activity or 300 minutes of moderate activity weekly, along with resistance training—and the reality that many older adults, as well as healthcare providers, struggle to meet these standards. Dustin addresses the tension that arises when considering effective interventions that may fall short of conventional expectations, particularly in settings like home health and skilled nursing facilities. 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.
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 discusses the critical relationship between protein intake and bone health, particularly in older adults. He highlights the growing conversation around protein, often associated with muscle benefits, and emphasizes its significance for bone health, noting that 33% of bone mass is made up of protein. Dustin reviews current evidence on how protein influences bone growth through mechanisms like insulin growth factor IGF-1. Jones underscores the concerning trend of malnutrition in adults, particularly regarding protein intake, and calls attention to studies that examine whether older adults meet the minimum recommended protein guidelines. 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.
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 discusses the crucial yet often overlooked component of care for older adults: psychosocial resources. Despite thorough evaluations and well-crafted intervention plans, many clinicians find that their patients struggle to engage and make progress. Dustin highlights the importance of assessing psychosocial factors that can significantly influence patient outcomes. He shares insights from his experiences, emphasizing the need for healthcare providers to consider these variables to enhance their effectiveness in treatment and improve the lives of their older adult 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.
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 discusses the crucial topic of myocardial infarctions, commonly known as heart attacks. Drawing from a personal experience involving a loved one, he highlights the importance of understanding both the intervention and the long-term care following a heart attack. Dustin points out the seasonal increase in heart attack risks, particularly among older males, as physical activity tends to decline during winter months. He emphasizes the dangers posed by sudden, higher-intensity activities, such as shoveling snow, which can lead to increased heart attack incidents. The episode serves as a call to action for rehab and fitness professionals to support individuals during these challenging times, providing valuable insights into prevention and care strategies. 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.
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 discusses the concept of intentional under dosage, particularly in the context of working with older adults. Dustin shares insights on when and how to effectively implement this strategy across various settings, including clinics, homes, hospitals, and gyms. 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.
In this episode of the MMOA podcast, Dustin Jones interviews Mike Studer, a prominent figure in physical therapy, discussing his extensive career and the motivation behind his book, 'The Brain That Chooses Itself.' The conversation explores the importance of choice in health interventions, the role of autonomy in patient care, and the value of discomfort in therapy. Studer emphasizes the need for clinicians to create moments of unexpected success for their patients and the significance of identity in health choices. The episode concludes with resources for clinicians to enhance their practice and patient engagement. Chapters 00:00 Introduction to Mike Studer and His Impact 02:55 The Motivation Behind 'The Brain That Chooses Itself' 06:03 Structuring Choice in Health Interventions 09:01 The Role of Autonomy in Patient Care 11:52 Conversations on Health Span and Patient Engagement 15:03 The Value of Discomfort in Therapy 17:49 Creating Moments of Unexpected Success 21:01 The Power of Near Misses in Therapy 23:55 Earning Self-Efficacy Through Experience 26:52 The Importance of Identity in Health 29:55 Conclusion and Resources for Clinicians Links: https://Mikestuder.com mike@mikestuder.com
Send us a textThe official Road To Nashville 2025 starts now! Dustin Jones joins Alex and Nick for the first of a weekly series we will be doing as we lead up to the 2025 GNCC and NWTF Convention. From stories past to present ideas, Dustin brings some great conversations to the table as well as some interesting takes on things. Thanks for listening and continuing to support us! Videos Available for your viewing pleasure over on YouTube at https://www.youtube.com/channel/UC1dWYyR5QqE_dVwGvr6_eAQ Find us on the socials!!! https://www.facebook.com/talkaboutitoutdoors https://www.instagram.com/talk_about_it_outdoors/ Check out our partners! Cruzr Saddles https://www.cruzr.shop Grim Reaper Broadheads https://www.grimreaperbroadheads.com The KT Team https://thektteam.org Cal Hardie Arrowhead Land Co. 770-296-2163 All our links! https://linktr.ee/talkaboutitoutdoors
In this episode of the MMOA podcast, Dr. Dustin Jones and Rashelle Hoffman discuss the various paths to specialization in physical therapy, particularly focusing on geriatric care. They explore the pros and cons of pursuing a geriatric residency versus sitting for the Geriatric Clinical Specialist (GCS) exam, highlighting the importance of mentorship, clinical reasoning, and the impact of physical therapy on older adults. The conversation emphasizes the need for better representation of geriatrics in physical therapy education and the potential for significant improvements in patient outcomes. Dr. Rashelle Hoffman Faculty Profile: https://www.creighton.edu/campus-directory/hoffman-rashelle Takeaways: -Specialization in physical therapy can enhance skills for specific populations. -Geriatric residency programs offer structured mentorship and clinical experience. -Sitting for the GCS exam demonstrates knowledge but lacks practical application training. -Continuing education can be a viable alternative for specialization. -Financial considerations are important when choosing a specialization path. -Residency programs can fast-track the process to sit for specialization exams. -The impact of physical therapy on older adults can be profound and rewarding. -Not all residency programs provide the same quality of education and mentorship. -The demand for geriatric specialists is growing, but interest in the field remains low. -Collaboration with fitness professionals can enhance care for older adults. Chapters: 00:00 Introduction to Specialization in Physical Therapy 03:41 Exploring Geriatric Residency Programs 20:09 Pros and Cons of Sitting for the GCS 29:15 Continuing Education as an Alternative Path For More helpful content, go to https://MMOA.online
Dustin Jones, MMOA Faculty & StrongerLife Co-Founder, was recently interviewed by CrossFit to discuss "Coaching the Aging Athlete". This is a great conversation discussing limiting beliefs, the importance of intensity, how to get folks into the gym, and much more! Watch the original live stream here - https://www.youtube.com/watch?v=R6zY6kwqVgw
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 discusses the concept of cognitive fitness. What are the key steps to build cognitive fitness? A recent publication by Harvard Health has outlined 6 steps to maximize cognitive fitness, cognitive reserve, and overall mental health. 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.
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 the keys from a newly published article he co-wrote with Dustin Jones. The article focuses being providing tips to for rehab professionals to have a smooth transition of their patients into group fitness. 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.
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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. 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. Jeff Musgrave, Doctor of Physical Therapy shares about his experience helping to build an Older Adult Group Fitness program called StrongerLife with his buisness partner Dr. Dustin Jones. This episode includes helpful considerations and access to free resources that will help you if you build your program! *Want to make sure you stay on top of all things geriatrics? Go to https://MMOA.online to check out our Free eBooks, Lectures, & the MMOA Digest!
@thefowlhunter sits down this week with owners and operators of @737duckcalls and @737duckclub Kyle Sanders @737chief and Dustin Jones @djones737 We discuss their season, what's new for this season, the ongoings at 737 and give details on their upcoming Duck Bash at the incredible 737 faciility in Seminole, OK on June 1. Thanks for listening in and hope you make plans to come see me and 737 team next month #enjoythejourney To learn more about 737 Duck Calls, visit their web site: https://737duckcalls.com
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 discusses helping patients better understand their osteoporosis diagnosis, including learning to read a DEXA scan. Dustin also shares tips on discussing prognosis with patients as well as using the data supporting their osteoporosis diagnosis to inform your treatment choices & plan of care development. 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 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, an 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 JONESWhat's up team? Dustin Jones here. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Today we're talking about osteoporosis diagnosis, prognosis, and treatment. This is a big topic that so many of the folks, older adults that we work with, they will receive this diagnosis or have this discussed with them. And a lot of times it's not given a lot of context or they don't have full understanding of what this really means for them and what they can do about it. Most importantly, what they can do about it. All right, so let's get into this. OSTEOPOROSIS: DIAGNOSIS We'll start with the diagnosis piece, just really defining what is osteoporosis and then spend a little bit more time on the prognosis side of things and the treatment because I feel like that's where we have a lot of opportunity to really serve our folks well. So osteoporosis, we're going to review, go all the way back to your formal training when you learn some of these numbers. that we may have forgotten, all right? So when someone is, when that conversation of bone mineral density starts to come into play, usually it's for postmenopausal women or males over 50 years old, start to look at bone mineral density. And the way that we can measure, objectively measure bone mineral density is through a DEXA scan. You'll see that D-X-A or D-E-X-A, that's Dual Energy X-Ray Absorbed Geometry or DEXA. This is the reason why everyone calls it that. So you're basically looking at bone mineral density. And if for individuals that are over that kind of 65 year range, you're going to get a score. That score is going to be a T score. And so we're taking the measurement of the minerals in the bone in a certain area and comparing that to same sex and race norms for a younger population. So we're comparing it to a younger cohort, and that's where you'll get those T-scores. And so based on those T-scores, you will get maybe something from 0 to negative 1, and that is considered to be normal and healthy. Then that negative 1 to negative 2.5 is that osteopenic range or osteopenia which means the bones are a little bit weaker but not full-blown osteoporosis just yet and then below negative 2.5 and below they will receive that osteoporosis diagnosis. Typically, along with the DEXA scan, a physician is doing a FRAX screen. This measures the 10-year risk of having a fracture. There's some different lifestyle questions and it'll basically spit out a percentage of likelihood that that individual is going to have a fracture within the next 10 years. And so those two pieces of information really formulate the, or someone giving a diagnosis, but then also the treatment that follows. And then based on those T-score readings, as well as the FRAC score, the pathways are typically, there's gonna be some pharmacology involved, right? Whether we're preventing bone resorption or really encouraging more bone formation and remodeling. And then they're typically going to give some blanket generic recommendation of exercise of weight bearing exercise. All right. Now, the tough part about this diagnosis, it can come from a whole host of different providers. So you can see primary care physicians, you know, kind of leading the charge of, you know, looking into bone mineral density. Internists can as well. Orthopedic physicians can as well. And so there will be different doctors that will be kind of looking into bone mineral density. And then they will often refer out to someone like an endocrinologist, for example, for further treatment and so there's a lot of people kind of involved talking about this and what at least I have seen is that this has been a topic that has been brought up and a lot of fear has been revolving around this topic but not a ton of guidance of what it really means day to day to really influence bone mineral density beyond taking that pill and you know quote-unquote weight-bearing activities. I've just worked with so many people that did not understand that diagnosis and what it actually meant. So just understand that. I'm not saying that always happens, but in a lot of the folks that I work with, that is typically the case. OSTEOPOROSIS: DIAGNOSIS So they're given this diagnosis and now let's talk about the prognosis. In particular, what I want to speak to is the opportunity to really dive in to the DEXA scan that our patients receive. And I'm not saying it is our place to kind of give a medical prognosis per se. Well, I guess when I'm saying prognosis is what can they expect going forward and to give them context of that diagnosis. So I'm mainly working the context of fitness now at Stronger Life in Lexington, Kentucky, and it's a gym for folks only over 55. And we're about four years old now, and so over the past four years, we've had a lot of members that have had at least a couple DEXA scans at this point. And so I'll put a field out for folks to send me some of their DEXA scans, and this is something that, these are conversations I'll typically have with folks anyway, once they get their DEXA scan. This is something I want you all to do. I want you to ask some of your folks that have osteoporosis on their, you know, their chart, their diagnosis list. Say, Hey, can I see your DEXA scan? Or, you know, if you're in a medical system, look up their DEXA scan, because it's really interesting. And you start to look at a lot of these reports and you'll have some of them that are more kind of narrative based, um, that, you know, are basically just several paragraphs kind of outlining, um, you know, what to expect, what they found, something more along the lines of, a bunch of words if you're not watching I'm just holding up some of these DEXA scans but more narrative but then a lot of them will actually have graphs of T-scores when they had that DEXA scan and where. So the most common areas are going to be the lumbar spine, the neck of both femurs, bilateral femurs, and then they'll kind of zoom out a little bit and look at the total hip as well. And so get those DEXA scans and look at some of those numbers. And when you start to look, what you're often going to find is variation amongst the different sites. So you can have individuals that may have that negative below negative 2.5, negative 2.5 or below, let's say at the neck of the left femur, for example. And then the neck of the right femur may be negative 1.7, osteopenic. The lumbar spine may be negative 1.5, for example, osteopenic. And so technically that person has osteoporosis on the left, on the left side, right? The right and the lumbar spine does not have osteoporosis, osteopenic, still a concern, right? But not as bad as that left side. That message is often missed by many of our patients. Now, I believe they're getting that message, you know, when they are getting these reports and having conversations with some of the physicians, but they're probably getting all kinds of recommendations. They're getting that diagnosed and all kinds of things that, you know, we only may only hear half of what is actually being said. But a lot of folks I work with, they will receive that diagnosis of osteoporosis that in reality is only in their lumbar spine, for example. and they will take that and own it as if every single bone in their body is brittle and about to combust under any type of pressure or load. They embrace that diagnosis as it's this global systemic osteoporosis. Every single bone I have is tremendously weak without acknowledging that there's some variability in different areas of the body. That piece of information for folks can be really eye-opening and very empowering. Oh my gosh, are you saying that I only really have this in this particular area of my body and not everywhere else? That's a sense of relief for a lot of folks. A lot of folks will take this diagnosis and view it as almost like a death sentence. everything. I am so weak. I'm so fragile. I need to be very careful. I'm going to break something, any bone I need to be very, very concerned about. Right. And that's not necessarily what's happening. It's usually in kind of one, maybe two areas that are a concern, particularly folks that are initially receiving these DEXA scans. And the cool thing about where I'm at now, working with folks for over four years, this individual, she's had a DEXA scan every two years. She was on a negative slope, negative three in 2017, negative 3.1 in 2019, negative 3.4 in 2022, and her most recent scan a couple months ago was negative 2.8. This is at her lumbar spine. and when you are able to give context to the diagnosis but then also be able to see over time you'll be able to spot trends and then hopefully be able to potentially reverse trends or slow down trends and we're seeing this at Stronger Life and I know many of y'all don't have the luxury of working with folks consistently you know three times a week over the course of several years but man if we can apply some of the interventions I'm going to talk about here in a second over the course of years you can have a significant influence in a lot of these DEXA scan readings and we're definitely seeing that and you can too. But I think that conversation, the prognosis, them understanding the diagnosis, where in particular that may be, that they understand every single bone in my body is not going to combust under pressure. This particular area may be more concerned, but I'm doing okay in these other areas. It's really good for them to hear that and that can be a more empowering message. OSTEOPOROSIS: TREATMENT Now the most important thing I think is that we take the information from this DEXA scan and then we use it in our plans of care. And so if I have someone that has maybe normal osteopenic in terms of the DEXA scan in their bilateral femurs, neck of their femurs, but then they're kind of borderline osteoporosis in their lumbar spine, for example, as a physical therapist, That gives me something that I can focus on, that I can give targeted interventions to give specific forces and stressors to that area in a very progressive manner, keep in mind, to stimulate a change in that bone mineral density or increase the odds that we can see change in their bone mineral density. So we take that information, use it for our plan of care. Some folks, you may be focused, all right, this left hip, let's load up this left hip a little bit more, do some unilateral stuff, staggered stance type things, not neglecting the other side per se, but if there's a big difference, we may want to give preference to one side or the other. If it's a spine, lots of loaded carries, deadlifts, those types of things where we're getting that axial compression, getting those forces through the spine. We can give target interventions. that's gonna encourage those bones to remodel, to get stronger, or potentially slow down, decline. So we take that information and take it into our intervention piece. Now for the intervention piece, you know, this is a 15, 20 minute podcast. We have a whole week on this in our NYA Level 2 course. But what you need to know is there are three things that are really, really important if osteoporosis is on board. One is balance training. This doesn't directly impact bone mineral density, but if we're able to improve people's balance capacity, I would even go as far to say their fall capacity as well. Do they know how to land? Do they have the balance capacity to even prevent the fall? That whole conversation of falls prevention and falls preparedness that we speak to, particularly in our live course, is really helpful for these individuals. Because if we can prevent a fall or even teach people how to fall in a more efficient or safer manner, you can potentially prevent an injurious fall or an osteoporotic-related fracture. So that's the first thing. Second thing is progressive resistance training. Bones really like progressive resistance training, where we're working up to relatively higher percentages of a one rep max, 70, 80, 85%. We're not going to come out the gate hitting that, but it'll take some time. But there's some really promising studies showing that, man, if people are able to regularly train at those higher intensities, they get really strong. They improve in a lot of the functional outcome measures that we care a lot about, but also their bone mineral density as well. Lyftmore trial is a great example of one group that's been able to show that. And then probably one of the more neglected things that we can definitely implement that can be intimidating for a lot of folks, but I found a lot very empowering for patients once they're able to do these things, and that is impact training. Weight-bearing as well. Loading the bones, but really thinking about the rate of loading. Progressive resistance training puts a ton of force, a bunch of load through that skeletal system that gets really good results. But bone can also respond really well to rapid loading. So think like plyometrics, stomping, heel stomps. step-ups, maybe a plyometric push-up, for example, or a quick bearing of weight through the upper extremities, something along those lines, where we're getting those increased ground reaction forces, we're getting those impact that can give the bones a signal to remodel. You take balance training, you take falls preparedness, sprinkle in some progressive resistance training, and then sprinkle in some of that impact training, and you stretch that out over years, And I will put my money that you're going to see some solid results when your patient comes back and says, Oh my gosh, Alan, look at my DEXA scan I just got. Remember the previous year, about a couple of years ago is like right when we started working together. And then man, I just had this DEXA scan and I've reversed my osteoporosis. We've seen that. Not to say it's going to happen every time, but people have the capacity to change and we often don't perceive that with this particular diagnosis. It is not a death sentence. There's a lot we can do. So understand the diagnosis, but then also understand that prognosis and give your patients context. Get that DEXA scan, look at it, analyze it. It's going to give you a lot of helpful information that they may not have comprehended and it can ease their mind of a lot of concern and worry, but it can also give them, something that they know they can do. And we can take that information and give a targeted intervention to a particular area that may be more troublesome than others. But man, if we combine that balance training, falls preparedness, progressive resistance training, and impact training with folks over a long duration of time, we can see some really significant results. All right, y'all. I appreciate y'all taking the time to listen. Let me know if you have any thoughts, questions, or your experiences working with folks. I do want to make sure I'm not saying everyone's going to get better. Everyone's going to improve their bone metal density. That is not the case. But man, if we can try without causing more harm, I think that's a good thing to pursue. And oftentimes, we can see some improvement. SUMMARY Before I go, I do want to mention our MMOA courses. I already mentioned that level 2 where we talk a lot about osteoporosis. Our online level 1 course is starting May 15th. Our level 2 course is starting May 16th. These are both 8 weeks long, about 2 hours a week, so you'll get 16 CEUs for PT, OT. and we equip you all to be the go-to clinician to best serve older adults in your community. It's likely gonna make you a very, very busy clinician serving these folks. And then our live course, we're gonna be in Bismarck, North Dakota, in Richmond, Virginia on May 18th and 19th. I'm gonna be in Scottsdale, Arizona, the beginning of June 1st and 2nd, and then we'll be in Spring, Texas, June 8th and 9th. We'd love to see y'all on the road or see y'all online. Y'all have a lovely rest of your Wednesday and go check out those Texas games. See y'all! OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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.
How much are you challenging the older adults you work with What biases do you have about someone when you see their age or comorbidities? Are they limiting how much you push them? Have you ever thought about the consequences of not pushing someone enough?? On today's show we interviewed Dr. Dustin Jones, PT, DPT, GCS about his approach to working with aging adults and how it challenges the norm. He was working in skilled nursing facilities and seeing nearly everyone with the same exercises and plans of care despite varying abilities. This led to a desire to change the approach to care to be about determining what is really possible for aging adults and questioning why we only reserve more challenging work for those who are younger. In the episode Dustin explores how many therapists make assumptions (often ageist) about what someone is able or not able to do that isn't backed up by research. He discusses the fear that something could go wrong when you challenge an older adult and challenges you to consider what could go right. If you approach it the right way, honoring their system and giving time to adapt, older adults have so much to gain by doing heavy lifting and strength training. The bigger risk for this population is actually to underdose them. People who are stronger and more fit have an ability to overcome more illnesses and stay independent longer. We discuss how to have conversations and set expectations for hard work outs that could lead to soreness or even orthopedic flare ups and how this is actually less risky as a consequence of pushing someone than the alternative outcomes that can happen is they aren't as strong as possible, such as illnesses and chronic conditions from being sedentary. Keys to success with a fitness forward approach include ensuring the exercises are aligned with the patient's primary goal. If they have pain, address that first but still have the conversation about where you're going. Keep tying the exercise approach back to their independence and functional goals, and help them see the connection. Make sure they know the worst thing they can do is stop. Assure them to keep coming back so you can help them through it. Dustin runs StrongerLife, a gym for people over 55 and teaches Modern Management of the Older Adult as part of the Institute of Clinical Excellence, or PT on ICE. Learn more about Dustin and StrongerLIfe at www.StrongerLifeHQ.com Modern Management of the Older Adult - PTonICE.com @mmoa.icephysio @strongerlifehq
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 discusses the gap between someone given a diagnosis and then a prognosis. Whether it's a matter of seconds or decades, we'll discuss the huge opportunity in that gap to impact our patients as well as practical takeaways. 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 JONESGood morning, 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 lead faculty within the older adult division. Today, we are going to be talking about minding the gap between diagnosis and prognosis. Mind the gap between diagnosis and prognosis. I'm going to share a personal story of some experiences I've had lately as a patient within the healthcare system. And I've experienced what many of our patients are experiencing as well, and that is that gap between receiving a diagnosis and then potentially, sometimes not even, right, receiving a prognosis of what that diagnosis actually means. This is an area that we spend most of our time in with the folks that we serve, and I think this is a huge opportunity to serve these folks well and potentially do some damage control and kind of rewrite a narrative that's going on in their head. So this Mind the Gap phrase, it originates from the United Kingdom. So if you ever go on any public transit, you're in a subway, for example, and you've got kind of the train platform and the train pulls up on kind of the curve of that train platform, it's going to say, mind the gap, basically beware, right? Beware of the gap between this platform and the train. And this, this phrase, you know, is a cautionary tale, right? That you are being careful. And I feel like that, cautionary perspective, it needs to be applied to when we give something a name, aka a medical diagnosis, and then the prognosis. That we need to mine that gap, that space in between giving someone a diagnosis and when they're giving the prognosis of that particular situation. I'll share my story. If you're watching this, you see an obnoxiously large bandage on my forehead. I have recently had a spot on my on my temple that was a little curious, right? So I went to the dermatologist to get it checked out. I haven't been to a dermatologist in, man, probably 20 years at this point. I don't get regular checkups or anything along those lines. But I went, they saw the same spot. They say, hey, let's take a biopsy of this and see what this is. All right, cool. So they take a biopsy, about five days to get results. And in that five day period, you got all this stuff running through your head, right? What could this be? Could this be some super gnarly, Skin cancer, for example, is this gonna be something serious or is it is it, you know Just something to not worry about. I don't know. I'm in that five-day period then I get the call from the office This is a call that I've been waiting on for about, you know Five days solid days now and I get a call and the individual that called me was I would say Roughly kind of 22 24 year old pray fresh out of undergrad working as kind of the billing clerk within this dermatology practice. And she calls me and says, hello, is this Mr. Jones? I said, yes, this is him. All right, thank you. It's good to talk to you. I wanted to give you your lab results and just kind of tell you the next steps going forward. So with that area on your temple, well, you have, you know, basal cell carcinoma. So you got skin cancer there. and we're gonna schedule a Mohs surgery to take that out. And then you've got a dysplastic nevus, I'm probably butchering the pronunciation of that, on your scalp and we're gonna excise that as well. When would you like to schedule these procedures? Literally, that's all this person said. And so I want you to put yourselves in the shoes of someone that may at some point have learned about the different types of skin cancer and which ones are more concerning than others. But in that moment, you may not remember, right? You're giving this diagnosis of cancer and a procedure that you have had some patients, right, that have had a Mohs surgery before. Very straightforward procedure where they basically just shave off skin and then assess if they got all the cancerous cells. And they just continue to do that until they find no cancerous cells. A lot of our patients, especially if you work in geriatrics, you're used to these types of surgeries, but you may not necessarily understand what it really means, right? And then, you know, the seven-syllable diagnosis for the other lesion, and it's gonna get excised, you know, just all these words. And just imagine what can happen, what runs through your mind in that situation. And it was fascinating for me because this was all laid out on me. without any context, without any prognosis, no understanding in the moment of what this actually meant. and they were trying to schedule a procedure. And I asked to speak to someone to kind of give me an idea of what this means. And it took about three minutes to get a PA on the phone to kind of give me an idea of what this actually meant, right? Basal cell carcinoma, very, it's the least aggressive out of any of the skin cancers. You take that out, you don't have to worry about it. We'll just follow up with regular skin checks. Not a big deal whatsoever. all this other piece that you have, it's basically just a mold that we're not necessarily sure if it could turn into something gnarly, so we're just gonna take it out just to be sure. That was not given to me, but that three minute gap, the stories that I told myself were fascinating. I was thinking about my life insurance policy. What are my kids gonna do if I'm not gonna be on this planet for much longer? What's Megan, my wife, gonna do? Just thinking about all the ripples that come with that getting that diagnosis and just realizing, you know, your mortality in that very short period of time. So I would say overall, this is, I would say a relatively minor interaction, right? Everything's all good. I had this Mohs surgery yesterday. It's bandaged up. You know, I've got a nice little scar. It's going to be fine, right? But think about what this is like for so many of our patients. When they go to that doctor's visit, that specialist, and they get that diagnosis, And sometimes it is hours, days, weeks, months, and even decades before they get that prognosis of what it actually means to have that name, that diagnosis on your medical chart. This is where we typically operate, right? This is where we are typically interacting with individuals. and this can be a very, very scary place for folks. It has huge implications in their day-to-day life. So let's go through some common examples that we're gonna see where we are kind of in the midst of the gap between that diagnosis and prognosis. Two of the most common ones that I've experienced working with older adults is degenerative joint disease and then osteoporosis. So degenerative joint disease, you know, you have someone that may have some back pain, whatever, maybe knee pain. They go and get the image, right? and they see the image report, especially nowadays with your access to MyChart, for example, where you can see a full-blown report without full context, right? You're reading, you know, radiologist's report verbatim, and you see degenerative joint disease. And oftentimes, how often are these folks actually given context of what that actually means? How often are they told? You know what? At this stage of the game, this is actually considered to be normal. If we were to take a hundred pictures of a hundred people, right, at least 75 of those individuals are going to have the same findings, right? But not all those people are going to be in pain. So yes, you have this on your image, but it's not necessarily abnormal or something to be that concerned about. How many folks are hearing that when they see that diagnosis on that report, right? so often is left untouched, unnoticed, unaddressed, and they can have this perspective that their joints are just absolutely disintegrating day by day by day. And you stretch that out over years and decades. Think about how they can learn to perceive their joints, their body, their ability to adapt, their ability to improve. Do they have a positive or negative perception of the days ahead, right? Oftentimes, it's going to contribute to a negative perception that it's just downhill from here. That is something that we can clear up. We can show, hey, we know you had this diagnosis. This is actually considered to be a relatively normal part of aging that a lot of folks have this on their imaging and they're doing awesome. They're doing things. similar to what you want to be able to do, I know that you can get to that point and I can help you get there, right? So DJD is one. The next one is osteoporosis. This is more common in the realm that I'm working in. I'm working in the context of fitness right now at Stronger Life in Lexington. So it's a gym for folks over 55 and we have so many folks that come to us that have a diagnosis of osteoporosis. And oftentimes that diagnosis is given based on a number of a certain area of the body that may be demonstrating low bone mineral density. And I always ask folks when they have that diagnosis, do you have your DEXA scans? Has anyone gone over your DEXA scan with you? And nine times out of 10, they say, no, no one's ever really walked me through this DEXA scan and what it actually means. So I had them bring it in. And when you talk through a DEXA scan, you'll see that they will run their bone marrow density at different parts of their body. And so you could, you know, have those numbers ran at, you know, their bilateral femurs, for example, the lumbar spine, thoracic spine. And so if someone shows below negative 2.5, for example, on that DEXA scan, in one of those areas, they're gonna be giving this diagnosis of osteoporosis. And oftentimes when you're looking at that DEXA scan, it may only be one one place it may be osteoporosis like a negative 2.6 in the right neck of the femur and then the left femur may be in an osteopenic range it may be kind of under that negative 2.5 maybe negative 2.3 negative 2.2 that's a different story right that when they are given that diagnosis of osteoporosis nine times out of ten they perceive that every bone in their body is brittle and is going to self-combust under any load, right? And that is just not the case whatsoever. Usually it's in a certain area that is a little more troublesome than others and we can give target interventions to build that area up and to show noticeable changes in that DEXA scan if we can work with these people over a longer period of time. And so osteoporosis diagnosis is another one. They're often not given what that prognosis actually means, and often not, they are given a message of hope that they can actually do something about this beyond taking a pill and crossing their fingers for that next DEXA scan for those numbers to change, right? There's a lot that we can do. So these are two of the dozens of situations that we often encounter, right, where people are given that diagnosis And then they may get a prognosis or they may not. And that is where we live. And I want us to just really consider and appreciate the negative implications of this. The fear, the lower physical activity. Increased fear will often encourage them to be more conservative with their physical activity because they're afraid to get hurt for example. We've had folks at Stronger Life that have gone to a doctor's visit and gotten a diagnosis, osteoporosis being one of the, I would say three, but one of them that if not given a clear prognosis and they will be scared to death and almost try to cancel their membership to say they can't exercise anymore. That this is a very, very delicate situation that we often find ourselves in. So now let's talk about what we can do about this, right? I think I like to think about this in three steps. Assess, inform, and advise. Assess, inform, and advise. When you're doing your chart review, when you're doing that evaluation, you see some of these diagnoses. Congestive heart failure is another one. The different categories of congestive heart failure, some are more serious than others, right? But man, that term alone will scare you to death, right? Assess what diagnosis do they may have and what's their knowledge of that? I would include surgeries in that as well. Knee replacements. Total hips, right? Assess their knowledge and perception of that particular diagnosis. Do they have an accurate perception of what it means to have osteoporosis? Do they have an accurate perception of what it means to have a total knee replacement and the implications that that actually has on your life after? Right? Because so many folks think they can't do X, Y, and Z and that's just not the case. We're learning that day in and day out with these folks challenging a lot of these perceptions. So assess. once you assess and you can inform. I feel like this is where this is something that I wish we would not have to do, right? I don't want to have to feel like I need to clear up someone given a medical diagnosis without an accurate prognosis, but sometimes we have to. But I think we do need to be very careful here that we don't kind of overstep our boundaries and really speak to this person's situation in the sense of where we probably don't have any right to do that, right? So this is where I'd like to speak in generalities. I don't, I'm not going to pull up someone's, you know, imaging and assess it myself per se and say, Oh, this is, you know, okay, this blah, blah, blah, and compare it to others. Like that, that's not my job. Right. But I can say I've had folks that have had that diagnosis that have responded really well to this treatment. I've had folks that had that diagnosis and they were able to do X, Y, and Z. We can inform them of what can happen with some of these diagnoses, but I would want to respect our medical colleagues there, so hear me out on that. So we assess and then we inform, all right? This is where, particularly with osteoporosis, this is where I will get their DEXA scan, And I will just say, hey, this area, this is where you have osteoporosis. This area over here, this is actually osteopenic. It's a little bit stronger, a little bit more dense than this area over here. Give them context and inform them of that particular diagnosis when we can, right? And then last but not least, we advise. What can they do about it? What can they do about it? We need to give them control to give them the ability to rewrite the script, to develop some of that self-efficacy of the confidence that they can do something about that diagnosis that they've been given. And that's going to look different for each person, right? But there's so much that we can do, especially with DJD, with osteoporosis, with congestive heart failure. These are not, not death sentences. They are not death sentences. There are a lot of things that we can do as clinicians to help maybe improve their situation, and ultimately, a lot of times, to prevent further decline. There's a lot that we can do with a lot of these 10-syllable, very scary medical diagnoses. So, we assess where they're at, their perception of their diagnosis and perception of their prognosis. Is it accurate, right? Then we inform them. We want to try and make it more accurate and realistic based on the evidence, but based also on what you've seen as well in your clinical practice, and then we want to advise. When we're able to do that with someone that has not been given a clear prognosis or context of their diagnosis, man, you've really given their life back. You've answered so many difficult questions they've been wrestling with for sometimes hours, but sometimes decades, and you can really change their life as a result of some of these conversations. All right, thank you all for listening so far. I appreciate y'all. Before I log off here, I want to mention a few of our MLA live courses coming up. So this is an awesome two-day, very practical weekend where we dive into a lot of exercise, application, prescription, but also a lot of these nuanced conversations about kind of the softer skills of implementing that fitness-forward approach in the context of geriatrics, where we may talk about diagnosis and prognosis and how we can bake that into an exercise regimen to get people to really push themselves at a level they probably haven't done before. SUMMARY Awesome weekend. So, I want you to check out, if you're around Madison, Wisconsin, we're going to be in your neck of the woods March 23rd, that weekend. Then April 5th and 6th, we've got four MOA Lives across the country going on at the same time. I'll be in Urbana, Illinois. We have one in Raleigh, North Carolina, Burlington, New Jersey, and then Gretna, Louisiana, just outside of New Orleans. All right, there's tons of other MLive courses across the country going on through the spring, summer, fall, so be sure to check on there if none of those are close to you, but we're grateful for y'all listening and watching wherever you consume this podcast. Y'all crush the rest of your Wednesday, and we'll see 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.
Dustin Jones
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 Dives into why working on kneeling is not a matter of IF we should do it but WHEN. Dustin covers a sequence of kneeling progressions, designed to gradually expose patents to kneeling in a manner where they have control over how much they flex their knee & how much pressure they allow onto the knee cap. 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 JONESWhat's up crew, good morning and 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 lead faculty within the older adult division and today we are going to be talking about kneeling after a total knee replacement. kneeling after a total knee replacement. We're gonna dive into this somewhat hot topic if you will or debatable issue that we come across so often with our folks but more importantly give you progressions so you can actually get people's knees to touch the ground again. Alright this is a big issue that in my clinical experience I would often see the detriment of people not working on kneeling you know years decades after they had said surgery and it was really eye-opening for me and I'm sure many of you all as well to see what that does to people when they go for so long thinking that they are not allowed to kneel to let their knee apply pressure to the ground or that they're they're just afraid to right just think of all the functional implications that that has when you are scared to death to let that knee kiss the ground to be able to pick something up off the ground to be able to play with your grandkids to be able to kneel and garden right this is a This has huge implications for our patient's quality of lives and what's unfortunate is that it's often neglected, right? You think about your standard post-op protocol, what are you working on, right? You're trying to get full range of motion, trying to get that full extension, then really working on getting that flexion to be symmetrical with the other side. We're working on our strength deficits, we're working on our balance. and working on getting back to their independence in terms of gait as quickly as possible. But how many of y'all are getting applying pressure to the knee and progressing it to the manner where they're doing half kneeling, full kneeling, floor transfers, burpees, for example. How often is that getting neglected in the rehab setting? And it is far too common, far too common. NO EVIDENCE THAT KNEELING IS HARMFUL AFTER JOINT REPLACEMENT Now the unfortunate reality is we do not have any evidence to state that kneeling is actually harmful for individuals after they've had a knee replacement. There's even a really good article in the Journal of Knee Surgery, all right, so this is an orthopedic surgeon journal, in 2020, that basically said, I'm gonna read this verbatim, which I love this, there is no biomechanical or clinical evidence contraindicating kneeling after a total knee replacement. I'm gonna repeat that again for the folks in the back, there is no biomechanical or clinical evidence contraindicating kneeling after a total knee replacement. The folks that wrote this article and this quote are orthopedic surgeons from Johns Hopkins University that work in the orthopedic surgery department. These folks are doing lots and lots of total knee replacements, doing lots of follow-up visits. And they're saying there's no reason why we should not be kneeling with these folks. So I think for us as rehab providers and some fitness professionals as well that watch this or listen to this, it's not a question of if we're going to kneel, it's more a question of when. When are we going to kneel in that rehabilitation process? And how do we progress people to the point where they can bear full weight on those knees and trust that they're going to be just fine, right? KNEELING PROGRESSION So let's kind of go through some of these progressions. I'm going to do a reel later on, probably the next couple of days, giving you some tangible video examples. but I'm going to talk through this, especially for the folks that are listening, we'll make sure that you're able to understand kind of this progression that we're talking about here. Alright, so kneeling progressions, this could be in the span of, you know, a few visits for some of your patients, it could be the span of weeks, but there's some important things that we want to have when we're talking about kneeling progressions. is an Airex pad or some type of pillow, right? The home healthers, you got a pillow, probably have an Airex pad as well, right? But you want a soft surface that is mobile, that you can apply to different surfaces, like when you go to the ground, when you go to a box, for example, or some type of elevated surface. You want something that you can take in terms of a soft surface. That's going to be very, very helpful for that individual. And then you want to have good elevated surface options. In the home, it is the couch, right? It is maybe a step. It is a kitchen chair. It's a recliner. It's a bed. In the clinic, it's a therapy table. It may be a plyometric box that you can apply the Airex pad on to give some padding. It may be a lobby chair, for example. Or a bench is another one. You want to have lots of options for these elevated surfaces. So typically when we're thinking about kneeling, where we want to start is with just manual overpressure into extension, maybe their legs just propped up, that person is applying pressure themselves. They are in control, and that first entry into kneeling, we want to do it in a manner where they feel like they're in control. You're probably already doing some manual overpressure, working on getting that full extension back, so we're already covering that, but that is going to translate well when we're applying pressure to kneeling, all right? So doing all that work that you're already doing to get range of motion, that's a good place to start when we're thinking about getting to the point full kneeling. The big thing is that they are applying that pressure. We want them to be in control. because that is going to give them the ability to probably progress a little bit quicker. Alright, so manual overpressure, we're already doing that stuff. Now we're talking about actually getting maybe in a standing position or we're talking about maybe getting to a kneeling position. You want to think about what available flexion do they have, right? And what is the status of the incision? Is the incision healed? Is the scar tissue solid? Are we not worried about any splitting, any tearing, any bleeding, so on and so forth. So if we're kind of well past that healing phase, then all right, we're somewhere, we're in a good spot, but we also wanna be considerate of how much flexion that they have. So if they are really struggling with their flexion, let's say they don't have 90 degrees, or 90 degrees is really tough, we can still apply kneeling in a 45, 60 degree angle, but in a standing position where they're going to apply pressure into a horizontal, or sorry, a vertical surface, all right? So let's say you're standing, your knee is bent to 45, 60 degrees, can have some type of vertical surface. In the home health setting where I would do this, it would be a kitchen cabinet, typically, and I would have some type of padded surface. I would get them to bend as much as they're able to bend, and I would have them shift their weight and basically think about putting their knee into that cabinet or that vertical surface, applying pressure in that manner. They're still in control. They are grading how much pressure they're applying, but they're getting used to applying force through that knee. Alright, now when we get more or closer to full range of motion, 90 degrees is real easy for them to do, then we can think about tall kneeling. When we go tall kneeling, what can be helpful is to have one leg on the ground and one leg on an elevated surface, right, like a bed is a great example, but what's really important here is to have upper extremity support. In the home setting, what I typically do is at a kitchen counter, so I have the hand on the counter and And then I would have a chair on the same side as the surgical side. I would have a cushioned mat, like an Eric's pad, for example. They would put that knee on that chair, and then with their hands, they would shift their weight, shift their weight. They would be grading that pressure, and over time, they would get more and more comfortable, all right? The upper extremity support is really important. Some type of cabinet. If you're in a clinic with parallel bars, that's really great as well. That's going to be very helpful for these individuals. All right, that checks out. Awesome. Let's go on to quadruped. Bed therapy table can be very, very helpful where we're able to really grade that pressure and they're able to rock and shift back and forth. applying more and more pressure to that surgical side. Once they're in quadruped, you are 75% home, right? If they're able to get in that quad position, you're in a really good spot. This is where we're going to start working our way to the ground. Now, when we go to the ground, you want to think about the softness of that surface, right? That's going to be way more tolerable for many of these individuals in a really hard, cold surface. So, if you have maybe a gymnastics pad, if you can maneuver that Arix pad that you've been carrying around under their knee when they're going to the ground, that can be really helpful. You may have a set of knee sleeves. which can be very, very helpful for these individuals. Or you may say, hey, let's get on, you know, two pairs of sweatpants, for example. So just think of some cushion and some padding. When you go down to the ground, that's going to make it a little bit easier for folks. Then we can go all the way to the ground, get in quad, work on getting in prone, working on coming up. In this phase, you do want to have some upper extremity support around. We cover this extensively in our MOA live course where you troubleshoot floor transfers, but there are certain positions where you want a box or a chair at certain phases of a floor transfer that's going to make it conducive for them to be able to use their upper extremities. But have a chair around that you can move around so you can place it appropriately. they can put their upper extremities on it and help grade some of that pressure that they're experiencing through the knee. And as we're working on floor transfers, and they're getting pretty comfortable going to the ground and up from the ground, that's where we may just speed it up, where we may go on to a full-blown burpee, right? So this progression from kind of that manual overpressure early on, still kind of worried about the incision side, we don't have full range of motion, to where they've got partial range we can start to do some standing, not necessarily kneeling, but driving that knee into a vertical surface if they can't get that full 90 degrees and then we're progressing it down to where they're in that quad position doing floor transfers and progressing to a burpee. This is a kneeling progression that almost all of us can do with our folks in some way, shape, or form, right? And I challenge you clinicians watching right now that are listening right now. Zach Kaufman, what's up? I challenge you all to not think of if you want to consider kneeling in your post-op protocol or plan. It's more a matter of when. You need to do it. I've seen the implications of what that means for folks 10, 20 years down the road when they have had the fear of God instilled in them to get down on their knees. dramatically lowers their quality of life and what they are able to do and what they choose to do. It is absolutely sad to watch and you can prevent that by incorporating kneeling and kneeling progression into your plan of care that you're gonna give this person so much freedom to experience so many good things in life when they have the ability to let their knee hit the ground. All right, appreciate y'all. Let me know your take on kneeling after total knee replacement. We could say total hip as well. It's just as applicable for hip replacements too, but let me know your thoughts in the comments of this YouTube video or hit us up on YouTube podcast listeners. We'd love to have you jump on social media. I think this is a really important discussion, something that we often neglect, and I think we need to really change that narrative. All right, appreciate y'all watching. Have a good one. SUMMARY Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. 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 discusses what it looks like to discharge as a fitness-forward clinician. In this episode, we'll cover the do's & don'ts to discharging and even challenge the whole notion of discharge itself. 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 y'all to the PT on Ice daily show. My name is Dustin Jones, one of the lead faculty within the older adult division. And today we are gonna be talking about the fitness forward discharge, the fitness forward discharge, how we can set our patients up for that fitness forward lifestyle once they leave our doors, all right? So before we dive into this conversation, I wanna start by really saying that the whole concept or notion of the discharge as we know it, traditionally, really needs to be challenged, right? The whole concept of, I'm gonna see this person for six to eight weeks, and then I'm gonna have no contact with that person whatsoever, and then cross my fingers and hope that that person will hopefully come back if they do have issues down the road, right? Hopefully, we see some of the issues with that. Hopefully, we can see the problem with bragging about how few visits it takes for you to get particular results, right? It's like we've created this badge of honor for how little that we're seeing people. And if you spend any time around the Institute of Clinical Excellence at any of our courses, you start to see what you have to offer people. Why in the world would someone like you, a fitness-forward trained clinician, want to be around someone less. You have so many valuable skills. You have such an amazing influence. Your be a valid approach, this fitness for lifestyle that you lead and can ultimately give to your patients. Why would you not want to rub shoulders with these folks that you can absolutely change their lives, right? So the whole notion of discharge, I really want to challenge. I think the Onward Physical Therapy crew is doing such a good job with this with their Restore and Perform program where they will have patients and they will transition to more of a maintenance type situation. I know many of you all watching have similar services where they may come off of quote-unquote physical therapy but you're still getting those touch points to change their lives. That is really, really good. What I want to speak to today in terms of the Fitness Forward Challenge is for many folks that are working with individuals and patients that do not partake in fitness, that these folks are not a part of a fitness community and you're going to work with this person and we need to set them up for success after your course of care. How do we handle those situations? I know for The vast majority of you all watching and listening, that is the case. I can say that for myself, definitely in the context of home health where I've spent most of my time. clinically, but now I'm on the other end of the equation where I am mainly in the fitness space at Stronger Life Fitness in Lexington, Kentucky. So I've really enjoyed experiencing what it's like to get people into our fitness community from different clinicians and what clinicians have done really well to set them up for success, but also what they've done really poorly that's made our job really difficult. And I think about all the folks that even come into our doors because of something that happened in that course of care. All right, so the fitness forward discharge for you clinicians that are working with folks that do not partake in fitness right now. We're gonna dive into some practical things. I want you to think of this in three steps. All right, number one is that we start with the end in mind. Number two is we prepare for what's ahead. And number three, we test the plan. All right, I'm gonna dive into some specifics. within those three chunks. START WITH THE END IN MIND So number one, starting with the end in mind. Many of us will hear this saying all the time, especially when you are in a more acute setting like acute care clinicians, right? As soon as they do their eval, they're planning their discharge, right? That is For many of them, the goal is that, all right, what's the discharge disposition so we can get this person to a place where they can receive care? And I think that's a good mindset for us to have across the continuum of healthcare. Discharge planning starts day one. Where is this person headed? where are we taking this individual? Now, for you all, the fitness forward clinician, the question that we often ask ourselves, but ultimately ask the patient or the client, is how fit will you let me get you, right? Betty comes to you for her back, her back pain, and we're gonna take care of that back pain for sure, but ultimately we don't wanna stop there, right? We change lives, not just pain. We're gonna see how fit we can get Betty ultimately in her one rep max living and help her live the fullest life that she can imagine right that goes beyond pain reduction techniques right so how fit will you let me get you now what is really important when we start thinking about the next step after our course of care when we're discharge planning and starting on day one we need to consider what this person is going to be willing to start and but then also sustain in terms of a fitness routine. What they're willing to start and then sustain. And I would say the latter is more important. It's easy to start something, it's tough to sustain it for months, years on end. So this is where we really need to spend a lot of time understanding this person's goals, their desires, their deep desires of what they want to be able to do. What keeps them up the night? What would they want to be doing if they had no pain whatsoever? And then match the fitness regimen that could ultimately make that happen, right? And with that, we have to consider so many factors, like personal preferences. past experiences, their perceptions of certain communities or fitness modalities. What's their financial situation? What do they have available to them to help offset some of the financial barriers? If someone is on Medicare or have a Medicare Advantage plan, there's lots of things available to help reduce the cost of fitness services. Where are they located, right? Location is such a huge variable in the adherence and consistency of an exercise program when someone is leaving their home to partake in fitness. It's a lot easier for someone to go around the corner as opposed to driving across town, right? And what social support, what resources does this person have? We need to take all of these into consideration and that is going to form our recommendation of where we are headed and we can set that out very early on in the process. So for the outpatient clinician, many of you all watching, many of you all are probably a part of some type of CrossFit community or CrossFit box, right? And you may be treating some patients in the outpatient setting where that transition may make a lot of sense. They may be familiar with it. They may not have a lot of baggage associated with that brand or that gym, that CrossFit box. And that transition can be relatively easy for you. And that's a no-brainer for many of you all. But for a lot of folks watching and listening, they have patients that are likely never going to step foot in a CrossFit gym. And I would go as far to say that CrossFit gym is not the best place to serve some folks, right? I know that's blasphemous on this podcast, but the local CrossFit box may not be suitable for every single person that you're working with as a physical therapist. So we need to understand, are there communities out there that can meet this person where they're at and help them make this a sustainable long-term fitness routine? and for the home health clinicians watching. Is there something that could be done for someone that is currently a homebound status? Is there some type of online community? Is there some type of online service or some type of YouTube channel, for example, that someone could partake in and consume that's going to be suitable for their situation? You cannot make these recommendations without truly understanding the person sitting in front of you. So we have to dig in. What are they willing to start and then what are they willing to sustain? Now, this is going to require some work, right? You need to know the communities out in your area, of the differences of them, of how some may be more suitable or welcoming to other groups of people. there's gonna be big differences there. You need to understand what services are available online to folks that may not be able to get out, what services are available that are willing to accept some of these Medicare Advantage plans or Silver Sneakers or Renew Active if they're on United Advantage, for example. So we need to do some work so you can make some of those recommendations. If you're like, what in the hell is he talking about? Hit me up or join the MMoA community where we have a lot of these discussions and we have a really helpful resource of where clinicians threw in some of their favorite YouTube channels, for example, and different resources that they help encourage that fitness-forward lifestyle beyond discharge. But there's options out there. We can do the hard work for you. Hit me up, DM me, and I'd love to share some of those resources. So that's the first one. Start with the end in mind. PREPARE FOR WHAT'S AHEAD Two, we prepare for what's ahead. So we start with the end in mind and then we prepare for what's ahead. When we start with the end in mind, we get a good idea of maybe what type of fitness regimen, what type of fitness community is gonna be good for this person so they can sustain and continue their health journey, right? If we understand what that community and that regimen is about, we can prepare that person for said regimen in our course of care. And I view this kind of like graded exposure. or gradual exposure, where we're gradually exposing people to elements of that fitness community or fitness regimen. Let's take CrossFit, for example. Let's say you have a patient that has never done CrossFit and they have agreed, yeah, I'm going to join that community down the street once we're done. That's really interesting to me. You can do that person a solid by exposing them to some of the CrossFit movements, of some of the movements that you're commonly going to see in the programming. getting a barbell in their hand, teaching them some of the basics of a squat, a deadlift, a press, and then maybe even getting to Olympic lifting. Expose them to those movements to reduce that new member suck, right? We've all experienced it. There are some benefits to the suckiness of being new and not knowing a lot about what's going on in the community. I do want to acknowledge that, but man, it's really nice if you come into a community having a little bit of familiarity with some of these movements and jargon and so on and so forth. So we want to gradually expose them to the movements that are going to be coming down the pike. We also want to expose them to the intensity that they're going to see. This can also be new for a lot of individuals, particularly going into something like a CrossFit gym or some high intensity interval training bootcamps type fitness community, that if these folks have not experienced true intensity, we can do that in the course of our care and expose them to that so they're not blindsided when they join this fitness community. We would also argue within the MOA division that you want to do that regardless to get better outcomes, keep in mind. But when we also think about that fitness forward discharge, this is really, really helpful to do. So gradual exposure to that intensity that they're likely going to experience and then gradual exposure to the movements that they're likely going to see. The beautiful thing about this is it reduces that new member suck when you're partaking of something for the first time. But for a lot of our folks, it often gives them trust in their bodies, that they can trust their body again. Think of what so many of these folks have been through, especially the older adult population that I particularly work with. We're talking decades of different healthcare interactions, maybe a dozen courses of care in the context of physical therapy, who knows how many surgeries, who knows how many diagnoses that were given without context, who knows how many damaging words have been said to this person where they believe that they are weak, fragile, slow, that they are broken pieces. We have the opportunity to show them that is not the case. That is not the case whatsoever. You can trust your body again and you can push your body again and your body can improve and get better and you can do things that you thought were absolutely impossible. You can show people that through this gradual exposure. So that's how we wanna prepare, that gradual exposure to intensity and movements. Number two, we also want to give people a plan to troubleshoot the difficult scenarios that are going to come up, right? Jeff Moore always says this, and I love this, where he will talk about the path to fitness is always gonna run through some musculoskeletal issues, right? And this is where we are such a huge service for individuals, that we, throughout our course of care, can give people a plan to be able to troubleshoot what is ahead, what is common, the question of hurt versus harm. When am I doing damage versus when a little bit of discomfort is okay? Maybe giving them something like the traffic light analogy where, you know, that zero to three out of 10 is kind of that green light. Still send it, you're good. But if that lingers on to, you know, that four, five, six range, that's kind of in the yellow. We need to start thinking about modifying. We're still moving, right? And then, you know, that seven, eight, nine, 10, where we're in kind of that red light, where we're thinking, still need to keep moving but I may need to go come back and see you physical therapist or PTA or whoever you are so that strategy of if this than that so they understand the difference between hurt versus harm and when they need to come back to see you can be very very helpful another one particularly in a population that's not used to exercising is DOMPS. For many of you all you don't even remember what it was like the first time you felt delayed onset muscle soreness if you've been exercising regularly but for someone new it's a very frightening thing when they do something that they perceive is going to be beneficial and helpful for them and then they try to get out of bed the next day or the day after and they're absolutely miserable. a lot of things can go in your head of what may not be helpful or beneficial about what you did that caused so much discomfort and so you can give them context. I've made this mistake way too often where I did not give context to delayed onset muscle soreness and it really comes back to bite you. You can lose that that clip that trust of the patient but ultimately we want to give them the ability to handle kind of the ups and the downs to understand hurt versus harm, to understand DOMS and what to actually do about it, and ultimately, when they really need to come back to you versus continuing on in their fitness regimen or community. Alright? So, number one, start with the end in mind. Number two, prepare for what's ahead. TEST THE PLAN And then last but not least, and where most people really drop the ball, is we test the plan. we test the plan during our course of care. So as the course of care is winding down, we may be kind of reducing some of the focus on pain reduction and thinking more about building physical capacity. We're starting to stress test this person, of how they're handling what we know they're gonna experience down the road, right? This is where Alex Germano, she's watching here, but she has said before that we need to make PT sweaty again. And I absolutely love that phrase, and I feel like that is very, very pertinent throughout the whole course of GARE, but particularly for this phase. That last few weeks where we're stress testing our plan of care, where we're getting people sweaty in PT, seeing how they respond. These folks, we also, during that transition, want some overlap where they're actually partaking in that fitness regimen or a part of that fitness community. When we still have those regular touch points and we're able to handle some of the ups and the downs and what may come and answer some questions and just make sure this person is well prepared while they're under our care, that makes it very, very easy for them to continue and make this a sustainable effort. So we want to test the plan. stress test them in your session. Make PT sweaty again. And there's usually kind of a turning point that you'll see, particularly in Jerry PT, Jerry OT. And sometimes it happens sooner, right? If you really push intensity and your sessions are very challenging and it kind of catches them by surprise. But at the latest, this should happen. during this test the plan phase and what typically happens you got bob that's been coming in bob good old boy wearing his wranglers tucked in button up got a big old leather belt probably has some 30 year old fry cowboy boots rolling in here He's getting after it, just sweating his rear end off during your sessions. Then the next session comes around. What's Bob wearing? Bob's probably still wearing his boots, his fry boots. He's probably still wearing his button up, but he swapped out the Wranglers for some Fruit of the Loom sweatpants. still tucking the shirt in, the hem's probably right around his belly button, you know, that waistline area for them. He has seen, oh my gosh, this is not, quote unquote, physical therapy or occupational therapy. I'm going here to work out. We're getting sweaty, right? We're stress testing Bob, and he changed his outfit as a result. I cannot tell you how many times this has happened in the context of even home health, but then outpatient, and we definitely see this in the context of fitness. as well, but we want to try and see that. We want to stress test for if something bad happens, if they have some type of flare-up, for example, if they have some type of questions, we can handle it within our course of care. And ultimately, you're allowing a little bit of overlap where you're still seeing this person, but they're transitioning to that fitness community. That is what a fitness forward discharge looks like. We start with the end in mind. We're thinking about where this person is going. How fit are you going to let me get you and where are you going to end up? Whether it's a fitness community, whether they're doing something at home, whatever fits their particular needs, we start there. Number two, we prepare them for what is ahead. We make them familiar with the intensity, the movements that they're going to experience and we help them troubleshoot the challenging scenarios that are going to happen. DOMS, hurt versus harm. When should I seek care? when is it okay, when do I need to modify what I'm doing, right? Then number three, we test the plan. We stress test them while we have them in our course of care, while we're regularly seeing them. They may even already be starting that fitness program or fitness regimen. We're able to handle the bumps that come with that and really set them up for success as they continue forward. The fitness forward discharge. I appreciate y'all listening. SUMMARY Before you go, I want to mention MMOA courses. We've got a bunch of stuff lined up for 2024. If you want to see us on the road, I want to highlight a few weekends that are coming up. February 17th, 18th, this upcoming weekend we're in Oklahoma City, so catch that if you're in that area. March 2nd and 3rd, we've got Tripleheader. We're going to be in Rome, Georgia, Halifax, Canada, Glencoe, Maryland. We also have our Level 1 and Level 2 online courses. Our Level 1 course is going to be starting March 13th. We'd love to see you on that. Appreciate y'all. Have a lovely rest of your Wednesday. Go Crutchets! 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.
Accessories for Hand/Grip Issues with Dr. Dustin Jones, PT, DPT --- Want to make sure you stay on top of all things geriatrics? Go to https://MMOA.online to check out our Free eBooks, Lectures, & the MMOA Digest! #oldpersonintraining #oldnotweak
Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones covers some good accessories to have on hand (ha) when working with older adults. Links to these accessories and TONS of other equipment ideas are in our NEW Ultimate #Geri Equipment eBook. Download now by clicking HERE. 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 everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. DUSTIN JONES What's up crew? This is Dustin Jones. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'm one of the lead faculty within the older adult division. Today we are going to be talking about accessories for grip in hand issues. We do not want a sore hand, sore grip, sore wrist be the limitation of us being able to achieve higher intensities, right? This is a very common thing that we run into, right? When you are working in that old not weak mindset and philosophy that you are trying to put higher intensity loads on individuals, right? You're gonna run into bears, and we're gonna talk about how we can overcome these with different accessories and different strategies, all right? The first one I wanna speak to is a very important intervention that we will do very often in the realm of geriatrics, and that is weight bearing, floor transfers, think ground mobility, right? The ability to have confidence and independence in a floor transfer just has huge implications for folks in so many areas of life that it really reduces their fear, their fear of falling, and ultimately improves their confidence in what they can do. The walk across the room, if they fall, becomes a little bit less scary. And just think of the implications of that, right? But when we often go to do those transfers, when we go to bear weight on the ground, that can be kind of troublesome for the wrist in particular. but we don't want that to be the reason we don't do this type of intervention or transfer. WEIGHT BEARING: THE SURFACE So if we're bearing weight, one thing I want you to think about is the surface. If we're going to and from the ground or maybe a higher level like a bed or a therapy table, think about the The surface in the sense of, you know, you probably want a little bit of cushion, a little bit of softness is great, but if you have too much, that can actually be troublesome for folks. It may feel great on their knees, but it's not gonna feel great on their wrists for most individuals. If it's too soft, what ends up happening is when we go to bare weight, our palms really press down, we end up going into wrist hyperextension, which for a lot of folks is not a comfortable situation. So when we think about surface, when we're going to do floor-based activities, ground mobility, Soft, but firm. Soft, but firm. You don't want a super soft, cushy surface. Soft, but firm is going to be better, provide a little bit of cushion for the knees and a little bit better for the upper extremities and the wrists, for example. WEIGHT BEARING: CHANGE TE HAND Next thing you want to think about is maybe if we don't go open hands, maybe we go fists. That'll be a little bit easier. We could also think about using the forearms as well. And so that's the first trouble area, very common trouble area for a lot of folks. We can work around that. We could also use an accessory as well. This is the first one I want to bring out. This is basically going to be show and tell, all right? So for those that are listening, for those that are watching, I'm gonna share where you can get links to all of these things at the end of the episode, but if you're listening, I'll be sure to kind of describe these as well, so you'll get just as much out of it as the folks that are watching. So weight-bearing, floor-based activities, think about the strategies, think about the surface. WEIGHT BEARING: THE WRIST WRAP Also think about compression using something like this, a wrist wrap, a wrist wrap. Basically, a little elastic loop that you put your thumb through and then a lovely you know kind of elastic strap that you wrap around your wrist and applies compression and that can often allow people to bear a little bit more weight through their hands also typically allows them to to hold a little bit more weight particularly with something like a overhead press for example makes it a little bit easier on folks so wrist wraps our wrist wraps can be helpful in in the situation of a floor-based transfer all right so that's The first thing I wanted to mention out the bat, now I'm going to be talking about some different accessories that are focused more on working around hand grip issues, alright? WORKOUT GLOVES So, the first one, and I cannot believe I'm going to say this, because this is an accessory that I often have maybe made fun of, never thought I would ever recommend, or even wear at some point, and that is workout gloves. I said, I never thought I would say this, but workout gloves, yes. The ones with the fingers cut out and the padding, you know, you see them, right? You see them all over the place. A lot of our folks here at Stronger Life will wear them, and I was very critical of this initially, and then once I checked my bias and just dug in a little bit of why people actually like these, particularly for folks that may have arthritis, that may have a painful grip, With that workout glove, it obviously reduces friction so you don't get blisters and all that stuff. Whatever, right? I don't care about that. But what's really cool about these workout gloves is when you wrap that hand around that barbell, that dumbbell, that kettlebell, that padding basically increases the circumference of the grip and if you've ever worked with anyone that has you know that kind of arthritic pain just grip issues that the wider the circumference of the grip up to a certain point the more comfortable they're going to be. It can be very painful to kind of lock down on a barbell or a dumbbell or a kettlebell, but when you increase that circumference of the grip, even by a little bit with that padding, it makes it a lot more tolerable. And so we found a lot of folks really respond well to using workout gloves for that manner. Never thought I would say that, but I'm going to go ahead and recommend them now. So workout gloves is going to be the first one that can be helpful if we do see a grip kind of limitation or pain. WEIGHTLIFTING STRAPS Next one, weight lifting straps. All right, lifting straps. So this is basically a glorified piece of nylon that's stitched so it has a loop and you basically wrap that strap around your wrist and then you wrap it around either the barbell, dumbbell, or kettlebell. Traditionally you see it with the barbell, but I've used it with dumbbells and kettlebells with a lot of folks and they've responded really well. And it basically That strap helps support your grip strength so you can lift a lot more weight and it distributes that load more across the wrist and so you're able to hold more weight and it's usually a little more tolerable if folks do have painful, you know, painful grips while they're loading heavily. The only drawback with this one, particularly with the folks that I work with, we're talking geriatrics, I typically have to assist them in setting this up. It can be kind of clumsy to get a really good grip, a good purchase with that loop on the weight, and so I'm usually helping them out. If you're in home health or you don't have a weightlifting strap, you can kind of rig this up with something like a gait belt. Wrap that gait belt around the wrist, loop it around the weight and hold on on top of that and you've functionally created a lifting strap. So gait belts work. The only downside to that one is the thickness or the width of the gait belt is pretty big which can cut into the wrist a little bit and you're going to have a ton of extra slack or extra gait belt to manage, but it gets the job done. If you're having to help that person in any way, it's not too big of a deal. All right, so we mentioned workout gloves. Can't believe I said that. We mentioned workout or lifting straps. LIFTING HOOKS The next thing is going to be a lifting hook, a lifting hook. So what this is, is basically a Velcro strap around your wrist, and that has sewn into it a metal hook. So this is really helpful, particularly for folks that have painful grips, but also very weak grips that you can still load them up in a heavy manner, do a heavy deadlift with someone, even if they can't hold on to the bar. It is convenient for barbells, dumbbells, kettlebells. Also helpful if someone's had a stroke, for example, where they have one side of weakness and their grip is not up to par, but they can still handle some weight using kind of the rest of their body. So a lifting hook. This is really convenient. And all of these things are very affordable as well. Like we're talking, you know, south of $20 that you'll be able to find. And I'll show those links at the end. So lifting hooks. All right. WRIST WRAPS REVISITED And I also want to mention here, the wrist wraps again, because I find them helpful with weight bearing activities, but then also with anything where you're holding the weight particularly in like a front rack position or overhead where you're going to press particularly for folks when they are new to handling heavier loads and they're really pushing those higher intensities there's that adaptation period and all y'all probably felt this too right when you started to press heavy overhead or work on that clean or a lot of folks will feel when they start to work on handstand or inverted gymnastic movements, the compression can help. We don't want to use it as a crutch, we want to build tolerance in that joint, but it can help early on. All right, so those are some accessories that I've found very, very helpful in working with older adults. Now let's talk about what we can think about if we just need to take the whole upper extremity off the table in the sense of we don't even want to load the upper extremity at all, right? Because let's say I have someone with a right-sided stroke and they have a weak grip and so I'm going to use this lifting hook. Well, what if they don't have great right shoulder stability, right? That's not going to be great if I'm going to do something like a loaded carry for example, and they're not able to maintain that shoulder stability and could potentially, you know, sublux for example. So how can we distribute the weight just taking the upper extremity off the table? THE ALDRIDGE ARM So the first one I want to mention, it's a really cool piece of equipment, is the Adaptive Single Arm Lifting Attachment. And so what this is, it is a popularizer created by Logan Aldridge who is He has upper extremity amputation. He's now a Peloton coach, but he's really well known in the CrossFit space, definitely in the adaptive athlete space. And he's thrown around some super heavy weight, particularly barbell deadlift with the single arm lifting attachment. It basically hooks on one side of the barbell, goes up over your shoulder, and then hooks up on the other side of the barbell. And so the upper extremity is taken out of the equation. You're still able to load very, very heavy. Next up, kind of a similar philosophy, and that is a purse carry. So this is something that I learned from Alex Germano, faculty within the Older Adult Division, and that's basically taking, kettlebells are great for this, where you basically take that kettlebell, gait belts are useful, you loop that gait belt through the kettlebell handle, and then you just put that weight on like a purse, one side or cross body, and you're basically getting load through the trunk and you can do lots of movements, carries are great for this, but you're not asking hardly anything of the upper extremity. Gate belt, I typically use gate belts for this one. So that's the purse carry. We talked about the adaptive single arm lifting attachment, the purse carry. WEIGHTED VESTS Next, think weighted vest. How can we wear the weight not using the upper extremity? Weighted vests are a great option. Backpacks, loading them up with cans of beans if you're in home health, great option to wear the weight to remove the upper extremity. Belt squats is another great example where we have a belt Around our waist and that is that belt is attached to some form of resistance You can get some real fancy pieces of equipment You could use the gait belt again wrap the gait belt around the waist and then loop That the gait belt through the handle of like a kettlebell for example and get a similar stimulus but you're basically loading up the pelvis and the legs and and able to achieve a higher intensity, particularly for the lower extremities, without bothering the upper extremity at all. And then think about some different pieces of equipment outside the barbell, dumbbell, kettlebell, but think about like the rower, for example. Cardio piece of equipment that we still want to maintain that cardio fitness, you can get a single arm rowing attachment. So you are not having to use that upper extremity that's limited and you can use the other one. So there's lots of options. I think the big thing from this is that we don't want to let that sore grip, hand, wrist be the limiting factor in being able to apply heavy loads to folks. We can work around these issues so folks can achieve those higher intensities and get the results that we know they deserve. THE ULTIMATE GERI EQUIPMENT E-BOOK All right, so I've mentioned a bunch of stuff. I showed a bunch of stuff. You can get links to all of these things in one place. Last week, the MMOA division, we released our new e-book, the Ultimate Geri Equipment e-book. In that e-book, you will see links for all of these accessories, but also all kinds of ideas for other pieces of equipment that you would want in your clinic or gym if you're going to be working with older adults. This is basically, if we had a blank slate, what would we want in our spot? And the whole team contributed. We organized that list by what's fundamental and what's optional, but then also by benefit, strength, endurance, balance, and mobility. All right, so you can get that ebook for free. It's a free download. It's in the Humpday Hustle email that just went out. So it's the first link on there or you can go to ptonice.com and then click on free resources And you will find that at the bottom of that page Tons of good stuff on there. So check out that resource lots of good stuff Just to mention those links are not affiliate links or anything. We don't get any kickbacks for any of that stuff We just want to share helpful information and basically our wish list right of what we think is cool And hopefully you'll find some good ideas in there as well. All right, so check out that ebook. Don't let those grip or hand issues be a limiting factor in the progress of your patients. SUMMARY And before we go, just real quick, want to mention our CERT MMOA courses, our level one online, level two, and then our live courses. All three of those culminate into the CERT. Level one just sold out. Our next cohort is going to be March 13th. Level two starts tomorrow. There's some seats left there. Our next cohort will be around May or June. and then three live courses I wanna bring your attention to. We're gonna be across the country all year, so we're gonna be close to you at some point, but three in particular that are coming up pretty quick. January 20th and 21st will be in Greenville, South Carolina, and then Clearwater, Florida, and then on January 27th and 28th, we will be in Kearney, Missouri. We'd love to see y'all in the row. We'd love to see y'all in the online cohorts and pursue that CERT-MMOA. All right, appreciate y'all. Have a lovely Wednesday. Grab that e-book. I'll see y'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.
Dustin Jones
Leave NOTHING on the Table with Sarcopenia with Dustin Jones. This is a review of the following publication: https://eurapa.biomedcentral.com/articles/10.1186/s11556-023-00333-4 --- Want more info and resources to help you better serve older adults? Check out https://MMOA.online
Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses the scary stats of sarcopenia: increased risk of falls, fractures, loss of independence and the list goes on and on. Dustin emphasizes that rehab providers have HUGE opportunity in this department but often leave so much on the table. Listen in as Dustin shares some new research about Sarcopenia and it's implications for our work. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. DUSTIN JONES Alright Instagram, good morning, good morning YouTube. This is the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division and today we are going to be talking about leaving nothing on the table when it comes to sarcopenia. Leaving nothing on the table when it comes to sarcopenia. We're going to be covering some new literature that looked at the variations of intensity of different exercises with and its impact on sarcopenia and what that means for us as clinicians or fitness providers. Before we get into the goods, I do want to mention CERT-MMOA is rocking. CERT-MMOA is for those that complete our three MMOA courses, our online level one and level two. then our live courses. We have shut things down for the rest of this year but I want to let you know as soon as 2024 kicks off in January we are hitting the road hard. Both of our online courses are gonna be starting that second week of January and then we've got a few courses I want to mention that are gonna be absolutely awesome in that month of January. We got Santa Rosa, California January 13th, 14th. On the 20th, 21st we're gonna be in Greenville, South Carolina the 27th and the 28th we are going to be in Missouri. So we'd love to see y'all on the road. SARCOPENIA So let's talk about this, sarcopenia. So sarcopenia, for those that are not familiar, is age-related loss of muscle mass and strength. Sometimes now you are going to see the word function or physical function be thrown into that definition, but by and large, most of the time when you see this, it is age-related loss of muscle mass and strength. This is very important for every single person listening to this podcast because the vast majority of y'all are treating older adults in some way shape or form. But what we're seeing is that the term sarcopenia is starting to apply to individuals that may not have that older adult tag on them. Maybe those folks that are south of 65, maybe those folks that are in their 50s, sometimes even their 40s that are gonna qualify based on the criteria of sarcopenia. So this is a big issue and it impacts a large, broad audience. Just some stats, just so you are aware of how this could impact the folks that you're serving. 10 to 40% that's a wide range, but estimates are saying that 10 to 40% of community dwelling older adults have sarcopenia. All right. So 10 to 40% of folks, independent older adults that are walking amongst this, out in the community walking into your outpatient clinic would be categorized as having sarcopenia. And we would argue that that number is largely artificially low, that there may be even more. If you are a clinician that is working in a more acute setting out of the community, right, like acute care, home health, skilled nursing facility, this number goes up exponentially. So for you all, the vast majority of individuals, particularly older adults, would fall into that category of having sarcopenia based on the diagnostic criteria. So all to say, a lot of folks across the whole healthcare spectrum would fall under this category. SARCOPENIA: WHAT'S THE BIG DEAL? Now why is this a big deal? This is a big deal because if you have that label sarcopenia, you are at 60% increased risk of falling, If you fall, you're at an 84% increased risk of having an injurious fall or with a fracture. Those are big statistics, and we know the negative implications of those health outcomes. It is a big deal. It is an absolutely big deal, and it's important for us to understand how big of a deal this is, but then also to know what to do with it, all right? And this is where this new research, this new literature that was just published comes into play. There's a recent systematic review and a network meta-analysis that was published in the European Review of Aging and Physical Activity that looked at randomized controlled trials that use exercise in different intensities of exercise and how that impacted different outcome measures with folks that have sarcopenia. So they found that there were about 50 randomized controlled trials that totaled of about 4,000 participants. And all of these studies looked at the following outcomes. They looked at muscle mass, which we're usually measuring with something like a DEXA scan, right? Muscle strength tested by hand grip strength, chest press, and then a leg press on a machine. And then physical function, functional outcome measures, five times sit to stand, 30 seconds sit to stand, timed up and go, short physical performance battery, which is, you'll commonly hear us refer to it as the SPPB, the six minute walk test, and gait speed. All right, so these studies were measuring a lot of things that have huge implications for a lot of physical therapy and even fitness outcomes. All right, so all these studies were looking at those things. and they performed exercise at different intensities. So they performed exercise potentially at light intensity. This is categorized as at zero to four out of 10 on that modified Borg score where we're looking at relative intensity or RPE, rating of perceived exertion. that could also equate to under 49% of someone's one rep max. So typically what you saw in this meta-analysis is that the randomized control trials that were using that light intensity, they were often using aerobic-based training. So we're going to throw that in, kind of that light intensity category. Then we had moderate intensity. So this was that five to six out of 10 on that RPE. kind of 50 to 69% of a one rep max was considered to be moderate, and then vigorous, six to eight out of 10, and kind of that 60 to 80% of that one rep max. All right, keep in mind the updated ACSM recommended guidelines are calling, particularly for sarcopenia, are calling for 60 to 80% of someone's 1RM. They're calling for vigorous exercise, in particular resistance training for these individuals, all right? So they had those different intensities and they saw, all right, what's going to happen here with these folks that have sarcopenia? And the interesting thing to think about this is there's a lot of individuals, particularly when someone has sarcopenia on board, that the main focus is that, hey, this person may be relatively sedentary. They have low physical activity levels. Let's just get this person moving, right? Let's get them started in some type of physical activity. Let's bump up their overall physical activity. That's going to be a huge win. I would agree with that. Anytime that we move someone from being relatively sedentary or low physical activity levels and we can bump that up, we are going to see some positive benefits. We cannot deny that there's good in getting people to move more. STOP STOPPING AT LIGHT INTENSITY But what we need to acknowledge, especially after these results, is we cannot stop there. That is the first part of the journey to pushing people to more activity, but more intense activity. So what they found with this meta-analysis is the individuals that only received that light intensity, the only improvements that they saw across all those different outcome measures that I mentioned before was they did see some improvements in their hand grip strength. Awesome, that's great. That's a great correlation to lots of health outcomes, right? It's not a bad thing to have an improvement in hand grip strength. Great, that's awesome. There's a point for light intensity exercise. Now, moderate intensity exercise saw improvements in hand grip strength and important outcome measures like a 30 second sit to stand, a timed up and go, and leg press. Awesome. That's a few points for moderate intensity. We should probably be giving more preference to that than light intensity. And then the vigorous intensity crew saw improvements in all of those things previously mentioned that the light and moderate intensity experience, but they also saw improvement in muscle mass. They saw improvement in gait speed along with 30 seconds at the stand, five times at the stand, timed up and go, hand grip strength, leg press, chest press as well. They saw significant improvements across that broad spectrum of outcome measures that I talked about before. They get 10 points for those types of benefits, right? So if we're to rank them, the vigorous benefited tremendously much more than the moderate and the moderate benefited more than the light. So what this is basically telling us is that these folks that had that sarcopenia tag, which is based on, you know, a DEXA scan, but then also, you know, SPPB under 8 out of 12 or hand grip strength under 26 kilograms for males and under 16 for females. That's what we would typically look at, right? SARCOPENIA NEEDS VIGOROUS INTENSITY Folks that have that diagnosis that we need to be giving them vigorous intensity activities, particularly resistance training. If we do not give them vigorous exercise, we are leaving a lot on the table. Yeah, they're going to get better. They're going to improve on some of these outcome measures, but we leave so much potential benefit on the table that we're ultimately doing a person a disservice. So based on this research, I wanna focus on three main takeaways that we should walk away with after coming across some literature like this, all right? The first one, particularly for the ICE crew, you have such a unique opportunity that you spend so much time with these individuals, comparatively more time than any other healthcare provider, that you need to be well-equipped to screen and identify when sarcopenia is on board. We cover this extensively in MMOA level one and in our MMOA live course, but you need to be able to run an SPPB. You need to be able to run a hand grip strength. You need to be able to interpret those results and let that influence your course of care, particularly for the outpatient clinicians, because why do people come to you, right? What is a primary driver for your services? People are typically coming to you for pain, which you need to focus on, but that may not be the biggest issue. All right. So one we're screening, we're identifying number two, we are leveraging intentional under dosage. You've heard us talk about this podcast before. We've done whole episodes on this. So I'd encourage you to search that if you had, if this is a new term for you, but we need to leverage intentional under dosage because that is typically we're lowering the barrier of entry for individuals. So they're going to partake in particularly a new activity, right? For so many of these folks, they have not exercised before, they've not performed any intensity of resistance training. This is completely new territory for these individuals that we need to make it approachable. And so we may typically underdose initially. SHORTEN YOUR UNDERDOSAGE But in light of this evidence, that intentional underdosage period needs to be as short as possible. We don't have a lot of time here with these individuals and we need to make the most of our time. The quicker we can get to that vigorous intensity level so we get all those benefits that this meta-analysis discusses, the better, right? So that intentional under-dosage period needs to be as short as possible. That's a very vague thing, right? For some individuals, you may have their first visit where it may be intentionally under-dosed for their capacity. and then the next visit based on their response, their trust in you, their willingness to perform maybe a more challenging activity, that intentional under dosage period may be the span of one visit, right? But I know for me, particularly in home health, I've had intentional under dosage periods that have been well into the months. based on the person that I'm working with. Whatever it is, make it as short as possible. So we screen and identify, we leverage that intention on your dosage. And then number three, and I think this is something that we really need to grasp, is the clinical urgency in this situation. that if you continue with your light, with your moderate intensity exercise with these individuals, you're leaving a lot on the table. And ultimately, you are harming that person. You are robbing them from the potential benefits that we've seen in this meta-analysis, that they see the big improvements in the functional outcome measures, in their strength, in their muscle mass. These people have the capability to get those kinds of results. And if we waste our time and spend too much time in that intentional underdosage period where we're doing that sedentary, doing light to even moderate intensity activities, you are doing that person a disservice. You are doing that person a disservice. It is a dangerous situation that you're playing with. We need to have a sense of urgency when we're talking about sarcopenia. All right. I'm going to drop the link to this meta-analysis at Open Access. Really good read. It gives you a good idea of kind of the big body of literature around sarcopenia, but what they found in terms of these outcome measures. I'll drop that in the comments. If you have a tough time getting that link, just shoot me, DustinJones.dpt or the ICE account a direct message and we'll get that over to you. But this is a big conversation for many of you. You all are seeing tons of folks that would have that sarcopenia label put on them if they were properly screened and identified and you have a huge opportunity to give them that vigorous intensity, that amazing dose that is going to give them huge benefits across such a broad spectrum of outcome measures that have a huge implication for their quality of life. Alright, y'all have a lovely rest of your Wednesday. Go crush it. I'll talk to y'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. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses the concept of "DUDS" and "STUDS" when working with patellofemoral pain syndrome. Mark describes three outdated treatment paradigms or "DUDS" including an overemphasis on imaging, patellofemoral tracking, and VMO specific-strengthening. Mark encourages listeners instead to focus on the four "STUDS" of patellofemoral pain treatment: assessing current work demands on the knee vs. current tissue capacity, addressing power & not just strength of the knee, working in motor coordination & skill training especially when reintroducing functional movements like jumping, running, or squatting, and finally, ensuring load distribution across tissues is as equal as possible by working on range of motion. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MARK GALLANT All right, what is up PT on Ice Daily Crew? Dr. Mark Gallant here, Clinical Tuesday, coming at you the Tuesday before Thanksgiving in 2023. So first off, I want to say super grateful to have the opportunity to be on this podcast, rapping to you all and going around the country talking about these topics. So thank you all very much to anyone who's listened to this podcast or anyone that's caught us on the road. But before we dive into today's topic, last couple opportunities to catch the extremity crew crew on the road for 2023, we've got Cody is going to be in Newark, California on December 2nd and 3rd. So so a nice West Coast opportunity. And then Lindsey is going to be in Windsor, Colorado, December 9th and 10th. So those will be the last two for the year before we we take a little break and then we will kick off the second weekend of January for a full slate in 2024. So if you're trying to catch us on the road this year, those are your last two opportunities. And then make sure you grab those seats for 2024, because courses are selling out now and hitting max capacity. So make sure that you get those sooner than later. In addition, tonight on our Vice, so if you're signed up for the Vice program, our virtual ICE, Paul Killoren is gonna be on talking about peripheral dry needling. If there's any topic that pairs well with what the extremity crew is typically saying, it would be the ICE dry needling department talking about peripheral dry needling. So definitely catch that one tonight around 8.30 Eastern Standard Time. DUDS & STUDS FOR PATELLOFEMORAL PAIN SYNDROME All right, for today's topic, what we wanna talk about is duds and studs when it comes to patellofemoral pain syndrome, or what I would prefer calling kneecap pain. So what are the things that we've known over the years or we've tried over the years with kneecap pain that the research really does not shake out very favorably for? And what are the things with kneecap pain where it's like, Ooh, that that's something that we definitely want to pay more attention to. So I'm going to list all the duds and all the studs off, and then we'll break each one of those down individually. So for the duds, we've got imaging to the kneecap as a dud specifically for chondromalacia patella, patellar tracking and trying to impact patellar tracking would also be a dud, and then specific strengthening or specific loading or an attempt at specific loading to the VMO or the oblique fibers of the vastus medialis. So those are our duds and our studs are going to be building work volume capacity or looking at that person's work volume compared to their current capacity and making adjustments in their training. We have specific strengthening or building capacity to that anterior knee with both strength, endurance, and power. We have skill training or motor coordination, and then we have mobility towards the anterior knee and surrounding structures. So those would be the three duds, the four studs. DUD #1 - IMAGING OF THE PATELLA Now let's break each one of those down individually. So for most body parts, We now know that when we take asymptomatic folks and we image that region of the body, we're going to find as many tissue changes as we would for those folks that are symptomatic. Historically, we've called these abnormal tissue findings. Again, these are fairly normal findings for asymptomatic individuals, again, in every single region of the body. What we see with chondromalacia patella, so softening of the cartilage of the posterior patella, What we see when we look at that is if we take a bunch of asymptomatic individuals and symptomatic individuals, run them all through the MRI tube and say, who's got signs of tissue softening to that cartilage of the back of the knee, that number is equal or close to equal for both the symptomatic group and the asymptomatic group. So it would be hard to say that the finding on the image of chondromalacia patella is driving kneecap pain in any considerable way. DUD #2 - PATELLOFEMORAL TRACKING The second dud is patella femoral tracking. So there was this theory for a long time that the lateral structures of the patella or the structures that attach laterally to the patella are pulling that patella off track or creating some level of tilt or compression to the patella that is driving that anterior knee pain. What we now know is that this is not the case typically. The other thing with that was that the VMO was weak and not allowing that even force. We now have studies, it's a pretty cool study, where they took a group of 14-year-old women, they asked them all about their knee pain, how much pain are you in, and then they used imaging to track how their, to look at how their patella was tracking. So they got all that data at 14 when those individuals were at their peak symptom level. They then followed up with those individuals four to five years later, so now they're 18 to 19 years old, All of these individuals had significantly reduced pain. So the patella femoral pain or the kneecap pain had relatively worked itself out. And then they re-imaged and retracked how that patella was tracking. What was interesting is most all of them had a full reduction of symptoms. the knee was tracking the exact same way. So they found no difference in how the knee was tracking, yet that person had significantly reduced symptoms, which again, hard to say that that knee tracking is one, are we even able to intervene on it? And two, does it mean anything if all of the symptoms become reduced despite that knee tracking changing? DUD #3 - SPECIFIC TRAINING TO THE VMO And along those lines, the third dud, is specific training to the vastus medialis oblique fibers. What we now know is it's incredibly hard to isolate those fibers. When we activate the quads, we're getting the whole quad, all of the heads of the quad. And even if we did attempt it, we have no proof of correlation that those specific fibers are driving the symptoms. So our three duds, looking at imaging to drive treatment, specifically with Chondromalacia patella, being overly concerned with with patella tracking and trying to impact that patella tracking with the one thing that we've shown the good research that impacts patella that that would be theoretically impacting patella tracking is that medial knee taping mcconnell taping what we now know is that is much more of a symptom modulator and has no long-term impact on that patella tracking. And then VMO, specifically training the oblique fibers of the quad. What we now know is getting the quads more robust and resilient is the way to go, being far less concerned about those very specific fibers that are very hard to isolate anyway. So those are our three duds. STUD #1 - WORK VOLUME VS. TISSUE CAPACITY Our four studs are going to be looking at that person's overall work volume compared to their capacity. So this weekend is a prime time example. We're going to have tons of folks going out for turkey trots. We're going to have a lot of folks going out and playing backyard football with their family on Thanksgiving. They may not have been doing any training over the last four to six months to prepare their anterior knee. for that capacity. Family members might say, hey, I'm jumping into this turkey trot, and then Bill says, you know what, I'm gonna jump in with you, even though I haven't run since 1968 when I was training for Vietnam. That individual may encounter some anterior knee pain because the capacity of their anterior knee is not matched to the work that it's about to do. So anytime we've got one of these pain symptoms, syndromes, kneecap pain, looking at, okay, what is it you're doing? and what is the capacity of the knee currently, and trying to figure out where those gaps are. STUD #2 - TRAIN POWER, NOT JUST STRENGTH Along those lines, the second stud is can we increase the load capacity, the capacity to handle speed or power, and the capacity of that anterior knee to handle endurance. What is your ability to produce load or to tolerate load in knee extension or squat? What's your ability to sustain that over long periods of time for high repetitions or high time intervals? What is your ability to generate power with those things? Dustin Jones came on here a couple weeks ago and talked about how we may have named the wrong enemy when it comes to deconditioned older adults that it may be more power instead of strength is the problem that a lot of folks actually have load capacity tolerance to their tissue. What they lack is the ability to handle that load while generating high speeds or force. We see the same thing when it comes to kneecap pain. We're getting better at getting people stronger to build that load capacity. We also need to make sure they can handle that at fast speeds. Our box jumps, our broad jumps, our cleans, our snatches, or sprinting, those sort of activities, we need the same sort of intention to build the tolerance. So building the local strength capacity or building the local tissue capacity of the knee. STUDF #3 - MOTOR COORDINATION & SKILL The third stud is skill or motor coordination. The law of specificity has reigned true in strength and conditioning since it was looked at. If you want someone to get better at running, train them in running. If you want to get them better at squatting, they need to train the squat. If you want their step up to look better, they need to be working on step up variations. So this has a very much skill component like any other skill in life. It takes repetition, It takes breaking it into chunks, it takes slowing it down, speeding it up. If we want their step up, or their step down, or their running, or their squatting to look better, making sure that we break those things down individually and look at it in addition to the first two components. STUD #4 - RANGE OF MOTION And then the fourth piece that's a stud is range of motion. What is the range of the tissue surrounding the anterior knee that's gonna dictate how much force is going through that knee? So a couple of the big ones are, what is ankle dorsiflexion like? If that person significantly lacks ankle dorsiflexion, we know those forces are going to go up the chain, often landing on that anterior knee. So attempting to impact or offload dorsiflexion will help with that anterior knee pain. What is the length of the rectus femoris? What is that quad length like? If that tissue is super gummed up and tonic, we may want to work some eccentrics to improve the mobility of that tissue overall. And along those same lines, what is that individual's hip extension looking like? If that person lacks significant hip extension, again, they may encounter more force to the anterior knee. DUDS & STUDS FOR PATELLOFEMORAL PAIN So again, for our studs or duds, looking at the three duds, looking at imaging or being overly concerned with imaging, specifically chondromalacia patella, being overly concerned with patella tracking and trying to impact it, and being overly concerned with the VMO. Those would be our three DUDs that we want to spend less time addressing or no time at all. Our four DUDs are going to be looking with the patient at what is their overall work volume compared to their current capacity. What is the ability of the anterior knee to tolerate loads from a load capacity or strength perspective, from an endurance and from a powers perspective. What is their skill in the movement that they're trying to perform? Do they need to become a better runner? Do they need to get better at squatting? Do they need to get better at step ups? Looking at that specific motion. And then finally, looking at any range of motion deficits of the lower quarter. Specifically, what is that quad length like? What is their ankle dorsiflexion? And what is their ability to extend their hip? Hope this helps. Hope you all have a wonderful Thanksgiving and get some good relaxation and time with your families. Lindsay and Cody will see you on the road in early December. I'll see you on the road in 2024. Hope you have a great week. 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, Modern Management of the Older Adult division leader Dustin Jones discusses the difference between sarcopenia (the loss of muscle mass) and potentiapenia (the loss of muscular power). Dustin reminds listeners that performing functional outcome measures & then creating a treatment plan based on functional deficits uncovered during assessment is the most important thing in ensuring patients receive the individualized care they need: "Assess, don't assume." Dustin also discusses the utility of using functional outcomes to assess & track progress so that insurers like Medicare will continue to pay for treatment. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - DUSTIN JONES All right, welcome y'all. This is the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division as we call MMOA. We're going to talk today about a really interesting topic. We're going to name the enemy and that is potentiopenia. We're going to name the enemy particularly when we're working with older adults and that is potentiopenia. This is brought to you by a listener question, a commentary that they wrote and I want to dive into the topic of power, strength, Sarcopenia as well. What should we really be focusing on? How can we screen? Before we get into the goods, I want to mention about some upcoming MMOA live courses. MMOA live is a part of the cert MMOA curriculum. Part of that curriculum is a live course. Also our MMOA level one online course, which was formerly called MMOA essential foundations. And then MMOA Level 2, which was formerly called Advanced Concepts. You complete all three, you get your cert MMOA. We have three upcoming weekends where you can go to that live course. We're gonna have Annapolis, Maryland and Central South Carolina. This upcoming weekend, November 11th, we're gonna be in Wappinger's Falls, New York. And then right before Thanksgiving, November 18th, that weekend, we're gonna be in Westmont, Illinois. So if you are looking to get some Con Ed before the end of the year, be sure to check us out. PTOnIce.com is where you can find all that. POTENTIAPENIA All right, so naming the enemy, potentiopenia. So this is a term you probably have never heard about because it's not been coined, it's not been researched, it's not been agreed upon in literature. This is a word that was made up by Dr. Ronald Michalak. So Dr. Michalak is an orthopedic surgeon that's been practicing for roughly 20 plus years that has quitting his surgical practice to go back and pursue his PhD in Rehabilitation Science. Dr. Michalak is an avid listener to the PT on ICE Daily Show, so I want to take the time to shout out to him, but also for all of y'all that listen to this show that aren't our typical physical therapy crowd, right? The OTs, the speech-language pathologists, the other healthcare providers. I know we have some PAs, some NPs in here, but we're really grateful for y'all tuning in because we're starting to see we have a fitness-forward army clinicians that are trying to solve the same problems. This is one example. So Dr. Mitchell like you know 20 plus years doing orthopedic surgery you start to see some patterns right? You start to see the issues with focusing on the tissue, right? Of focusing on, oh, that bone-on-bone, we should probably just go ahead and replace that whole joint, and that will solve all your problems, right? There's some issues to that, that when we focus so much on the anatomy, the structure, that we apply surgical interventions to non-surgical problems, that creates issues, right? And so over his career, he started to see, man, the biggest issue is not the quote-unquote bone-on-bone, it's the fact that these folks are deconditioned, they're weak, they're not able to do the things that they want to do and it leaves them susceptible to some of these medical situations that I'm often performing surgery on. What can I do to prevent them from even having surgery? And so we started to dig into the research and science and what he has come to the conclusion of is we are really missing the boat to where we're focusing on the wrong things and what we need to focus on particularly with this population is their lack of power. hence the term potentiopenia, the lack of muscular power. So, I want to give some context for this discussion because I think it's really interesting of how much progress has been made in this area, particularly in geriatrics and geriatric rehabilitation. SARCOPENIA So, sarcopenia, you've heard us talk about this so many times on the PT on ICE Daily Show. If you've taken any of the MMOA courses, you've heard this term. Sarcopenia was first coined in 1989 by Dr. Rosenberg, and at the time, the definition, the accepted definition of sarcopenia was age-related loss of muscle mass. That we thought, oh man, these folks are losing muscle mass, therefore, they are losing their strength, they are losing their ability to do what they need to do. This is a big issue. It's age-related, but we may be able to do something about it. As this was studied more and more, and just this whole concept, was being critically you know thought about that the term of sarcopenia or the definition of sarcopenia was missing a little bit right because you can have someone that is losing muscle mass but may still be really strong or you may have someone that does have a good bit of muscle mass that is rather weak or they're not able to produce their force quickly aka they have low power So, in 2008, Dr. Clark really started to push against this definition of sarcopenia and say, hey, this isn't the issue. The issue is the lack of strength, the age-related loss of muscular strength. And he coined the term dynopenia. That was a back and forth, back and forth. And now in terms of the term of sarcopenia, what we're seeing is that it's starting to incorporate some of the things that Dr. Clark really was pushing for. And now you're often going to see sarcopenia defined as the age-related loss of muscle mass and strength. That's what we speak to in the MMA course. And so a lot of the screens that you're seeing of being able to identify folks that have sarcopenia are mass related screens of actually measuring muscle mass and having cutoffs based on certain age groups and so on and so forth. But then there's also functional measures, right? Gait speed is one, grip strength is another one, the SPPB, the short physical performance battery test can indicate that someone is at risk of sarcopenia. Sarcopenia has changed a ton over the past few decades. Now, what's interesting is that the amount of research, which is so massive in this particular topic, that we have really good evidence to show, man, if this person scores below one meter per second, for example, on the gait speed, that this individual is at risk of sarcopenia, also a host of negative health outcomes. It's very predictive. We have a lot of data to show that poor performance on some of these outcome measures is a big issue and very predictive and warrants medical treatment or physical therapy, if you will, or occupational therapy, some of these rehabilitation-based services. Now, here's the issue. Here's what I think Dr. Michalak is going towards, is a lot of these screens that have been used to say, hey, this person has sarcopenia, age-related muscle mass and strength, that these screens may not actually be measuring what we think, right? If you think about gait speed, normal gait speed, for example, is that a measure of strength? Not really, right? Is it a measure of, let's say, power, the ability to produce that strength quickly? Potentially, right? Definitely, if it's a fast gait speed, or if we're looking at gait speed reserve, the difference between max gait speed and normal gait speed. Think about the 30 second sit to stand test, where we're standing up and sitting down 30 times. Is that a measure of strength? You can make a strong argument that, no, not necessarily, but it's more of a measure of how people can use that strength quickly to perform that transfer. Same thing could be said for the five times sit to stand. And so these outcome measures that are often tied to quote-unquote sarcopenia, the age-related loss of muscle mass and strength, isn't really measuring that. We can say that those tests are very predictive of some of these negative health outcomes. That's not what we're talking about. What we're talking about is do these tests actually measure, indicate what they're saying that they measure, right? Now, here's the, I think the important part about this is that if I am performing a five-time sit-to-stand test or a 30-second sit-to-stand test and think that, oh, this indicates that this person has impaired lower extremity strength and I focus on strength-based interventions, right, I'm just worried about getting them stronger, not necessarily trying to help them get stronger, produce force quicker, aka power. THE NEGLECT OF POWER-BASED TRAINING And so what Dr. Michalak is really proposing is that our focus on age-related loss of muscle mass and strength, the focus on strength has resulted in the neglect of power-based training. We need to really think differently about these terms and ultimately what they result in. I think we should have a new term, potentiapenia. That was his argument. This is all in a beautiful commentary that I loved reading that I'm going to link in the notes. So here's our take on this. I agree that… we have really dropped the ball on power-based training, right? That we often neglect that in this population for many reasons. One is just we haven't named the enemy as one. Two is that we often have ageist assumptions about what people can handle, right? That, oh, that's too intense for them or they will get hurt. It's not as well studied as strength-based training. There's a lot of reasons that go into that, but I do agree that we have really dropped the ball there. A new term, creating a new term, and everything that's associated with that, I don't know if that's the answer, but I do think we need to continue to be critical of the term sarcopenia and what that actually represents. It's already changed to age-related loss of muscle mass and strength, which is lovely, and I would love to see that conversation continue to include power as well. Clinically, here's what I think is really important for us when we think about some of these deficits that folks are undergoing and we're throwing around some of these terms. STRENGTH VS. POWER TRAINING I think the big thing that needs to be focused is we're diving into the weeds of strength versus power and you know reps and sets and volume and all that type of stuff that when first one is when we're working with individuals that are relatively sedentary or inactive and Movement is king. I don't care what they do. The fact that they are moving is ultimately important, right? We got to get people moving first and we need to be less picky of what that looks like, especially with sedentary and active individuals. That's the first thing. The second thing is we need to really think about our assessments and challenge our assumptions with this. This is why in our courses we always say assessments over assumptions. It's very easy for us as clinicians, when you're doing an assessment, you're doing the five-time sit-to-stand test, 30-second sit-to-stand test, to assume, oh, this person needs to do more lower extremity-based strength training, right? That's a very common thing for us to correlate. Now, that test may not be and probably isn't testing pure strength, right? There's other ways to do that. One rep max testing, estimated one rep max testing. We can use dynamometry as well. There's other methods to test strength. These functional and very practical outcome measures may be more a testament to someone's power ability. So when we use these tests, particularly the 30 seconds sit to stand, five times sit to stand, I think is a great example. that we need to be thinking probably about strength training, but we also need to be thinking about power training. Can they produce that force quickly? Because it ultimately is an indicator of power, the ability to produce that force quickly and do that transfer. So what your outcome measures tell you, we need to be very careful of how that informs the intervention, right? And ultimately what we're often going to find, I think this is not an or conversation, strength training or power training, in the realm of ice, you will hear this so often, it is and not or, right? Probably both, strength and power, we can do both. In reality, when we do get people stronger, you often see, especially in folks that are untrained, you are gonna see an improvement in power production. You could do specific power training, where you're doing force movements quickly, you're probably using lighter loads, and you're probably gonna see an improvement in strength, right? That's gonna happen with a lot of untrained individuals. But I think in the context of rehab, in the context especially of One Rep Max Living, that we probably want to do both. Heavy loads are really good. Heavy loads provide an amazing stimulus to promote muscle mass, our strength, but also the strength of our bones, also our soft tissue remodeling. It makes us more resilient individuals. But fast loads are really good too, right? They give us that type 2 muscle fiber stimulation to prevent some of that preferential decline. in those fibers. That quick speed is so practical for so many things that we do in the real world and also in high-risk situations. It's an and conversation. We want to do both. Now, Dr. Mitchell, I had two specific questions that I also wanted to hit on. Could referrals be written or phrased better from the physician end to encourage PTs to try to help get these individuals moving toward fitness? Now, I want everyone to listen here, and by and large, the PT on ICE Daily shows largely physical therapists, physical therapy assistants. Think about what this physician just asked. This physician is basically saying, where are my fitness forward clinicians, right? Where are my fitness forward clinicians? Where are the people that I can trust with my patients? I love this question. I think from our angle, from kind of the rehab fitness side of things, Let it be known. What are you about? Lock arms, lock shields with us, the ICE tribe, the ones that are really pushing this fitness forward message because there are healthcare providers looking for you. Now, Dr. Mitchell, from the physician's standpoint, I do think it is helpful to make it clear as a physician that you have that fitness forward approach. And oftentimes, we don't see that on referrals, right? It's the diagnosis and treat, which you love as a PT, to be honest, but if you do run a 30 second sit to stand and acknowledge that it is under or below a particular cutoff let it be known and let it be known what you are thinking about that it is a potential loss of power production potential right and let the PT do the job of assessing to determine is this a bigger power issue or a bigger issue of just producing force of strength. FUNCTION-FORWARD HEALTHCARE PROVIDERS But let it be known, I love it whenever I see another healthcare provider perform some type of screen, like a 30 second sit to stand, a timed up and go is another one, that tells me that this is a function focused healthcare provider. And we're speaking the same language, especially when we're coming from the MLA tribe. We speak function, we speak that fitness forward mindset, include some of that information and that's really going to get the point across particularly to the fitness for clinicians. I would also say Dr. Michalak is go to PTOnIce.com, look at the find an ice clinician map and build relationships with that person that is local. The second question that he asked was, are there any insights into Medicare billing or reimbursement that would allow them to do so and actually get paid for their expertise? So the question here is mainly looking at, he's interacted with some PTs where he sent the referral that was not pain based, where these clinicians said, I can't get this covered, right? I treat pain, I get paid to treat pain. That is not correct, right? So you can definitely get reimbursed to have the fitness forward approach when you use appropriate outcome measures. When you can demonstrate medical necessity through the performance of these validated outcome measures that we cover extensively in our MMOA level one online course, and a little bit as well in our MOA live course, when we're using those outcome measures to demonstrate, hey, this person has a score, which based on the literature is showing that they are at a higher risk of whatever, negative health outcome, usually it's a fall, that that warrants your services. It is medically necessary. So we can have fitness-forward physical therapy. This is what we often see in the context of home health. We treat more function than pain in the context of home health. Outpatient, not so much. It's more of a pain driver, but you can still have a fitness-forward approach in the context of outpatient. These outcome measures are absolutely key because they demonstrate medical necessity. Multiple outcome measures I should say great conversation. So what I want y'all to do if you like this topic I want you to come to Instagram and I'm gonna drop a couple links. You could also send me a direct message At Dustin Jones dot DPT and I'll send you the links as well because it's a really great conversation. I think by and large Yes, we need to get people stronger We're already really pushing forward with that and I love that but we may need to take it to the next level of power based training In terms of a new name, potentiopenia, I don't know. I'll let the really smart people debate that and discuss that, but I'm going to keep pushing the message that we need to build people's resilience. We need to end one rep max living and really show that people may be quote unquote old, but not weak. Also that they may be quote unquote old and not slow. Y'all have a good rest of your Wednesday. 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 CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.
Dustin Jones
Dustin Jones, with his co-founder Jeff Musgrave are physical therapists in Lexington, KY who identified a submarket within the fitness industry that most of us were ignoring - 55+ aged individuals. So they set out to R&D their concept within the local CrossFit gym they were both members at, and it proved to be a winning proof of concept. They have since opened their own standalone location for Stronger Life to help this underserved population achieve life-changing fitness. https://www.strongerlifehq.com/ @strongerlifehq --- Send in a voice message: https://podcasters.spotify.com/pod/show/wtfgymtalk/message
Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses evidence based recommendations on shoe wear for older adults. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up, everybody? Welcome back to the PT on Ice Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app.physicaltherapy.com. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code IcePT1MO. When you sign up is that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:43 DUSTIN JONES Welcome folks to the PT on Ice daily show. My name is Dustin Jones and today is Wednesday where we're going to be talking about all things older adults in particular. shoe recommendations for the older adult population. Shoe wrecks, heel drop, doesn't matter, barefoot, minimal, conventional shoe, what the heck's the deal with the toe box, what in the world is a shoe last, we're gonna talk about all these things, what the evidence says, and then what we're kind of seeing out in the real world, right? Many of us are seeing in clinical practice or in the context of fitness. Before we get into the goods, just a few quick announcements. Our online MMOA Modern Management of the Older Adult courses are going to be striking up here within the next couple weeks. So Essential Foundations, that is our foundational online eight-week course, is going to be starting October 11th. And then our Advanced Concepts course is going to be starting on October 12th. That's just for folks that have taken Essential Foundations. We've got a bunch of live courses coming up through the fall across the country. The one that I really want to point your attention to is Falls Church, Virginia. That's going to be the weekend of October 7th. 02:51 SHOE RECOMMENDATIONS All right, shoe recs. This is a topic that I really enjoy digging into. I've got a decent amount of experience around shoes. I used to sell shoes right out the gate of PT school. I was working in outpatient PT clinic and then working in the first kind of barefoot style shoe store in the country. Two of his treads out of Shepherdstown, West Virginia, currently in Charlestown. And just had a lot of, made a lot of mistakes, learned a ton, met a lot of interesting folks that were in this space that were really challenging a lot of conceptions. around shoes and what is good for individuals. And I was very dogmatic at one point and I've kind of come to the middle a little bit in terms of what I perceive to be beneficial and the evidence is starting to show that as well. 03:55 THE OLDER ADULT FOOT So when we talk about recommending shoes for older adults, I think the first thing that we need to acknowledge is that the foot is different in an older adult than when you're younger, right? We see age-related changes typically in the older adult population that warrant us to really question the shoe that they're in, right? The reality with the footwear industry is that many of the shoe lasts, lasts being the shape of the foot where they basically create the shoe from. The shape of that shoe last largely mimics what you may see in a younger individual, not necessarily the common things that we will see in older adults. What do we see in older adults? Typically, you're going to see a larger circumference of their midfoot. larger circumference compared to when they were younger, you typically will see a lowering of that arch in many older adults. We often do see that the angle, the toe angles of that first and fifth toe typically do go in, which we're well aware of all the issues associated with that. And we see these changes yet 99% of the shoes out in the market are looking at a younger foot and creating the shoe around that as opposed to an older adult individual. So we need to acknowledge these changes because that is what's going to influence the current evidence-based recommendations. So what I'm going to go through is kind of what the current evidence says, the most recent systematic review looking at shoe recommendations for older adults, and then I want to dive into the whole minimal barefoot shoe versus conventional shoe debate, particularly for this population. So what do we know to be true in terms of some key characteristics of shoes that are gonna be helpful for older adults. One, and probably the biggest issue, is that it fits. I know it sounds super simple and silly, but if you check the fit of many of your patient's shoes or your client's shoes, you will see some very ill-fitting shoes. Whether it is the shoe is too big, there's a lot of wiggle room, their foot is moving a lot within that shoe, or it's the opposite, right? The shoe is way, way too tight for that individual, and that creates a whole host of issues related to skin breakdown related to performance breakdown as well. And so we want to be very aware that it fits well, all right? So that's the first thing. Next thing is that it has fixation. A shoelace system, for example, we could say Velcro as well, but laces are typically better, is that if that shoe is properly fit and it's fixated to that foot, that is going to allow them to do what they need to do when they need to do it, all right? The second thing, third thing is going to be a firm supportive heel counter. So I've got a shoe here. If you're listening on the podcast, you can come to YouTube or Instagram to see the video. So this is just a Reebok Nano. I can't remember the model of this one, but back here, you know, is a pretty solid heel counter. So it's this back portion of the shoe. And so you want this to be firm and supportive. and snug when people put this on so you don't want a ton of room around the heel with this heel counter you want to be nice and snug and that's why trying shoes on is super super important. Next thing is around a 10 millimeter heel drop and this is where some of y'all are going to say no Dustin it needs to be just a zero drop shoe Current evidence shows that 10 millimeters around that range that older adults do really well there. If you start to go above that, particularly above 15 millimeters, you see an objective change in their balance performance through different outcome measures and their postural stability as well. If you're not familiar with heel drop, it's the difference of the thickness of the heel to the forefoot. This information can be hard to find on most websites when you go to look up shoe specs. That's why you want to look up the reviews of that shoe. Typically, a running world, there's a bunch of running related sites that will do all kinds of shoe reviews and they will give you some of those specific specs. When we worked at Two Rivers Treads, we would literally get a demo product and then we would cut the shoe right down the middle and we would measure the heel drop because a lot of those numbers weren't being published. We found some really interesting things. What the trend in the heel drop realm You know, 20 years ago, it was very, very common to see heel drops north of 10. You know, you'd be going, you know, 14, 17, 18 range in a lot of running shoes in particular. And over the past 20 years, particularly the past 10 years, that that average has gone down and down and down to where it's pretty normal to see a four to five millimeter drop from the heel to the front. That was not the case 20 years ago. So that has changed tremendously in the footwear industry. So around 10, excuse me, around a 10 millimeter heel drop. Next is a firm midfoot. So when we're looking at kind of the sole that it is relatively firm, you will typically see firmness in the midfoot and the forefoot is going to, excuse me. All right now, the forefoot is going to be a little more flexible. That allows for, you know, terminal stance, that we have a lot of extension, big toe extension is a big one, but that midfoot, a kind of firm, medium thickness is a good thing for older adults. In terms of the traction, a slip resistant sole that's multi-directional and tread. There's not a lot of evidence to support, you know, super thick, aggressive tread like you would see in something like a trail shoe. but some tread that is going to allow them that slip resistance in several directions, not just anterior to posterior. The next thing that you are going to want to look at is the beveled heel and then a rocker angle. All right. So this is really important for older adults that you typically want to see around a 10 degree beveled heel. So towards the back of the shoe, when we're going towards the very back of the heel, there's kind of that upward curvature. So it's not completely flat, but there's a little upward tilt around 10 degrees is really great. This allows or decreases the amount of them kind of catching their heel, especially during that swing phase. On the other side of the shoe, the front of the shoe, we have our rocker angle. You also hear this referred to as a toe spring. Now, not the fact that there is a spring in the toe or the front of the shoe, it just references that upward slope that you will see towards the front of the shoe. around a 10 to 15 degree rocker angle or toe spring is really good for older adults. The reason being is that when you're going into that terminal stance, you need a good bit of big toe extension, right? Some more ankle dorsiflexion as well. Usually you need about 45 to 65 degrees of big toe extension. And if you don't have that or it is painful, then having that upward slope basically gives you some artificial big toe extension. It can be really helpful with walking, but particular activities that require a lot of big toe extension, think going uphill, think lunging or getting to and from the ground, that rocker angle is priceless. And then last but certainly not least, we want an anatomically shaped toe box and this has changed dramatically over the past 20 years as well that we typically saw the shoe last kind of curve inwards and now you're starting to see that wider toe box to where the widest part of the shoe is almost towards the very end of the shoe or the front of the shoe. Now don't mistake a wide toe box to be a loose fitting shoe, because you will have a little bit of room to wiggle your toes in a properly fitted toe box. But if you have good fixation, particularly around the waist or the middle of the shoe, it is not a problem to have some wiggle room in the toe box. So we're talking length, but we're also talking width as well. so that is really important so when you look at all these characteristics hopefully you're starting to say oh my gosh that's a lot to think about this is why it is so so important for two things one to have a good relationship with A local, particularly running stores are usually the best around town. If you have an awesome local running shop to where you can send your folks, they have a solid fit system and they have some solid recommendations that can meet some of these characteristics. you're going to refer your folks and they're going to be in good hands, right? But it's also important to encourage folks to not just go to Amazon, to not just go and buy the shoe online, but you need to try this on. These characteristics, but then also that shoe feeling comfortable is very, very important. All right, so those are kind of the current recommendations. That is based on a systematic review that was released in 2019. I'll drop the citation for that in particularly the Instagram post. I'll do that there. 12:39 MINIMALIST SHOES: PROS & CONS All right, now let's shift gears a little bit and let's talk about the whole minimal shoe, barefoot shoe versus conventional shoe debate. Once again, I will say I was so dogmatic about this. I was the guy that ran half of a marathon without any shoes whatsoever. And the first half I wore Vivo barefoot because we were running on gravel, right? Like I was that guy. I drank the Kool-Aid hard, um, and then learn some valuable lessons along the way. And I've changed my stance a little bit. I'd say a lot actually on this, but let's talk about some of the pros and cons of particularly older adults wearing a barefoot style shoe. The first one is, there is evidence that a barefoot style shoe, when I say a barefoot style shoe, some of the key characteristics, typically it is a zero drop shoe. What I'm holding now is a Merrell Vapor Glove. I've bought three pairs a year of these things ever since they came out back in the day. I love these shoes. So it's typically a zero drop, a very flexible sole. So if you're not watching the video, I can roll it up like so. and it typically has a wide toe box. So the widest part of the shoe is going to be towards the front. That's kind of the typical characteristics of kind of a minimal barefoot style shoe. It also has a very low stack height in terms of how high it is off of the ground. So there are a couple studies, particularly with older adults, looking at how that's influenced some different parameters. And what they found is that when they wear a barefoot style shoe compared to a conventional style shoe, is that it does improve their postural sway. How does it do this, right? So think about the somatosensory input. You get a lot more input from that system whenever there's less stuff between your foot and the ground. You also have a lower center of mass, which can be very helpful for balance. And also, without that heel slope or heel drop, it doesn't shift your center of mass anteriorly. And so based on a couple studies, postural sway was improved significantly compared to conventional shoes when wearing those minimal shoes. So less sway, less postural deviation when folks were in static and dynamic situations. 15:07 CHANGES IN WALKING GAIT The next thing is that when folks put on that barefoot style shoe, they adapt their walking gait, running gait as well, right? Like we'll have the endurance crew talk about that all day, but I'm mainly talking about older adults in particular with walking. Their ambulation parameters will typically change. What we typically see is that we see a shortened stride length, we see an increased cadence with their walking, and the big one is that they have a decreased stance time. So they're moving their feet a little bit quicker and their stance time is a little bit shorter. Now, this is really important because let's think of if you have some type of external perturbation, you lose your balance. You try that ankle strategy, that hip strategy, it ain't working. You got to do that step strategy. When you're taking short strides, you have that increased cadence. When you have a relatively lower stance time, you are much more agile and adaptive to be able to take whatever stepping strategy you want to take. That is a big one, so that is a big reason why these barefoot style shoes can be helpful for older adults. What are the cons to wearing these with these individuals? One is that there's hardly any rocker angle. If you look at the video, there's a slight upslope for these shoes, but if you wear Xero shoes, Vivo barefoots, for example, you don't see any upslope or rocker angle towards the toe. and very little support in that area. And if you have limited big toe extension, if you don't have at least 45 degrees, for example, terminal stance of your gait is gonna be pretty tough, especially if you're symptomatic at in-range big toe extension. So these rocker angles can be helpful for individuals, especially if they're on uneven terrain, going uphill, limited big toe extension, they want that rocker angle. It's helpful for them, get them in one, all right? Though also the cons are the zero drop for many individuals, that life requires some ankle dorsiflexion to navigate the world, especially if you are going uphill, stairs as well. If you don't have hardly any ankle dorsiflexion, zero drop shoes are very difficult and what ends up happening is you end up shortening your stride even more. increasing your cadence even more, and ambulation can become less efficient. What that also does, especially when you're going uphill, if you're wearing a zero-drop shoe and you have limited ankle dorsiflexion, when you're going uphill, you max out your dorsiflexion, you don't have anywhere to go, so you start to see different deviations, and you also start to see a lot of pressure on the forefoot and the ball of the foot. If you have skin breakdown issues, neuropathy for example, this could have a whole host of complications. So there's some drawbacks to having a zero drop shoe for particular individuals and we need to be very aware of that. Now with all that being said, I, this is me, Dustin, anecdotally speaking, I am definitely for most individuals to be in some type of minimal barefoot style shoe. I think by and large, for many of the things that we do throughout our lives, it's a really good thing, but there's a lot of times where you want a solid shoe, right? You want some stuff between your foot and the ground. You want some help with that big toe extension. You want some help with that ankle dorsiflexion. So when I'm thinking about recommending barefoot style shoes to older adults, I'm thinking about three main things. And this is kind of a checklist that I want you to think about. 18:28 PROTECTIVE SENSATION One, and maybe the most important one, and this is probably one of the bigger mistakes that I've made in this realm, is that they need to have protective sensation. They need to have protective sensation. You need to get your monofilament out, your Seams 1C monofilament out. Check that protective sensation because if they do not have that, I highly recommend not recommending a barefoot style shoe because you will have lots of bumps, lots of bruises, stepping on gravel, you can create some trauma, if you will, and if they don't have that protective sensation, they may not be aware, and most individuals are not regularly checking the bottom of their foot to see if they're having any issues. I learned this one the hard way. I was treating someone that had type 2 diabetes and recommended, at the time, Altra, A-L-T-R-A, made a lot of barefoot style shoes, and I recommend the Altra Atom. You can look that up. It's one of my favorite shoes and basically gave this person a foot ulcer from some of the trauma that they received over several, several days. So learn from that mistake. Number two, you want at least 45 degrees of big toe extension. That's kind of the minimum for most individuals through ambulation, particularly through that terminal stance. So 45 degrees of big toe extension and also kind of symptom-free big toe extension. A lot of folks will have painful in-range big toe extension. So you need to be aware of that. If they don't have that, then you want a shoe that has some bit of a rocker angle. And I'm not saying you go to some like maximal style shoe, but even a relatively, I wouldn't call it nano, a minimal shoe, but the stack height isn't anything crazy. The heel drops three to four millimeters from the back to the front. And it has somewhat of a rocker angle. Something like that could be helpful for individuals and not putting too much between their foot and the ground. And then last but not least, their ankle dorsiflexion. At least 10 degrees of ankle dorsiflexion. That's kind of the minimum that we're looking through throughout gait. They need more than that when they're navigating uphill, when they're trying to do squatting, for example. But that's kind of the minimum. And I'd be very clear of when they want to wear these. When they're doing activities that don't require a lot of dorsiflexion or big toe extension, rock those barefoot shoes. But if you know you're going to be getting to and from the ground a bunch, if you're going to be guarding and kneeling, if you're going to be doing a bunch of squatting and lunging, then you probably want a solid heel drop. You probably want a nice rocker angle to support some of those deficits. So, I know that's a lot. I'm going to drop all these studies that I'm referencing in the comments of the Instagram post, but I think we need to be clear that we have evidence-based recommendations for older adults. I went through them at the beginning of this. I would say they're rather somewhat outdated, especially as the evidence is starting to evolve of looking at some of these different styles of shoes. But we're starting to see some early evidence supporting a minimal or barefoot style shoe in older adults. But we can't just do a blanket recommendation. Everybody gets Vivo barefoot. Everybody gets Xero shoes. That's not the case. We need to have that checklist, protective sensation, 45 degrees of big toe extension, 10 degrees of ankle dorsiflexion, and you're probably going to put someone in a good position. All right. Thank y'all. Y'all have a lovely Wednesday. I'll talk to you soon. 21:41 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.
Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the role of carbohydrates, the relationship between carbohydrates & performance, carbohydrate loading, and carbohydrate consumption timing. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 02:14 ALAN FREDENDALL Good morning everybody. Welcome to the PT on ICE Daily Show. Glad to be back again. Hope your day is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and elite faculty in our fitness athlete division. It is fitness athlete Friday. We would say it's the best darn day of the week here on Friday, live on Instagram, live up here on YouTube, and wherever you get your podcasts. Thank you for joining us. Some announcements really quick. If you're looking to join us in the fitness athlete division, we have a couple chances online and about a dozen chances live before the end of the year to catch us out on the road. Our online courses, fitness athlete essential foundations, that's our eight week entry level online course. All things relevant to treating the recreational athlete, the cross fitter, the Olympic weight lifter, the power lifter, the orange theory athlete, the boot camper, so on and so forth. That is the course for you. That starts this coming Monday, September 11th. We still have room in that class. And our advanced concepts course, also eight weeks online. Pre-requisite for that class is essential foundations, our entry level course. Advanced concepts is only taught twice per year. It is taught spring and fall. So this is your last chance to catch it this year. That will kick off the week after September 17th. That class has just two seats remaining. So if you're looking to round out your fitness athlete certification, make sure that you get into fitness athlete advanced concepts this fall. Live courses coming your way between now and the end of the year. Your next chance will be September 30th on October 1st. That will be out on the West Coast in the Bay Area with Zach Long. Also on the West Coast, October 7th and 8th, you can catch Mitch up in Linwood, Washington. That's outside of the Seattle area. Also on the West Coast, October 21st and 22nd, Zach will be on the road again, this time up in Vancouver, British Columbia. You have two chances the weekend of November 4th and 5th. You can either catch Mitch down in San Antonio, Texas, or Zach will be down in Birmingham, Alabama. Mitch will again be on the road in November, November 18th and 19th. He'll be in Holmes Beach, Florida. That's right outside of the Tampa area on Anna Maria Island. You can catch Joe Hanisco in New Orleans. That'll be December 9th and 10th. And then our last course of the year will be December 9th and 10th as well. That'll be out in Colorado Springs with Mitch. So that's your chance to catch us on the road in the fitness athlete division. Today's topic, let's talk about carbohydrates. Let's take a deep dive into what a carbohydrate is, how it's relevant to us here in the fitness athlete division as far as exercise, energy and performance goes. And then let's talk a little bit about when and how to kind of dose out your carbohydrates, who needs to be eating them, who maybe needs to think about eating more. And let's talk about timing of getting those in to best suits whenever we're going to be exercising to maximize and optimize our performance. 04:18 WHAT IS A CARBOHYDRATE? So starting very basic, if you know nothing, what is a carbohydrate? It is a sugar, a starch or cellulose plant material. So commonly we know carbs traditionally are things made out of maybe table sugar, candy, soda, that sort of thing, potato chips, things that are maybe less than optimal carbohydrate choices but are overwhelmingly what is often consumed when people eat carbohydrates. We also think of fruit being fructose. We think of the sugar that's in milk, lactose. We also think of carbs as vegetables that we eat when we're primarily eating the cellulose in a vegetable, we're eating that plant matter, we're eating things like green leafy vegetables, broccoli, kale, asparagus, that sort of thing. So different ways we can consume carbohydrates. They're not all equal as far as content goes, but those are all kind of classified as carbohydrates. Why do we care about them? Well, we really care about carbohydrates because eventually they become glucose in our body, which is an energy currency, a way that we metabolize energy reactions and chemical reactions in our body, but we also store glucose as glycogen. We store glucose as glycogen both in our liver and in our muscles. At any given time, we only have about four grams of circulating glucose in our system. So we have a relatively small amount. Our body does not really like to have glucose moving around in our blood system. So when we tend to get beyond that four grams circulating throughout our body, that's when insulin is released, insulin is released, and at the end of the day converts that glucose into glycogen, either stored within our muscles or stored in our liver, or if we do have an incredible excess of glucose in our system, it can be also stored as body fat. 09:13 MUSCLE GLYCOGEN Aside from the four grams circulating in our body, we have about 400 grams stored inside of our muscles, and we have about another hundred grams stored in our liver. For most people, a total of about 500 grams of muscle glycogen or about 2,000 calories worth of energy. And that's kind of where, if you ever wonder where is the recommendation that I should eat 2,000 calories a day to maintain a healthy weight, where does that recommendation come from? It comes from estimations of how much muscle glycogen we are storing and throughout the day using for regular physical activity, but also for exercise. And that if we deplete that glycogen throughout the day, we will need to eat 2,000 calories of food to replenish that glycogen back into our muscles and back into our liver. We can make glucose and then store muscle glycogen on demand. This is that process you may remember back from middle school or high school biology and chemistry called gluconeogenesis, gluconeogenesis, make new glucose. This is a very, very slow energy intensive process. We can only make about 30 grams of glucose per hour. Now this typically comes from our body fat. It's synthesized, made into glucose, and then is either stored as glycogen or pushed into circulation for energy. So this is kind of where the all day energy you have of being at work, maybe working around the yard, relatively low intensity activity. The energy, the glucose that supports that energy, those metabolic reactions comes from that process of taking body fat, turning into glucose in the liver, about 30 grams per hour. 11:17 GLYCOGEN DEPLETION DURING EXERCISE Now when intensity increases is really our concern in the relationship between carbohydrates, glucose, glycogen, and exercise. That when we start to exceed about 65% of our VO2 max, we start to use more glucose, use more glycogen than our body can produce per hour. So we start to dig into the reserves that are inside of our skeletal muscle and our liver. Now at very high intensities and very long durations, especially if heat, if temperature, is a factor as well, humans can use up to 150 grams or more per hour of that glycogen, which means at any given time, there are only about a couple hours of energy stored in our body for higher intensity activity. So above 65% of that VO2 max, what we call a low oxygen environment, we can no longer make enough glucose and glycogen to replenish what we are burning with that high intensity exercise. We are in a high oxygen environment, relatively low intensity activities. Our body can again make those carbohydrates, make those sugars from the fatty acids from our body fat, but as intensity increases, we start to dig into our reserves. Now that typically happens around the 90 to 120 minute mark. That is going to be a little bit different for every person. Bigger people, people with more muscle can store more muscle glycogen. Those who are better trained, who exercise at all, but especially those who are used to doing long endurance training, can store a little bit more muscle glycogen. And then certainly you've heard of the concept of carb loading, where if we taper our activity for two to three days and we increase our carbohydrate consumption accordingly, we can supersaturate our muscles with glycogen as well. And overall, we may have about 50% more glycogen reserves than the average person. We might have maybe 600 to 700 grams available. So maybe we can kind of flirt with having two hours of energy total for high intensity activity before we need to start thinking about eating, eating food, eating it to not only continue exercise, but feel better after, which is part of what we're going to talk about today. The relationship between carbohydrates and performance, especially if you want to be training multiple times a day or otherwise just not feel terrible the rest of the day after you finish exercise. Now it's not an all or nothing concept. It's not, I have a hundred percent of my muscle glycogen or I've used it all and I need to stop exercising and eat. We certainly know that we can consume food during long endurance activities, but also that as those reserves deplete, we feel a performance shift as we're doing different activities of we can feel maybe speed slow down on a run, maybe power slow down if we're out and we're on the assault bike or something like that. And we know we can run out. That's a concept that's called bonking of where we have depleted almost all of our muscle glycogen and our body is going to take us from that high intensity, low oxygen environment and say, Hey, you need to cool it. We need time to recover some of this energy and your body's going to stop you for you. And that's the concept of bonking of shifting you to a high oxygen environment by lowering your intensity in an uncomfortable manner, maybe even possibly losing consciousness, but definitely not feeling like exercising anymore. It's really important that we never hit that point. If we can avoid it, we've all we've all done it. I have a story of hiking in the smoky mountains of bonking at the top of a mountain, mainly because my wife ate all of our food on the way up and I had nothing to eat. So I had no choice and bonked at the top. But it's important to know that we don't want to get to that point. We never want to use all of our glycogen and hit that wall because there is a compensatory recovery point afterwards where for one to three days after we're going to feel really low energy as our body slowly recuperates and restores all of that glycogen in our body. We're not going to feel like pushing the pace. We may not feel like exercising at all. It's going to impact our training. And what you don't want to get into is kind of this weekend warrior phenomenon. Where maybe you go you go for a really hard run for two to three hours. You hit the wall and then you don't feel like exercising maybe for another week, right? Where you don't feel like you can work out again for a couple of days. That's not very productive training. So we want to avoid that. 13:58 CARBOHYDRATE CONSUMPTION And we'll talk about that now as we talk about when should I eat my carbohydrates. So it's really cool that technically a human being does not need to eat any carbohydrates at all. You may have heard of the keto diet of being low carb, maybe no carb, under 50 grams of carbohydrates, being in a state of ketoacidosis of only utilizing your own body fat as an energy source and the fat and protein that you consume. But it's cool that we don't technically need to eat carbohydrates. Yet almost all of the metabolic and chemical reactions in our body are fueled by carbohydrates. It's very, very interesting how our body operates. So you can go without eating carbs. So again, your body can make carbs about 30 grams per hour, but we need to understand that that takes time as we talked about. And especially if we are doing longer, harder events, we're thinking about maybe training twice a day, something like that. Then we need to understand that that process is slow and we need to give the body either a lot of time or we do need to consume carbohydrates. We also need to recognize at some point that eating carbohydrates is like consuming jet fuel for a mechanical engine. Of it's a very caustic chemical reaction to our body, a lot like burning gas inside of a gasoline engine, that it does create some low grade, low grade inflammation that's kind of always present as we're eating carbs and fueling our chemical reactions with the carbs. And so kind of the longevity side of the research would say, if you want to live as long as possible, avoid that. However, that's in direct conflict with the performance research, especially if you want to be a more competitive athlete. You want to do longer, more intense activities. You want to maybe train multiple times a day. You need to understand that those are two kind of diverging thoughts of longevity versus performance. At some point, those tend to dissect and not reconverge of needing to eat carbs to fuel your activity, especially multiple activities in a day or a busy workday after you exercise or avoiding carbs. Maybe even you may have a longevity physician who recommends you take metformin prophylactically to keep as much glucose out of your system as possible because of the inflammation that's present. But nonetheless, we need to talk about that relationship between eating carbs and performance. So it's that that longevity versus performance question that we have a need to eat carbohydrates if we are a long duration endurance athlete, that when you start to run 10 miles, 15 miles marathon, ultra marathon, when you start to do long trail runs, long bike rides, long hikes, that sort of thing. Again, you are using your reserves faster than your body can make more. And you either need to know that at some point you're going to hit that wall that we talked about or you're going to need to start consuming carbohydrates as you exercise. Higher level elite endurance athletes may eat 90 grams of carbohydrates per hour in the forms of liquid carbohydrates, gels, chews, that sort of thing. Folks who maybe are doing half marathon or marathon training may be eating less, maybe about 30 grams per hour. Our fitness athletes don't necessarily need to eat carbohydrates during exercise. We think about a typical one hour CrossFit class. We're not really at the level of intensity and duration long enough to need to eat carbs during that hour. We can get away with doing that hour of fitness and then worrying about carbohydrates after. But there's also a want, a need versus want. The want for carbohydrates is understanding that performance trade off, but also understanding that your body can only make about 30 grams per hour. So what does that mean? That means if you do go to that one hour CrossFit class, you don't technically need to eat carbohydrates before or during, but that you might want to front load your consumption afterwards, especially depending on the time of day in which you do your exercise. If you're like me and you like to get up and exercise first thing in the morning and then you might be looking at, hey, I have 8, 10, 12, 14, 16 hour day ahead of me. Those subjective feelings that you may feel your patients, your athletes may feel of, I feel tired all day after exercise. I feel like I just need to go home and go to bed. I feel weak. I feel like I can't do my work tasks. I can't take care of my kids. Maybe even feeling lightheaded or some sort of impaired cognitive function. Like my mind just feels cloudy. All of those are good subjective reports to tell you that you should probably eat some more carbohydrates after that exercise session or to recommend that to your patient or athlete. And then we get in now to how to do that of our long duration endurance athletes. We've already talked about they're probably going to be or hopefully should be consuming those carbohydrates as they're exercising, especially once they cross maybe that one hour mark of again, it's not an all or nothing equation of go until I can't anymore of as those reserves of muscle glycogen get depleted, I'm going to feel worse and worse and worse than my performance. And how I get ahead of that is eating, eating those carbohydrates while I'm exercising. So the combination of me eating them and my body making some more keeps them relatively high, keeps my performance, my output higher, keeps me away from feeling kind of that onset of losing power, losing speed, losing energy throughout my workout. 22:08 CARBOHYDRATE CONSUMPTION & TIMING How to eat those? Well, I'm still trying to figure that out. As I get more into long endurance training, I have tried chews and gels and my body doesn't really sit with those. I tend to do better with liquid nutrition like Gatorade. Every person is going to be different, but definitely those people who are going out for longer workouts, especially crossing an hour need to find a way to start to consume that as they're exercising. This is also relevant to our fitness athletes who may be doing a multi event day. Maybe they're doing a local CrossFit competition. Maybe they're a quarterfinals or a semi finals athlete where they have multiple events per day, multiple days in a row. I always laugh now when I go to a CrossFit competition and I see that person after workout eating chicken and salad, right? Just not enough carbohydrates in that meal to replenish what was used in that CrossFit workout in order to have those reserves restored and ready for the next workout, which might be two to three hours after the first one. They might have a third one two to three hours after that, right? Those are athletes who they don't necessarily need to eat carbs during the workout because it's a relatively short event, maybe 10, 20, 30 minutes. But if they have to workout again in three hours, they're definitely somebody who's going to want to eat higher carbohydrate food. That's the case. You see CrossFit Games athletes eating gummy bears and Snickers bars, just getting as much carbohydrates as they can. Again, they're trying to maybe replenish 200, 300, 400, 500 grams of carbohydrates within a two to three hour window to be ready to work out again. So understanding it's important to get those carbs back in if you're wanting to train or you have to exercise again in a relatively short amount of time. I hiked the Grand Canyon last year with Dustin Jones and Jeff Musgrave and we did it. It was about a 12 hour hike up and down about 20 miles and we did it almost exclusively on water, Gatorade and gummy bears, right? Just high carb food that's going to keep our reserves up because we're basically hiking and walking in a hot environment at moderate to high intensity for a very long period of time. I'm thinking I just ran 10, 800s this morning. I have a 12 hour day ahead of me. The first thing I did was eat three bananas, right? The first thing I did was house 100 grams of carbs to give my body that jump start on replenishing that glycogen, which was not entirely gone, but definitely mostly gone at the end of that running workout. And that's really going to determine how you recommend carbohydrate intake to that patient athlete in front of you of what does the rest of your day look like? When do you train and what does the rest of your day look like? If you work out at 5 a.m. and then you have to go to work all day and you're maybe a physical therapist, right? You have a relatively physically active job. You're getting your steps in. You have an eight to maybe 10 hour day in front of you. You'll probably feel a lot better if you eat the majority of your carbs earlier in the day to replenish those reserves. You will find yourself feeling subjectively better. If you work out early in the morning, maybe you run and you want to lift weights at lunch or go to CrossFit after work. How can we fuel our body to be able to do double sessions in a day, two a days, right? The same thing, we need to front load that carbohydrate consumption in the morning, at lunch, in the early afternoon so that by the time we are going to work out again, most of those reserves are back. They're probably not going to be 100% back where I can PR my 5K in the morning and go PR a CrossFit benchmark in the afternoon. It's probably not going to work out that way to be 100% ready to go for a second session in the same day. But you will feel better during the day subjectively and you will definitely perform better objectively in that second session if you eat a lot more carbohydrates in between. Now who is that person that maybe works out in the afternoon or evening and that's their only session of the day and then they go home and they basically watch some TV, get ready for bed and go to bed? That is maybe a person who can get away with maybe a lower carbohydrate or could maybe play with a keto diet, right? Of hey, I work out at 6 p.m. when I'm done with work, I get home around 7.30, take a shower, eat some dinner, go to bed. That is a person that they do not necessarily need to replenish as much of their glycogen as possible because of their schedule, right? They deplete their glycogen in the evening, they are going home consuming some with maybe a dinner meal and then they're going to bed. They're giving their body maybe 8 to 10 hours to replenish hundreds and hundreds and hundreds of grams of muscle glycogen overnight while they're asleep. So that is a person who maybe could get away with lower carbohydrate or no carbohydrate consumption between when they work out and when they wake up again. That's a person who's going to work out, have dinner, sleep, have breakfast and have lunch again before they work out again 24 hours later and they're in a really good position where maybe they don't need to worry about it as much. So carbohydrates, what, when and how? Understanding they're very important for performance, especially for longer duration exercisers, for long endurance athletes. They're definitely linked to performance, especially if you are wanting to train multiple times a day. You are in a competitive environment where maybe you're doing multiple events in a day and then we need to understand timing of when should I eat them. For most people, if they're working out in the morning, they're maybe doing multiple sessions in a day. They're going to work and they want to feel like they have high energy. They should probably eat a good portion of their carbohydrates earlier in the day, but there is that person who maybe trains later in the day who doesn't have a lot going on between when they train and when they're going to train again, who maybe can get away with not eating as much carbohydrates as somebody else. So understanding that food is our friend, food is fuel and understanding how your body creates, consumes and utilizes carbohydrates for energy can be a really big game changer for performance during and after exercise. We all probably have that patient who seems really active, really fit, but complains all the time of being tired, of feeling weak, of not hitting PRs. And that can be a good person, yes, to evaluate their protein consumption, to make sure that their muscles, their musculoskeletal system is recovering appropriately, but also to have a conversation of what their carbohydrate consumption looks like. If we can up our carbohydrate consumption a little bit, we'll often find that that subjective fatigue, weakness that comes after a training session, especially if we're going to train again later or we have a long day of work or whatever ahead of us, we can alleviate a lot of that just by tweaking our diet a little bit. So I hope this was helpful. If you're going to be on an ice course this weekend, I hope you have a fantastic weekend. Have a great Friday. Have a great weekend. Bye, everybody. 24:46 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.
Dustin Jones
In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses how healthcare providers can learn to assess patients' readiness to change when becoming more active, barriers they perceive to exercise and confidence in implementing a regular exercise program. Alex challenges providers to become a "guide to self-efficacy" with patients to increase their regular physical activity. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're sure to use the code ICEPT1MO when you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:33 ALEX GERMANO Good morning, Instagram. Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today's segment of Jerry on ICE. My name is Alex Germano. I'm a member within the older adult division. We are going to talk about a recent article that came out talking about how to address inadequate physical activity in our patients, especially older adults. The older adult division continues to charge across the country this fall with courses in Charlotte, North Carolina, Fort Collins, Colorado. That's happening this weekend. You can catch us in Oklahoma City, Bellevue, Washington and Falls Church, Virginia to round out September. Head to the PT on ICE.com website to learn more about our current course offerings. It does not seem like we're slowing down coming into the end of this year. 02:31 INCREASING PATIENT'S PHYSICAL ACTIVITY I know it seems a little lame to come on the podcast and talk about increasing our patients' physical activity clinically. I mean, I say this is a little lame because I think it's something like we're like, duh, we all know. We need to get our patients more physically active. And so it doesn't seem like the coolest thing we can talk about if it's a problem we all know about. But I thought this article added a lot of value to this conversation. Clinically I've really gotten to this point as a therapist where I believe that most of my patients' ailments, their balance concerns, the unsteadiness they have, the lack of endurance they have, the lack of strength could all really be fixed by joining a gym or performing some type of meaningful fitness in their lives. I have really begun to embrace and step into this role of being a guide to their land of fitness for my patients. And I do care about the reason I'm there and trying to work through that with them. But really the ultimate goal in the back of my mind the whole time is how can I lead this person to meaningful fitness for longer durations? Because I know that my physical interventions are not going to stick around too long if the only thing that they're doing for physical activity is physical therapy or occupational therapy. Now because this is the way I approach my patient care and sometimes I'm all by myself out there in the world doing home visit, I really thought that every physical therapist out there was trying to increase their patient's physical activity. And I think I'm a little blinded by the community that I'm a part of, ICE, and that we're probably all trying to do this. So I just thought every physical therapist is out there really trying to do this thing and everyone's going to be super bored by this conversation until I saw the statistic in this paper that despite 91% of older adults over the age of 65 not performing recommended activity guidelines, 91%, which is costing the world $53.8 billion a year, 50 to 75% of healthcare providers are not assessing and addressing inadequate physical activity in their patients. 50 to 75% are not addressing physical inactivity. And I thought to myself, oh well let me look at the studies that they're citing for these statistics because clearly physical therapists or occupational therapists are definitely addressing this. They probably lump together all these healthcare providers. No, most of the studies they cited for the statistic were involving physical therapists or other rehab providers. Yikes, mind blown. This is significant. And I think a lot of us are trying. We're probably trying. We are making some of these light suggestions for home exercise program. We tell people to break up sedentary behavior and sedentary time. But how often is that really working? How often does that patient go off to join a gym? How often do they start seeing the personal trainer? Do they start telling you every time you come, I am doing all of my home exercise? Honestly, not very often. So it's not maybe our lack of trying, but rather the way we're trying to approach this conversation is what's off about how we're trying to solve this problem. So this article that I am referencing, which will be in the links on this Instagram page, suggests that we might not be advocating for physical activity well due to a few factors. It could be our lack of knowledge or confidence on how to assess and address inadequate physical activity. It could be an uncertainty on how to use behavioral change techniques in clinical practice. 04:05 LACK OF PHYSICAL ACTIVITY AWARENESS So the first part, how do we get more comfortable and confident in assessing and giving our patients physical activity recommendations? At the Institute of Clinical Excellence, you've heard it a million times. We do it ourselves. We walk the walk. We be about it. We can't say this enough, right? By having a solid foundation of our own exercise program, you're going to be much more convincing, much more inspirational to your patient whom you're trying to get to the land of fitness. Now I will admit sometimes though, I'm going to be and not worry about this. I don't think that this is, I think this is important that we're this way, but it's also important that we remember what it was like to not be fitness forward at all because having this strong personal practice and exercise can be detrimental. I am on vacation and I, when I'm on vacation, I love to exercise. Like love it. I got out there for a run this morning because we're coming up to our marathon and I wanted to get out there, got a good run in. I love to work out because on vacation I have extra time. I'm not in a rush to be in the gym early and get out of there early. So I love it. 07:21 EXERCISE AS A CORNERSTONE A lot of my patients though report that exercising on a vacation is like absolutely not going to happen, right? It's like, it's so easy they're not going to be able to do it. And like I was thinking about like, why do I exercise on vacations? Because it means so much to me and I really know and appreciate exercise in my life, right? This is the curse of knowledge that I have. I know how good exercise is going to make me feel for the rest of my days. My patients do not feel that way. Dustin Jones talked about this actually a number of years ago talking about the curse of knowledge. I know how good it feels, how easy I can fit it into my life even in exceptionally busy times. We don't remember what it's like to be that newbie. And it's a huge excuse I see for my patients and I almost want to laugh when I make patients tell me they don't have enough time to exercise, especially knowing they're retired. They're not really having much to do around the house. Like most of their chores are kind of outsourced to other people and like as a new, like a newer mom, right? Like I have a one and a half year old and I've worked multiple jobs. Like sometimes I feel like I'm barely hanging on. Exercise remains a staple in my life. I could sit on my high horse and tell them I'm so busy and I still can fit in five days of exercise during the week. How many hours of TV a day are you watching? Don't you think you could sub in one of those hours for exercise instead? That conversation has never worked in clinical practice to elicit change in my patients. Okay? When I hear my patients don't have time, that really tells me something more. It tells me a lot about their readiness to change their lifestyle. And this might be really the missing piece around some of our education surrounding physical activity. So after you ask your patients about their current activity levels and compare these to the traditional guidelines set out by the ACSM, those ACSM guidelines, you can start to assess their stage of change. I think that's the most important thing we answer first. How ready is my patient to change? How ready are they to change? So an important question could be, do you intend to change your physical activity in the next month or in the next six months? I'm trying to determine a timeline. Now you can decide based on the answer if they kind of fall into these different categories. Are they in the pre-contemplation phase? Meaning they're not interested in really changing their physical activity at all. Or are they in the contemplation phase? Do they intend to increase their physical activity in the next month or the next six months? And do they have a plan in place to make that change? Most of my patients really land in the pre-contemplative phase where they're not considering changing really anything. They're not coming to me for an exercise program. They just have a problem they want me to fix. Now if there's some, you might even meet somebody who's in a preparation phase, who's actually made a plan to change some of their physical activity. They've reached out to a local gym, something like that. And if they're in that preparation phase, you're going to want to follow up on what's their action plan to increase their physical activity levels. If someone is in the pre-contemplative stage of change, we want to validate their current perspective. We don't want to convince them to switch sides. Not yet. It's our turn to show them what physical activity can do in their lives and wait for them to be interested in doing more. This is a call to action to make sure our patients really see the value of rehab that we provide. They should see a super clear connection between their goals and the exercises we select. If our patients are in that contemplative phase without a plan, so they're thinking about it in the next six months, they don't really have a plan to get there, it's our job to develop specific goals for them and an action plan while assessing their confidence to committing the plan. I think that's what we miss is that confidence piece. We usually miss it and we only kind of set out a goal or action saying you're going to do this exercise five days a week, sounds good, I'll check back in on that later. 11:20 ASSESSING CONFIDENCE WITH EXERCISE The confidence assessment is key. You can ask your patient how confident they feel on executing a plan. Ask them on a zero to 10 scale, how confident are you that you're going to be able to do this exercise program five days a week? If the patient says anything less than a seven out of 10, we need to reevaluate the goals and the action plan. We probably should drop that down. Do you think you're going to be able to get three days of exercise in a week? Assess confidence, super important. Now if the patient already has a plan going, it's worth it to stop and talk about barriers. The article mentions using the 27 item inventory of physical activity barriers, which works through a patient through eight domains of barriers that could impact physical activity. That is a super thorough assessment. 27 items is a lot. So this could be appropriate for some, maybe not for all. The simpler one would be the self-efficacy for exercise scale. That's a bit simpler. It's a far fewer items. I'm sorry, I don't remember the exact number, but it's far fewer items than 27. But if you're really interested in figuring out what's going to cause your patient to stop being physically active, these are assessments you definitely want to do. Now as your patient begins to execute their plan, it is our job to constantly check in. In the article they say, recognizing success is essential because it increases self-efficacy. And I couldn't agree more. I am all about and in the business of improving my patient's self-efficacy. Honestly, I wonder if that is the job of the physical therapist for the older adult at this point. Bringing our patients back in control of their lives and giving them this feeling and sensation of self-efficacy. So I'm a guide to that land of self-efficacy. Now how do we do that is we check in constantly with our patients about their program, their physical activity program. And we cheerlead and recognize and give kudos to every little step that our patient makes towards these goals and especially when they work around barriers to completing the activity. So make sure if you have physical activity goals for your patient that these are things you're asking about every session. We're not giving them the plan and then not checking back in. It's really our job to continue to check back in. It's why we are different than medical doctors who see our patients once every six months and you know six months to a year. At that six months to year visit our MDs are usually telling people, hey you have to be more active and that's all they're doing. No, we get to do the hard work and really check in with our patients how this plan is going. 14:00 AGE-FRIENDLY HEALTHCARE Now this article also describes age-friendly healthcare which helps to foster a person-centered care. So for older adults in particular you kind of have to determine what matters. They call this the four M's but what matters, M matters, knowing what our patient's mentation state is which I love, taking this consideration towards dementia and delirium that we need to understand before giving these guidelines. Talking about mobility optimization that making sure our patients maintain high levels of mobility and safety is critically important to the population and optimizing medication. So there's a lot that goes inside of this, there's a lot that goes into this conversation rather of physical activity and addressing inadequate physical activity in older adults. This article was really lovely, I really recommend a look because in the back of the article there's a resource guide of all the different physical activity related measures that you can compare and contrast to see if you can find some that are appropriate for your patient population. It's at the very end of the article. So I'll link it in the Instagram page but just remember first and foremost we are in the business of addressing physical activity, absolutely. We have to recognize that we have a bias towards exercise that our patients do not have so we need to come back to that newbie state of mind and really address physical activity from that place and not from our high horse of exercise. By doing this we have to first assess my patient's readiness to change. How often are they thinking about implementing a physical activity program in their day to day life? Think about those things first before you start giving recommendations because if they're in the pre-contemplative phase of behavior change they are not ready to hear from us that they need to be doing a physical activity program. Not yet. Think about the barriers that our patients are going to encounter and potentially use some scales like the physical activity barrier scale or the self-efficacy for exercise scale to address these barriers that are going to inevitably pop up when we start engaging in a physical activity program. Think about some older adult specific techniques such as thinking about mentation, thinking about medication in order to optimize our recommendations. Alright, so you guys are in the business of increasing physical activity for older adults. It's actually probably one of the bigger parts of our job. 91% of older adults are not meeting physical activity guidelines so get out there, let's start attacking these numbers. Have a good Wednesday. 16:29 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.
What is Modern Management of the Older Adult? with Dustin Jones https://www.MMOA.online
Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult Division Leader Dustin Jones discusses recent changes to the Modern Management of the Older Adult Division and its mission to help clinicians provide the best possible care to older adults in their community as the provider of choice. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're make sure to use the code ICEPT1MO when you sign up as that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:33 DUSTIN JONES We are live on Instagram. We are live on YouTube. Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the faculty members within the older adult division. This is Older Adult Wednesday. Today we are going to be talking about what is MMOA? What is this division? What are we about and what are we trying to achieve? We are going to spend some time diving into this because we have so many new folks that are new to the ICE community. We want to make sure that you're crystal clear on what MMOA is about and if you'd want to join forces with us. Before we go into the goods, I want to mention a few courses we have. We have a few live courses coming up in the next couple of weeks. We're going to be in Southern California this upcoming weekend with Alex Germano. I'm going to be in Windsor, Colorado outside of Fort Collins on the 9th, so the weekend after Labor Day. I believe Julie Brower is going to be down in Fort Mill, South Carolina, so you can catch MMOA live on the road the next couple of weeks. 02:43 MODERN MANAGEMENT OF THE OLDER ADULT What is MMOA? Modern Management of the Older Adult. Our division, we just went through our big live revamp, so our MMOA live course is all new material and we're spending a lot of time reflecting on what we are about as a division. What are our goals? What is our mission? How can we get to that mission and what traits do we want our MMOA team to really demonstrate? I want to share this publicly just so you all are very clear of what we're about, so our goals and where we're headed and to propose that you join forces with us to achieve that mission of really changing the game for physical therapists, occupational therapists, fitness professionals that are working with older adults. So MMOA, Modern Management of the Older Adult, it really grew out of a big problem that we still see that we're still fighting. That older adults by and large in our society are underserved in so many areas, but in the context of rehabilitation, in the context of fitness as well, that most individuals, most professionals that are working with older adults will look at a date of birth. They'll look at medical diagnoses. They'll look at the medications that they're on and make assumptions about what that person is able to do. And when those assumptions don't line up with reality, we have a very, very unfortunate situation where people are not being served appropriately. They're being underdosed. They're being handled with kid gloves and we're not getting the results with these folks, the life changing results with these folks that we can get. That is a huge issue that pains every single MMOA faculty to see and we are on mission to try and solve that problem. How do we solve that problem? It is you. It is you that is watching this on Instagram, on YouTube, that is listening to this on the podcast. It is you, the rehab or fitness professional that has, we believe, has the most qualified skills to influence this population compared to any other healthcare provider. And we mean that. When we look at the research of how we can really influence older adults, it continually points back to that fitness forward approach. That exercise, that movement is such a big lever that we can pull to change these people's And you all watching and listening to this are the best professionals in the context of healthcare to administer this to this population that we love so dearly. Another big problem that we see that we're trying to solve is we have so many clinicians, so many fitness professionals, especially coming up in their training that they think, man, I want to work with the athletes. I want to work with the sports teams. I want to do the fun, sexy outpatient ortho clinic. And we go through our training and our training talks about a lot of things, but by and large, not a lot about older adults and how to best serve these individuals. And then we get out into the real world and what happens? You wanted to work with the sports team. You wanted to work with athletes, you know, from 8 a.m. to 5 p.m. or whatever. And who are you working with? By and large, on average, over half of your all's caseload, everybody watching this or listening to this, over half of your caseload is likely someone that is on Medicare, someone that is over 65 years old. And are you equipped to serve that person? And what happens when you're not equipped and yet you have these folks as the majority of your caseload, there becomes a big mismatch, right? It can be frustrating. It can be challenging and could lead to a lack of fulfillment and enjoyment in your work. And we're trying to absolutely crush that, to show you, the clinician, the fitness professional, of the life-changing impact you can have on these folks. When you use your skill set and you embrace that old-not-weak mindset, that you give interventions that actually meet that person where they're at to drive change, that it can be some of the most fulfilling work that you can do in the context of rehab and fitness, that you can change someone's life in a matter of weeks in certain situations with this population. And that has really driven a lot of the MMOA faculty. And we just want to spread that and share that just far and wide, as much as we can through many different means. So those are the big problems. The solution that we are trying to provide is we're trying to create an army. We're trying to create a community of like-minded clinicians that are locking shields to really fight ageism, to fight the under-dosage in our profession, and to show people what is possible when we serve these folks with an evidence-informed, fitness-forward approach. We do that through many different avenues. We'll do that through this podcast that you're watching or listening to, the PT on Ice Daily Show. We also have an MMOA podcast that's specifically older adult material. We have a Facebook group of about 5,000 clinicians from across the world that serves as a resource for so many individuals in terms of certain research cases. So much good conversation is going on in that group. We have our MMOA Digest. It's a bi-weekly email where we're sending out all the relevant information related to geriatrics. And then we have our courses, our certification. 07:49 CERT-MMOA Cert MMOA. This is the certification that is our promise to clinicians. That if you go through our certifications, three courses, MMOA Live, our two online courses, Essential Foundations and Advanced Concepts, that you will confidently be able to serve that person, that older adult that walks through your door, or you walk into their home, or you walk into their hospital room. It's also a promise that when you see those letters behind someone's name, you can trust them. Our goal is that cert MMOA means I am 100% confident that my mother, that my father, that my grandmother could go to you and you are going to deliver an evidence informed and a fitness forward approach to my family member. That is what we're trying to do, selfishly trying to do to ensure that that cert MMOA holds some weight and you've got the goods. And so there's a group of 10 individuals from across the country that are working towards trying to solve these problems and providing the solution through those different means. We absolutely love what we do and it is such an honor to serve you all and to interact with all the students when we're out on the weekends and live courses and the online courses as well. And this team, this team of 10 all-stars of folks that really embrace that old not weak mindset that have been through our curriculum are spreading this information far and wide to try and equip you, the rehab and fitness professional, to better serve your older adult patients or clients. And each member is going to demonstrate three main traits. We call this our DNA. And what we're going to do over the course of the next couple of weeks on our MMOA channel or Instagram account, we're going to go live and really dive into what these DNA traits are and the specifics of them and how we may see that play out whenever you come to a live course, whenever you interact with us online as well in essential foundations or advanced concepts. These three DNA traits that we're all going to embody is that we're all leaders. Regardless of your role on the team, we're all leading someone and there are certain characteristics and traits of leaders that we embody. We're also teachers. We understand this material, but we're also methodical in how we relay that information to our students so you can use that come Monday. And then last but not least, we're performers. We are performing. We're trying to entertain you so to continue to engage and learn. And whenever we're having fun and you're having fun, we know learning goes up across the board. You will never come to an MMOA course and see someone read off of a PowerPoint presentation for three straight hours while you're sitting in your butt getting a pressure ulcer. That ain't happening, right? We're going to have fun. We're going to get the music cranking. We're going to be moving. It's going to be an absolute blast. So over the next couple of weeks, we're going to dive in. What does it mean to be a leader? What does it mean to be a teacher? What does it mean to be a performer? And how are you going to see that within the MMOA division? So tune in there. We'll be posting over there, but I just want to take this opportunity just with all the folks on here now, I just want to say a big thank you. We've had a lot of change as a division, a lot of growth as well. We're interacting with so many of you all in person on Instagram, you know, in our courses as well. And it is an absolute honor to get to do this, to get to share our passion with you all through these means. And you all just really fill our cup up. When you share, when you execute, you know, that particular tip or intervention, or you just share, man, I got to use this on Monday after this course, that makes it all worth it for us. So we're just incredibly grateful for you. All right. If you have any thoughts on that, or if you've experienced some of this in our course, we'd love to hear in the comments, but just wanted to share this, put it out into the world, and we're going to continue to break down our DNA leaders, teachers, performers over on the MMOA account. We're grateful for y'all. You have a lovely rest of your Wednesday. Talk to you soon. 11:46 Outro Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.
Dustin Jones
Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Dustin Jones explores the concept of creating impactful memories for customers and how it can enhance business success through word-of-mouth marketing. He shares examples from the restaurant industry, illustrating how exceeding customer expectations can cultivate lifelong customers and improve business growth through positive word-of-mouth. Dustin emphasizes the significance of creating "legends," which are memorable experiences that surprise and make customers feel special. These legends become synonymous with the business and leave a lasting impression on customers. When businesses go above and beyond to provide such memorable experiences, it not only fulfills the customers but also benefits the business owners. Dustin encourages listeners to consider what legends they can create in their own businesses. It could be as simple as acknowledging a customer's birthday with a card or text, or going the extra mile by taking a discharged patient to play pickleball or organizing a group trip. The possibilities are endless, and creating legends can have a positive impact on the business, the community, and the overall satisfaction of everyone involved. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Welcome back to the PT on ICE Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show. 01:43 DUSTIN JONES PT on ICE Daily Show. It's Dustin Jones here. It is Wednesday. We're going to be talking about making legends. What, how, and then the why behind this. Making legends is going to be about how to create memorable, impactful experiences for your patients and why it's good for them, it's good for you from your professional standpoint, and good for your business. All right. So what I want to talk about first before we get into this are the modern management of the older adult courses that are coming up. We are picking back up. We usually kind of take a little break during the summer, regroup, do our revamps, update all the literature and the slides, and we're hitting the ground running. So we're going to be in Boise, Idaho, in Watkinsville, Georgia at the end of July 29th and 30th, and August 5th we'll be in Frederick, Maryland. And then on August 12th, we will be in Lexington for the MMOA Summit where all the MMOA faculty are going to come together and deliver the brand new revamp of MMOA Live. We're super pumped about that. And then we have Essential Foundations, our online course starting August 9th. All right. Legends. Let's talk about this. I'm really excited about this topic. This has been something I've been thinking about since about February when I read the book Unreasonable Hospitality. So this is a book that you probably heard some of the ICE faculty talk about that Jeff Moore recommended. Anytime Jeff Moore recommends a book, you should probably check it out. The guy doesn't recommend a lot of books, but when he is very critical of a lot of books, so when he says, hey, this is worth reading, you probably should add that to your list. And this definitely proved to be true with this book. So Unreasonable Hospitality, I'll just give you the 30,000 foot view. Will Guderia is a restaurateur, very successful in that business or that industry. And he kind of talks about some of the principles that he used to create such impactful businesses, restaurants in particular, and how a lot of those principles that he used also translate over to business in general. And just so many different industries can benefit from kind of that hospitality mindset. And so he talks about a lot of different practical strategies that all of us can use in the rehab and the fitness profession. But he speaks to one particular of how we try to create legends. And when he says the word legends, what he's really talking about is creating impactful memories for folks where they are surprised, they feel special, and they will never forget. That moment and the business that is associated with that moment. He's got all kinds of crazy examples from the restaurant business, where he just went above and beyond what people were expecting and thus created customers for life. And that really improved his business, word of mouth marketing, and a lot of different things that made their job more fulfilling. And so he speaks about that concept of legends a lot in the book. And I walked away from that book just thinking about, man, we have such a huge opportunity to create legends in the rehab space, in the fitness space. And I'm going to talk through, you know, just through that of why we may want to do that, and then particularly the how and give you some examples. So in terms of the why, the first thing that I want to acknowledge is that when we go above and beyond and provide a memorable experience for folks and do it in the mirror, that they're kind of surprised and taken back. That is very fulfilling for us. I'll give you one example. Ellen Sefi. So she teaches with MOA. She has created lots of legends for a lot of her patients. She had one patient in particular that she was treating in a more acute setting. I forget the exact situation, but she this this patient had a long road to recovery. And Ellen ended up switching jobs into outpatient as that that patient was kind of leaving that acute setting and going into outpatient. So Ellen was able to treat her in that setting. This is a long road road to recovery for that individual. And Ellen worked with this person to help her get back to being able to hike. That was a big goal for this patient. And I think this is where a lot of us kind of stop, right, is we get people to the point where they can do the thing, right? Whatever that particular goal is for this patient, it was hiking. So she worked on her lower extremity strength. She worked on her dynamic balance. She worked on her endurance and she checked the box of all the kind of prereqs to be able to go on a hike in Colorado. And that's where we stop. And that's where we have such a huge opportunity to take a one step further and create a legend. And what Ellen did is she actually organized a hike and did a 14 or with this patient, right? She gave her the prerequisite skills and abilities required to achieve that goal. But then she facilitated that goal to actually happen. And she went on that journey with that patient that for Ellen, that's one of the most memorable professional moments for her. The fulfillment of being able to see of all your hard work and time that you have invested in this person, that they're able to do something epic like that. That is so fulfilling. So it's good for you. It's also good for your business because that happens. What do you think that patient is going to tell all their friends and their whole networks? Do you think she took a thousand selfies on the top of that summit and posted it all over social media? And guess how many patients Ellen probably had from that word of mouth, from impacting that patient on such a big level that it really sets you apart from a lot of your competition that aren't doing that. They're just checking the box. They're just improving strength, improving endurance. And you're actually facilitating your patients climbing 14 years, right? That has a compounding effect over time. It's going to be good for your business. All right. So that's the what of the legends. That's the why. It's good for you, for your fulfillment, for your career. It's also good for your clinic, your business as well. And so I want to get kind of dive into some practical examples of how we can create legends in the context of rehab and or fitness. I think we can do this in very simple manners and we can do this in kind of big, big, monumentous events as well. On the small side of things, just think about how you can surprise your patients, make them feel special. This is could be as simple as acknowledging someone's birthday. You have their date of birth that you send them a card, a gift card, whatever that just that simple act kind of puts you above them. Beyond most clinics and in gyms, for that matter, it could be that easy. It could be that simple. It could be more like what Ellen did, where she worked on building physical capacity with a patient, which is usually the case in our plans of care. Right. We're trying to get them stronger, improving their endurance, improving their balance, all that fun stuff that is tied to a patient centered goal. Right. We're already asking a lot of those things. What if you take it another step further to facilitate them being able to participate in whatever that activity is? Right. I'm not saying you got to climb a 14 or like Ellen did, but what if you proactively, you know, organize the hike that they could go on? What if you address the barriers that they may have on going on that hike, like going ahead and printing out directions of going ahead and planning out the day, recommending restaurants to hit up after the hike, just reducing barriers and facilitating that or even connecting them with a local hiking group that's going to increase their odds of actually doing the thing that you help them be able to do. Right. We could do it in that manner. Ellen took someone up a 14 or for me, especially in the context of home health, this happened a good bit where it was usually something a lot simpler than going to climb in a 14000 foot mountain. It was, you know, once that person was discharged from homebound status that we would go and do something in the community that they loved about. One in particular, I will never forget this. Me and my wife went on a double date on Valentine's Day at Waffle House with Walton Peony Smith in Columbus, Ohio, that I was discharged in Peony. She was no longer considered to be homebound. And it was right around Valentine's Day. And she had just regained the ability to navigate her community safely and efficiently. And so we crushed the All-Star Special. I still remember that meal. It was absolutely amazing. A double date on Valentine's Day at Waffle House. Something like that is just takes things to the whole another level that I will never forget. Very fulfilling from the professional standpoint. Peony will never forget. And then all of her friends, her family won't forget either. And when they want PT, guess who they're going to be calling. Right. We could take it up another notch. And this is something that we have been trying to do more at Stronger Life. We have a couple examples of this recently, which has really fueled me wanting to talk about this. One is that we had four individuals compete at the National Senior Games. These four women have basically never ran their life before, about 12 months ago. They qualified at the state games last year and then went to Pittsburgh last week to compete in the National Senior Games. And one of our athletes, Carolyn Holmes, 89 year old woman, got third in the 5K. And her whole family, three kids from all across the country, their kids, and then she had a couple of great grandkids were all there to witness this. And I will never forget this. Carolyn Holmes, 89 years old, running across the finish line with her eight year old great granddaughter. We got Carolyn stronger. We improved her endurance. We improved her balance. We checked all those boxes. But we created the opportunity for them to really flex their muscles and really pursue something that they had never even thought that they would be able to do. And then to do that in front of their community, in front of their family and then the whole Stronger Life community watching this from afar. Those are potent moments. Those are legends that I will never forget. Hands down, my most fulfilling professional moment. Carolyn will never forget that. And anybody watching that story will never forget what happened on that day. It's good for me. It's good for Stronger Life. This is good for our communities. It's a win win win for everybody involved. All right. We've got another one coming up this winter where we're taking 25 of our members to Costa Rica in an all inclusive adventure retreat where we work on their balance, their strength, all this stuff inside the gym. And then we create the opportunity for them to use those skills and do things that they never thought were possible. Right. These are legends. They're good for you. They're good for your business. They're good for your community. So I want you to think what legends can you create in the context of your own business? Some of you, it may be, all right, I need to acknowledge that someone had a birthday and just write a card and send it or send the text or whatever it may be. Some of you may think, oh, man, I may end up taking that patient that I just discharged actually to go to the pickleball court and play some pickleball with them or connect them with that pickleball group. And some of y'all may climb a 14 or some of y'all may organize a group trip to the Caribbean. I don't know. But there's so many opportunities for us to take things to that next level to create legends. I've really enjoyed this. I think you will as well. And I know your business will benefit, too. All right. Let me know your thoughts in the comments. If you have any legendary stories or any ideas, I would love to hear what you're going to do. We'll get lots of ideas in the comments, which will be very helpful to make this more practical. All right. You have a good rest of your Wednesday. I'll talk to you all soon. 13:24 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.
Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines cold plunging, discusses the research behind cold plunging, and how to practically approach practicing cold plunging. Take a listen to learn how to discuss cold plunging with your patients or athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:25 ALAN FREDENDALL Alright, good morning PT on ICE Daily Show, happy Friday morning. Hope your morning is off to a great start. My name is Alan, I'm happy to be your host today. Currently, I have the pleasure of serving as a faculty member here in our fitness athlete division and the chief operating officer here at ICE. Fridays, our fitness athlete Fridays, we talk everything related to the recreational athlete, whether that's somebody in the gym doing CrossFit, powerlifting, Olympic weightlifting, bodybuilding, out on the track, the road, running, biking, swimming, whatever, that person who is getting after it. Four to six days per week is the focus here on fitness athlete Friday. We're biased, but we would argue it's the best darn day of the week. Courses coming your way from the fitness athlete division. Taking the summer off, we have some live courses coming up in September. You can catch Mitch Babcock out in Bismarck, North Dakota. That will be the weekend of September 9th and 10th, so the first September of the fall. And then you can catch Zach Long, aka the Barbell Physio out in Newark, California. That's the Bay Area. That's going to be the weekend of September 30th and October 1st. Online courses from us, our Essential Foundations, our eight week entry level online course starts back up September 11th. We're currently halfway through the current cohort. And then our Advanced Concepts course, our level two course that requires Essential Foundations, that drills down deep into things like Olympic weightlifting, gymnastics, programming, both for CrossFit and strength, injured athletes, all that sort of fun stuff. That starts September 17th. So you can find out more about our courses at ptenice.com. So today's topic, let's talk about cold plunging. You can't trip over a rock in public these days without finding somebody trying to get neck deep in some cold water somehow. Everybody's doing it. They're posting about it. There are probably a million ads you've seen on social media for this tub. This thing that looks like a bourbon barrel. This thing that looks like a fancy bathtub. All these different ways to essentially cool down your body. So I want to attack this topic from three different angles. I want to talk about defining a cold plunge and how probably most of the people cold plunging currently or certainly what we see happen on the Internet is not true cold plunging. I want to talk about the research supporting, not supporting the use of cold plunging. And I want to talk about the practical application of what we can recommend to our patients and athletes when they come into the clinic or the gym and ask us what we know about cold plunging. What's the best way to cold plunging and all that sort of thing. So let's start from the beginning. What is a cold plunge? We need to start at the top and understand that humans have a really large tolerance for heat at rest and a very poor tolerance for cold at rest. You can imagine it's much better to sit outside on a 90 degree day than a 30 degree day. So our perception of temperature is a little bit different. It's skewed based on if we're active or if we're resting. It flips entirely when we are active. You can imagine how terrible it would be to run on a 100 degree day versus running on maybe a 50 degree day. We would all probably much choose the 50 degree day because our bodies lose heat tolerance as our activity level increases, which is all that to say of we have a really poor tolerance for cold at rest, which means when we define the parameters of what's used for cold plunging in research, we'll quickly recognize that most of us, most of the people we see aren't doing it cold enough. They aren't doing it long enough and they aren't exposing as much of their body as they need to to the cold plunge. So a cold plunge is defined by the research is going to be exposure up to your neck or possibly your entire body for 10 minutes at 40 to 50 degrees Fahrenheit. That's a large portion of our body. That's a really long duration of cold exposure for a human being at rest. And that is relatively cold. Again, we have a really poor tolerance to cold at rest. Now, imagine we've we've all taken a bath. Imagine you you take a hot bath or sit in a bathtub and then you get that feeling of, oh, I'm getting really cold. Like this water has cooled down significantly. Again, our perception of temperature is really skewed. When we decide it's time to get out of the bath because the bath water has become too cold, we've probably started in bath water of maybe one hundred and five to one hundred and ten degrees. And it has only cooled down to maybe 90 to 95 to the point where we say this is cold, quote unquote, cold. I'm going to get out of the bathtub now. But really, 90 to 95 degree water is remarkably warm compared to what we define as cold plunge in the literature. So most folks are probably simply not getting their water cold enough to even define cold plunging. Again, the duration of support in the research is cold plunging of 10 minutes. So if you are doing it for 30 seconds or one minute, just know you are not anywhere close to reaping the effects or the positive or negative that we've seen in the research. If you're only dipping your toe in for a few minutes or jumping in up to your knees or your waist and hopping back out again in the research, exposure would define itself as being exposed up to the neck, at least. So many folks just putting their legs in a cold plunge, just going up to the level of maybe the knee, going up to maybe the level of the waist or maybe belly button mid chest or something. Again, if you're doing that to slowly gain tolerance, that's OK. But if that's what you're calling normal cold plunging, just know you're probably not reaping as much of the effect. Again, positive or negative that we'll talk about here in a second as you could be. So cold plunging 40 to 50 degrees up to your neck, duration of about 10 minutes. So all that to say, most people are probably not actually cold plunging when we do it ourselves or we watch others do it. Excuse me. Simply not cold enough, not enough for their body to get in effect and not enough for a long duration. I do want to give a special shout out to ICE faculty members Dustin Jones and Jeff Musgrave. They are unashamedly posting their cold plunges every day on social media and they really get after it. You can see that they have a bunch of ICE in their backyard cold plunges and they're sometimes exposing their whole body to the cold plunges. So they are doing it right. That's the way to do it. So let's switch gears and talk about what does the research say. The research in this field is becoming overwhelming of just looking at the trend and volume of research. Eight hundred and seventy articles published on what the research would call cold water immersion since 2008. So an exponential growth in the people studying, the amount of people studying and the volume of research studying this particular area of what we might call athletic recovery. I want to talk about just two journals today, two journal articles. There are literally like we talked about hundreds and hundreds and hundreds and hundreds. But I really want to talk about two. What I like about these two articles I want to share is that they are 30 years apart and they essentially say the same thing. So first, I want to go way back. 1985, I wasn't even alive yet. Journal of Applied Physiology, Peterson and colleagues talking about cold plunging exposure after exercise. These folks did three sessions a week of what the again the research calls cold water immersion or cold plunging. They did do it at 50 degrees Fahrenheit. They did it for 15 minutes instead of 10. So they went up to their neck. They did it for 15 minutes and they did it cold enough. 50 degrees Fahrenheit. They did this three times a week after resistance training. Evaluation here looked at a lot of different things. One rep max leg press, one rep max bench press and some ballistic things, counter movement, jump, squat, jump, ballistic push up. And this article really wanted to focus on what happens to muscular hypertrophy. This journal article, 1985, now 38 years ago, said you can expect to have less muscular hypertrophy if you expose yourself to a cold plunge after resistance exercise as compared to control. Control in this group was people who just sat at room temperature like you might sit on the boxes at CrossFit class or on the curb after a really long hard run. They just sat and kind of cooled down for 15 minutes compared to the cold plunge group. Fast forward 30 years, 2015, Journal of Physiology, Peking Colleagues, very similar parameters. That's why I picked these two papers. They are perfectly 30 years apart. They use almost exactly the same parameters and they found pretty much the same thing. Peking Colleagues in 2015, very similar parameters, twice a week of cold plunge exposure, 10 minutes at a time, also 50 degrees Fahrenheit. They followed folks a little bit longer. Peter Peterson in 1985 followed those athletes for seven weeks. Peak in 2015 followed them for 12 weeks. Almost same exact parameters, though. They looked at almost exactly the same stuff. They looked at leg press strength, knee extension strength, knee flexion strength, both one rep max and eight rep max. So they're looking at maximal strength and they're also beginning to look at kind of what is your ability to produce force over time. So what we call maybe endurance, which really is indicative of hypertrophy. This team also did some muscle biopsies and what they found with the group exposing themselves to the cold plunge after resistance training compared to the control group, in this case, a group doing active recovery. So not even resting, just doing active recovery for 10 minutes after the resistance training session. The control group, who continued to exercise at a low level, had a 17% improvement in hypertrophy, a 19% improvement in isokinetic strength and a 26% improvement in myonuclei per muscle fiber. So the control group blew the cold plunge group out of the water. Now, that is not to say that the cold plunge group got weaker or smaller. They did not get as strong and big as the control group. And it's led to believe because they were the cold water immersion group, that it's the cold plunge, that something about that cold exposure seems to blunt the body's natural response for healing to encourage hypertrophy gains and strength gains. The big takeaway from this study is the myonuclei per muscle fiber. We can think of myonuclei as if one myonuclei per muscle fiber is great, but more is better. It's almost like having a personal assistant for everything in your life. Your life would be a lot easier if you woke up in the morning and someone was there who had your clothes ready for you. If someone was there who had already prepped your shower for you, if someone was there who already made your breakfast for you, right? The more people you have assisting you in your life, the more efficient you will be at running your life because they're doing everything for you. That's a lot of the role of the myonuclei in our muscles. The more the better. The interesting thing about myonuclei is they stick around even during a period of training, whether it's injury, whether we get busy with life, whether we switch training modalities, maybe we start prioritizing endurance training to train for a marathon or something. Those myonuclei stay around and that's kind of what creates that strength across life of that person who comes into the gym who says, I haven't worked out in 10 years and then deadlifts 400 pounds. You're like, where did that come from? That took me years to build to that strength. This person just naturally has it. Yes, they may naturally have some genetic strength, but what they probably had in the past from training was myonuclei that are now living in their body. And so losing those myonuclei or rather not gaining them through cold plunge exposure not only affects strength and hypertrophy in the short term, but affects really long term fitness gains over time. So very interesting study from PEEK and colleagues showing that cold water immersion after resistance training seems to really have a negative effect on strength and hypertrophy. So it doesn't seem to help. It maybe seems to have a negative benefit, at least after resistance training. Most people aren't doing it correctly. What is the actual practical application? What can we recommend to patients and athletes who ask us about cold plunging? The first thing is to make sure that they understand what it actually is and that they're doing it correctly. Of, hey, if you're going to do this, you should have a way to expose yourself up to the neck, your whole body up to your neck. You should build up your tolerance to do it in sessions of 10 minutes at a time. And the water should be really uncomfortably cold, 40 to 50 degrees Fahrenheit. We don't like to see colder than that. That can be a little bit dangerous, but we also don't like to see warmer than that. Right. Remember, cold bath water is technically hot, 90 degrees Fahrenheit. So we need to see somewhere between 40 to 50 degrees Fahrenheit. We need to talk about timing of cold plunging. The research would really suggest we should never do it after training, especially if we're just training once a day. We're training for life. We're training to be strong and be training for life. And we're not training to be competitive athletes. We're not training multiple times per day. If you're somebody that just exercises once a day, you should not finish that exercise session with a cold plunge. Maybe you start your day with a cold plunge or maybe you cold plunge before you exercise to get the effects that cold plunging can have aside from apparently blunting our strength and hypertrophy gains. And then there's a little bit of a caveat there for competitive athletes, folks who are, you know, let's think of a CrossFit Games athlete. Let's think of somebody running multiple races, an Ironman, a long cycle race. Maybe between events is the time for a cold plunge. We need to recognize those events are already really destructive to the body. Nobody goes to the CrossFit Games and comes away fitter. They come away significantly beat up with probably weeks or maybe even months of repair time needed to recover from an event like that. So at that event, we're not as concerned about not gaining as much strength and hypertrophy as possible because of the short duration. It's only a couple of days or maybe even a one day competition is only a couple of hours. So maybe that is the time between events to use cold plunging. But after regular training, we should not use it. We need to recognize the point of exercise is to create a micro injury that your body will repair and heal from. Your tissues get stronger from a tensile strength perspective and your brain more effectively learns how to use those muscles so that we get stronger and bigger over time. We become more adapted to the stress. We have an increase in tensile strength. We have an increase in myonuclide per muscle fiber. And that's what really creates robust lifelong strength. I love the quote from Pique and colleagues. Remember that anything intended to mitigate and improve the body's natural ability to improve resilience to physiological stress with exercise may actually be counterproductive to muscular adaptation. Cold plunging, NSAIDs, antioxidants, anything that can slow the chemical reactions, the natural chemical reactions in our body to respond to that micro injury is going to affect our ability to recover and be more resilient to that stressor in the future. So a lot like discouraging folks from taking a bunch of maybe ibuprofen or injectable steroids, we should say, hey, if you're going to cold plunge, make sure you start your day with it. Make sure you do it before training. You should really try to avoid finishing that workout and jumping right out into that maybe that cold plunge in the in the gym parking lot, because this research is really so profound of you're leaving maybe 20% improvement in strength and hypertrophy on the table when you cold plunge after training if you don't. So cold plunging, what is it? How does it work? Does it have a negative effect? Yes, it seems to. But also, that doesn't mean that we should say just don't do it. If you enjoy it, if it helps you start your day, if it helps you feel less sore, by all means, cold plunge. But let's rearrange when you cold plunge in your day to make sure that we're not doing it after training. And let's make sure we're doing it correctly up to our neck in the water, cold water, 40 to 50 degrees Fahrenheit. And duration should be at least 10 minutes, right? If you're just up to your knees in 60 degree water for two minutes, you're not actually cold plunging. You should feel good. You're probably not going to get a negative effect from that because you're not doing it correctly. But you're also leaving a lot on the table by not doing it correctly. So cold plunging. Hope this was helpful. We just revamped week five of our Central Foundations course to include a whole bunch of different training modalities like cold plunging. We talk about hot tubs now. We talk about saunas, both infrared and traditional saunas. We talk about compression therapy, massage, pneumatic boots, massage guns, everything folks have a question about. So if you've already taken the Central Foundations, head on over, check out week five for that update. If you haven't taken it yet, remember, September 11th is your next chance. So have a fantastic weekend. I hope you all have a lovely long four day weekend for 4th of July. We'll see everybody next time. Bye everybody. 18:00 OUTROHey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ice dot com and scroll to the bottom of the page to sign up.
This is Garrison Hardie with your CrossPolitic Daily News Brief for Thursday, June 8th, 2023. Club Membership Plug: (1/9) Ladies and gentleman, it’s never been a better time to become a club member at CrossPolitic. This year, CrossPolitic will be dropping exclusive content into our club portal for club members ONLY. Some of this content will include a pilot TV Show called This America, a Bible study series with Pastor Toby, a special with New Saint Andrew’s President, Ben Merkle, our backstage content, and our conference talks! You can grab a club membership for 10 bucks per month… that’s two cups of coffee. So again, head on over to fightlaughfeast.com to get signed up today! That’s fightlaughfeast.com. We start today’s news brief in the city of Greensboro, NC. Shout out to Wade Choate for sending in this story, and by the way, if you want to send me a news story, email me at garrison@fightlaughfeast.com - or you can find me on Facebook, or our own fightlaughfeast.com website, where we have our own social media page set up. https://greensboro.com/news/local/after-greensboro-firefighter-fired-over-straight-pride-and-other-facebook-posts-crowd-erupts-at-city/article_2a1fe822-04c6-11ee-8f48-078ab7addc66.html After Greensboro firefighter fired over 'Straight Pride' and other Facebook posts, crowd erupts at city council meeting The City of Greensboro has fired Capt. Dustin Jones of the Greensboro Fire Department, citing a history of social media posts criticizing transgender people and Black Lives Matter along with an unwillingness to accept training and heed warnings from his supervisors. Jones was fired on May 12, according to the city. On Tuesday night, citizens packed the council meeting, which was punctuated by loud outbursts as some protested Jones' firing and others supported it. North Carolina Lt. Gov. Mark Robinson, a politician known for his anti-transgender and anti-LGBTQ+ positions had weeks earlier urged "normal people" to "take a stand and absolutely flood this hall" in an interview shared on Jones' Facebook page. Jones had gone to Facebook to protest his termination in a video in which he claimed he was fired because of a "Straight Pride" meme post made on April 16. The image, covered with pink and white stripes, featured a white, heterosexual couple being married with the title "Straight Pride" and the caption "It’s natural, it’s worked for thousands of years and you can make babies." After Jones appealed his termination by the Greensboro Fire Department, the City Manager a upheld the decision in a letter obtained by the News & Record in a records request. In his response, Jaiyeoba defended the termination, citing Jones' "misuse of social media" and "disrespectful behavior." Jaiyeoba wrote that Jones had "grown defiant" after numerous coaching sessions and warnings from supervisors. The response letter includes other instances of posts and re-posts attributed to Jones included one that stated: "You know what’s insane... A white person can paint their face black and be accused of being a racist. Yet a man can dress as a woman and be called a hero… [shrug emoji]". All sides of the political spectrum flocked to the Greensboro City Hall to make their voices heard, and more than 40 people signed up to speak during the public comment period. Members of Guilford For All, an organization advocating for the rights of the LGBTQ+ community, wore green shirts and packed the inside of the assembly room. Outside the building, the Communist Party of America flew Pride flags and displayed a sign that read "FASCIST FIREMAN, YOU'RE FIRED." Jennifer Ruppe, the executive director of the Guilford Green Foundation and LGBTQ Center, addressed the room: "The true test of your commitment to creating a diverse, equitable and inclusive city is how you all show up when it's not all rainbows and parades. Because freedom of speech is not freedom of consequences." https://thepostmillennial.com/breaking-bidens-doj-tells-trump-he-will-be-indicted-next-week-on-charges-of-gathering-transmitting-or-losing-national-defense-docs?utm_campaign=64487 Biden's DOJ tells Trump he will be indicted next week on charges of 'gathering, transmitting or losing' national defense docs Former President Donald Trump has reportedly been notified by federal prosecutors that he is a criminal target and is likely to face imminent indictment in the classified document probe. People familiar with the case told Just The News that the revelation comes as the Justice Department has declined to delay charges to allow an investigation into allegations of witness tampering in connection with a senior prosecutor working on the case attempting to influence a key witness by discussing federal judgeship with the lawyer representing the witness provided by Trump’s legal team. The sources said that the allegation is still pending in a secret case before Chief US District Judge James E Boasberg in Washington, DC. A federal indictment brought by Special Counsel Jack Smith could be handed by a federal grand jury to Trump as early as next week. Smith’s prosecutorial team informed Trump’s team in recent days that the charges he faces include a violation of 18 US Code Chapter 37 Section 793 which prohibits the “gathering, transmitting or losing” of national defense information. Other charges reportedly being considered are alleged false statements and obstruction of justice. Sources told the outlet that Trump’s lawyers have been preparing their defense for months based on months of legal research in anticipation of charges. The 2024 presidential candidate’s lawyers are prepared to argue that Trump had Constitutional powers to declassify documents during his presidency and take them with him when his term ended. His lawyers will reportedly rely heavily on a US District Court case out of Washington over a decade ago regarding former President Bill Clinton, which concluded that a president had the power to determine what documents from his presidency can be kept in personal possession. A document posted to Twitter on Wednesday from the Federal Registrar has revealed that Trump declassified certain materials pertaining to the FBI’s Crossfire Hurricane investigation during his last days in office. "At my request, on December 30, 2020, the Department of Justice provided the White House with a binder of materials related to the Federal Bureau of Investigation’s Crossfire Hurricane investigation. Portions of the documents in the binder have remained classified and have not been released to Congress or the public," the document states. "I requested the documents so that a declassification review could be performed and so I could determine to what extent materials in the binder should be released in unclassified form," the document continues. "I determined that the materials in that binder should be declassified to the maximum extent possible." The document states that FBI had objected to further declassification of the materials, and gave suggestions as to redactions that the documents needed, which Trump obliged to. Crossfire Hurricane was the name given to the investigation into allegations of coordination between Trump and Russia that surfaced during the 2016 election. The Durham report, released in May, found that the FBI "failed to uphold their mission of strict fidelity to the law" in their launching of the investigation. https://thepostmillennial.com/cessna-pilot-was-slumped-over-in-cockpit-before-virginia-crash-that-killed-4?utm_campaign=64487 Cessna pilot was 'slumped over' in cockpit before Virginia crash that killed 4 National Guard F-16 fighter pilots revealed that the pilot operating the Cessna plane that flew over restricted airspace in Washington D.C. on Sunday was found "slumped over" moments before the plane crashed in a remote area of Virginia, which killed four people. United States Military officials said that the US fighter pilots attempted to get the civilian pilots attention for around 30 minutes before the plane plummeted at approximately 3 pm, Fox News reports. "The Federal Aviation Administration confirmed that the pilot did not respond to air traffic control instruction around 1:28 p.m. EDT," North American Aerospace Defense Command (NORAD) said in a statement. "Subsequently, the NORAD pilots visually inspected the Cessna as it was still airborne and confirmed that the pilot was unresponsive. NORAD pilots described the Cessna pilot as being slumped over." The people killed in the crash have been identified as Hamptons realtor Adina Azarian, 49, her daughter Aria Azarian, 2, Evadnie Smith, the child's nanny, and the pilot Jeff Hefner. Adina Azarian is the adopted daughter of a longtime GOP donor, John Rumpel, who owned the plane, according to Washington Post. The fatal crash sparked a flurry on Sunday after a loud "supersonic boom" could be heard in Washington D.C. following reports of an unidentified plane flying above restricted US airspace. According to Fox News, the US deployed six F-16 jets to intercept the plane, including two from Washington, DC, two from New Jersey and two out of South Carolina. Rumpel, who is a pilot and runs Encore Motors of Melbourne Inc., said his family was returning to their home in East Hampton after visiting his house in North Carolina, Fox reports. On Monday, the White House expressed its "deepest condolences" and National Security spokesman John Kirby said during a press brief regarding the US military response, "What I saw was just a classic, textbook response." Authorities are still investigating the cause of the crash but experts say it's likely that the plane lost pressurization, causing hypoxia, a condition that occurs when someone's brain is deprived of adequate oxygen, according to Fox News. https://www.dailyfetched.com/cnn-ceo-chris-licht-to-leave-network-after-just-16-months/ CNN CEO Chris Licht to Leave Network after Just 16 Months On Wednesday, Licht announced he would leave CNN after meeting with Warner Bros. Discovery CEO David Zaslav. The CEO will be replaced in the interim by a three-person leadership team, including CNN executive Amy Entelis, who worked closely with former cable news boss Jeff Zucker who left in February of 2022. “For a number of reasons, things didn’t work out, and that’s unfortunate,” Zaslav said. “It’s really unfortunate. And ultimately, that’s on me. And I take full responsibility for that.” Zaslav said CNN is “in the process of conducting a wide search” for a new leader that could “take a while.” As The Daily Wire reported: Licht’s tenure at CNN was rough from the start. Weeks after Licht took over the reins, the cable news giant’s attempt at launching a streaming service failed after a month in operation, attracting fewer than 10,000 daily users. The CNN executive also faced criticism from his employees and poor ratings performances in the news channel’s primetime slots. Familiar faces on the network, such as longtime journalist Brian Stelter and host Don Lemon, were axed under Licht’s reign. The tumultuous leadership of Licht came to a boiling point when the network hosted a town hall with President Donald Trump in May. Leftist critics ripped the company for giving Trump a platform. Politicians and media personalities from Alexandria Ocasio-Cortez to Joe Scarborough were angered by CNN’s decision to host Trump on the platform that has consistently offered friendly coverage to Democrats. Licht faced fire last week after the Atlantic published a 15,000-word profile titled “Inside the Meltdown at CNN,” which angered executives at Warner Bros. Discovery.
This is Garrison Hardie with your CrossPolitic Daily News Brief for Thursday, June 8th, 2023. Club Membership Plug: (1/9) Ladies and gentleman, it’s never been a better time to become a club member at CrossPolitic. This year, CrossPolitic will be dropping exclusive content into our club portal for club members ONLY. Some of this content will include a pilot TV Show called This America, a Bible study series with Pastor Toby, a special with New Saint Andrew’s President, Ben Merkle, our backstage content, and our conference talks! You can grab a club membership for 10 bucks per month… that’s two cups of coffee. So again, head on over to fightlaughfeast.com to get signed up today! That’s fightlaughfeast.com. We start today’s news brief in the city of Greensboro, NC. Shout out to Wade Choate for sending in this story, and by the way, if you want to send me a news story, email me at garrison@fightlaughfeast.com - or you can find me on Facebook, or our own fightlaughfeast.com website, where we have our own social media page set up. https://greensboro.com/news/local/after-greensboro-firefighter-fired-over-straight-pride-and-other-facebook-posts-crowd-erupts-at-city/article_2a1fe822-04c6-11ee-8f48-078ab7addc66.html After Greensboro firefighter fired over 'Straight Pride' and other Facebook posts, crowd erupts at city council meeting The City of Greensboro has fired Capt. Dustin Jones of the Greensboro Fire Department, citing a history of social media posts criticizing transgender people and Black Lives Matter along with an unwillingness to accept training and heed warnings from his supervisors. Jones was fired on May 12, according to the city. On Tuesday night, citizens packed the council meeting, which was punctuated by loud outbursts as some protested Jones' firing and others supported it. North Carolina Lt. Gov. Mark Robinson, a politician known for his anti-transgender and anti-LGBTQ+ positions had weeks earlier urged "normal people" to "take a stand and absolutely flood this hall" in an interview shared on Jones' Facebook page. Jones had gone to Facebook to protest his termination in a video in which he claimed he was fired because of a "Straight Pride" meme post made on April 16. The image, covered with pink and white stripes, featured a white, heterosexual couple being married with the title "Straight Pride" and the caption "It’s natural, it’s worked for thousands of years and you can make babies." After Jones appealed his termination by the Greensboro Fire Department, the City Manager a upheld the decision in a letter obtained by the News & Record in a records request. In his response, Jaiyeoba defended the termination, citing Jones' "misuse of social media" and "disrespectful behavior." Jaiyeoba wrote that Jones had "grown defiant" after numerous coaching sessions and warnings from supervisors. The response letter includes other instances of posts and re-posts attributed to Jones included one that stated: "You know what’s insane... A white person can paint their face black and be accused of being a racist. Yet a man can dress as a woman and be called a hero… [shrug emoji]". All sides of the political spectrum flocked to the Greensboro City Hall to make their voices heard, and more than 40 people signed up to speak during the public comment period. Members of Guilford For All, an organization advocating for the rights of the LGBTQ+ community, wore green shirts and packed the inside of the assembly room. Outside the building, the Communist Party of America flew Pride flags and displayed a sign that read "FASCIST FIREMAN, YOU'RE FIRED." Jennifer Ruppe, the executive director of the Guilford Green Foundation and LGBTQ Center, addressed the room: "The true test of your commitment to creating a diverse, equitable and inclusive city is how you all show up when it's not all rainbows and parades. Because freedom of speech is not freedom of consequences." https://thepostmillennial.com/breaking-bidens-doj-tells-trump-he-will-be-indicted-next-week-on-charges-of-gathering-transmitting-or-losing-national-defense-docs?utm_campaign=64487 Biden's DOJ tells Trump he will be indicted next week on charges of 'gathering, transmitting or losing' national defense docs Former President Donald Trump has reportedly been notified by federal prosecutors that he is a criminal target and is likely to face imminent indictment in the classified document probe. People familiar with the case told Just The News that the revelation comes as the Justice Department has declined to delay charges to allow an investigation into allegations of witness tampering in connection with a senior prosecutor working on the case attempting to influence a key witness by discussing federal judgeship with the lawyer representing the witness provided by Trump’s legal team. The sources said that the allegation is still pending in a secret case before Chief US District Judge James E Boasberg in Washington, DC. A federal indictment brought by Special Counsel Jack Smith could be handed by a federal grand jury to Trump as early as next week. Smith’s prosecutorial team informed Trump’s team in recent days that the charges he faces include a violation of 18 US Code Chapter 37 Section 793 which prohibits the “gathering, transmitting or losing” of national defense information. Other charges reportedly being considered are alleged false statements and obstruction of justice. Sources told the outlet that Trump’s lawyers have been preparing their defense for months based on months of legal research in anticipation of charges. The 2024 presidential candidate’s lawyers are prepared to argue that Trump had Constitutional powers to declassify documents during his presidency and take them with him when his term ended. His lawyers will reportedly rely heavily on a US District Court case out of Washington over a decade ago regarding former President Bill Clinton, which concluded that a president had the power to determine what documents from his presidency can be kept in personal possession. A document posted to Twitter on Wednesday from the Federal Registrar has revealed that Trump declassified certain materials pertaining to the FBI’s Crossfire Hurricane investigation during his last days in office. "At my request, on December 30, 2020, the Department of Justice provided the White House with a binder of materials related to the Federal Bureau of Investigation’s Crossfire Hurricane investigation. Portions of the documents in the binder have remained classified and have not been released to Congress or the public," the document states. "I requested the documents so that a declassification review could be performed and so I could determine to what extent materials in the binder should be released in unclassified form," the document continues. "I determined that the materials in that binder should be declassified to the maximum extent possible." The document states that FBI had objected to further declassification of the materials, and gave suggestions as to redactions that the documents needed, which Trump obliged to. Crossfire Hurricane was the name given to the investigation into allegations of coordination between Trump and Russia that surfaced during the 2016 election. The Durham report, released in May, found that the FBI "failed to uphold their mission of strict fidelity to the law" in their launching of the investigation. https://thepostmillennial.com/cessna-pilot-was-slumped-over-in-cockpit-before-virginia-crash-that-killed-4?utm_campaign=64487 Cessna pilot was 'slumped over' in cockpit before Virginia crash that killed 4 National Guard F-16 fighter pilots revealed that the pilot operating the Cessna plane that flew over restricted airspace in Washington D.C. on Sunday was found "slumped over" moments before the plane crashed in a remote area of Virginia, which killed four people. United States Military officials said that the US fighter pilots attempted to get the civilian pilots attention for around 30 minutes before the plane plummeted at approximately 3 pm, Fox News reports. "The Federal Aviation Administration confirmed that the pilot did not respond to air traffic control instruction around 1:28 p.m. EDT," North American Aerospace Defense Command (NORAD) said in a statement. "Subsequently, the NORAD pilots visually inspected the Cessna as it was still airborne and confirmed that the pilot was unresponsive. NORAD pilots described the Cessna pilot as being slumped over." The people killed in the crash have been identified as Hamptons realtor Adina Azarian, 49, her daughter Aria Azarian, 2, Evadnie Smith, the child's nanny, and the pilot Jeff Hefner. Adina Azarian is the adopted daughter of a longtime GOP donor, John Rumpel, who owned the plane, according to Washington Post. The fatal crash sparked a flurry on Sunday after a loud "supersonic boom" could be heard in Washington D.C. following reports of an unidentified plane flying above restricted US airspace. According to Fox News, the US deployed six F-16 jets to intercept the plane, including two from Washington, DC, two from New Jersey and two out of South Carolina. Rumpel, who is a pilot and runs Encore Motors of Melbourne Inc., said his family was returning to their home in East Hampton after visiting his house in North Carolina, Fox reports. On Monday, the White House expressed its "deepest condolences" and National Security spokesman John Kirby said during a press brief regarding the US military response, "What I saw was just a classic, textbook response." Authorities are still investigating the cause of the crash but experts say it's likely that the plane lost pressurization, causing hypoxia, a condition that occurs when someone's brain is deprived of adequate oxygen, according to Fox News. https://www.dailyfetched.com/cnn-ceo-chris-licht-to-leave-network-after-just-16-months/ CNN CEO Chris Licht to Leave Network after Just 16 Months On Wednesday, Licht announced he would leave CNN after meeting with Warner Bros. Discovery CEO David Zaslav. The CEO will be replaced in the interim by a three-person leadership team, including CNN executive Amy Entelis, who worked closely with former cable news boss Jeff Zucker who left in February of 2022. “For a number of reasons, things didn’t work out, and that’s unfortunate,” Zaslav said. “It’s really unfortunate. And ultimately, that’s on me. And I take full responsibility for that.” Zaslav said CNN is “in the process of conducting a wide search” for a new leader that could “take a while.” As The Daily Wire reported: Licht’s tenure at CNN was rough from the start. Weeks after Licht took over the reins, the cable news giant’s attempt at launching a streaming service failed after a month in operation, attracting fewer than 10,000 daily users. The CNN executive also faced criticism from his employees and poor ratings performances in the news channel’s primetime slots. Familiar faces on the network, such as longtime journalist Brian Stelter and host Don Lemon, were axed under Licht’s reign. The tumultuous leadership of Licht came to a boiling point when the network hosted a town hall with President Donald Trump in May. Leftist critics ripped the company for giving Trump a platform. Politicians and media personalities from Alexandria Ocasio-Cortez to Joe Scarborough were angered by CNN’s decision to host Trump on the platform that has consistently offered friendly coverage to Democrats. Licht faced fire last week after the Atlantic published a 15,000-word profile titled “Inside the Meltdown at CNN,” which angered executives at Warner Bros. Discovery.
Dustin Jones
Racer, fabricator, philanthropist, and all-around fun guy. Dustin Jones joins us to talk three-wheelers, jean shorts and maybe some racing!
Dr Dustin Jones, from StrongerLife, talks about the important impact that preventing falls can have on an older adult's wellbeing. He explains how to assess falls risk and physical performance, and recommends his top measures and resources. Dr Jones addresses why it's important to focus, not only on preventing falls, but on helping older people prepare for falls too, and reviews some drills he uses with his clients. ------------------------------ RESOURCES STEADI: https://www.cdc.gov/steadi/index.html Ability Lab: https://www.sralab.org/additional-resources Stronger Life: https://www.strongerlifehq.com/
"Put on the Parking Brake!" is what everyone in the pits tells Kyle Chaney now that he ran over his own foot with his own race car! Lots of great convo with all the drivers, teams, and families on this great KOH Recap show for 2023.Guest include Vito Ranuio, Phil Blurton, Beau Judge, Hunter Miller, Mitchell Alsup, Dustin "Battle Axe" Jones, & Chris Meyer from Maxxis tires as Co-Host.KOH is gnarly and fun all at the same time and we dive deep!Support the showDM us anytime. Let us know what you want to hear. Join in the convo!Hang with us on SocialInstagram - @thedirtlifeshowFacebook - The Dirt Life ShowYouTube - The Dirt Life Show
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