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Dr. Ellen Csepe // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses eating disorders & obesity, the relationship between mood & disordered eating, binge eating as the most common form of disordered eating, and the role of the physical therapist in eating disorders. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. ELLEN CSEPEGood morning everybody and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a teaching assistant with the modern management of the older adult division coming to you live from Littleton, Colorado. I'm an outpatient physical therapist who practices with the same question in mind every day. Why aren't physical therapists more involved in managing one of the most pressing health crises in the world today. Obesity. On today's Leadership Thursday, we're going to discuss eating disorders in those with obesity. To feel complete in our treatment of those with obesity, we have an obligation to understand the link between eating disorders and obesity. This is a very nuanced topic with a lot of viewpoints and a lot of new research, but I want to be respectful of your morning and keep this discussion succinct and have this framework for today. First, we're going to open about how mood disorders and obesity are related. Then we'll talk about the most common eating disorder that affects people with and without obesity. Then we'll talk about our number one job as clinicians to avoid provoking disordered eating and then what we can do pragmatically if we suspect our patient is struggling with an eating disorder. So to open us up, for those of us who have never struggled with an eating disorder or obesity, having an issue with your weight can just seem like a physics equation gone wrong. Too many calories in, not enough calories out equals obesity. But for those who are struggling with their weight, this oversimplified physics equation really overlooks the emotional and mental language that can come with struggling with your weight or your perception of your weight. We see obesity as a complex biopsychosocial chronic disease with this framework in mind that it is anything but simple. And thinking that there's a simple solution and a simple fix can often make this problem worse in treating our patients. MOOD & OBESITY ARE RELATED So to start, obesity and mood disorders are related. Obesity and depression frequently occur together and actually there's a bi-directional relationship between mood disorders like depression and obesity. In fact, depression can be a risk factor for obesity and obesity can be a risk factor for depression. This risk and this association is the strongest in women. eating disorders are mental health disorders. The DSM-5 identifies eating disorders as mental illnesses that are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning. And in fact, eating disorders can be life-threatening and have the highest mortality rate of any mental illness. Eating disorders have their own diagnostic criteria in the DSM-5, and those eating disorders with diagnostic criteria include pica, rumination disorder, ARFID or avoidant restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. Anecdotally, many clinicians feel apprehensive discussing weight, exercise, and eating habits in part because they're aware that executing these conversations poorly can have adverse impacts on their patients and their mental health. But as clinicians, we have to know the basics of diabetes, cancer, Graves' disease, ALS, MS. And if we feel confident making dietary recommendations to our patients, For things like protein intake, calorie deficits, and reducing added sugar in our diet, we want to at least be aware of the most common eating disorder that will likely impact our patients. So we understand that there's a correlation between mood disorders and obesity. BINGE EATING AS THE MOST COMMON EATING DISORDER Now let's talk about the most common eating disorder that we're gonna see in our practice. So binge eating disorder is the most commonly recognized eating disorder among people with and without obesity. So it doesn't matter if you have obesity or not, this is likely going to be the most common eating disorder that a patient will suffer from. So eating disorder, let's understand this a little bit more so that we can really clearly understand what this looks like in our practice. So binge eating disorder is characterized by eating a large amount of food in a short period of time, all while feeling the loss of control during this episode and immense shame and guilt afterwards. So you might be thinking, well, do I have binge eating disorder? I chowed last weekend. There's a difference. Having unhealthy eating habits or chowing or going crazy now and again is not the same thing as an eating disorder. An eating disorder is not a choice. A diet is a choice. You can choose to not be a vegan anymore. You cannot choose to not have an eating disorder. And that's the best way to summarize the differences between diets and eating disorder. But binge eating disorder has some specific characteristics. Eating a large period of food over a short period of time without the feeling of control. Eating faster than normal. Eating until uncomfortably full. Eating large amount of food even when not physically hungry. Eating alone because of embarrassment with how much one is eating. and feeling disgusted with oneself, depressed, or very guilty afterwards. So this is a very common diagnosis that we'll see in the clinic. Other unhealthy weight control behaviors that would be reflective of disordered eating could include vomiting, skipping meals, fasting, laxative or diuretic use, smoking to manage appetite, and consuming stimulants to reduce appetite. So these behaviors aren't the same thing as having an eating disorder, but we should know that these behaviors are rarely successful in managing weight and, more importantly, can lead to depressive symptoms and eating disorders in the future. So we summarized the most common eating disorder that we'll likely see as clinicians. Now let's talk about our number one job. THE ROLE OF PT: PROVIDE AN ENVIRONMENT FREE OF STIGMA ABOUT WEIGHT So our number one job as clinicians is to provide an environment for our patients free of weight stigma. For us to be psychologically informed clinicians who want to help those with obesity, We have to be aware of how impactful weight stigma can be on disordered eating. Weight stigma implies that people who struggle with their weight are lazy, less adherent, less motivated, less deserving of empathy, sloppy, mean, have decreased willpower, are unsuccessful, or are otherwise unpleasant. And unfortunately, it's very common among healthcare providers. A recent survey of nurses suggested that 24% of nurses would see people with obesity as repulsive. and that 12% of nurses surveyed didn't want to touch those with obesity. These feelings are not only unhelpful, but they're really hard to hide. If you're repulsed by your patients, it's probably going to show on your face. And actually, a recent 2023 systematic review it'll be in the comments below on this Instagram post, looked at how weight stigma impacted disordered eating. So studies that looked at relationships between disordered eating and internalized weight stigma showed that weight stigma is helpful, unhelpful across the board in managing weight and can actually really commonly provoke disordered eating habits. So the studies reviewed looked at actual experienced weight stigma anticipated weight stigma, so for example, the fear of being judged by others, like if you're going to go out in a bathing suit, having that apprehension that you're going to be judged, and then internalized weight stigma, so the personal belief that you are lazy, unmotivated, have less self-control because of your body habitus. And the systematic review suggested that across the board, experiencing weight stigma made outcomes worse. And in several studies would suggest that experiencing weight stigma from a medical provider immediately caused a binge eating event afterwards. So not only are those weight stigma beliefs that we hold as providers unhelpful, they can make the problem much, much worse and can even cause a binge event for those with binge eating disorder. So I challenge you today to reconsider how you face obesity. If you have biases against those with obesity, I really challenge you to recognize with empathy how hard it is to lose weight and to manage your weight. Recognize that when we lose weight, our bodies fight to get that weight back by changing our hormone levels, our ghrelin levels go up, increasing our hunger, our leptin goes down, decreasing our satiety, and our bodies perpetually try and return to that weight that we lost. It's hard. Our world and our food landscape have changed significantly in the past 50 years. You don't have to grow an Oreo. You could go and buy them from the grocery store, and those are quick, low-nutrient calories that you can access without having to do any physical labor. It is extremely difficult to maintain weight, and those with obesity need our help and support in their journey to manage their health for the long term without judgment or weight stigma from providers. I recognize that obesity is a huge problem that our culture and our entire world face. I know that you likely agree if you're listening to this podcast. Weight issues are hard to manage and where we should start is with empathy and dignity and respect and compassion with those with obesity. SUMMARY So we talked about how mood disorders and obesity are related. We talked about the most common eating disorder, binge eating disorder, that affects people with and without obesity. We talked about our number one job as clinicians to make sure that we provide an environment free of weight stigma for our patients. And last, if you suspect that your patient is struggling with an eating disorder like binge eating disorder, we have some options. You can ask, have you ever struggled with an eating disorder? Or do you know if you have an eating disorder? Just as easily as we can acknowledge depression or anxiety on a past medical history form, we can identify eating disorder or disordered eating habits. Within the past 24 hours, a previous patient of mine shared that he had an eating disorder, but is only now getting treatment after years of struggling because nobody asked. So our job as clinicians, if we suspect somebody has an eating disorder, it's totally within our scope to ask. And if they say yes, you can refer them to the National Eating Disorder Association. The link will be below in the comments. Or this is a completely, this is not an ad, but there's an online virtual service called Equip Health that takes major medical insurances and provides mental health therapists, dietician, and medical provider support, as well as mentors who have overcome eating disorders and are there to help your patients. So we have lots of resources. To summarize, mood disorders and obesity are linked and we have to understand that as clinicians. Binge eating disorder is the most common eating disorder that we'll see for those with and without obesity. Our number one job as clinicians is to provide an environment free of weight stigma for our patients. And if you suspect that your patient has an eating disorder, ask and offer pragmatic support with a referral to another dietician or mental health therapist or an online program. Thank you so much guys. I know that we recognize that obesity is a growing problem in our world and you being a part of this podcast and a part of this team really reflects your genuine empathy and caring for those who are struggling. Thank you so much for being here and I hope you have a wonderful rest of your day. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.    

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

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Endurance Athlete Division Leader Jason Lunden discusses three factors to consider when transitioning from biking indoors on a trainer back to riding outdoors: equipment, road/weather conditions, and controlling training volume on the road. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. JASON LUNDEN Good morning. Happy Friday, everyone. Welcome to another edition of PT on Ice. My name is Jason Lunden. I am the lead for our endurance athlete division, which entails rehab of endurance athletes, including our professional bike fitting course and both our online and live versions of the rehabilitation of the injured runner. So today I am going to be talking about a very timely topic, transitioning back onto the road after training all winter indoors for especially those of us in the northern climates. And here in Montana, we are definitely seeing our transition back to spring and everyone's getting back out onto the road. after being on the trainer for the past four to six months. So I just wanted to give some tips for either yourself or your clients on how to make that transition as smoothly as possible and not interrupt their training cycle. So we're going to cover three things, equipment, conditions, and then the actual mechanics and transitioning of back on the bike in terms of volume. EQUIPMENT So first thing being equipment. Obviously, when you're on a trainer, you're not really all that concerned about, you know, are your brakes working? Is your headset working, et cetera? Do you have like your kit already with a spare tube and… Spare tube and… Pump etc. So first and foremost Making sure that you're checking that your headset is indeed tight. So that is going to be the top bolt where the handlebars go into the steer tube and Way to check that tightness is depressing the front brake and rocking the back the bike back and forth and you shouldn't feel any clunking at all. If you do feel clunking you need to tighten the headset. Things can get loose over time so it's an important thing to do. So loosening the two screws on the sides and then tightening the top down and then tightening the screws on the sides back too. And then also making sure brake wear and everything are okay as well. Because typically in the spring, you're going to be encountering wetter conditions. So it's really important that your brakes are working and to avoid any catastrophic, traumatic injuries. And then probably lastly is just making sure that you do have the supplies with you if you do break down. Again, typically at the end of the season, when transitioning back indoors, We always think that we're going to get those new CO2 cartridges, replace the used ones that are in our pack that we used already, as well as making sure that that spare tube is still working and adequate. So making sure that you're kind of restocking your kit or at least reassessing your kit for while you're out on the road, as well as making sure you got those tire level levers with that too. ROAD CONDITIONS Number two is conditions. Uh, obviously biking outdoors, there are a lot more environmental conditions and biking indoors. Uh, and that's really important to, to take account of. So again, in the spring, we're typically going to be dealing with some wetter weather, uh, some cooler temperatures, uh, especially for us, uh, working folks, uh, working athletes. We're going to be having to try to fit our rides in around our work schedule. So typically in the early morning. um, or after work where temperatures are already going to be cooling down. And so making sure that you, you are, you or your patient are dressing and layering appropriately. Uh, as if you're, if you are riding in cold weather, um, it can get cold really quickly because of the wind resistance and all of that. Um, and your muscles can get cold, which, uh, you know, anecdotally, I think a lot of us think, well, you know, we're more likely to actually strain or have injuries in the cold with not being warmed up and there's actually some very limited evidence on that but there is some evidence on that in looking at exercises in different temperatures and the incidence or likelihood of increasing the incidence of tendon strain or muscle strain. And anecdotally, this is the time of the season when I really the only time I see cyclists coming in with quadriceps tendinopathy or tendinitis, more acute. And I think there is a correlation with the colder weather and just not muscles being warmed up as well as maybe not quite being acclimated to the volume that they want to do. in the style of riding that they want to do. So just tucking that in the back of your head and just making sure that you're prepared for that. CONTROLLING ROAD VOLUME And then lastly, looking at how you're going to approach your volume in your training with transitioning outdoors. Training indoors is really efficient, especially you know, more recently with our direct drive trainers that can add resistance and simulate hills, et cetera. But we're still very, it's very easy and more comfortable to have your hands up on the flats of the bars and not all the way out on the hoods or in the drops. And I think a lot of us have the tendency to ride in that position of comfort. Either if you're watching the virtual screen of racing on Zwift, or you're watching a show, just being in more comfort even with putting that effort out. So realizing that your body may not be adapted to being in the drops or being on the hoods for a long time, as well as the increased instability of being on the road where you're having to balance more. So not maybe necessarily having the core stability strength for that as well. So ideally before transitioning into back onto the road for the month prior, making sure you are getting time in the drops on the hoods, making sure you're getting time where you're getting efforts standing up on the bike, and then doing an assessment of your core and spinal extensor strength to make sure you can sustain those positions. And then even with that, when you're transitioning back onto the road with your training, Have those first rides be just shake out rides, totally, um, just going out for, for fun rides, not really, uh, equating that into your training and keeping the volume on the lower side. One to make sure your equipment's working, uh, to, you know, the, the conditions are going to be more variable. And then three, just to, to be able to have a smoother transition back onto the road because of the. wide variety in terrain, conditions with the wind, and again, that instability and maybe being in slightly different positions and having slightly different mechanics while you're out on the road. And then after a week or two of that, well, two weeks of that, then diving back into your training plan with that. So while you're doing those shakeout rides, continuing your actual training indoors. It's easy to get excited when it's nice out. I've certainly been a culprit of it, too, where, you know, we're just stacking rides back-to-back days when it's nice out, especially here in Montana, in the mountains, where the weather can be changing rapidly, and we're getting to really try to take advantage of those nice days and getting in as much as we can. set ourselves up for success and pumping the brakes a little bit and just having those rides be enjoyable a little bit a little bit lower volume before really getting after it back to our training to prevent injury. So just some practical advice for you on again transitioning from the trainer back onto the road things to consider Double checking your equipment, making sure that's functioning well, especially the headset and the brakes, and that your emergency kit is dialed. Two, preparing for the weather, mainly in terms of layering so that those muscles, you don't get too cold, perhaps increasing the likelihood of a strain or a tendinopathy. And then three, just going easy with that volume back out onto the road and having those first few rides just be shakeout rides just for fun not really training rides. SUMMARY So hopefully that's that's helpful for you and you are getting back outside onto the road or if you've been in the south you've been on the road all along and you know If you're interested in treating endurance athletes, please join us for one of our offerings. We're really starting to ramp up here with professional bike fit certification. Matt Keister and I will be in Asheville, North Carolina, April 19th and 20th. We still have some spots for that. This should be a great time. It's the only time that we have both lead faculty at the same course for the year. And then I'll be in Minneapolis in the middle of May. Matt will be in Denver in June. For Rehab of the Injured Runner Live, we only have two offerings so far for 2024 until Megan Peach gets back from Austria later in the fall. Uh, first offering will be in Milwaukee the first weekend in June that is filling up. So, uh, if you have an inkling to, to, to join us there, uh, sign up sooner than later. And then second offering will be in Maryland in September. Uh, we're getting some signups there too. So hope to see you at a course. And then next, um, online cohort for rehabilitation of the injured runner is May 7th. Uh, everyone have a great weekend. Get outside, do something fun, get out on your bike if you can, or get out running. See ya. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses five different ways to work on correcting lateral shifts in patients demonstrating low back pain with radiculopathy, including standing, sidelying, and prone variations. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Lumbar Spine Management course, our Cervical Spine Management course, or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. JORDAN BERRY All right, what is up? PT on Ice Daily Show. This is Dr. Jordan Berry, lead faculty for cervical management and lumbar spine management, as well as our T and D content over all the spine division. I've got Jenna here with me today from the fitness athlete division, and we're talking lateral shifts again. So a few weeks back, we talked about the lateral shift and how we have to be able to pick that up in order to oftentimes move forward with the planned care. So when someone comes in that has really severe back and back related leg symptoms, oftentimes the lateral shift is the number one thing that you have to be able to pick up. and clear up, because if you don't, you're not oftentimes going to be able to work into this agile plane and start resolving those symptoms. So a few weeks back, we talked about the main ways from an objective and a subjective standpoint that we could pick up on the lateral shift. Today, we're going to change gears and talk about actually correcting it. So a few ways during our treatments that we can correct the lateral shift. Now, by far, the most common is the standing variation. or we're shifting the person that we'll talk about in just a second. But oftentimes the irritability is too high to allow for that. So we can't use that variation. We have to go to something in a non-weight-bearing position. So we'll talk about a few ways based on irritability that we can regress the standing lateral shift correction to be able to match that person's irritability and move forward during the plan of care, okay? CORRECTING THE LATERAL SHIFT IN STANDING So I'll have Jenna stand for just a second. and we'll demo as if she has symptoms on let's say the left side. Okay, so oftentimes we turn the camera just a bit here. If we have symptoms on the left side, almost always, 90 plus percent of the time, the shift is gonna be away from the side of symptoms. So we're gonna assume today that the shift is away from the side of symptoms. And Jenna would then, if she has symptoms on the left side here, right, would be shifted away from those symptoms. So for the standing variation, I would be standing on the opposite side of symptoms. So I would be in a staggered stance here, right? She's going to have arms either across like this or at least up away from her hip so that I can get around her hip. And I'm going to have my head on the backside of her shoulder blade with my arms wrapped around the very top of the hip. And so we're right here. And then I'm going to shift over and load towards this side of symptoms, right? So she's avoiding that side. And I'm wrapped around shifting towards the side of symptoms, okay? So we covered that technique in a lot of detail during our lumbar spine management weekend course, so we're not gonna spend a lot of time on the standing variation right now. But what I do wanna do is show you a few non-weight-bearing variations, because if you go to test that out, and the irritability's high, and that person either starts to peripheralize or pain increases, we have to have a variation in a non-weight-bearing position that is a little bit less vigorous that we're gonna start from. CORRECTING THE LATERAL SHIFT: SIDELYING Okay, so immediately if that's not working, my first regression here is in the sideline position. So now we're going to have Ginego on the table here. And I'm actually, I'm going to change sides for the video, but it'll be easier to see here. So Jenna is lying on her side, and we're going to say that the side that's up on the table, in this case, the right side, is the side of symptoms. And so for their side-lying technique, we're going to do a side-lying lateral glide. Again, during our lumbar spine management weekend course, we cover this in depth and we typically refer to it as a way to improve range of motion and mobility, just generally speaking in the stiff back. But it's a great technique for a lateral glide or a lateral shift correction as well. And so the way that we set up is I'm facing the bottom corner of the table and I have my contact hand that weaves through Jenna's arm here. and right around my hypothenar eminence rests along the paraspinal right here that's on the top. So I'm just hooking my hand in, facing the bottom corner of the table, and I just drop my weight down here. So again, we're saying that the top leg here is the side of symptoms, and we are gliding down towards the table or away from the symptoms if you want to think of it like that. And oftentimes that, because we're not in the weight-bearing position that we were in standing, the patient will be able to tolerate that much better. CORRECTING THE LATERAL SHIFT: PRONE Now, what if they can't tolerate the side-lying version or they're peripheralizing or not seeing the changes that you would expect? Well, we could then go to a prone variation. And so appreciate for that last technique, right? I was standing above the side of symptoms and we were gliding away from the symptoms. So we're doing the exact same thing in this prone position now. I'm going to bring the camera slightly closer here. And the same idea here in the prone position. So we're going to say that the side that I'm standing on right now, right, the side towards me or closest to me is the side of symptoms. In this case, it would be Jenna's right side. So instead of having my hand fully on dropping down into the lateral glide, I'm still going to glide laterally or away from the symptoms here. But I've got my thumb pads here together. and they're on the side of the spinous process that the symptoms are on. So again, for those listening and for those watching, just to make sure we're on the same page, if we have right-sided symptoms, the pads of my thumbs are on the side of the spinous process on the right side. And I am just gently gliding away. This is the exact same thing as the sideline lateral glide. It's just a less aggressive version. So again, my thumbs are together like this on the side of the spinous process where the symptoms are and I'm gliding away. And oftentimes just that very, very gentle, soft mobilization is enough to start to get some centralization. Okay, but what if we can't tolerate that, right? What if, for example, the actual spinous process or the area in the low back is too sensitive to actually be able to put contact or pressure on the spinous process? So then we could do the exact same thing, only now we're contacting the torso and the hip. So our contact hands are above and below the lumbar spine. So with the exact same setup that we had, again, the side of symptoms or the right side, the side that's closest to me, I'm going to have one hand on the right glute, right to the glute on the side of symptoms. And then I'm going to have my other hand on the torso on the opposite side. and I'm pushing the glute away and pulling with the torso towards me. So again, it's the exact same thing that we're doing the previous two techniques in the lateral glide. We're just not contacting the actual lumbar spine now. So we push away with the glute and pull towards with the torso here. Push away at the glute and pull towards on the torso. And now we can do the exact same mobilization in the lumbar spine without actually having to contact the lumbar spine. CORRECTING THE LATERAL SHIFT: BELTED MOBILIZATION OK, I've got one more. So this is my my go to if someone cannot tolerate any of those other variations. It's very, very rare that someone would not be able to tolerate one of the ones that we just went over. But I want you to have a technique in your arsenal where if the person really isn't tolerating anything at all, where you're going right at that area where they're having to cross that leg over on the table that's painful. I want to give you a version that is completely passive on the patient's end where we're actually going to use a belt around the person to lift the hips. So for the setup here, the painful side now is actually down. So this is the opposite of that first version that we showed. So we move the camera so we can see here. Jenna's painful side would be down towards the table. And what I'm going to do is take a belt here, mobilization belt, you could use a gait belt, and I'm going to wrap it underneath Jenna's hips. So we're going to weave this through. And I'm just making a loop with the belt. And so what I can do now is actually get on the table. I'm going to be up above the person and I can lift Jenna's hips up while she's completely passive and does nothing. And what that's doing is the exact same thing as what we were doing with the lateral glide, right? When the painful side was up and we were gliding down. Well, now the painful side's down and we're the ones that are pulling up. So I would be on the table above pulling on the belt. here. And Jenna can stay completely relaxed. She doesn't have to do anything at all. And I can do a lateral glide with the painful side down. Again, very rare that I would ever have to go to that technique, but it does happen and it's nice to have that in your arsenal. SUMMARY So those are five ways, five of my most used ways to correct a lateral shift in the clinic. The one that we're probably all familiar with, again, is the standing variation. That's the one that you see in most courses. That's the one that you see in most textbooks. And it's a great technique when it works, right? It's a great technique when the irritability allows for that weight bearing position to be used. But plenty of times in the clinic, the person's not going to tolerate a weight bearing or a loaded shift correction. So we have to go to a non loaded or non weight bearing position. I love the lateral glide that we started with. You can also go prone and do that really small, gentle lateral glide with the pads of your thumbs on the side of the spinous process. We could also go above and below the area if it's too hot to actually get your hands in there and contact it. You could go one hand on the glute, one hand on the torso, push and pull to do the exact same loading to the lumbar spine. Or you could go painful side down, belt around, lift the hips up. All right. Well, those are five variations. Hopefully that helps you out in the clinic with managing some of these folks with back and back related leg symptoms. If you're going to be at a cervical spine or lumbar spine management course in the future, we will see you there. Have a great day in the clinic. Thank you, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses the concept of kipping in 2024. After 128 years of kipping movements in Olympic gymnastics, we still have high levels of contention over the use of kipping in recreational fitness despite poor evidence to support or refute the safety or efficacy of these movements. What evidence do we have, and what can we do in the gym and the clinic regarding kipping? Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLGood morning, PT on ICE Daily Show. Happy Friday morning. Hope your day is off to a great start. Welcome to the PT on ICE Daily Show. My name is Alan. Happy to be your host here today on Fitness Athlete Friday. Currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member here in our Fitness Athlete Division. It is Friday. It is Fitness Athlete Friday. We would argue it's the best darn day of the week. We talk all things Friday related to that person who is recreationally active. The CrossFitter, the Boot Camper, the Olympic Weightlifter, the Powerlifter, the endurance athlete, running, rowing, biking, swimming, whatever, that person that's getting after it on a daily basis, how to address that person's needs and concerns and be up to date on the research in this space. THE STATE OF KIPPING IN 2024 So today we're going to talk about kipping, a sometimes usually, it's fair to say, usually contentious topic. related specifically to the CrossFit space, but now as more and more functional fitness gyms open that are doing CrossFit style exercise, we see that even folks who would not say or know that they're even doing CrossFit style exercise are doing kipping movements. So I want to have a discussion. on where we're at in both the public facing, the clinician facing aspects of kipping, what kipping is, and really, what is our goal, especially when we have our clinician hat on? What is our goal when we're looking at kipping and considering Is Kipping safe? Is Kipping dangerous? Is Kipping right for this athlete? So let's start and talk about Kipping. So if you don't know what it is, or if maybe you have athletes or patients who don't know what it is, the public facing side of searching for things related to Kipping can be really gnarly, right? If you just type Kipping into Google, you get a real bunch of crazy stuff. What do you get? You get endless videos on kipping pull-ups specifically, but also a bunch of articles on why kipping is dangerous, why it's cheating. My favorite Google search is the top two results are in direct contention with each other, right? The top result for kipping is an article from Men's Health. Why swinging around at CrossFit isn't for everyone right so a little bit a little bit of a mean article a little bit condescending of an article But then the next article is from our very own Zach long the barbell physio the truth about kipping pull-ups right a lot of research on kipping a lot of practical information on kipping and a lot of the stuff that we're going to talk about today that is public facing, but in a very educational manner. So you see a lot of stuff. It can be very confusing for our patients and athletes because they're being given this message of, Hey, if I'm already doing this, here is really an endless wealth of human knowledge on how to get better at these, how to improve my performance. But also I'm seeing articles from people who tell me that this is dangerous. that this is cheating. This is actually reducing the effect of exercise on my body. It could be making me weaker. All of these different essentially thought viruses are going around simultaneously. RESEARCH ON KIPPING IS NON-EXISTENT So stepping back away from what's public facing, the social media content, the blog articles, what else is available on Kipping? Not a lot. If we're being really honest and we go way back in history to the start of modern gymnastics, we know that it started in 1896, so 128 years ago. Across that 128 years, we have watched the sport of gymnastics develop We see gymnasts use kipping on their hands, on the mat, up on the bars and rings, doing things like muscle ups and handstands, and using a lot of kipping to do so. But across that 128 years, we really still only have one research article that is relatively recent in that big span of time. that even discusses anything related to kipping. It's an article that we share in our Fitness Athlete Level 1 course by DiNuzio and colleagues. It's a randomized controlled trial back from 2019 in the Journal of Sports and Biomechanics. and it's titled The Kinematic Differences Between Strict and Kipping Pull-Ups. So a very basic article looking at subjects who performed a set of five strict and then five kipping pull-ups and just looking at what are the differences in the muscular activation patterns between folks performing the five strict pull-ups and between folks performing the five kipping pull-ups. And what we already know to be true was found in the research that we see a little bit less activation of shoulder muscles and bicep muscles and a little bit more activation of quads and of core muscles when we look at the difference between when somebody begins to kip their pull-ups or when somebody does strict pull-ups. And that's it. That's it. That's all the research we have, right? When you kip, you offload your shoulders and your arms a little bit, and the force is taken up a little bit more by your lower extremities and your core. And that's all the research we have on kipping. We have no research that it's dangerous. We also have no research that it's safe. We really have almost no research in this space, and we need to be cognizant of that. We have absolutely no research related to injury. of how many strict pull-ups can we do before we should kip. What level of strict pull-ups makes our shoulders safer from kipping pull-ups? What is the limit of kipping pull-ups volume-wise that we'd want to see somebody perform? Some sort of structured progression towards performing kipping pull-ups. We have absolutely no research on that. We need to be aware of that. And we also need to realize that's probably unlikely to ever happen. If you think about the recruitment for a study that would evaluate some of those concepts, it would look totally insane and be unethical, right? Let's take different groups of people, let's randomize them, and let's see, based on strict pull-up capacity, who does a certain amount or a progressive amount of kipping pull-ups, and then let's see how long it takes for someone to develop an injury, if ever, and then crunch that data and come up with some sort of Conclusion that we'd all love to hear, or at least be interested in seeing, of how many strict pull-ups is enough, how many strict handstand push-ups is enough, before we begin to create and allow, quote-unquote allow, kipping in our athletes. So we need to know the public facing space is out of control with this, can be very confusing to our patients and athletes, but the clinician facing, the research side, there is almost no information and there's probably not likely going to ever be something change here in a really substantial manner. WHAT IS KIPPING? So what do we do in the absence of research? Step back and better understand what kipping is. Kipping is just momentum creation and transfer. If you have taken fitness athlete level one in the past couple years, you know that we talk about this in week four when we talk about metabolic conditioning. We talk about why are we doing kipping? Why are we doing things the way we're doing them in the functional fitness gym, in the CrossFit gym? Well, we're primarily doing them to get our heart rate up, right? We're primarily exercising for power output. to create a cardiovascular response. That's why we're primarily going to CrossFit. Yes, we lift some heavy weights every now and again. And yes, we do some lower intensity, maybe zone two, zone three, steady state cardio from time to time. But primarily, we take a couple exercises, we smash them together in an AMRAP or rounds for time or an EMOM. and we're doing them in a manner that facilitates our heart rate getting up ideally into zone four and maybe if we're not careful, maybe sometimes a little bit of zone five. So when we talk about kipping, we're just doing it for momentum transfer. It's allowing us to do more work in the same or less amount of time. so that we can keep that heart rate elevated. You all can imagine that it would take a very long time to do a workout with 100 pull-ups if you did them all as strict pull-ups. We just had a great workout last weekend at Extremity Management up in Victor, New York. We had some pull-ups, or should I say pool-ups, as Lindsey Huey would pronounce it, programmed in the workout, and the folks that kip their pull-ups or butterfly their pull-ups got a lot more work done in that workout than the folks who just did strict pull-ups. So kipping is just momentum creation and transfer. I think it's important to understand we so intensely and closely begin to associate kipping just with gymnastics, specifically vertical pulling gymnastics, pull ups, and toes to bar and muscle ups and that sort of thing, that we forget that as humans, we kip almost everything in our life, right? I am standing still right now, if I begin to walk, I'm going to begin to use global flexion to global extension patterns, to propel myself forward. If I want to transition from a walk into a run, that is going to become even more intense. I'm going to begin to use more of my core, more of my shoulders, more of my glutes to produce a flexion to extension, back to flexion moment that generates momentum. If you don't think humans should kip, I want you to jump into a pool and not use your shoulders, core, or hips to swim. What you'll find is that kipping is very functional to daily life. If we begin to disassociate kipping from being up on the pull-up bar, on the pull-up bar, we recognize that we kip almost everything, right? It's a very functional thing. We kip to go from walking, from standing to walking and from walking to running. We kip when we stand up from a couch. We kip when we're swimming in the pool, or the pool, I should say. And we need to understand as well, some part of this, of why we don't just do strict gymnastics, why we don't just do strict weightlifting, is that it really limits our top end performance, right? Imagine if you watch the Olympics, and gymnastics was strict work only, right? Only the very strongest people would be able to do that stuff, and they wouldn't be able to do a lot of it, right? We would watch somebody come out on the floor, we would cheer for them, This is this is Steve from Belarus. Hey, Steve. And he does like maybe three strict muscle ups, right? He's not swinging around on the bars anymore. We don't really care about his landing, because he can't generate momentum to swing around to land. Imagine if Olympic weightlifting did not allow momentum and people just performed a deadlift to a strict high pull to a strict press, it would limit top end performance, we would not see people clean and jerking 500 pounds, we would not see people snatching 300, 400 pounds. So that momentum generation is a very functional part of being a human being and of performing these functional movements. And we can't take that away from people. Because even if for nothing else, it would become really boring, right? So not only is it functional, at some level, it's kind of fun to do. And it's fun to move along that progression from Okay, I can do some strict pull ups. Okay, I can do some kipping pull ups. Cool. Now I'm working on muscle ups, so on and so forth. WHAT IS THE GOAL WITH KIPPING? So what is the goal? If we put our clinician hat back on and we think, what is the goal with our athletes? Really the kind of the question we're answering in our mind, and when we ask questions like, how many strict pull-ups is enough? What we're really asking is, what level of strength in the shoulder begins to be protective of injury? And the answer we don't wanna hear is that it depends. And what does it depend on? It depends on that athlete's history, right? Somebody who has been performing a lot of strength training for a very long time that comes into a CrossFit gym or a gym where they might be doing kipping movements, that person has a lot less concern for the momentum on the shoulder or the momentum on any other joint in the body, right? We could say the same thing about runners, right? That person comes in with a higher what we call training age and therefore less worry about the capacity of that person's body as we begin to produce and create momentum with it. So the answer is, it depends. We can't say one strict pull up is enough. Five is the minimum. 13. Is five safer than one? Is 13 safer than five? It depends on that athlete. It depends on their training age. If they have never done any sort of vertical pulling, exercise, then we're just a little bit more concerned, right? We want to see that person begin to develop that strength. We'd love to see that person get one strict pull-up. We'd like to see them continue working on it. The answer, at least in our gym and the way that we coach, is that you should always be working on your strict gymnastics. You should always be doing strict pull-ups. You should always be doing strict handstand push-ups. We had a workout just last week with a bunch of strict pull-ups, and I coached it, and I was very, very adamant. Do not kip these. Do not use a band to kip these. I want a strict pulling stimulus today. If you can't do strict pull-ups, here are the scales that are going to help you get a strict pull-up. We're not going to bypass the strict training stimulus just to be able to go faster. If you can't go faster with strict work, we need to scale and work on that strict work. The other thing is, anecdotally, if you work with these athletes in a gym or you work with them on the patient side as a clinician, having a super high strict pull-up capacity does not guarantee high quality kipping pull-ups. That person who comes in who's been doing lat pull-downs and strict pull-ups for 30 years They can do a ton of pull-ups, but their kip probably needs a lot of work. What we see is opponents of kipping don't kip, and so they don't interact with individuals who do kip. And so we begin to develop this false belief that being able to do 10-strick pull-ups guarantees large, high-quality sets of kipping or butterfly pull-ups, which is completely unfounded. We all know that athlete who can jump up on the bar and do 10 or 15 or 20 strict pull-ups in a set, and then we ask them to, hey, try kipping those, and you're like, oh, God, what's happening, right? You are just swinging around on the bar. So just having the strength doesn't necessarily guarantee the technique that's going to lead to efficiency in that movement. So the truest answer is we always have to be working on both. When it's time to do strict work, strict pull-ups, strict handstands, whatever, we need to be doing those strict or finding a scale that allows us to progress to strict, and when it's time to allow momentum, kipping pull-ups, kipping, handstand push-ups, toes-to-bar, whatever, we need to find maybe also scales there, even if the person has the strength to do them in an ugly fashion, that allows the development of the technique, so the person that can do 10-strip pull-ups is somebody that goes on to be able to perform very large sets of high-quality kipping or butterfly pull-ups or toes-to-bar or muscle-ups or whatever. So once someone has demonstrated that they really have that functional shoulder strength, we need to recognize that they're naturally going to increase the volume of vertical pulling, and it's slowly going to ideally increase over time. And at that point, we're really dealing with an issue of volume management, we're no longer dealing with an issue of foundational shoulder strength, that person has the capacity to do strict work. Now we just need to carefully watch that person's volume, making sure that when they begin to develop kipping pull ups, they can do sets of five, they don't decide to help themselves to a workout where maybe they're doing 150 pull ups in a workout or 200 pull ups in a way that Volume is now the concern for the shoulder and not necessarily the foundational strength. SUMMARY So where's kipping at in 2024? The same place that has been for 128 years. There is a lot of public facing information out there that is confusing to our athletes and patients of how to get better. how to work on these for performance, how these can improve your performance in the gym, but also an equal amount of information on why these are dangerous or deadly or detrimental to your fitness progress. So understand the concerns that your athletes and patients are going to have when it comes to the KIP. Know that on the clinician facing side there is almost no research for or against kipping. We have just one article that looks at muscular activation patterns between strict pull-ups and kipping pull-ups and shows that when we kip we reduce the demand on the shoulder a little bit and increase the demand on the lower extremities in the core. Understand really fundamentally what we're looking at with kipping. We're just looking at momentum transfer and that we do this in a wide variety of movement patterns away from the gymnastics bar in the gym. Yes, we can kip pull-ups and toes to bar muscle-ups and handstand push-ups, but we also kip when we stand up. We kip when we transition from walking to running and jumping in the pool and swimming and so on and so forth. What is our goal? Our goal is always the pursuit of as much vertical pulling strength as we can get. So when things like strict pull-ups show up, things like strict handstand push-ups show up for vertical pressing, we need to make sure that we're working on strict work and not bypassing the foundational strict work with kipping just because we can't do the strict work. What's the answer to how many strict pull-ups is enough? Two answers. Strict work does not guarantee performance, efficiency, safety with kipping, but also you can never be strong enough. So always continue to work on strict pull-ups, even once you develop kipping pull-ups. And even once you believe that your kipping pull-ups or butterfly pull-ups or toes-to-bar or whatever are in high capacity and high quality, you're still working on that fundamental strengthening of the shoulder because we know Strengthening is protective of injury. And understand that once someone develops the strength work and begins to kip, we're not really dealing with a volume management issue. We're dealing with maybe the future potential development of a tendinopathy, not necessarily a lack of functional shoulder strength once that person can do a couple of strict pull-ups. So I hope this was helpful. I know it's a very contentious area across the functional fitness space. Happy to take any questions, comments or concerns you all have thrown here on Instagram courses coming your way from the fitness athlete division. Our next level one online course starts April 29. Our level two online course starts September 2. and then we have a couple of live courses coming your way before summer kicks off. Mitch will be down in Oklahoma City on April 13th and 14th. Joe will be up in Proctor, Minnesota on May 18th and 19th. That same weekend, Mitch will be out in Bozeman, Montana. The weekend of June 8th and 9th, Zach Long will be down in Raleigh, North Carolina. And then the weekend of June 21st through the 23rd is a really special weekend. It's our Fitness Athlete Live Summit here in Fenton, Michigan. We'll have all of our lead instructors and teaching assistants here. So Zach will be here, Mitch, myself, Joe, we'll have Kelly, we'll have Guillermo. We'll have all the fitness athlete crew here for a special offering of Fitness Athlete Live at CrossFit Fenton. So I hope this episode was helpful for you all. I hope you have a fantastic Friday. Have a wonderful Easter weekend if you're celebrating Easter. We'll see you all next time. Bye everybody. 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Dr. Alan Fredendall // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the relationship between value & price, how to arrive at a potential price, avoiding assuming the value that patients perceive from our services, and understanding that not all physical therapy is created equal. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLAll right, good morning, PT on ICE Daily Show. Happy Thursday morning, hope your day is off to a great start. My name is Alan, currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member in our Fitness, Athlete, and Practice Management divisions. We're here, Leadership Thursday, talking all things clinic ownership, management, personal development here on Thursdays. Leadership Thursday also means it is Gut Check Thursday. Gut Check Thursday is back, the CrossFit Open is over. We have kind of a You're going to row 2,000 meters or 1,600 meters on the rower. That time domain is normally around the same time domain as a one mile run, about a seven to maybe 10 minute effort. But of course, we're going to make it a little bit more difficult. Every two minutes, but not the start of the workout, you're going to stop and do two rounds of three wall walks. six hang power cleans at 115.75 and then 12 ab mat sit-ups. The challenge there is when that clock beeps on the two minutes to get off, race through those wall walks unbroken, race through those hang power cleans unbroken, move through the sit-ups very fast, trying to get that work done in ideally a minute so that you have a minute or possibly even more to jump on that rower and chip away 200, 250, maybe 300 meters at a time. Extend that normal 7 to 10 minute 2k 1600 meter row out to maybe a 15 to 20 minute workout. Scale appropriately. Make sure your wall walk option you can do unbroken. Make sure your hang power clean option you can do unbroken. Make sure your sit-up option you can do unbroken. You don't want to have to stop and rest anywhere in there, or you're taking away from your time to do the real work of the workout, which is to move the distance on that rowing machine. So be careful you don't trap yourself where you're just doing wall walks, hang power cleans, and sit-ups, and you never actually get back to the rower. Scale that appropriately so that you have at least a minute, maybe a little bit more, each round back on the rower to chip away at that distance. VALUE VS. PRICE So today, sorry, Leadership Thursday, what are we talking about? We're talking about value and price. So we had an interesting conversation. The last cohort of our Brick by Brick Practice Management course just ended a couple of weeks ago. And one of the big themes of that course is folks deciding, especially those folks who may decide to be 100% cash-based, how do I know how to price my services? A lot of folks don't know where to start. A lot of folks look to maybe competitors in the area. They look to maybe national clinics that have different prices listed online to try to get an idea of what they should price their physical therapy visits at. And insurance providers are very similar of what is good payment for physical therapy quote-unquote good and so I want to talk today about Discussing what is value? Discussing what is price? Discussing how they can sometimes be the same but how usually especially if we're doing it, right? They are very different and some tips and tricks for you out there on to hopefully understand that the services we offer, at least as we teach them here at ICE, are probably much more valuable than what your competition is offering, and therefore worth a lot more when you're considering charging your rates, especially if you're going to be a cash-based physical therapist. WHAT IS PRICE? So understanding price is maybe the best and easiest way to start. If we talk about what is literally the definition of price, it is the arrival at the amount of money we'd like to make after we've accounted for the expenses of whatever it is we're selling. The physical cost, the expenses of making a thing to sell it, or the costs that go into what we might price a service for. So understanding that we're in the service industry, our expenses might not be as high as maybe a company that sells furniture or cars or something like that, but that our services do have a cost. We do need to pay ourselves or pay those individuals who work with us. And we also need to account, we do have some supply costs. We have to pay for power and heating and cooling and internet and needles and linen and all the sort of stuff that goes into keeping a physical therapy clinic running. And that comes at a cost. And so factoring in cost of expense, otherwise better understanding, especially on a patient by patient basis, What does it actually cost you to see that patient? So if you're already in practice, having an idea of what that number is, is really, really important because it lets us better come to an educated arrival on what our price could be. At the end of the day, though, we need to recognize that that is really just a guess. It is yes, assuming costs. Yes, it is assuming what we need to pay ourselves or pay someone else. and then having some sort of idea of ideal profit, but that it is a guess at what the perceived value of what we're offering is to our patients, to our customers for the sake of argument today. A calculation of ideal potential profit. How can we better understand the value that we're offering people? THE SWOT ANALYSIS I highly recommend, if you've never done it, even if you don't think that you would ever own your own practice or manage a practice or anything like that, I recommend that you do a little thought experiment called a SWOT analysis. S-W-O-T SWOT. Strengths, weaknesses, opportunities, and threats. This can be very in-depth, this can be very short, it's kind of an experiment that it's what you make of it, but sitting down and thinking what are the strengths of myself if I'm an individual practice owner, what are the strengths of my clinic if I have maybe one clinic with multiple providers, maybe multiple clinics with many providers, What are our strengths? What services can we offer? What are the strengths of the clinicians that I have on staff? What are the strengths of essentially the value of the product that we can offer? The inverse of that, what are the weaknesses? What are areas maybe of practice that we don't have somebody who could treat it? Maybe we don't have anybody who could work with pregnant and postpartum patients. Maybe we don't have somebody that's very keen on treating the vestibular system, treating folks maybe with falling or dizziness or balance issues. Maybe we don't have anybody who's comfortable working with older adults, youth athletes, so on and so forth. So understanding where are the weaknesses in your practice. And then O is the opportunities. What opportunities are there, not only in shoring up those weaknesses, but what opportunities exist outside of our clinic? Do we live in a town that's really big on running, right? Maybe we live out in Asheville, North Carolina, or we live in Johnson City, Tennessee, and we have a big mountain bike or trail running population. Are we able to target that population? If not, we know that's a weakness, yes, for a clinic, but also an opportunity to provide value to a new pool of potential patients. And then threats. Threats can be, yes, direct competition, but threats can also be external things. We can label things like inflation under threats. We can label higher than normal cost of commercial real estate under threats. But going through that SWOT analysis and saying, do I have any chinks in my armor? If yes, then I know the value of what I'm offering is probably a little bit lower than I'd like it to be. If I go through this analysis and I think, gosh, especially compared to the competition, I think we're doing really well. Then now you have an idea of actually I think what we offer here is more valuable than the competition. And that will overall let you better arrive at how to price your services. TAKING A GUESS AT PRICE And at the end of the day, when we're thinking about price, I love what our CEO here at ICE, Jeff Moore, says of thinking about what you need to charge per hour is really working in reverse. A question of what does it take to make a certain amount of money for a year, whatever that is for you or your clinicians or both, to treat five to eight patients per day, three to five days per week, 48 to 50 weeks per year, right? Having two to four weeks off for vacation, seeing maybe 30 to 40 patients one-on-one. What volume do you need to treat at and what do you need to charge as far as your price goes to achieve the amount of money that you would like to make each year? And now we need to understand, back to the threats portion of the SWOT analysis, that there are always going to be forces we can't control that are going to affect that, right? If we live in a really big city and with a really high cost of living, then we know we're either going to need to be happy taking less money home, or that we're going to need to charge maybe more than we're sure is going to be an appropriate price to offset some of those expenses. So at the end of the day, setting a price but not being so locked into it that it can't go up, ideally it won't go down, you won't continually lower your price over time, Ideally, your price will continue to increase as more folks find your services valuable, but at the end of the day, picking a price and starting there and then seeing how expenses, seeing how external threats, market forces, inflation, that sort of thing, change your price over time. And if you're doing it right, and this is maybe a personal belief, I don't have research to support this, but if you're doing it right, if people truly find your services valuable, you should find yourself slowly getting busier over time such that you can begin to charge more because you will end up in a position where you have more people that want to see you than you have time to see. And of course, that's where we can discuss growing beyond yourself into multiple clinicians, but that is a really good point to be at. It's not great to start with a full caseload and need to slowly decrease your price to try to hang on to it over time. It's a race to the bottom and that never ends well regardless of what industry that you're working in. So that's a conversation on price. WHAT IS VALUE? Talking about value, I love the quote by George Westinghouse. If you don't know the story of George Westinghouse, his company eventually defeated Thomas Edison in the race to electrify America, essentially in the late 1880s. He said, the value of something isn't what someone's willing to pay, but what it contributes, right? And that kind of says that the customer drives the bus on value. We can certainly set our price, But the folks who are buying our service, paying for physical therapy, buying our widgets, whatever, they ultimately dictate the value that they perceive from what we're offering and that that's going to be different from person to person. Some folks are going to find more or less value even if our price is flat and never changes. And we need to accept that just like we need to accept that price is never permanent. There's no business that's selling stuff for the same amount of money 50 years ago as they were today, for example, except maybe Costco with their $1.50 hot dog. But for most businesses, things tend to get more expensive over time to adjust for inflation and that sort of thing. So value is kind of in the eye of the beholder. A lot like price is not really a fixed thing for us on the other side of the equation. DO NOT ASSUME PATIENT'S VALUES In most businesses, and I think especially in physical therapy, we do way too much assuming about how our customers, our patients, our clients, what have you, perceive the value of our services. We see a lot in brick by brick. We see a lot on social media. We see a lot of conversations. that I'm worried about charging too much. I'm worried that my patients won't find value with the price that I'm charging. We are assuming way too much about how much money people have to spend, but also again, that value is this fluctuating thing. and that folks place different levels of value on different products and services in their life in ways that are, yes, in line with the price, but sometimes that are not in line with the price, right? A good example is cell phones. Almost every human being on the planet has a cell phone. In the United States, 94% of all Americans have at least one cell phone that connects to high-speed internet. In particular, they have a smartphone. What does that tell us? At least as Americans, we highly value having a smartphone, right? We're willing to pay $1,000 to $2,000 out of pocket to initially buy it. We're willing to spend $100 or $200 a month on the subscription so that that cell phone has access to the cellular network and can text and email and look at apps and all that sort of stuff. So there's a high value on something like a cell phone. What we're really talking about in the conversation between price and value is that we need to show folks the value of physical therapy such that they don't even consider the price of what it is. Of yes, of course, if we try to charge $1,000 a visit, we're probably not gonna get too many takers, but also we shouldn't feel like we need to undercut our competition and perform visits for $50 or take insurance payments for $40 because we're uncomfortable asking for too much money. Again, do not assume what your patient values. If they find your services valuable, trust me, they will find a way to pay for what you're charging, just like they find a way to pay for their cell phone and all the other stuff in their life that they truly find value at, even if they think, gosh, that's high. If their perceived value is high enough, they will find a way to pay for it. I think of myself as an example, across the week, most days I work about 16 hours, most weeks I work seven days a week, and most months I work most weeks. On average, I make about $28 an hour across everything that I do. An incorrect assumption is that an hour of my time then is therefore worth exactly $28. And that is a misunderstanding between the relationship between price and value. There are hours of my time that you cannot pay me a million dollars to take that hour away from me, right? You cannot offer me $28 to not exercise an hour a day. You cannot offer me $28 to skip the mornings that I have with my son where I get to get him out of bed and get him ready for school or the days where I get to pick him up and bring him home and play with him and put him to bed. That has a value on it that really has no price that can be associated with it and I hold on to those hours very, very much. Likewise, when I myself am injured and need physical therapy, I place a high value on the physical therapy that I obtain because I find that it helps me a lot, right? The manual therapy helps me a lot. The guided home exercise program helps me a lot. I tore my meniscus two weeks ago tomorrow, just finished a workout. I'm back to lunging. I'm back to light impact. I'm back to light squatting in just two weeks. An injury that might put some folks out for three, six months might cause them to seek surgery. I'm already modifying around it and slowly getting back to full activity, probably realistically within a month. That has an extreme level of value that I would argue is more than the cost of what I pay for the physical therapy with the price that it holds. So do not assume what folks value, how much they value things, or that relationship between value and price. Because it's not always exactly equal, even though in our heads we tend to think value equals price, that is simply not the case. WHAT IS THE VALUE OF TIME WITH A HIGH-QUALITY HEALTHCARE PROVIDER? I will challenge you before we sign off for today to really step back and ask yourself the question, especially if you're in this scenario right now where you're thinking, what should I charge for my services? Should I increase my price? What are people around me charging? What is the value of a high quality healthcare provider? who can keep you from otherwise consuming tens of thousands of dollars and hours and hours of your time otherwise in the healthcare system to usually ultimately not get any better than you were doing nothing on your own. I would argue the value there is really high. The value is high to the patient. The value is high to the healthcare system in general as well. And the question then becomes, what is ethical? What is too much? What is too cheap? What is an ethical amount of money to be paid? And the answer to that, unfortunately, that we don't want to hear is that it depends. Well, what does it depend on? It depends on the perceived value of the patient for our services. Sure, you can charge $500 for an hour of physical therapy, but that probably needs to come with a really high quality level of care. That's probably more concierge care, direct access to your provider at all times, evening visits, weekend visits, visits at the office, visits at the home, whatever. That's kind of a more high caliber level service versus what is the value of a visit of physical therapy that costs $33. Well, we might assume that's so cheap, it might not be really valuable, but at the end of the day, we don't know that either, do we? There are a lot of folks accepting insurances that pay almost nothing who are providing high quality care, or at least trying to, in a way that their patients perceive value. So don't assume what the value of our care is, and certainly never assume the value of the care a competitor is providing until you know what they are offering their patients. that we can say, wow, they're charging $500. The default assumption there might be it's really high quality of care. It must be. It's $500, right? The natural association in our brain is higher price equals higher value. but that is not always the case. There are a lot of people charging a lot of money cash for patients to walk in and lay in a circle on treatment tables and just get dry needles for an hour. And I would argue that's probably not really valuable care to the long-term health and fitness of that patient. Yet they are charging and receiving that money, which again kind of shows us the asymmetry between price and value. If those patients perceive value, they will find a way to pay that amount of money, and that is true for you as well. So at the end of the day, don't shortchange yourself. Don't set your prices just because it's what somebody else is charging. Don't set them lower. Don't set them a little bit higher. Step back and ask yourself, What is an ethical payment for an hour of my time given the value that at least I believe I'm providing to my patients? Set that price and then adjust fire as needed later on. We say here at ICE, ready, fire, aim, right? Set it up, lock in the price, see what happens. Your patients will determine your value. Do not assume it for them. Do not assume someone does not have the money or cannot find the money to come see you once a month for a cash-based physical therapy treatment. Again, if those patients truly find value, they will find a way to come pay you. So price versus value. They're not always related. Sometimes they are, but usually not. We often see an asymmetry where the value that folks perceive can often be significantly higher than the price they're paying. We hear that a lot in physical therapy. I would have paid double what I paid. This was such great service, you erased a decade of back pain, I'm back to playing with my grandkids, I'm back to walking without a walker, whatever. We hear all of those things in the clinic. We hear that folks are significantly happier with the value they receive from our services than the price they were charged, so keep that in the back of your mind. What price is sustainable? What price is sustainable for you to believe that you're making enough money to do the work that you're doing? And what price is sustainable for your patients? Demographics, socioeconomics, market forces, inflation, commercial real estate, all those things that are really out of our control do play a factor in our price. What price targets your ideal customer the best? Do you want to provide a high level of elite concierge service? If so, you can probably charge a little bit more as long as you're comfortable knowing that that patient is probably going to demand a lot more out of you than if you charged less. Again, keeping in mind at least your perceived value of what you're providing to somebody, what price is ethical? I guarantee you an ethical price is not the $43 flat rate payment from an insurance that's an HMO that requires a 30 minute authorization before you can treat that patient. I don't know what an ethical amount of money on average across the United States is for a physical therapy visit, but I know it's not that for sure. And then what is a fair market value for a similar service? Again, do not assume the value that your competitors are providing until you know exactly how they treat and the value that they at least are attempting to provide to their patients. It's easy to look on someone's website and see what they're charging and just make your price $5 more or $5 less, but that doesn't really understand the whole picture of the value they're providing, the value you're hoping to provide, and what the difference between those two services might be. I think of it a lot of getting a haircut, right? Yes, I can get a $10 haircut at Bo Rick's or Fantastic Sam's or whatever. My hair is not going to look the greatest. What is the price at a barbershop? It's a little bit more. What is the price at a high-end salon? It's a little bit more. And what am I getting along the way? Well, with those services, quality tends to go up and the value tends to go up, right? The haircut tends to be a little bit better. You tend to get a little bit more time with the person providing the service as you go up each tier. And that can be the case in business, but it's not always. SUMMARY So remember, Price isn't firm. It can change. You're the one responsible for changing it and do not assume the value of what you're providing. Let your patience dictate that. If you set a price and you have a full caseload and you have a two or three month waitlist, guess what? Your price is probably too cheap compared to the value that your patients are perceiving, and you're okay to bump that price up at the beginning of the year. So don't assume that. Don't assume people can't or won't find the money to come see you if you truly believe in the value of the product you're providing. If you want to learn more about this stuff, our next cohort of Brick by Brick starts April 2nd. We take you all the way through from having no idea how to run a business to finishing the course in eight weeks, having all of the legal documentation you need to formally start a business, to have a better idea if you're going to take insurance, take cash, take a mix of both, and to be able to open your doors potentially at the end of that eight-week class. So we'd love to have you. More information at PeteDenise.com. That's it for me. Have a wonderful Thursday. Enjoy Gut Check Thursday. I'm going to be out in Rochester, New York this weekend watching Lindsey Huey teach extremity management. So I'm going to be at that course. I'm looking forward to hanging out with you. And I imagine we'll probably hit Gut Check at lunch on Saturday or Sunday. So have a great Thursday. Have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.  

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Alexis Morgan discusses what a pelvic floor exam looks like in light of updated practice patterns & research,. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION ALEXIS MORGAN Good morning. Welcome to the PT on Ice daily show. My name is Dr. Alexis Morgan. I am one of the faculty with the pelvic division and happy Monday. I'm excited to be here this morning to talk to you all about the 2024 version of the pelvic floor assessment. We've been through so many iterations as a profession of the pelvic floor assessment. And I want to just take a few minutes today to talk with you all about the 2024 version, the updated version, the modern way to assess the pelvic floor. Thanks for joining me. Let's jump right in. HISTORY OF THE PELVIC FLOOR EXAM So when we think about the history of the pelvic floor exam, this goes way back, all the way to Dr. Kegel. I've actually done some podcast episodes on the history, and if history's not your jam, don't worry, I won't bore you with the history details today. But our pelvic floor exam does go way back decades, closing in on 100 years now. And over the last several decades, of course, we've had a lot more research come out and a lot more evidence, a lot more understanding of these muscles that are at the base of the pelvic floor. And so with, of course, new updates, new pieces of understanding, we're still gathering information, but of course, as we change in the way that we understand a group of muscles, of course we're gonna change in the way that we assess them clinically, right? We see this so frequently when we look at the evidence on strength. So strength is not necessarily indicative of problems or lack thereof problems. Yet we are so often talking about assessing strength and obsessing about what manual muscle test grade is there. And yes, if you're not familiar, we do have a manual muscle testing score for the pelvic floor. but realize that that is such a small piece of the entire picture. And we're starting to see this in the evidence as just described, and there's several studies that are making us go, hmm, maybe it's not all about strength. But how do we then take that into our clinical practice? FOCUS ON RANGE OF MOTION & MUSCLE COORDINATION First and foremost, we ourselves need to back off of obsessing about strength, right? We need to really get a full understanding of the person in front of us and really gather that information and not just talk about strength, but talk about the entire picture. So, here's the updated version of the way that we do our assessments. First, we're going to test their range of motion. I'll dive into each of these details, but I want to give you all the overall picture first. So first, we do a range of motion assessment. Then we go into coordination. And after coordination, then we might go into a strength assessment. We might go into a palpation assessment. or we might go into a prolapse assessment, depending on how that person shows up in front of us. We may take it a few different directions, our assessment, but we're going to start with the range of motion and coordination assessment. Range of motion and coordination are important for all people. No matter what we are assessing, no matter what problem, no matter what genitalia we are looking at, all of the people that we are assessing with the pelvic floor, we need to start with range of motion and coordination. So what is the range of motion of the pelvic floor? What do you mean by coordination? Well, range of motion of the pelvic floor, you've heard us talk about this a lot here at ICE, is squeezing up, we call it squeezing into the attic, going up towards the head, going to baseline, and then going into the basement. So in our A-frame analogy, we've got the attic, the first floor, and the basement. So we need to assess all of these areas. That is the range of motion. There are going to be problems if somebody can't raise it up. There's also gonna be problems if they can't push their pelvic floor down. There's problems when the full range of motion does not exist. So we need to A, assess it, and then B, help them find their full range of motion. That's beyond the scope of this podcast. Come to our live course where we talk more about this. But that is range of motion assessment. Very important as it is first. Then we go into coordination. So coordination is me assessing your pelvic floor with certain coordinated movements or certain movements that you do in the day. And I'm assessing to see what does your pelvic floor do and is it coordinated with the core muscles? How does that function? So we might would look at a cough We would definitely look at a brace, especially if the individual is having issues with some type of bracing mechanic. And you may do it in a lot of other different positions. I have clinically assessed pelvic floor coordination for a yogi who is having difficulty with downward facing dog. Yes, we got into that position to assess the coordination of her pelvic floor. That was where her primary complaints were. That's where we need to do that assessment. It's not a strength assessment at that point. It's a coordination. What is she doing with her core and pelvic floor in the problematic position? That is coordination. With these two important pieces of the assessment, There's a lot of different ways in which you might assess. Range of motion, coordination. That could be assessed just visually. Just externally, I am looking at maybe the rectum, maybe the vagina, male or female. Whatever it is, I might be just looking externally. Or I might do an internal assessment. vaginal or rectal. I might would do it in standing, a standing assessment. There's a lot of ways in which we're going to match the assessment with the problems that the person presents to us with. We're going to match them, but realize that they're going to start with a range of motion assessment and coordination. Then of course we can dive into our other three options, that strength assessment, that palpation assessment, and the pelvic organ prolapse assessment. So it's important for you to know that All of these options that exist, you may not use all of them in a client. You may not use them all in one day. It may take you several months or weeks, depending on the person in front of you, to go through all of these assessment tools. That doesn't matter as much as what matters is that you're testing the problems that they're presenting with, and of course, that you're making progress along the way. So that strength assessment is important. It is a piece of the puzzle. Someone needs to be able to generate enough force in their pelvic floor to squeeze off their holes. That way they do not have problems of a lack of force. That is important. But only when we know that they're coordinated enough to squeeze their pelvic floor. Right? Because if they can squeeze it on their own, but whenever they're bracing, they're not squeezing it, it doesn't really matter to work on strength. It matters to work on coordination. You see where I'm getting at? So once they get that, those first pieces, the range of motion and coordination, then we move on to strength. WHAT NEXT AFTER RANGE OF MOTION & COORDINATION? So with that strength assessment, we might do that in supine, we might do that in standing, testing their strength, their ability to squeeze the pelvic floor. With the palpation assessment, and again, we go into all the details. I'm skimming the surface here. We go into all the details in our live course. When we are doing a palpation assessment, that is purely to reproduce their pain. You hear us at ICE all the time talking about, and no matter which course you're taking, when we are doing a palpation exam, we are trying to reproduce their main complaint that they're coming in to see us for. So, same is true in the pelvic floor muscles, each of the layers, left side and right side. Does this reproduce their problem? Their problem might be urgency. When I gotta go pee or poop, I've got to go. Let's see if pressing on some of these muscles causes that urgency. or round ligament pain or adductor pain or might even look or sound like what the patient may come in with is sciatica, right? Or radicular pain. All of those could be caused by the pelvic floor muscles in which you would find in that palpatory exam. So that palpation exam is important to rule out the pelvic floor as a potential root cause of some of their symptoms that they are experiencing. And then lastly is pelvic organ prolapse. So we may not do this pelvic organ prolapse assessment. There's a lot of podcasts where we're talking about our thoughts on POP or prolapse, and I will have to guide you to those. I'm not gonna take all of your time talking about that this morning either, but it is a piece of the exam that you might would add in. We might would add in the prolapse exam if the person is coming in with their main complaint saying the word prolapse. Saying that I've been diagnosed with prolapse. Discussing some concerns about prolapse. Similar to the obsession about the strength scores, we can also see an obsession about a prolapse grade. Something about these numbers gives us this black and white, this very clear picture in our heads, but it's not exactly the full clinical picture. So really, do the pelvic floor assessment. If you need to do the prolapse assessment, absolutely do that. And again, you can do that in supine. You can also do it in standing and apply that to that individual. But just remember that 50% of individuals assessed objectively are going to have some sign of dissent, aka some sign of prolapse, so we don't need to be freaked out about it. Rather, what we need to do is focus on their range of motion, focus on their coordination. Those two pieces are so incredibly fundamental and important for everyone to be able to utilize their pelvic floor effectively. Whether that is in preparation for birth, whether that is performance under the barbell, or trying to reduce pain with sex, Whatever the topic is that the individual is coming to us for, we're going to start with that range of motion assessment. We're going to go into that coordination and we might hang out there for a while and work on the goals of pulling pelvic floor up, pushing down, feeling all of those differences of the pelvic floor, and then coordinating it. Coordinating it with diaphragmatic breathing, with bracing, with whatever problem they have, matching it to that. That right there added with it the three options of the strength, the palpation, and the prolapse assessment, that is the updated version of the pelvic floor assessment. That is what aligns with how we understand, as of today, the pelvic floor function. It matches what we see in the newest literature all the time, which is maybe it's not all about strength. Maybe there's some other aspect. And when you look at these studies, we recognize that individuals are assessing this, but it's not really been discussed about in this way. This is what we're doing. This is how you create change. This is how you have some organization in your assessment. This is how you get the patient on board. You tell them we're gonna do range of motion. We're gonna do coordination. We're gonna see how you do with each of these. This is gonna look a lot like this problem that you're experiencing. We're gonna match that up and we're gonna talk about what optimal is. Really focusing in on what matters to them helps them stay focused. SUMMARY So use this, let me know what you think, and if you are so excited to see us maybe in Greenville, South Carolina this coming weekend at the live course, we're excited too. Or we've got several courses coming up in Colorado, in Missouri, in Alaska, In New York, we're all over the place this year. So look for a course that's near you or near somewhere that you would like to travel to. We would love to have you at our course. We also are discussing these topics in a little bit different ways in our Online Level 1 and our Online Level 2. Our first cohort of the Level 2 is actually sold out. Our second cohort of the season of the year is in August. It will sell out. If you are interested in joining us, you should go ahead and purchase that ticket. We'll be talking about all of these aspects of what we just discussed today in both of those courses. head on over to PTOnIce.com, check us out, we would love to have you join us in the courses. Have a wonderful day, a wonderful week, and let me know what you think about the new way of doing the pelvic floor assessment. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses the concept of a lateral shift when addressing low back pain, as well as three objective & 1 subjective ways to assess the potential presentation of a shift. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Lumbar Spine Management course, our Cervical Spine Management course, or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JORDAN BERRYAll right, what is up PT on Ice daily show? This is Dr. Jordan Berry coming at you live on a technique Thursday or an assessment Thursday for today. So I'm lead faculty for cervical management, lumbar spine management. And today we're talking about the lateral shift and how in the clinic we can pick up on the lateral shift so that we're not going to miss it. So we're going to talk about just a few ways from an objective and a subjective standpoint that we can pick up on the shift so that we don't miss it. And so one thing that I commonly see in the clinic, whether it's a client who is not getting better, or it's a client who's not progressing like we think they should be, or if I'm doing a case review with another clinician or watching that clinician evaluate the lumbar spine, one thing that we commonly see is the lateral shift is not on that person's radar, or they don't know all of the different ways that a lateral shift can present. We're going to unpack that over the next few minutes here. WHAT IS A LATERAL SHIFT? When we talk about a lateral shift, what we're really talking about is when someone has an acute episode of low back pain, oftentimes it's back and back related leg symptoms as well. they will oftentimes have what we call a lateral shift. And so that is when, quite literally, the body is shifted in a direction where the hips go one way and the shoulders go the other way. And there's a bunch of different theories on why this can happen, but really the person is going to inherently avoid this side of pain. So almost always the shift is going to be in the opposite direction of the side of symptoms. And so when we talk about a lateral shift, we name it based on the shoulder position, not the hip position. So for example, if I had pain on the left side and I was shifted this way, away from the side of symptoms, then we would name the shift based on where the shoulders are heading. So in this case, it would be a right lateral shift if I am going towards the right with my shoulders and towards the opposite side with my hips. And so again, there's a bunch of different theories on why this can happen, but one thing for sure that we see very consistently in the clinic is if someone presents with a lateral shift and it's not corrected or that treatment does not respect the lateral shift, you will typically not make very much progress. But it's not just a visible shift. There are other ways that we can sometimes pick that up. And so we're going to spend just a few minutes unpacking that. So I've got Jenna here to help me with a couple of demos. So if you're listening on the on the podcast right now, jump over to YouTube or Instagram if you want to see an actual visual of what we're talking about. So I've got four ways that you can pick up a lateral shift in the clinic. FINDING A LATERAL SHIFT: USE YOUR EYES So starting with number one, number one is the most obvious. It's actually visible. So when someone has really significant back and or back related leg symptoms, you'll quite often see a visible, a literal shift when you're looking at them square on. And so if I have Jenna stand right here facing the camera. So let's say that Jenna had symptoms in the left part of her low back and then going down the left leg. almost always what you will see is the shift would be towards the opposite side of symptoms. So we would see Jenna's shoulders going towards the right away from the symptoms on the left. And the best spot to look when you're staring square on at the client would be at the forearms. And so we're looking at a difference in space between the forearms. So sometimes you might have to snug up the shirt a little bit or ask the client to relax the arms, but you will see a difference, more space on the side that the person would be shifting towards. It can be very obvious sometimes or it can be really subtle, but I'm always starting just getting a good visual of looking at the person square on. So number one is an actual visible shift. Okay. FINDING A LATERAL SHIFT: LATERAL FLEXION RANGE OF  MOTION OR SYMPTOM ASYMMETRIES Number two is an asymmetry in side bend or an asymmetry and lateral flexion. So when we're going through active range of motion, we will typically see that side bending towards the side that they're already shifted towards is gonna be much better than going towards the opposite side. So using this same example here, if Jenna is shifted towards the right, right, her shoulders are going towards the right side, what we will typically see is that she side bends towards that side, right, towards the right side, that it's pretty solid because that's the direction her body's already wanting to go to. And then when you go to the opposite side, it's gonna be, yep, very limited and oftentimes painful. And so anytime I see an asymmetry in lateral flexion or an asymmetry in side bend, I'm for sure gonna test out a lateral shift correction to see if it makes a difference. And when we say asymmetry in side bending, it's not always just an asymmetry in range of motion, can also be an asymmetry in symptoms. So even if the side bending is relatively similar from a range of motion standpoint with how far the person can side bend, if one side is dramatically different from a symptom, from a pain standpoint, that's also sometimes indicative of a lateral shift. Okay, so number two is an asymmetry in side bend. FINDING A LATERAL SHIFT: HIP RANGE OF MOTON ASYMMETRIES Number three, an asymmetry in rotation of the hip. Specifically, internal rotation is usually the one where you're going to pick up on it. So if I have Jenna sit right here on the table and she just does internal rotation while she's sitting right here. So we're just assessing how much internal rotation we have. And then if I had Jenna fake a lateral shift, so let's go in the same direction, right? She's shifted towards that right side because she's off when her shoulders go to the right, she's offloading the left side. And so now it's going to present like she has much better internal rotation on the left versus the right. Now, it might not be true internal rotation that is different. It might just be of the position of the hips that it presents as if it's different. So picking up on internal rotation again, either because of symptoms or because of range of motion, can be a third way to differentiate between someone having a lateral shift. You can test it in sitting like what we're doing here. You could also test it in supine, but Very commonly it is the side opposite of the shift that actually might have a bit more internal rotation. Again, because of the position of the torso or the position of the trunk. FINDING A LATERAL SHIFT: THE SUBJECTIVE HISTORY And then lastly, the fourth way that we can pick up on a lateral shift is in the subjective. So the first three are going to be more in the objective exam, right? The last one, the subjective, is going to be a preference for sleeping or lying on one side versus the other. So that could be, again, sleeping, that could be laying on the couch, it could be any time the person's non-weight bearing, they prefer to go in one side versus the other. And again, because they're offloading the painful side. SUMMARY So if I hear any of those four things, whether it's in the subjective or the objective exam, I'm for sure going to test the lateral shift correction because I can't afford to miss it. So again, as you're going through this week and you're seeing someone that has acute low back pain, back-related leg symptoms, and you're trying to pick up on the lateral shift, what are those four things that might indicate that? Well, number one, the most obvious, it's visible. So you're gonna look at the person square on, and you're gonna look at the forearms to see if there's a difference in space side to side with their arms relaxed. Number two, an asymmetry in side bend. That asymmetry could be range of motion, being asymmetrical or symptoms being asymmetrical side to side. Number three is a difference in hip rotation, more specifically internal rotation. And then lastly, the subjective exam is a preference for sleeping and or lying on one side versus the other. All right, that's all that I got for you today. This is part one of two. So we're going to come back in a few weeks and jump on again and go over different ways that we can actually correct the lateral shift. The one that we know most commonly, right, when you're standing on the side and you're shearing the person or shifting the person in the opposite direction, that is by far the most common. But we've got a lot of other cool variations when the person might not tolerate that position. So as always, if you want to learn more about this, hit us up at one of our live lumbar management courses. And we've got a bunch coming up from the spine division over the next few months. I know we've got two coming up this weekend to next weekend as well. Cervical and lumbar spine management. Have an awesome day in the clinic. Thanks, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the strategy behind helping athletes & patients consider adding extra training volume on top of their normal exercise routine. Why should we add it, when should we add it, how should we integrate it into our normal training, and who is appropriate for extra volume? Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLWelcome in, folks. Good morning. Welcome to the P-Town Ice Daily Show. Happy Friday morning. I hope your day is off to a great start. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader here in our Fitness Athlete Division. It is Fitness Athlete Friday. It's the best darn day of the week, we would argue here, from the Fitness Athlete Division. Those of you working with crossfitters, Olympic weightlifters, powerlifters, endurance athletes, anybody who is recreationally active, part of that 10% minority of the human race that exercises on a regular basis enough to produce a meaningful health and fitness effect. We're here to help you help those folks. INCREASING TRAINING VOLUME So here on Fitness Athlete Friday, today we're gonna be talking about increasing training volume. A hot topic, especially this time of the year, the CrossFit Open has begun as of yesterday. This is often the time of year as people go through the Open, maybe they did not perform as they thought they would, and they begin to ask questions about how can I make my performance look more like someone else's, right? So 24.1 was released, a couplet of dumbbell snatches and burpees over the dumbbell. I just finished it this morning, just finished judging a few hours as well. First workout, usually very approachable. People maybe have questions of how can I get faster as we get into the later weeks of the Open. Heavy barbell comes out, high skill gymnastics comes out, people begin to have more questions. What else could I be doing besides coming to CrossFit class? This relates to other athletes as well. Endurance athletes who maybe want to get faster in their mile time, faster in their race times, stronger to have less injuries. All of those questions tend to come up of what else could I be doing? So today we want to focus on asking in the concept, in answering the question of increasing our training volume. Why should we do that? When should we do it? Who is the person that's appropriate for it? And then how should we actually begin to introduce increasing training volume? WHY SHOULD WE INCREASE VOLUME? So let's start from the top. Why should we increase training volume? I think this is really important and that's why I have it as the first point today. often folks are maybe disappointed with their performance in the open or a recent road race or competition or something like that and they want to do more training and just adding in more training without understanding why we're doing that training or having a goal for that training can be a very rocky foundation to build upon and can really ultimately maybe set us up for an unsuccessful addition of volume that doesn't meaningfully improve our performance and maybe leads to an increased risk of injury for no reason. because we don't really know why we're training for more volume, right? Just doing more CrossFit metabolic conditioning workouts or just doing more accessory weightlifting or just running or biking more miles without a goal is really just adding meaningless volume to the equation. We need to understand why should we do this. So when folks come to you with that question of What should I be doing extra outside of my running or outside of CrossFit class? We should be asking back, why do you feel the need to add more training volume in? What specific deficit are you understanding or do you feel has been recently exposed that we need to add more training volume in? To just improve general fitness, with those folks we would say, Be patient, right? Continue going to CrossFit class. Continue if you've only been running for a year or two, continue your normal running training, right? Understand that high level performance often comes with most folks. When you look at them, they have a large training age, which means they have been doing whatever they're doing for a long period of time. And so expecting to close that fitness gap in just a couple of years by just adding in more volume is not really an intelligent way to approach that. But if we have identified some specific deficits, then that can be an argument to maybe add in some extra volume. So, folks who are maybe long endurance athletes who are noticing the longer my runs, the slower I become. I perceive that I maybe need to add in some speed work. Folks may be doing CrossFit that say, you know what, I'm great when the weight is body weight or when it's a low to moderate weight, dumbbell, kettlebell, barbell, whatever, I'm okay. But as we get heavier, I perceive that my strength, my upper limits of strength is limiting me from moving the weights around. In CrossFit class, where I'm perceiving that if I added in some more resistance training to whatever I'm doing, Maybe my tissues would be healthier or I don't have some of the skills and I would like to begin to practice them, right? I would like to practice double unders outside of class. I would like to practice pull-ups or muscle-ups or handstand push-ups outside of class or maybe add in an extra day of running if I'm a CrossFit athlete. So understanding why we're adding volume in is very, very, very, very important and it should be to address a specific perceived deficit and all the better if we can actually objectively test that so that we know if we're starting to make up ground on that deficit or not with the extra volume that we're being asked to add into our programming. So starting with why is very important. WHEN SHOULD WE INCREASE VOLUME? The next question is, when should we do this? I would argue that we should really only add in extra training on top of what we're already doing when we feel like our current training has plateaued. Of that person who says, I have been going to CrossFit six days a week for 10 years, and I feel like my ring muscle ups are not getting any better. I feel like I have literally not added a pound to my max, clean and jerk, whatever. When a perceived plateau is there, That can be a good argument to begin to add in some extra volume, especially those folks, uh, endurance athletes as well. Like, Hey man, I have been running for a decade and my marathon pace got faster, faster, faster the first couple of years, but it's been pretty much the same pace for the past two or three years of races. I feel like something needs to change. Or, again, those folks who do not have a skill. So that's when we begin to action that extra volume. For me, over the past year, my extra volume looked like adding in some more running. Doing pretty well, pretty happy with my CrossFit performance, but when runs showed up, especially in workouts where the runs were longer, 800s, miles, workouts like Murph Hero workouts with a lot of running, really, really, really impacted my performance despite doing pretty well on the other stuff that wasn't running. So beginning to add in extra running outside of CrossFit class. HOW DO WE INCREASE TRAINING VOLUME? Now, how do we do this? This is as important as why. How do we add in volume in a very intelligent manner? The key is with anything else, just like when somebody first began an exercise program, we need to start low. We need to go slow. We need to stair step this volume. A lot of folks perceive a deficit or otherwise feel like they want to add in more volume and they just do more of what they're already doing. And sometimes they do it every day, right? The person who leaves CrossFit and goes to Planet Fitness and does an hour on the stair stepper. or does an hour of machine weights, whatever. Adding in a big chunk of volume, again, if we don't have the foundation of why and when we should be doing this, can be a really unintelligent decision. So we should do this carefully. For me, this looked like one extra day of running for a couple of weeks, two extra days of running for a couple of weeks, so on and so forth. Using a running coach to very carefully and controlled add running volume in on top of working with a nutrition coach to make sure that I was fueling appropriately. So making sure that if we do come to the decision that we could benefit from extra training aside from what we're already doing, that we do it very, very, very, very carefully. What we're trying to do adding in extra exercise pieces is we are trying to push ourselves maybe into a short period of what we would call overreaching, functional overreaching. We're pushing the margins just a little bit, but we also need to be mindful of all the other training that we're doing, and we have to be careful that this functional overreach does not become overtraining, right? We need to make sure that if we're adding an extra stuff, we respect this new volume. We do it carefully. This extra volume should come with a progression in a deload. So for example, my running coach always had me on four week cycles. where every fourth week was a deload, added a little bit of miles every week for three weeks, and then a deload, add, deload. That deload week is a chance to give my body a break, go back to essentially my pre-running amount of volume, but it's also a great week to assess how did my body respond to the previous three weeks of training. Should we continue with the next block of extra volume? Or should we stay where I was at? Or should we maybe even regress a little bit because it was a little bit too much of an overtraining feeling rather than that functional overreach? And again, being objective with why are we doing this can really help us know did that little burst of extra volume create a change? Did mile split times go down? Did a race time go down? Did strength go up maybe two pounds or five pounds or whatever? Can I do two muscle-ups now instead of one muscle-up? So on and so forth. Having those objective indicators lets us know, okay, we're making the progress we want to see, and as long as everything is feeling good, we're good to continue going to that next step on the staircase of increasing volume. And when we think about how we add in this training, most importantly, we have to ensure that this extra training does not impact the normal training, right? The worst thing you can do is have your extra volume, make it so that when you show up to your normal training, so in my example, I never wanted to get to a point where my running made it so that I could not come to CrossFit, right? That's a dangerous spiral to get into, where now my normal baseline strength and conditioning program can't be performed, and now I'm adding extra volume even though I can't handle the current level of volume I was already doing before I added in my extra training. So being sure that whatever we're training at baseline, CrossFit, weightlifting, running, whatever, that does not become impacted by whatever extra stuff we're doing. Now that being said, if we're feeling good, we feel like we're making progress, we are objectively making progress, and our normal training is not impacted Okay, continue to either maintain that extra thing, whatever you're doing, or maybe even progress it a little bit. WHO IS APPROPRIATE FOR EXTRA VOLUME? Now the final part of the equation is who should do this? I would argue the answer is very few people should do this. Who is the type of person that is appropriate for extra volume? that person should be incredibly consistent with whatever they're already doing, right? Which by default erases most of the people who want to do extra volume. A lot of people perceive a gap in fitness between maybe themselves and their friends in CrossFit class or themselves and their friends and their run club or whatever. They want to close that gap even though What they don't want to hear is that maybe the gap there is because they're already not consistent with what they're doing, right? They hit the snooze alarm a couple days a week on CrossFit class or going for their run, right? I want that individual who is already incredibly consistent with their normal training. They are training four to six days a week, every week. They understand the importance of active recovery and rest days. They are prioritizing their sleep and their nutrition. The volume means nothing if we can't match that volume with an appropriate dedication to recovery. Again, we're trying to create bouts of small windows of functional overreaching. We're trying not to throw somebody into a downward spiral, a death loop of overtraining where they're going to be at increased risk for injury, where their fatigue, their soreness, whatever is going to impact all of their training, not just the extra volume that they're now doing. Most people are not consistent enough with what they're already doing to consider taking on extra volume. And I think that's tough to hear, but it's the right decision. for you as the coach, the clinician, whatever your role is, to have in a conversation with that athlete. If you are only coming to CrossFit on Monday, Wednesday, Thursday, you sleep in on Tuesday because Monday wrecked you, you sleep in on Friday because you're sore, you don't come to the gym on the weekend, let's see what your fitness looks like when you're consistent with your current fitness routine, and then maybe later on we can revisit talking about extra volume. I have found in my coaching career that the folks who come up to me and tell me, hey coach, I'm ready for butterfly pull-ups, happen to also be, coincidentally, the people who maybe can't even do strict pull-ups, right? The folks who are able to tolerate extra volume, extra skill progression, are the folks who are already very consistent and it's very clear that they, because they are consistent with their normal level of training, recovery, attention to their sleep and diet, They are aware, and I am also aware, that they can probably handle extra stuff, and that the people who want it really, really, really, really bad are almost always likely the people that should probably not do it because they are so inconsistent already. CASE EXAMPLE: RYAN A really good example I have is our friend here at the gym. His name is Ryan Battishill. You may know him. He develops a lot of your websites. He's a website developer by trade. He's a member here at our gym. I love how calculated and intelligent he is with just a little bit of extra training every day after class. So I want to tell you a little bit about him and then tell you the volume that he's added in in the results. So Ryan's been doing CrossFit for five or six years now. He has a history of running as well. He has a good morning fault squat. So a very kind of hingy squat. It tells us there's maybe a deficit in the quads, wants to get better at gymnastics, and wants to train for a half marathon as well. So, a lot of different goals, but it's good. Again, why are you adding extra volume? Are you just doing it meaninglessly, or do you actually have a goal? Okay, we have a couple of goals here. We want to improve our foundational lifts, we want to improve our back squat, our deadlift, We want to improve running. We want to improve our gymnastics. Okay, good. We have concrete objective ways to know that volume is working. What does that extra volume look like? And I think you would be surprised to hear that his extra volume is about 10 to 15 minutes a day after class. It's nothing crazy. One day he does an EMOM, usually a 10 minute EMOM of strict pull-ups and push-ups to help his gymnastics foundations. One day he focuses on front rack barbell step ups to focus on quad strength. Another day he does hip thrusts to work on his posterior chain and low back strength. And a fourth day of the week he adds in a couple extra miles of running. Nothing he does conflicts with his ability to come to CrossFit five days a week. He's a Monday through Friday regular, very consistent with five days a week of CrossFit training, very consistent with his nutrition, very consistent with his recovery, right? Somebody that's getting on most nights, eight plus hours of sleep, getting plenty of fuel as well. What are the results? A lot of people might look at the work he does and say, there's no way that 10 to 15 minutes of extra work could translate into anything meaningful, right? A lot of us look at extra volume, we think, if I want to be better, I need to run five miles extra a day, I need to do an extra hour of CrossFit a day, right? I need to do more and more and more volume instead of really intelligently planned extra accessory work. Over the past year of adding in that extra volume, he has broken through plateaus on his back squat, his deadlift, and his bench press from all of the strict gymnastics, the front rack step ups, and the hip thrusts. He has improved his running, even though he's already a great runner, in accordance with his goals to be able to run and complete a half marathon. and his gymnastics are certainly becoming on another level. His kipping pull-ups, his toes-to-bar, his muscle-ups, his handstand push-ups are all also improving accordingly because of his focus on strict gymnastics work. So I hope from that you glean that when we're talking about adding extra volume, it doesn't need to be this grueling stuff. It doesn't need to be very high-intensity stuff. It just needs to be intelligently designed in a way that does not affect our current training, And that puts us in a short state of functional overreaching, but does not become this long-term overtraining issue. Understanding that as we increase that volume, our nutrition, our calorie intake should increase as well. And we definitely need to make sure that our recovery is on point because we're now taking on extra physical volume that our body will need to recover from. SUMMARY So extra volume, why should we do this? We should do this only to address a specific perceived deficit that we can objectively measure the impact of extra volume on. When should we do this? When we have perceived a plateau, right? If every time we're testing a lift or testing a mile pace or a 5k pace and we are still getting faster, getting stronger, whatever, we have not yet reached that plateau. And so I'd argue it's not yet a time to consider taking on extra volume. If we do decide extra volume, extra work, extra accessory work is appropriate, how should we do that? We should do that very carefully. We should do that as a stair-step approach. We should do that in a manner that we can reassess the impact of our extra training. Is it actually working? And we should do it in a way that our normal training is also not impacted. We should never be skipping our normal run because of our strength training or our speed work. We should never be skipping CrossFit class because of our extra running or our extra accessory work that we maybe do before or after class should not impact our normal training. And then who should do this? Again, I would argue a very small amount of people should actually do this. Folks who are already incredibly consistent with their normal training routine, who are training four to six days per week, understand and are consistent with recovery, right? The stuff that happens outside of training, diet, sleep, nutrition, recovery. and folks who are aware of the nutritional goals are meeting them and are also aware that adding extra volume is going to increase the demand on how much and the dedication we have to our recovery. And then finally understanding it doesn't have to be crazy high volume, crazy high intensity to have an impact. 10 to 15 to 20 to maybe 30 minutes of extra work just a couple of days a week can go a really long way if the extra volume is done in a meaningful manner to address those extra deficits. finishing a metcon and doing another metcon is usually just going to result in that metcon being of even lower intensity that you may have to scale the weights and the ranges of motion more rather than coming over and doing some front rack step-ups or doing some strict pull-ups or doing some sort of skill practice or really judicious strength piece or run piece, cardio piece, something like that, right? Extra metcons, a 60-minute AMRAP, at the end of a 40-minute AMRAP is really not going to push the needle. Again, we're looking for that functional overreach and making sure we don't push that into overtraining. So, extra training, who, when, why, and how, those are our thoughts. So, hope you have a wonderful weekend. If you're going to do 24.1, I hope you have fun. My advice, go fast at the start, go fast in the middle, go fast at the end. It's designed as that kind of workout. Low skill, high work. one of my specialties. So hope you have a great Friday. Have a fantastic weekend. If you're going to be on a live course this weekend, we hope you enjoy yourselves. Have a great Friday. Have a great weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses how to introduce a fitness forward philosophy with your clinic/co-workers. Julie describes four main points to use when trying to change practice philosophy: put fitness forward on display, host in-services, let patients be your voice, and be a mentor to other clinicians. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JULIE BRAUER All right, good morning crew. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Julie and I am a faculty member of the older adult division. This morning, I am going to be answering one of the most commonly asked questions that we get in our online courses and our live courses. That question is, how do I get others on board to a fitness forward philosophy? How do I create consistency when my coworkers don't understand this philosophy or potentially they don't care? The answer to that question is that we are going to pull and not push. We want to pull, not push to attract a fitness forward culture. So let's unpack it and I will give you guys a few actionables that you can start implementing right away. PULLING VS. PUSHING TOWARDS BEHAVIOR CHANGE So what do I mean by pull, don't push? You want to be attractive. You want to be magnetic. You want to pull people towards you and towards a fitness forward culture. You want people to be drawn to you versus pushing your agenda on others aggressively versus sending a message that could potentially be received as my way is better and I am better than you. All right. So I want to relate to so many of you in that I know so many of you are incredibly fired up and passionate about underdosing older adults. You get, I mean, your blood boils when you see that out in the clinic and I understand this. I've been there. And I know that it makes you want to call people out left and right. been there, done that, and I'm telling you that's not the way to get people to change the way that they do things. Now, I do think it's incredibly important to call our profession out as a whole. If you've been to any of our live courses or taken our online courses, you know that we call our profession out. and we ask our students to self-reflect on their clinical practice. However, I do think there's a way where you can be aggressive in that messaging and aggressive towards this mission of ending the professional pandemic of underdosage, but there's a way to do it and be kind about it. APPROACH WITH GRACE What I want to emphasize is that we have to approach this with grace. And believe me, I have made a ton of mistakes in my messaging and been way too aggressive. And that's not going to change culture. That's not the way to do it. But we need to realize that behind a lot of underdosed exercise that we see, there's still humans behind that underdosed exercise. Many of these humans are burnt out clinicians who are just trying to do their very best. And many times in a system that does not set them up for success. I know this to be true. I have hurt feelings of my own friends who are colleagues who are really good clinicians because of my aggressive messaging and because I wasn't realizing that people are out there and they have, they are in different seasons of life. They could be going through a lot of crap. And they're just treading water and they're doing the best that they can. It's not that always someone just doesn't care and wants to phone it in with older adults. We don't know what people are going through. So many people are in tough seasons of life that last a short amount of time or a long time. And we have to have some grace there. So instead, we want to invite people in towards this fitness forward culture. We want to be attractive. We want to be magnetic. So how do we do that? Here are a couple ways. PUT FITNESS FORWARD ON DISPLAY Number one, do your sessions out in the open. Put that fitness forward philosophy on display as much as you possibly can. Why? Because it's the most powerful way to share this message. And instead of, again, pushing a message or telling people what the right way is, you get to show them. So imagine this. You work in inpatient rehab. And instead of kind of flying under the radar, this is what I did a lot for a long time, and you bring your equipment in your own bag and you do that session in the room because you don't want people to ask questions and you just want to do your thing and move on. Instead, go do it out in the open gym. When you know all the people around you, you're going to look around and see we have yellow TheraBands, we're playing balloon toss over there, people are on the new step and chatting it up for 10 or 15 minutes, but you are in the middle of the room. You are loading your patient up with a kettlebell, they're doing a deadlift, you are blasting like really pump up music and drowning out the really like low slow music that doesn't make anyone want to work out so you're pumping the jams your patient is working really hard they're having fun you're having fun everyone around you gets to look over and see like damn i have that patient later in the afternoon and i saw them yesterday i had no idea they could do that Huh? They look like they're having a really good time. That is how you start to get people curious. Like, Whoa, how are they doing that with that patient? That's awesome. I want to learn more. You are pulling people in towards you without saying a word, without telling people, Hey, I want you to do things my way. So that's number one. Do your sessions out in the open as much as you possibly can. Put that fitness forward philosophy on display. Okay. HOST IN-SERVICES Number two, put on an in-service. Be a wave of influence here. This is one of the easiest ways to spread this message to as many people as possible. Okay. Now, a lot of you are like, I don't have time to put together a workshop or an in-service. I don't like to speak in front of a group. I totally get it. That is why the MMOA division has created workshops for you. They are done. They are skeleton slides. You can put your branding on them. You can add to them. You can do whatever you want with them. They're all done for you. They are on topics such as One rep max living, osteoporosis, arthritis, build better balance, learn how to fall. They're done for you. Even better, if you're thinking, okay, I love that the information is there for me, but I'm really nervous presenting in front of a group. We have a solution for you too. The workshops also come along with a recording. of one of our faculty members presenting this information to their communities and to other individuals. So all you have to do is watch the recording and you can say the phrases and do exactly what they do. So it completely mitigates this fear of public speaking because you have a perfect example of how to display this information. I will put the link to all of the workshops. They're on our website on mmoa.online under free resources. I will link it there for you. But that's one of the easiest ways to spread this message to a lot of different people. You get everybody in the same room, hopefully not only clinicians, so your peers, but managers and supervisors. If you were able to get some of the rehab doctors in on that workshop, that would also be amazing. So a wonderful opportunity there to spread this message wide, be a wave of influence. GUIDE YOUR PATIENT'S VOICE All right, number three, guide your patient's voice. Guide your patient's voice. If you want your colleagues to get on board with a fitness-forward culture, empower your patient to help you guys out. Think about what's going to be more effective here? You going to your colleague and saying, hey, I want you to do this with my patient or your patient when they are with one of your colleagues for their session that day or that week saying, hey, I did this thing called a deadlift with a kettlebell last week with Julie, and it was really awesome. I loved it because it really helped me realize how strong I can get so that I'm able to lift my granddaughter up from the ground. If a patient comes to you and says it like that, and they're so excited, you sure as hell bet that therapist is going to be like, okay, this is exactly what my patient wants to do. I'm going to figure out how to replicate what that other therapist did because clearly my patient is all about it. That is really powerful if your patient can also use their voice to help drive this change. So that could be a conversation you have with your patient. Hey, do you think what we're doing during this session has been really helpful? Your patient's going to say, yeah, I mean, it's hard and it's strenuous and I sweat, but I know this is going to help me. Then you guide them, all right, so next week, because I'm not gonna see you for another two weeks, let's figure out a way where you can advocate for yourself and so your next therapist continues to do this work so you continue to get better. So you and your patient come together and figure out what that conversation looks like and then your patient goes to your colleague and has that conversation. it's going to be a lot more powerful than you directly just saying to your colleague, do this, don't do this. Guide your patient's voice. All right. BE A MENTOR And then lastly, be a mentor, be a mentor. So we have a lot of people who at our courses will say, you know, let's say it's a, let's say it's a CODA. Okay. and who's at our course and they're like, well, what's going to happen? I mean, I will be doing this stuff, but my OT isn't going to be doing this stuff. Or it's a, it's a PTA saying like, I love this stuff, but my PT is definitely not going to do this stuff. What do I do? You want to be a mentor. Look at it Not like me versus you, right? Not what I'm doing is right, what you're doing is wrong. Look at it as this is a really great opportunity to teach my colleagues. how to do these things and and think about in a way not just because you know it's going to benefit your patient but because it's going to benefit your colleague. We all want each other to be elevated and we want each other to be inspired to do one percent better the next day with older adults. So why wouldn't we want to invite them in to share how to do this stuff? There could be a lot of reasons why your colleague isn't following your plan of care. They may not understand what an EMOM is or an AMRAP. They're like, what are those letters? I have no idea. Like we're spell check. I don't even understand this. They could never have seen a deadlift before in their life. And they're just very confused about what these movements are. Again, there could be a lot behind it. Don't assume someone is not reading your documentation or likes what you're doing. It could just be that they lack the confidence and they don't have the knowledge. So be a mentor. This is where you can go to your colleague and say, hey, Betty is loving what we've been working on. We're doing some really cool loaded carries and squats and deadlifts. I would love to show you what we're working on so that we can maintain consistency, because I know that Betty's going to get better faster if we do that. You can use your time. Donate your time as a mentor to pull them over, show them some of these movements, show them how you document them, and even better, If they have some time, be like, hey, I've got Betty at this time, right? Maybe you can have some overlap if you're in home health, or you can have some overlap if you're in acute rehab and be like, hey, could you come over and watch a little bit of my session with Betty so you can see what we're doing? and you really make it that individualized mentoring experience. And I guarantee you guys, if you approach this with kindness and try and pull people in and get them to be curious and present yourself as someone that an individual, your colleague can come to you and say, I'm a little nervous, I don't know how to do this. If you're able to do that over and over again, you're gonna start to have a lot of colleagues asking you questions and getting curious because they know that you're an approachable individual that they can seek mentorship from. And I promise that's going to make you feel really, really good about not only the work that you're doing with your patient, but being able to give back to your colleagues. All right. So those are the few ideas of how you can pull people in towards that fitness forward culture versus pushing that agenda on them. SUMMARY So to recap, number one, do those sessions out in the open. Put that fitness forward philosophy on display. Make it as visible as possible. Two, do an in-service. Be a wave of influence. I'm going to link that website for you guys in the comments of this post. Three, guide your patient's voice. Realize it's going to be so much more effective if your patient is advocating to do these fitness forward things versus you just telling your colleague to do them. And then lastly, be a mentor. Donate your time and energy to showing and educating your colleagues how to do this. realize that you're going to be helping them enjoy doing their jobs more, not just benefiting your patients. So it's a win-win. All right, guys. Lastly, I will let you know about what courses the older adult division has coming up. So in March, we're pretty darn busy. Well, first, well, yeah, March is this weekend. It's crazy. So we are in Maryland as well as Georgia this coming weekend. There are spots open for those two courses if you want to snag one. Then we will be in Madison, Wisconsin and Kansas the rest of the month, and we have our next L1 eight week online course starting March 13th. So March is super busy. Go ahead and jump into one of our courses. We would love to see you on the road. We would love to see you online. Have a wonderful rest of your Wednesday. Let me know if some of these techniques worked for you all the rest of this 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. Jessica Gingerich // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses the sport-specific nature of gymnastics to the fitness athlete, introduces the strict pull-ups, considerations for when to modify, including the rack pull-up and box-assisted pull-up. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION JESSICA GINGERICH Good morning! Hello, my name is Dr. Jessica Gingrich. I am on faculty with the ice pelvic division here at ice. And today we are going to jump in to treating the pregnant athlete during gymnastics. So gymnastics is a broad term and it encompasses a lot of different movements that are utilized in a lot of different sports. So sports like gymnastics, kind of what we typically think of like with the beams and the floor routines and the uneven bars. That's what we typically think about. We also have cheerleading and we have yoga and trampoline, um, um, stuff, um, and CrossFit. So CrossFit is what we are going to focus on today. There are many movements in CrossFit that are under the term gymnastics. So we have pull-ups, we have handstands, we have toes-to-bar, we have muscle-ups, rope climbs, and even things like pistol squats are considered gymnastics. And of course these movements can be done either strict or kipping. The term gymnastics is defined as physical exercise used to develop and display strength, balance, and agility, especially those performed on or with an apparatus. You will see a lot of things on social media around the dangers of kipping movements within the sports of or in the movements of gymnastics. You may even think that yourself. And so what I want to do, I want to challenge you to reframe how you view kipping. So we're not going to talk about this today, the kipping, uh, any kipping movements. I'm going to talk about that next time I'm on the podcast, but I want you to start thinking about this because this is sports specific, right? So let that sit for a second. GYMNASTICS IS SPORTS-SPECIFIC FOR SOME PATIENTS We talk about sports specific as physical therapists all the time. So if you are talking to an athlete and you're talking about how dangerous and how funky it looks or whatever, it is part of their sport. And you see it in CrossFit and you also see it in gymnastics. We don't tell the baseball player or the baseball pitcher specifically to stop pitching, even though his arm goes through a really gnarly range of motion and kind of looks funky in those pictures once they're slowing down. What we do as physical therapists is we prepare them. We prepare them from a mobility perspective, a strength perspective. We talk about things like programming, sleep, nutrition, stress management, and we try to maximize their recovery so they can maximize their performance. So I wanted to mention this before we dive in to what we're going to talk about today, because I'm going to talk about it later. And then also during pregnancy, we also get that same language, right? We get the language around something being unsafe or dangerous, and it's simply just untrue. It's more about preparedness. So pregnancy does not mean that you have less of an athlete in front of you. So what does it mean for our pregnant athletes that want to come in and they want to continue doing gymnastics movements? THE STRICT PULL-UP So today we're gonna talk about specifically the pull-up, and even more specific, the strict pull-up. So first and foremost, we want to talk about points of performance. Whether your client listens to you or not with the points of performance, because you will run into that, that is something we should be teaching in our space. So the points of performance for a pull-up are your hands are just outside your shoulders, You have a full grip on the bar, so your thumb is wrapped, it's not here. And you start in a full hanging, full elbow extension position. And the movement is complete once you pull and your chin is over the bar. So, is pull-ups during pregnancy dangerous? No. Short answer and long answer, no. When coaching or modifying the pull-up, we want to consider those points of performance that I just talked about. We even want to consider having that athlete get into a hollow position, maintaining a hollow hang throughout the range of a pull-up. If your athlete just simply cannot do it, we modify. But if they can do it, and they are doing a strict pull-up, but they break the points of performance, then we also modify. Now, I know that a lot of you are thinking, what about coning? What about doming? What do we do when we see that? If your athlete is maintaining points of performance at any point or any modification, if you will, in a pull-up, so that is a strict pull-up, that's a band-assisted, that's a box-assisted, we're gonna talk about a couple of modifications. If they're breaking that point of performance in whatever modification they're using, then we further modify. CONSIDERING CONTINUING If they're maintaining their points of performance, but they're still coning, you may consider letting them continue. Now, all of you may be like, oh boy, that's not what we see. Right. However, that's where also when we program, when we talk about sleep and nutrition, all of this stuff comes together. So if you have someone who is, who is maintaining points of performance, but they're also coning, you're not going to necessarily say, Hey, go do a hundred pull-ups. That's where our skills and programming can also benefit these athletes. Remember that some of your athletes may have been able to do, these pregnant athletes may have been able to do a strict pull-up even one week ago during their pregnancy. So that can be incredibly frustrating when they come in and they're like, gosh, I could do this a week ago, what happened? Even five pounds of weight gain, if you've ever done a weighted pull-up, it's significantly harder. Now that weight gain is normal, but it's sometimes really difficult from a mental, physical, emotional perspective. But we want to still be able to give them the appropriate challenge. So their grip strength, their core strength is continued to, is able to continue to grow. So when we modify, we are encouraging movement. We are encouraging strength. we are encouraging that mental load, something where they can go to the gym and just like let the day go and not be even more frustrated by something they can't do. So now, before we go into the modifications, I will say I have had athletes that have maintained points of performance in strict pulling even well into their third trimester. So they keep going. We just let them go. We talk about symptoms to modify for, so if they're doing a pull-up and they're peeing in their pants on that pull, we wanna modify. If they're losing those points of performance, we wanna modify. Those who can't, when we modify, we really just wanna encourage the pull strength. When we talk about the strength, talk about grip and I've talked about core, I am lumping lats into core because I know some of you guys are thinking that. MODIFYING THE PULL-UP: THE RACK PULL-UP & BOX-ASSISTED PULL-UP So, two of my favorite pull modifications are the rack chin pull up in the box assisted pull up. So, where you're uh you got your feet assisted on the box. So, the rack chin pull up is going to be on a low bar or the child's pull-up bar. And so the athlete will stand and you want the bar just under their chin. Then they're going to hang from the bar and they're going to pull from that low bar, both feet on the ground. The box assisted pull-up is going to be the same setup, just with a box. Maybe they have to put a plate on top of the box and they'll stand up and their bar or their chin should be over the bar that they're doing their pull-up on. So the reason we love these is if you have a foot-assisted pull-up, you can use as much or as little assistance as you need in that moment. And if you haven't tried these, I'm gonna encourage you in your clinic or at the gym, try them. I've done these modifications for some shoulder stuff before, and they are hard. I am very sore after using these as a modification. And so this can be awesome. A really awesome, awesome modification. They're on the rig, they're feeling really good. With that box assisted, you can also use one foot instead of two. You can work on negative, so time under tension. They're really, really awesome. This will allow your athlete to continue pulling vertically instead of horizontally with a ring row at really any point in their pregnancy. They can use these as modifications in their workout. They can also use it as accessory work. They can do EMOMs, you can do anything with it. And so, as you go out this week, you've got your pregnant athlete, maybe you even have a postpartum athlete and they're wondering about pull-ups, try these modifications. They're hard, they're challenging. Do it with them so you can see what it feels like. Maintain those points of performance. Get that hollow position. and see how you do. SUMMARY So before I hop off, I'm gonna talk quickly about some of our upcoming courses. So our next online course is already sold out. So if you are wanting to hop on that course, head over to ptonice.com to sign up for our next one. It's gonna be April 29th is that start date. We are on the road this month. We'll be in Newark, California on March 2nd, and then Bismarck, North Dakota on March 9th. So we hope to see you out on the road. And like I said earlier, stay tuned for when I am on the podcast. Next, I'm going to talk about kidney and pull-ups during pregnancy. 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 CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses current recommendations on protein intake, new possible recommendations, and barriers to showing efficacy with different amounts of protein consumption. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALL All right. Good morning. PT on Ice Daily Show. Happy Friday morning. Hope your morning is off to a great start. My name is Alan. Happy to be here today. Currently have the pleasure of serving as the Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Friday. It is Fitness Athlete Friday. We talk all things related to CrossFit, Olympic weightlifting, powerlifting, endurance athletes, If you are working with a patient or client who is recreationally active, out on the road, on the bike, in the gym, Fitness Athlete Friday is for you. Just a quick announcement before we get into today's topic. If you're going to be at CSM or you're already at CSM, join us tomorrow morning, 5am, CrossFit Southie. We have a free workout going on, led by me. I'm getting on a plane later tonight to fly out there and run the workout tomorrow morning. So whether you have many years of CrossFit experience, whether you have zero minutes of CrossFit experience, we're going to have a fun workout tomorrow morning at five. Please go on our Instagram, go into the pin post and sign up for the sign up form. The link is in that pin post. So today, Fitness Athlete Friday, what are we talking about? We're talking about a paper that just came out at the end of 2023 and was published a few weeks ago, looking specifically at protein digestion. Hang on, buddy. Come here. Sorry about that. We're going to talk about protein digestion and the upper limits of what we think can happen with protein digestion. So we're going to talk about current protein recommendations based on the current body of research. We're going to talk about what this paper found and the conclusions it drew that may change those protein recommendations. And then we're going to talk about barriers to this research. CURRENT PROTEIN CONSUMPTION RECOMMENDATIONS So the paper we're referencing today, the title is the anabolic response to protein ingestion during recovery from exercise has no upper limit in magnitude and duration in humans. was a paper published in December 2023 by Tromelin and colleagues, pardon my sick son coughing, and the journal title is Cell Reports in Medicine. So that's the paper we're referencing. Current protein recommendations quite old and they typically recommend and advocate that humans can't digest or otherwise synthesize protein in amounts above about 20 to 25 grams of protein per hour and If you're like me, you were sitting in a lecture in undergrad maybe 20 years ago and you heard that based on literature from the 90s and the early 2000s and you thought, hmm, that seems really specific and also really impractical given how much protein we're recommending that people eat. How can somebody possibly only synthesize and utilize 20 to 25 grams per hour. That would mean an individual, especially a larger, more muscular individual, would basically need to be always eating protein, right? A lot of these studies look specifically at whey protein, a faster digesting version of protein. Whey protein is essentially the watery portion of milk with all the fat strained out. But even at moderate protein consumptions, think about an individual who's maybe 6'6", 300 pounds. No, no. No, no, okay, we're gonna hold you all the time. Somebody who's 6'6", 300 pounds, that person would need to eat 20 to 25 grams of protein for 12 to 14 hours in a row to get all of their daily protein in, maybe just at a maintenance protein level. That is really impractical and yet, up until this paper was published in 2023, we don't really have any other recommendations that we could give. So cue this paper being published at the end of the year. You see yourself, hi. NEW PROTEIN CONSUMPTION RECOMMENDATIONS This paper, fantastic methodology, amazing study, really good incorporation of inclusion and exclusion criteria of the subjects used, but also did a really good job of being very thorough in measuring and tracking the protein synthesis in the subjects in the study. So let's talk about that study. This study looked at 36 healthy males between 18 and 40. Inclusion criteria, they had to have a BMI between 18 and 30. They had to have already been exercising one to three days per week, so they needed to basically be familiar with exercise, particularly resistance training. And exclusion criteria included anybody who smoked, anybody who was lactose intolerant, and anybody who was taking any sort of prescription medication. So basically we looked at rather young, rather healthy men. What did we do? We had them all perform the same type of resistance exercise. We had them perform the same resistance exercise protocol. They went into the gym, they performed one set of 10 reps at 65% of their max on lat pulldown, leg press, leg extension, and also chest press, so bench press machine. They then did four sets to failure at 80% of their max. So they did all the same resistance training protocol. And then what changed, what varied in this study was how much protein they consumed after the resistance training protocol. So some subjects were given no protein, that was the control group. Some subjects were given 25 grams of protein. And then another group was given 100 grams of protein. So four times current best recommendations. And the hypothesis was, how much protein synthesis might we see compared to the 25 gram group in the 100 gram group. We looked at immediately post-exercise, we looked up to 12 hours post-exercise and we found some really interesting results that essentially the higher protein group saw continually increased levels of protein synthesis out to the end of the study, the end of the 12-hour period. So the 25-gram group had increased protein synthesis obviously compared to the zero-gram group, but the 100-gram group had 20% increased levels of protein synthesis in the zero to four-hour measurement window and 40% higher in the four to 12-hour post-exercise window. So this paper is great because it really opens up the notion that we can front load our protein and that we can potentially catch up on a protein deficit later in the day. For a lot of our folks, especially our active folks who are also maybe working, wrangling kids during the workday, trying to get enough protein in and trying to get it in those 25 gram feedings is probably just not feasible when we're looking at individuals eating 200, 250, maybe even 300 grams of protein a day. Simply not possible to get that. So a lot of those folks have issues with timing of protein intake. and also the belief that any consumption beyond 25 grams might be wasted. This article is really a landmark paper because it shows that that might not be the case, that we can front load large doses of protein or catch up with big doses of protein later in the day and see really long windows of protein synthesis after resistance training. Again, 40% higher at the 12-hour mark compared to 20% higher at the 4-hour mark tells us protein synthesis actually increased the further away we got from both the exercise and the actual consumption of that protein. RESEARCH BARRIERS Now there are some barriers with this research, we need to be mindful of what this paper does not say. This paper did not look at objective measurements of things like strength or hypertrophy, so it would not be fair, hi buddy, you're gonna knock my tripod over, It would not be fair to use this study to say that eating 100 grams of protein at a time makes you stronger, makes your muscles bigger because the study did not look at this and therefore we cannot conclude that 100 gram doses are better. What we can conclude is that this may be an alternative way to consume our protein that results in equal or even higher amounts protein than the traditional recommendations of 25 grams per hour. What we also need to be mindful of is that all of the research on 25 grams per hour looks specifically at subjects fasted eating whey protein. This study literally did the opposite. It looked at individuals who were fed, who had just performed resistance training, and who were essentially eating casein protein, the fatty portion of milk protein. So eating basically the opposite aspect of the protein and doing it under a different mechanism, doing it after exercise as compared to doing it fasted. So it is a little bit of comparing apples to oranges. Nonetheless, what we can take away from this paper is an alternative feeding strategy, especially for those individuals who we see in the clinic, who we see in the gym, who may tell us that they simply don't have time in their day, time in their schedule to eat protein in 25 gram feedings. If those patients, if those athletes, if those clients are already saying, hey, I know I'm not getting enough protein because I don't have time to eat 25 grams every hour for 14 hours, and I'm just simply not eating protein, then this is a very viable alternative solution of, hey, let's try front-loading your protein before you leave the house for the day. Let's try eating, you know, 50, 75, 100 grams of protein, maybe half, maybe 75% of our protein intake for the day before we leave the house. Now again, what we can't promise those people is that they will have equal or better levels of muscular strength or hypertrophy gains, but nonetheless we know how important protein is at least for recovery. so we can make that alternative recommendation to those patients and clients. SUMMARY So, protein, is 25 grams an hour the maximum? It doesn't appear so. It appears that the more we eat, the higher levels of synthesis that we have, at least in the scope of this paper, up to 12 hours after we've consumed that protein. Is it better? We don't know yet. We need more research. We need to now look at a study of folks eating 25 grams versus 100 grams and now measuring them more longitudinally and seeing what does muscular hypertrophy look like, what does muscular strength look like, even what does functional outcomes look like, different functional tests. but that being said this is still a very landmark foundational paper that should change our mind about how we think about eating protein that we can think about front loading if we need to we can think about catching up at the end of the day eating a big dose of protein maybe with dinner. I know Mitch Babcock who teaches here in the fitness athlete division a big fan of a big bowl of cereal with protein powder on it on the end of the day just to get a big lump of protein in before the day's end and that might be a viable successful alternative for a lot of our patients and athletes. So protein get it in get it in where it fits in even if it's a bigger dose than previously you may have been led to believe would be effective. Courses coming your way really quick. If you want to come learn more about protein, recovery, nutrition from the Fitness Athlete Division, our Level 1 online course starts again April 29th. Our Level 2 online course starts September 2nd. And we have a number of live courses coming your way throughout the year. A couple coming your way the next couple months. We have Zach Long down in Charlotte, North Carolina. That'll be February 24th and 25th. Zach will again be out on the road, this time in Boise, Idaho, March 23rd and 24th. And then we have a doubleheader the weekend of April 13th and 14th. Joe Hineska will be out in Renton, Washington, near Seattle. And Mitch Babcock will be down in Oklahoma City, Oklahoma. So I hope you have a wonderful Friday. Please join us at CSM if you're going to be there. 5 a.m. tomorrow morning, CrossFit Southie. Other than that, we hope you have a great Friday. Have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the essential, yet often overlooked as aspect of early postoperative care. Alexis explores the wide range of concerns and adjustments individuals face postoperatively beyond the usual need for return to exercise. From emotional and mental health needs to navigating the logistics of daily life, we share valuable insights on how to care for individuals early postoperatively. Save this podcast and share it with your communities to educate them, and let them know what an early postop visit with you might would look like too! Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 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 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. In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the essential, yet often overlooked as aspect of early postoperative care. Alexis explores the wide range of concerns and adjustments individuals face postoperatively beyond the usual need for return to exercise. From emotional and mental health needs to navigating the logistics of daily life, we share valuable insights on how to care for individuals early postoperatively. Save this podcast and share it with your communities to educate them, and let them know what an early postop visit with you might would look like too! Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 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 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. ALEXIS MORGAN Good morning, YouTube. Get Instagram going here. Good morning. Welcome to the PT on Ice Daily Show. Happy Monday. My name is Dr. Alexis Morgan, and I am one of the faculty with Ice Pelvic. In our pelvic division, we enjoy talking about all things around exercise. And, you know, if you are part of ICE, you know that and understand that. But sometimes our reputation scares people. It might scare our community like, oh, that's the exercise person. They're definitely going to make me exercise immediately. Today's topic is surrounding non-exercise topics for that early post-op care. non-exercise topics for the early post-op care. This is incredibly important, maybe because of the reputation that you have in your community, which if you have that, great, so do I. Awesome reputation to have. However, we need our potential patients, we need our clients, we need them to understand a lot of the things that we can do early post-operatively that don't necessarily involve exercise. And that's not just to get them in the door, but that's also because there's a huge role that we play in early post-op management. Now I'm discussing this with the lens of early post-op post C-section or post-op post hysterectomy or any of these post hernia surgery, any kind of core and or pelvic floor, pelvis type of surgery. That's the lens that I'm going to be discussing this in. However, I will say this is going to be in many of these cases pertaining to really post-op, any surgeries. And we've had a couple of great podcasts on this topic. And Lindsey Hughey has one that comes right to mind on things that we can do to educate to reduce inflammation postoperatively. But I'm going to add a couple other things to that list. So let's go ahead and jump right into those. ASSESSING VITAL SIGNS So number one, we need to be assessing vital signs. This is incredibly important in the postpartum period as maternal death rates are actually increasing in America. And for black women, maternal death rates are three times the rate as white women. Many of these are because of some type of cardiovascular event. We have got to check blood pressures. And in many cases, we as the conservative care providers, those physical therapists or rehab providers, we're some of the only ones that are checking postpartum. Or we might be able to catch something very soon before they might have a six or eight or 12 week follow-up postpartum. we've got to be checking their vital signs and assessing and making certain calls when necessary. That is absolutely important and definitely not exercise related at all. We can get them in and get their blood pressures checked. OWNING SCAR MANAGEMENT Additionally, we, we assess sutures or incision sites or whatever whether that was an abdominoplasty where they have an incision from ASIS to ASIS, whether that is a C-section incision, a little bit smaller, more midline, or that might be smaller little incisions all throughout the belly from some type of laparoscopic surgery. Whatever the case, We, as their rehab providers, assess that incision. We're gonna look for signs of infection and we're also educating about those signs of infection. We're assessing to see how the patient feels about it. Maybe we need to set some expectations surrounding what the C-section scar or what any of these scars are going to look like in a month and in six months. And with that, we can go ahead and begin some scar mobilizations. Now, very early postpartum, we're still in the proliferation phase, inflammation, then proliferation, and then maturation. We're still in that proliferation phase, so we're not gonna be doing scar mobilization on the actual scar, but we can come inches above and below and surrounding. We can teach them how to pull on their skin and press on their skin well away from the scar to go ahead and begin that desensitization. That is incredibly valuable. And just going ahead and painting the picture of what that scar rehab is going to look like over the next three to four months. Many individuals have a lot of fear and concerns surrounding the scar. And we are the best people to be giving them home exercise program, these interventions and helping them understand what it's going to look like. We know we're the rehab providers that have seen this all along the way in several other of our patients. So we can help them understand what to expect and If there's concerns where we need to refer to a mental health provider, then we're absolutely going to do that. That is completely within our realm to assess that and to refer out. And what a great opportunity to help someone. Body image is rather difficult. It always has been, but with social media and the way the world that we live in right now, It is incredibly difficult. And so we need a lot of times mental health providers to help us navigate that. So first we talked about vital signs. Now talking about sutures, we can absolutely discuss fueling. That's the podcast I mentioned with Lindsay Huey, so I won't jump into that necessarily. ASSESSING DAILY FUNCTION But next is ADLs. I was just looking through my messages, some screenshots that I've saved from various, um, various people who have messaged me about, um, pelvic floor related topics. And what I saw was this message from someone who said, I just went to my, uh, follow-up and they told me not to lift any weight. And the person asked, can I lift my baby? And they said, no. Now, obviously this is hopefully a one-off. Hopefully that word is not being said. And who actually, I don't know if the doctor actually said that, but the point is, is that this individual did think that that's what the doctor said. We are here to help them understand how can they be safe? How can they hold their baby? How can they get out of bed? How can they bend over and get the clothes out of the dryer, out of the washer? We can help them navigate these things. This is a great opportunity for occupational therapists as well. We can lean into their expertise here. Helping individuals with these ADLs can be really valuable for these individuals and can help them feel more confident in their body in that early postpartum period. Sometimes they just need to share their story. I think a lot of times we as rehab providers really feel this urge to do, do, do, put hands on, give home exercise program. I need you to do all three of these. We feel like so rushed in order to provide and sometimes The best thing that we can provide is a listening ear, is someone to be someone who can just ask questions about their surgery, about how they felt, about how they felt going into that and how they felt coming out of it. That can be incredibly helpful. ASSESSING READINESS TO EXERCISE While we're talking about non-exercise plans, I said that we wouldn't be doing exercise, but I didn't say that we wouldn't be talking about it. So when we have someone early postpartum, they might be an exerciser and they might be saying, oh, I'm not ready for exercise just yet. Well, that's okay. Let's talk about what does exercise mean to you? What does readiness look like to you? What do you want and what are your timeline expectations? And do they match up with what we have seen or what we expect? Having a conversation about an exercise plan and exercise expectations can be incredibly helpful. Some people may not understand that they can go ahead and start to move now. and they think exercise is any type of movement, and we can kind of break that down. We can discuss different exercises that individuals can do or that this person in front of us can do in this early time, like walking or some basic hip exercises or arm exercises. A lot of times there's several restrictions surrounding surgeries. But just because there's restrictions doesn't mean that there has to be zero exercise. So we can discuss that plan and kind of help them understand what that overarching picture of exercise and health looks like. I already mentioned one referral, but there are several other referrals that we can also make. So in the postpartum realm, referring back to their provider, their OB or their midwife. We can refer to a lactation consultant, to mental health providers. Postpartum doulas are another great referral source, particularly for people who are postpartum and maybe don't have a lot of family nearby. There are so many ways in which we can help people and We don't hold the keys to everything. I can't help with mental health. I can listen, but I don't have all of the tools, but I can absolutely refer to somebody who does. And together we can work to get this person in front of us feeling really good. SUMMARY So vital signs, checking the sutures or those incision sites, discussing fueling, helping them with their activities of daily living, their ADLs, listening to them, listening to their story, figuring out an exercise plan and referring out. The last thing I'll just mention here with pelvic floor and particularly with postpartum, we're gonna discuss with them expectations surrounding those. That's a whole nother podcast for another day, but discussing the expectations surrounding bleeding postpartum, leaking heaviness and pain and giving them what to listen to when we say, listen to your body, giving them a key to understanding what that exactly means. That way, once again, they can be successful. So that's just a little sneak peek into a whole lot of what you're going to learn if you take our online level one course. Our next cohort for our online level one starts March 5 so upcoming in one month at the beginning of March. It is going to sell out, just like this current cohort did so if you're on the fence about it, I recommend going ahead and purchasing that ticket because. If you wait too long, you're not going to get a seat. And we are very strict on keeping our student to faculty ratio at an appropriate level. That way you get your questions answered and you get the care that you need as you're learning from us in the course. So sign up for that. And we also have our first online level two course coming up at the very end of April. And so you're not going to miss that. Once again, that is definitely going to sell out. We are still months away from that, but only a few few seats remain for that. We're going to shut that one down pretty soon. So if you're on the fence about the online level to go ahead and sign up for that one. We are all over the place in twenty twenty four. Our next upcoming cohorts. for our live course. We're going to be in California, North Dakota, South Carolina, and Colorado. Those are our upcoming next courses, all in March and April. So be sure to check us out on the road. And remember, when you do all three of these courses, you are eligible for the ICE certification certified in pelvic. We are here to change the game when it comes to pelvic floor health and pelvic floor rehab. And we need more of you. So please consider hopping on the train, coming to our courses. We know you're going to have a great time. Thanks for being here this morning and listening with me. Have a great rest of your day and we'll catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

Dr. Zac Morgan // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses how to subjectively & objectively identify patients presenting with acute back spasms, how to treat spasm, and how to follow-up treatment with appropriate homework.  Take a listen or check out our full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Lumbar Spine Management course, our Cervical Spine Management course, or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 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. ZAC MORGAN Alright, good morning PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty in the cervical and lumbar division, here to bring you a Technique Thursday talking about myofascial decompression or cupping for an acute back spasm. For those of you all who work with acute back pain, so this is something that early in my career I did not see an awful lot of, but as I have kind of entered the market of seeing more and more acute low back pain, you will see these people walk through the door that are clearly in a spasm. And I want to talk today about why cupping has kind of become the treatment of choice here for that exact presentation. ACUTE BACK SPASM PRESENTATION And let's just kind of narrow in on why we're focusing on back spasms to start. And the real thing is, this is one of those diagnoses you don't read a ton about in the literature, but it's one of those things that you know it when you see it. So it's fairly empirical. So every so often, people kind of walk through the door, and they're kind of in that shape of a question mark. They're really off to the side, and you can tell as they walk through the door that the severity of their situation is really, really high. Even just watching them move about the world, their activities of daily living are extremely challenging when they're experiencing a back spasm. They're not able to freely move through space and move that spine around because their erector or QL or some of that posterior musculature is in a full spasm. So this is something you will see if you're seeing people day of within a couple of days of a back pain episode. So it's certainly one of those acute low back pain scenarios. Now the issue is, you'll see a lot within our profession of people sort of argue about, well this is just going to regress to the mean. And I don't disagree. A back spasm is going to go away on its own, for the most part. So generally speaking, untreated, in my experience watching these things happen around the gym, having some of them myself, a lot of times people have some movement limitations for ten days or so, seven to ten days, maybe a week, maybe a little bit longer, but then they're usually back to normal life after that point. So it's not one of those conditions that sticks around for months the way like a radiculopathy would. It's just something that's acute, but while it's present, it's very severe. I think it's important for us to say We know it regresses to the mean. It will get better on its own. WHAT IF REHAB CAN BEAT REGRESSION TO THE MEAN? Here's the thing. With early treatment, what I'm about to show you all, I think we can take several days off of the episode. And I think that because of empirical data here in the clinic. So I'll watch people walk in in that situation that we just described. Very put off to the side, huge spasm in that erector. You can almost see it through their shirt. and they're unable to do much, and we treat them with some cupping, we treat them with some relaxation techniques that we're going to unpack here in a moment, and often that person feels tremendously better, tremendously quickly, so within a couple of days, maybe three max, versus that seven to ten. Now that's a difference, right? That's almost a week of time different that that person is going to end up walking around with pain or not walking around with pain. Why does that matter? When you think about how influential this spasm is to their activities of daily living, they can't do much. Now deconditioning is going to set in, even on healthy people. If healthy people move around the world for a full week without really flexing their back, without allowing it to move, they're going to have some deconditioning on board. And if we could have gotten rid of that a week earlier, we've given them more of an opportunity to maintain or even gain fitness during this period of time that they have some acute pain. So I think it's really important that we focus in on this because while it's not a usually a long-term disabling diagnosis, it is a short-term disabling diagnosis. And when people are in that disabled period, they're looking for short-term help. And I think we can be helpful with that. IDENTIFYING CANDIDATES FOR CUPPING So let's talk a little bit about identifying these before we actually get into the treatment. And from an identifying standpoint, you want to start with that body chart. So if you've been to cervical and lumbar management, you know we always start out with quantifying where are the symptoms on this person's body. When someone's in an acute back spasm, it'll be a little complicated to find the exact spot of symptoms. They don't usually point to one thing. They often kind of talk about that whole erector side. They might even point to that whole area of their low back and say it just feels locked up. I've certainly had plenty of clients who reported just like local pain sort of at the waistline, like right where the waist of your pants are. I've had unilateral, bilateral, it bounces around a little bit on the body chart, but typically whatever muscle is in spasm is where the pain is. And often the person has a hard time describing it because of the severity. They just say my whole back is out, my whole back's out of whack. So it's not one of those focal diagnoses on the body chart. Subjectively, you're going to see some common aggravating factors. The biggest one's flexion. The person probably won't even allow their back to flex. And when you look at that from the active range of motion standpoint, you see it's just hip flexion. The lumbar spine is not actually actively flexing. The person's just kind of absorbing into hip flexion. Any quick movements are often painful subjectively. So they talk about transfers, they talk about when they've been lying down to get up. Really anything where they have to move quickly will often be an aggravating factor. And then things like bending, sneezing can also be pretty painful for these folks. In their history, they'll usually tell you about some sort of fatigue-based activity that onset this. So this won't usually be like a one rep max deadlift. That makes me more think of a strain. Where this presents itself is in a workout with a bunch of deadlifts. So when somebody's, you know, several sets in and their back is already tired and then it just fully locks up and kind of worsens throughout the evening or worsens throughout the day, that's more of the spasm presentation. It's not just in weightlifters or competitive athletes. You'll see this really with any human who has exceeded their capacity. So I've definitely had plenty of folks that were gardening all day or mulching all day and just using their back a bunch and then it wound up in spasm. So it's really whatever over challenges that musculature tends to create the spasm. So subjectively, you'll see those common ags and then you'll also see that history where the person was either fatigued entering an activity or did an activity so much that it created enough fatigue that eventually created a spasm. Objectively, again, their lumbar spine, it's not going to reverse. When they flex, it's going to stay very flat. You're going to see a lot of guarded movement. The person's probably going to be very hesitant to move, and you'll notice that quite a bit through this active range of motion exam. You will even often see cervical flexion. bother that person's symptoms because the erectors, they attach all the way up in the neck, in the suboccipital spine. So you will see cervical flexion be bothersome, but then it's not like a sensitization thing from a neurodynamics exam because the ankle won't make any difference. So, when you see that cervical component create a lot of discomfort in that acute pain scenario, and then you dorsiflex and plantarflex the person's ankle, and it doesn't make any difference, that's ruling spasm higher on my list. So, objectively, that'll often be how it presents, and then a lot of it's just observation. You'll just look at this person's back, and like I said in the beginning, they'll be twisted off to one side. They may even be kind of in the shape of a question mark. Like you can see that that erector on that side has just shortened in the area of the lumbar spine. And so the person is fairly obviously uncomfortable. A lot of times the erector itself is swollen or hypertonic or larger, whatever you want to call that. And it'll be tender to the touch. So just palpating that region, a person is going to report most of their symptoms. So like I said, a fairly obvious diagnosis. And again, it's one that I didn't see a lot of until I got that really acute back pain person in the clinic. So that's sort of how they present. TREATING BACK SPASMS Let's talk about treatment. There are a lot of things that jump into my head that I would like to do. Like if you have acute non-radicular low back pain, the first thing that jumps into my mind is spinal manipulation. But often moving these people's backs through space is just not a realistic possibility for you on day one. Team, over the last couple of years I've spent a lot more time learning about cupping and doing a lot of cupping with clients and this is the one thing that whenever you see this presentation show up, whenever we drop the cups on that region, get it nice and relaxed and it doesn't even have to be all that vigorous. The person often gets off the table stunned at how much better they feel. So cupping has definitely become the treatment of choice and I like to just keep it really really simple. Now the biggest issue from a treatment standpoint when someone's in spasm is it's really challenging for you to get that person comfortable most of the time. They don't like laying in supine, they often don't like laying in prone, and then on one side or the other they're often really uncomfortable. If you can get them in side-lying, which is typically the most successful for me, you want the erector that is in spasm up. So I have Caitlin here behind me, and you can imagine in this situation, her left erector would be the one that would be in spasm. So that's the one that I'm going to target with treatment, and that side's up. You also want to prop a pillow between the person's knees just so that hip doesn't adduct and create even more tension on that lower back region. Instead, let's keep those hips nice and neutral and get this person in a relatively comfortable position. This will often be the position they've told you in the subjective exam that they like the most. So we're going to go right to that position and then treat in that position. So I'm going to move to the other side of the table, show you sort of where I put the cups, some of the verbal cueing alongside of that, and then we'll wrap this thing up. and summarize at the end. So anytime you're doing cupping you always want to use a little bit of cream. It's just a lot easier to glide the cup around and it's a lot more comfortable for your client. So make sure you add a little bit of cream to that region that you intend to cup just so that that way it's more comfortable for your client. You're then going to grab your first cup and localize it to the region that you think is in spasm. It doesn't have to be directly over it. Reminder, these muscles are literally all the way across the spine. So if the person's too pressure sensitive, you could certainly move away from it. But you want to be in that basic region. And then you're just going to get these things on. with a little bit of tension. So a couple of pumps to start is plenty. So I don't have this thing cinched all the way down where she's in a ton of a stretch feel. Instead, I just have a little bit of air out of the cup and a little bit of domed tissue within that cup. this gives you that nice decompressive feel if you're the client a lot of times they'll be a bit uncomfortable when you first do this but they're uncomfortable anyway they've been in spasm for a few days and so it's no major deal to them these cups are probably only like 30 to 40% pulled out. So typically if I'm being more aggressive with cups, I get it a little closer to that full capacity of vacuum. But for this, I've got a very severe patient in front of me, they're very fear avoidant, they're not moving all that much, and I've just got a little bit of tension in those cups. I start out just like this, like you all are seeing. So the person just kind of gets comfortable, relaxes, feels that pull. But after they've sat here for a couple of minutes, I'm going to start to try to cue that person to do a bit of a posterior pelvic tilt. The point of that posterior pelvic tilt is just to access a little bit of their lumbar flexion while they're in this nice, friendly, non-weight-bearing position. Anytime they're in weight-bearing, that erector tends to want to be in spasm. So I'm going to get them to just relax things a little bit here in sideline in a nice comfortable position. So I might have them move through 10-20 reps here, maybe even cueing some deep breathing in between if they're very severe. So 4-7-8 breathing pattern is often a helpful one, that physiological sigh. Either one of those are typical go-to's while we're in this position and the person's nice and relaxed. Now, for those of you all who treat human beings, you know a lot of times our female clientele is a little tougher than our male clientele. Sometimes the men are already sweating in this position and they're already having a lot of challenge. If that's the case, I'm going to stay right here and just have them work those pelvic tilts. If I do perceive that the person, if they're telling me, hey, this feels quite a bit better, you know, it seems like they would like a little bit more treatment, the next move I'm going to have them carefully make is getting into the position of quadruped. So they don't like prone and supine, so I'm going to leave the cups on and the person is going to ease their way to quadruped. And then from this position, they're just going to do some gentle angry cats. So I'm going to cue them up into some spinal flexion, telling them to separate the cups. They do have a tendency to pop off, so you want to keep that gun handy. But I'm essentially just going to cue her through 10, 15 reps here of angry cats, thinking about really elongating this whole erector. If you want to make it a little bit more vigorous, you can have them gently flex their cervical spine as they go into the cat position. That's going to give you even more stretch across the erectors and often feel pretty tight for the person, but quite good. Once we're done with that, I'm going to have them just lay back down in sideline in the original position. And this is where I think a nice little bit of massage can be helpful. So just popping the cups off, you may have some light bruising, but then getting in here and just showing that area some love and getting a little bit of massage going to that region. Team, I realize what I just showed you is quite simple. and I'm not trying to be overdramatic, but simplicity often makes this person pop off the table and feel dramatically better. FOLLOW-UP TO CUPPING I think what we follow it up with is very important as well. Earlier in my career, it was always, hey, let's load, load, load. Let's make sure we're getting this person moving. This person is overloaded. That's why they ended up in spasm. So what I'm actually going to target these days is a lot more relaxation techniques. So maybe that breathwork pattern we did with the cups on, I assigned for homework. I need five minutes of this a day minimum. Convince that person to give you some breath work. Convince that person to up their hydration by a bottle or two of water over the next few days. Hey, I really think this is going to help. If you're in a little bit more hydrated state, I think that muscle can relax more. Convince them maybe to add some electrolytes. Heck, I'm fine with a warm bath at night with some Epsom salts. It doesn't matter to me. I'm going to get this person to relax. I'm not going to go have them do more deadlifts. Their problem isn't necessarily that they're weak with deadlifts. It's that they got fatigued. Do we need to build the endurance of that region? Possibly. Maybe that's why it contributed to a spasm. But for right now, my main goal is relaxation. And team, I'm always going to argue for more treatment in this scenario. Earlier and more treatment. The reason being is imagine Kaitlyn is that person who has the back spasm. And she then loses 7 days of not just training, but also moving around like a normal human being. We only have 52 weeks in a year. I don't want to sacrifice an entire week of that person's life to fear avoidance, to lack of ability to move like a normal human being just because it's going to regress to the mean. Not when I could simply get in, assess it, help that person feel like, you know what, I think I'm going to be better in the long term. get them gently moving, teach them some relaxation techniques, and get rid of this thing seven days faster. It's gonna be hard to convince me that that is a harmful approach, even though we are utilizing passive tools to help that person relax. I think this is exactly why we need those tools, is to help put that fire out, and then in that process, convince this person to start addressing some of their lifestyle factors, to start addressing that ramped up nervous system, getting them to calm it down, to start addressing hydration. Some of the basics, right? Just the basics of what it means to be a human, people mess up quite a bit. So, we want to make sure that we check those basic boxes, and often you're going to follow up with this person in 48 hours, and they're going to say, Zach, feels tremendously better. Can't believe how much relief we have. and now we can perhaps get after some of that loading or regional interdependence or anything that you think might have contributed. But team, I think it's a simple approach and I don't think you should feel bad about treating people with acute back pain even though you know that they're going to regress to the mean. It's worth it to save them that week in my mind. I'm always going to opt towards more treatment. SUMMARY So team, that's all I've got for you this morning. Last couple things I want to leave you with is just the upcoming spine courses. So if you're looking for cervical spine this weekend in the DFW area, make sure you jump over to Hazlet, Texas. That course will be right there near Dallas-Fort Worth Airport, kind of north of Fort Worth. If you're looking a little bit later in the month, Simi Valley, California, that one's getting closer to a sellout, so don't wait if you're in that region, you want to take that course. There's not too many seats left. And then March 9th and 10th, will be in Kuna, Idaho. If you're looking for Lumbar, March 23rd and 24th, Brookfield, Wisconsin, that's right outside of Milwaukee, that'll be at Onward Milwaukee. And then April 6th and 7th, we have two courses going on, one on the west side of the country over in Carson City, Nevada, and then one right here in Hendersonville, Tennessee. And again, that's April 6th and 7th. So we hope to catch you at some of those on the road. We'd love to catch up with you, talk more shop like this, talk about the main patterns that show up in the back of the neck and how to best utilize them. Team, I hope you have a great rest of your Thursday. Crush it in clinic today and I will see you soon here on the podcast. SPEAKER_00: 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. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses the current literature around best practices for degenerative meniscal issues, including graded manual therapy, self-relief at home, and loading. Mark also discusses how to begin with the highly irritable patient & progress through the full plan of care as symptoms reduce & tolerance to load increases. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey 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, lead faculty of the Extremity Management Division alongside Lindsey Huey. Happy to be here today, coming at you on Clinical Tuesday. What I'd like to talk about today is degenerative meniscus tears and what is the best path going forward to treat them. So what we'll get into today is a few things of overall arching research and philosophy about degenerative meniscus tears. So those are those tears that person's around the age of 40. There's usually no relevant recent trauma. So we'll get into again, general research philosophy. And then what we're going to talk about is what do you do when that tissue is really irritated? How do you move them forward clinically? And then what do you do when it's, when it's less irritable and we're really trying to get them back to all the things that they love the most. GENERAL RESEARCH PHILOSOPHY So what we see with these degenerative meniscus tears in the research, a few interesting points. So first is, that when Horga et al in 2020 took 230 asymptomatic knees, ran them all through the MRI tube, what they found in their research is about 30% of those folks had a meniscus tear or some sort of meniscus degeneration. So even in asymptomatic folks, having some tissue changes to the meniscus tissue is quite normal. Then Thorland et al in 2018, they had a surgeon who went in and did a scope of arthroscopic surgery to over 600 knees and while the surgeon went in there determined is there damage to the meniscus or is there no damage to the meniscus. What they found was an equal number of folks with no damage to the meniscus reported signs of mechanical knee pain that we typically associate with meniscus injury. So things like catching, locking, and lack of extension of the knee, we have historically associated those with a damaged or torn meniscus. And what Thorland et al found is, no, this really is more of a sign of that the knee is not doing well, that the health of the knee is not at its max capacity. and that's likely why they're getting those catching, locking, lack of extension, not that one specific tissue or a couple of specific tissues are to blame. And then finally, over the last decade, we have study after study, systematic reviews, randomized control trials showing that if you compare someone who had conservative care like physical therapy versus having surgery to their meniscus, that after a year, the outcomes are the same, if not better, favoring the physical therapy side with far less medical cost. Last year, what came out is we now have Cochrane-level review evidence, a Cochrane study showing that scoping these meniscus knees, or knees that supposedly have meniscus damage, is no better than placebo. So again, many asymptomatic knees are gonna have changes to the meniscus, whether that's degeneration or tears, Most knees, whether they have a meniscus tear or not, if they are unhealthy and not doing well, they're going to show signs of mechanical knee pain such as catching, locking, and lack of knee extension. And when we take it even further and we look at who gets better if we treat them out for a year, again, Cochran level review evidence saying that we should not be scoping those knees, which has led my partner, Lindsey Huey, to often using the phrase, stop the scope. There's a couple podcasts here a ways back if you want to check them out where Lindsey went into more depth of the all the research showing why we should not be scoping degenerative meniscus tears or at least not scoping them as a first line of treatment. She also has a episode on our virtual ice where she goes in depth to the scoping the knees. STOP THE SCOPE: THEN WHAT? So what I want to talk about today is stop the scope, then what? Then what do we do after that? So how are we going to effectively treat these people to get them back doing the things they love? So Let's start with the highly irritable patients, someone who comes in, their symptoms are at that 7, 8, 9 out of 10 symptoms. How are we going to treat them? Well, modulating their pain is always a good place to start. So can you use your manual therapy, your joint mobilizations, your dry needling, your myofascial decompression, or your soft tissue techniques to take their symptoms from that 8 and get their symptoms down to a four, a three, a two, something that's a little more manageable. When we're doing our joint mobilizations for these folks early on, what we're going to do is we want to do them in more of a open pact or positions that are not challenging the end range as much. So both flexion mobilizations or knee extension mobilizations. Again, at this point, we are not trying to get after knee stiffness or range of motion limitations. We're trying to create fluid exchange. We're also trying to pump any chemical irritants out of the area. And really the biggest thing is we are trying to get a positive stimulus into those tissues so that the central nervous system will calm down a bit and allow us to load the knee, which will effectively improve its long-term health. So again, very mid-range, open-pack joint mobilizations. With your dry needling, what we typically see is it works well to go distal from the knee. So putting your needles in hamstrings, quads, glutes, tissues that relate to the knee, but are not going to create fear for that patient by putting the needle directly into the area or tissue that is sensitized. Same with your soft tissue mobilization or your cupping. When you, after you do your joint mobs, your dry needling, they're feeling a little better. Then we're going to give them a self-mobilization to follow it up when that person is more irritated. Again, we want that to be more of that open packed, less challenging end range. If they have a flexion deficit, we like to go on the floor doing a heel slide, but having a thick band provide an anterior tibial glide, which will further modulate their symptoms and allow them to get through a nice comfortable range of flexion. If their deficit is more knee extension and the pain and symptoms are high, we're going to have them do a quad set but put a towel behind their knee so that they know there's an end range and they're not going to bottom all the way out into their symptoms. You can also add a band to distract the tibia and that sometimes can be an added benefit for those folks. So you're going to do your pain modulation technique in the clinic You're going to give them some sort of self-mobilizLation to help further modulate pain at a fairly high volume, 15 to 20 reps to really pump that tissue. LOAD AROUND THE KNEE And then as early as we can, we want to load the tissues surrounding the knee. So the quads, the hamstrings, the gastroc soleus complex early on when things are irritated, it's going to be challenging to get a lot of tensile load through these, through these tissues. It's also going to be challenging to get them at an end range. So, we're going to do mid-range knee extensions and we're going to do Knee flexion, so either banded, monkey feet, whatever you can do to challenge those hamstrings with a light load and a mid-range at a high volume. And then whatever way you want to load the gastrocs and soleus, but again, going low tensile load, high volume. And then what sort of functional thing can you get that person into? A lot of times those folks have challenge with loaded knee movements. We want to get them back to that as early as possible. without stirring up their symptoms. Early on, what we find best is to go double leg activities that don't have a lot of shear involved with them. So not a lot of twisting and rotation. So we love a body weight squat and even a body weight squat to limited depth to keep that person comfortable early on. So again, symptoms are high. You're gonna go manual therapy, more for challenging symptoms, not challenging their end range. You're going to go self-mobes that have the same type of style where they're more mid-range, really creating a pump to that tissue, giving some positive input. You're going to start to challenge the knee extensors, the knee flexors, and the gastroc soleus complex with lighter tensile load. higher volume again thinking pump and getting positive positive stimulus in the system and we want to get them used to doing their functional activities double leg body weight squat with a depth that they feel comfortable with is a really nice way to do this now then that person is going to come back and their symptoms are going to be lower so they're going to tell you know what i was at an 8 out of 10 but over the last couple weeks, I've been hitting all the stuff we talked about. The manual therapy felt good. Now my symptoms are more in that two out of 10 range. I feel like I can get after it a little bit more. So now when we're doing our joint mobilizations, we are gonna go straight down to the end range and really challenge the end ranges of these tissues and make sure we facilitate that they can restore full flexion, full knee extension. For our dry needling, now we are gonna get much more direct at the tissues of the knee. So we really like to needle the popliteus, the hamstrings, the gastroc soleus, tissues that are right there interacting with the intra-articular knee tissues. For your follow-ups, now again, we want to get them right into those end ranges of tissues and really start to challenge them. CHALLENGE END-RANGE We love the classic terminal knee extension with a really thick band. Spanish squats can be another way to get after this. We also, for the knee flexion after the mobilization, we're gonna get into a child's pose position with a towel behind the knee. I'll come on tomorrow on our Instagram feed and demonstrate what this looks like. So they're gonna have a towel behind the knee with a band keeping it placed, and they're gonna rock all the way back into deep end range knee flexion to really challenge the end range of that motion. Now, loading up the local quad, loading up the local hamstrings and gastroc soleus at that point where they can tolerate more tensile load, we're going to go long arc quads, really loading that up, whether that's a classic knee extension machine, your monkey feet, banded long arc quads. you can hit spanish squats in this position to really load the quads up for our hamstrings we're really going to start to challenge the length tension relationship of those by doing things like nordic curls You can also do Nordic curls or bridge walkouts to really challenge those hamstrings can be another nice one. And then in this phase, we are really getting into the concentric eccentric in functional activities. We really like transitioning to single leg activities in this phase. your split squats, your kickstand RDLs, your single leg RDLs are very nice for this phase, really challenging that knee overall from both a proprioceptive balance and load perspective. When you're doing your squats and your deadlifts in this phase, really starting to load them up, how heavy and how much stress can that tissue take during this phase. Step ups are another really nice one to add in. So again, during that low irritability phase, now we are challenging end ranges of tissue. We're really trying to put positive stress into the quads, hamstrings, calves, Our functional activities, doing single leg, whether that's split squats, RDLs, heavier on the double leg squats, deadlifts, step ups, all work really well. Once they can tolerate that phase, with 2 or 3 out of 10 or less symptoms, then we've got to really get them back to their more dynamic activities if that's what they choose to do. Here's where we're going to do things like box jumps, rebounding jumps where they jump from one box height to the floor up to another box height. We're going to hit things like jumping ropes so they get their plyometric endurance up. single leg hops for distance, running for distance, cutting. This phase we really want to focus them on getting back to the activities that are challenging them and some pivot rotation movements that are going to challenge that sheer force to the knee. SUMMARY So overarching themes. For these degenerative meniscus tears or degenerative meniscus damage, surgery is never the first line of defense for these folks. When they're more irritable, our manual therapy is gonna be much more mid-range, calming things down, giving a positive stimulus to the nervous system. Our follow-ups are also gonna challenge more in this mid-range, again giving positive stimulus, mid-range knee extension, banded or monkey feet hamstring curls, low to the gastroc soleus, and typically double leg functional activities. Once they can handle those things where symptoms drop below that five, now our manual therapy gets much more into the end range of those tissues. Our follow-up MOBS are also gonna get into the end range of those tissues. I'll show that, Child's Pose Rock Back tomorrow on our Instagram feed. Our knee extension, our hamstring activities are gonna be much more higher tensile load. Our functional activities will switch into single leg or much heavier and stressful double leg activities. Once they can tolerate that at a two or three out of 10, then we're really gonna start getting into their running, jumping, cutting, dynamic motions overall. Hope this helps as far as treating out those alleged meniscus tears and avoiding them from going into an unnecessary surgery. If you'd like to catch us on the road, I'm gonna be in Highland, Michigan, just outside of Detroit this weekend. Lindsey will be in Scottsdale, Arizona this weekend. And then the next opportunity to catch us will be Lindsey will be in Carson City, Nevada, February 17th and 18th. Hope to see you all soon. Hit us up in the comments if you have any questions or things to add to this conversation. Have a great rest of your Tuesday. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

This episode covers the next part of chapter 10 from: “ As we made our way to the stone balcony...” to “...had never caught a glimpse of my guru.”  Summary:  So few words are exchanged between Mukunda and Sri Yukteswar in their six hour re-union (of this lifetime), but so much depth exists in between the lines. We try to break it down and fill in then blanks using readings from God Talks with Arjuna and Man's Eternal Quest.  0:00 Preamble;  1:15 I give you all I possess;  16.10 Precious words;  34:41 Unconditional Love;  54:32 Sri Yukteswar's clairvoyance;  1:01:54 Going back to Calcutta.   Links discussed used in this episode: https://bookstore.yogananda-srf.org/product/loyalty/  Homework for next episode— Read, absorb and make notes on the next part of chapter 10 from:  “We had had to travel for our meeting to...” to “...“swoop” perilously close to Calcutta!”  #autobiographyofayogi  #autobiographylinebyline  #paramahansayogananda Autobiography of a Yogi  awake.minute Self-Realization Fellowship Yogoda Satsanga Society of India #SRF #YSS

Dr. Ellison Melrose // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses key set-up, anatomy, and technique to target the subscapularis muscle. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling, Lower Body Dry Needling, and Advanced Dry Needling. EPISODE TRANSCRIPTIONINTRODUCTION 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. ELLISON MELROSE All right, U2 is up. Good morning, PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of Ice. I am here to piggyback off of the Fitness Athlete Fridays for the past two weekend, or two weeks. Two weeks ago, we had Alan going over the evaluation process for determining if the gene is subscapularis muscle. And then last week, Zach Wong went over some treatment techniques, and he hinted at one of the most efficient ways to treat the subscapularis muscle, which is dry needling. So what I wanted to do today was to go over a demonstration of how to needle the subscap muscle safely and efficiently. NEEDLING THE SUBSCAP So in order to be able to do this muscle, our patient needs to be able to get 90 degrees of shoulder abduction with some moderate external rotation as well. So patient positioning, they're going to be laying with their arm up in this abducted and externally rotated position. My patient here has some decent mobility, so she doesn't have any issues getting into that position. But for someone that maybe struggled with maintaining that position for the duration of treatment, we can bring their shoulder down slightly. And you can also prop their wrist up so they're not in so much external rotation as well. But again, this patient doesn't have issues getting into that range of motion. The reason we need to have this position is because we need this scapula to be protracted out from underneath the thorax for this to be a safe and effective drain forming technique. So we need to be able to palpate the lateral border of the scapula and appreciate the difference between the lateral border of the scapula and where the lateral border of the thorax is. In this position as well, we can think about the rib cage. It's not parallel, or excuse me, perpendicular with the table in this position. It's kind of diving around. It's oval shaped, right? So it's diving around and posterior and a little bit medial there. So if we get that scapula out from underneath that rib cage, we have some good real estate to needle this muscle. This is a direct technique. So we go for different types of techniques. We have a threading technique and a direct technique. Typically, when we talk about direct techniques, they are direct to a bony contact. So in order to ensure that we're at the depth of the subscapularis muscle, we need to have a bony contact with our needle in that subscap fossa there. IMPORTANT ANATOMY So again, patient positioning here. Some other considerations in this area. A, we have the lung field. Appreciating where that rib cage is and how it's diving away and where our scapula is in relationship to that. But we also have some other sensitive structures in the axilla. So we have our brachial plexus that actually runs just anterior to the subscap muscle and exits down the medial humerus here. So we want to orient ourself to where the brachial pulse is as to avoid needling in that region, right? So the best window for subscapularis is going to be just distal in the axilla. If we go too distal, we're likely going to miss that bony contact that we need for ensuring that we're in the subscapularis muscle. Some other considerations here is we have a really strong and powerful motor branch or motor nerve, the thoracodorsal nerve, that runs along that lateral border of the ribcage, which innervates the lats. So if we were to interact with that, we would likely get some fairly strong um, lat muscle activation. So typically it kind of looks like that sprinkler, um, dance move that we all know too well from middle school dance. Um, but so those are our main considerations. So one field and some other sensitive structures, uh, the brachial plexus and brachial artery and vein in that axilla. So again, first we want to bring our patient into this abducted externally rotated position. If you feel like you can't appreciate the, or you don't have a good real estate of that scapula, you can assist by protracting, like grabbing the medial border of the scapula and pulling it laterally. So again, you should be able to appreciate lateral border of the thorax is there, lateral border of there. So we have a good two inches of room to play with. A lot of these athletes that have So we're thinking the athletic population would be one where we want to treat this. Crossfitters, for example, they also have fairly hypertrophy flats. So that's another thing that we have to appreciate is we're going to have to be sinking in to get, again, that bony contact on the scapula. Another common patient population that you may be needling this muscle in is going to be the thawing stages of frozen shoulder, right? So this person was able to They're now in that pain-free, able to access at least 90 degrees of shoulder abduction, or post-op rotator cuff, where they're really struggling with some of that end range shoulder abduction, external rotation, and shoulder flexion even. Sub-scalp is going to be a good muscle target for those patients as well. So before we do anything, we want to prep the tissues. So we're going to clean the skin. SUBSCAPULARIS TECHNIQUE I prefer to do most of my needling techniques in standing, especially for this muscle, as sometimes our fingers are not going to, like just our finger pressure is not going to be enough pressure to sink in to approximate that subscap fossa that we want to. We're going to be needing a longer needle than we think. So for Sam, I have a 75 millimeter needle. Some folks may even need longer and that's just based on excess muscular tissue, the lat, the pec muscle that we're kind of orienting ourself around, the skin recoil. So as we compress that tissue, once you release, that skin recoil is going to potentially move that needle. If we don't have a long enough needle and it will choke up on the handle there and it'll pull it off of that bony contact that we've Spent so much time finding. So we want to make sure that we have a long enough needle to maintain that bone depth. ADDING E-STIM Another thing to consider is when we're with ice, we are dry needling with e-stim, right? So we're not doing a ton of heavy pistoning. Again, there's a lot of sensitive structures in this area, so it's usually not very comfortable to piston a lot. So we're going to be wanting to layer in the strategy with Easton. When thinking about ECM, you always want to be thinking in pairs. So how can we pair this muscle with another muscle that may be doing something, a similar movement pattern that may be also restricted, or something that's going to reach that motor threshold at the same time? So we want to be thinking about muscle spindle density in our muscle tissue of what's going to reach that motor response around the same time. Typically, I like to pair subscapularis with the clavicular fibers of pec major. So we have another technique for pec major clavicular fibers. Of course. Of course. Why was I logged out? OK, well, I was logged out on Instagram, so we're just going to continue on YouTube here. So we want to maintain the or we want to be able to pair this muscle with another similar muscle that has a similar muscle density. And it's also going to be limiting some of that external rotation in this position as well. So I like to pair those muscles. For today, we're just going to go with the dry needling demonstration of subscapularis. SUMMARY So again, we want to orient our patient into abduction external rotation. We want to maintain an appreciation of that lateral border of the thorax. And then we're going to compress the tissue down, down towards the subscap fossa. Usually your palpation here is going to be the most assertive part of the technique. And you might get what we call the Grunner sign, where some people don't tolerate that very well. So orient yourself to that brachial artery. We can find the pulse. So typically I would come around to the other side, palpate the pulse here. Pulse is under my index finger, so I've oriented myself to where that neuromuscular bundle is, and I'm going to be treating just distal to that. So, right in here. All right, so we have an appreciation of that anterior surface of the scapula. Again, using a 75 millimeter needle. So I'm doing a firm palpation, my medial aspect of my hand, so my pinky, ring finger are appreciating that lateral border of the thorax. My needle angle is going to be perpendicular to the scapula here. So really, it's fairly directly anterior to posterior, almost paralleling, or excuse me, yeah, paralleling the ribcage, anterior to posterior. So we're almost, we're very close to that ribcage, but we're going, we're paralleling it, so we're not going to be interacting with in a postural space or lung field here. So again, appreciating lateral border, knowing where that neurovascular structure is, that means safety, lateral border of our scapula, firm compression down. I feel that muscle. You can always do a little internal rotation, good and relaxed, to feel that muscle activation under your fingertips, compressing, giving yourself a little treatment window directly anterior-posterior. and you're on bone right there. So if you look at this, you're like, dang, she's got a lot of needle left over, but let's allow for that tissue recoil. So as we let for that tissue recoil, we have about a centimeter left. So a 60 millimeter needle would not have been long enough to appreciate that depth of the sunscan. As we allow for that tissue recoil, you may start to see like the needle directions a little bit and it may look a little bit suspect, but knowing that we're on that bony contact, that needle tip is not going to be going anywhere once we've reached that depth of the scapula. So we can allow for that tissue recoil and set up our next needle and then set up the stem and feel fairly confident that that needle is not going to go anywhere. Main concern with safety here is if this person were to move their arm, right? That would be something to be concerned. or if we're interacting with that thoracodorsal nerve and we get a very big motor response into that sprinkler dance move. So when we are bringing the stim up and looking for that motor response, typically I would suggest maintaining that appreciation of where that lateral order is and kind of bringing that needle back into its original orientation. Once you feel confident that we're not getting any sort of interaction a less of a motor response than what we want or more of a motor response than what we want, we feel fairly confident that leaving that needle at that bony contact is a safe needling technique. We are rarely or really ever, we shouldn't be leaving our patients stimming with needles in them by themselves. I feel like that is a best practice to be in the area with our patients. And so if this needle were to move slightly or anything like that, you can always maintain contact or redirect as needed. So there we have the dry needling demonstration for subscapularis muscle. Again, my name is Dr. Allison Melrose. I am the faculty with the dry needling division. Some of our upcoming upper quarter courses where you can catch this technique and a bunch of other techniques. We have a three-day course in Longmont, January 26th through 28th. Paul will be out in Wisconsin, February 3rd through the 4th. I will be down in Greenville, South Carolina, February 17th, 18th. Paul will be out in Bozeman, March 2nd through the 3rd. And then I'll be out in Maryland. It's Sparks, Maryland, 22nd through the 24th. So there we have our upcoming courses. And this, hopefully, was a good review or a new driving learning technique that you guys can use in the clinic. Awesome. 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.

Summary:So remember when Sid and Ashley first covered Go Go Power Rangers and they had to re-record the episode? Well, the original file magically wasn't that corrupted! So check out this “lost” version of their first brush with Go Go Power Rangers! Note: This episode was originally recorded June 2019 before Sid was going by their current name. However, it is fun to revisit the early origins of the podcast and this one is a special treat! Show Notes: See the original show notes for Episode 7 Join Our Patreon!

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses research supporting the effects of high-velocity resistance training on older adults, including benefits for bone mineral density, the effects of detraining, and different ways to implement power training with patients.  Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 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. JEFF MUSGRAVE Welcome crew to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. Super excited to be here with you. Hopefully you have been enjoying the holidays however you enjoy to celebrate over the last few days. Super excited to bring to you really interesting systematic review looking at high velocity resistance training for adults 50 plus. So what we're going to be covering today is you know what are the primary results, what can we learn about dosage when implementing this intervention for adults 50 plus and then we're gonna spend actually quite a bit of time talking about clinical considerations for this type of information and talking a little bit about just the body of research that already exists. So let's get into it team. This systematic review included 25 randomized controlled trials. We had 12 original studies. We had 13 follow-up studies. What they did is they were applying high-velocity resistance training to older adults. People 55 plus and they define this as having a slow eccentric phase with a explosive concentric phase. So in general, we would just reference this as power training, right? Kind of like a broad jump where you're going to slowly load the movement and then you're going to explode. then the other piece of this is having additional resistance with this. So traditionally this is basically just power training. Power training could include jump training, it could be Olympic style lifts like snatches or cleans with dumbbells, barbells, whatever implement you want, kettlebells, any of those type of implements. EFFECTS OF HIGH-VELOCITY RESISTANCE TRAINING ON BONE MINERAL DENSITY So What they did is after they included their studies that met their criteria, they dug in and they had to have pre and post DEXA scans to figure out what their bone mineral density was at the beginning and then also at the end. They also had to have a six-month follow-up One of the studies actually had a 16-year follow-up, which is pretty wild. Being able to get a randomized control trial with a year follow-up is pretty great, but 16 years was pretty wild. So they looked at bone mineral density at the femur, the femoral neck, the lumbar spine, and also the distal radius. Only two of the studies looked at the distal radius to see if there were any changes in bone mineral density. The rest of the studies did not look at that area. Unfortunately, those two studies showed no change. So we'd need to dig into those studies more specifically to look at the loading strategies for those to really try to figure out what happened there because we know Basically, in general, our body's gonna respond to all the load. So if we get proper loading, due to Wolf's Law, we know those osteocytes are gonna start producing osteoblasts, and then we're gonna lay down fresh bone if we get proper loading. So no changes in the distal radius with using high-velocity resistance training. They did, however, find statistically significant results looking at the total femur on the DEXA scan, the femoral neck, as well as the lumbar spine. So there were statistically significant findings there using high velocity resistance training, AKA power training. So that was pretty cool. So we know that that is a modality that would be beneficial. The dosage, if we're moving on from what were the results, so it was beneficial, then the results were the results in the dosage were that twice a week is kind of the minimal dosage to see change in the skeletal system. So at least twice a week is what we should be looking for for dosage. Unfortunately there was so much heterogeneity in our different interventions that they weren't able to conclude a specific loading percentage. We do know just in general when it comes to power training that our percentages are going to be lower than resistance training because we're adding the component of speed. So if we're going to slowly get into that eccentric position to then explode into concentric, it can't be at the same percentages that we use at resistance training. So we know as a blanket statement that it's lower load than resistance training traditionally is. But what that is, there was not any formal consensus found from the systematic review. But they did find that two times a week is the optimal frequency that we're looking for if we're trying to change the skeletal system. they did find because their minimal follow-up was at six months, that if there was no training across that six-month period, that the gains that were created were also lost. THE EFFECTS OF DETRAINING So we want to keep that in mind that detraining, just like for the musculoskeletal system, the skeletal system as well, if you don't maintain those results, you're not going to be able to keep them. A really easy way to think about this is fitness is forever. It's just like brushing our teeth. We don't go to the dentist and say, well, you know, you've done a good job the last 50 years, so you know what, let's just take off the last 40 years. You don't really need to brush your teeth anymore. No, the results are not gonna be sustained and the same thing goes for our skeletal system. So once we get those results, we wanna make sure that we're getting people to be loading their bones at least twice a week. And this to be a thing that it's like, it's gotta be scalable across a continuum, across a lifespan for people, or it's not gonna necessarily be beneficial. We can give them a little bump, but that just makes it so much more important. that we're selling fitness from day one. What are you gonna do once care ends? If you wanna maintain these results, we know we can give you results. We know we can get you there, but you're gonna need to continue this training, kind of indefinitely. So finding fun forms of exercise that's gonna include high-velocity resistance training to help maintain bone density is helpful. Now, where we're gonna spend the bulk of our time is on clinical considerations. So I talked about there being high heterogeneity in our interventions. So the interventions included dumbbells, they included machines, resistance training. I found this very interesting. There was actually a masters football team that was included in this study, which I think is super cool. There were also some Olympic lifts that were being completed. in this study as well. Now, probably the most disappointing part of this study for me was this quote, which I'm gonna read to you. It may be unlikely that older adults are willing to engage in Olympic style lifting or soccer and that performing explosive concentric with slower eccentric movements using machines or free weight style equipment may be more feasible, safe and result in better adherence for the population. Now that was researcher opinion. And I can understand if you've got someone that is super sick, super frail, super deconditioned, it may not be feasible to get them out playing football or playing soccer. But when we're thinking about our active 50, 60, 70, 80 year olds, I mean, we've got people pole vaulting in their 80s. These things are not out of reach for older adults. For them to be doing Olympic style lifting, explosive type movements, Just anecdotally at Stronger Life, we do tons of agility, power, jump training with people all the way up into their 80s with no injuries. So a little disappointed in that statement. I can understand clinical practice, maybe we're talking, you were in the ICU, you're in acute care, you're like, okay, yeah, we're not probably gonna be playing soccer in my sessions. "THE NEEDS OF AN OLYMPIC ATHLETE AND OUR GRANDPARENTS DIFFER BY DEGREE, NOT KIND" But when we're thinking about long-term, we're thinking about strategies for for people that are over 50 like these are not out of reach we can absolutely be doing olympic style lifts and it reminds me of the quote from coach greg glassman who created crossfitted the needs of the of athletes and our grandparents are the same. They differ by degree, not kind. We need these types of interventions for our older adults to help with their bone density. And I would argue that power training, Olympic-style lifting, some of these more explosive-style activities are actually way more fun. I mean, let's think about pickleball, for example. Pickleball has tons of power training incorporated in it. And I would say, although it is becoming more popular in younger populations, I would say 50 plus probably has a market cornered on those style of movements. So the big takeaway there is don't count out power training for our older adults, Olympic style lifting. where they're moving quickly. Now another interesting discussion in there while we're talking about power training is that there were specific adaptations that were special to some of these cutting and power agility type movements that they described as odd stressors. So when we're thinking about the bone, if the load is only in one direction, we're only going to get adaptations, by and large, in that direction. When we start thinking about loading the bone from different angles with different cutting and different movements, then we can get adaptations in different directions, which, by and large, is going to help make our bones more resilient, less likely to fracture if they've encountered load in multiple directions and odd type stressors. POWER TRAINING VS. RESISTANCE TRAINING Now the study was, this systematic review was not strong enough to say high resistance interval training, or sorry, high intensity, high velocity resistance training is superior to high load resistance training. So we can't say power training's better than resistance training. We can't say that those odd type stressors with agility type movements are superior either. So basically this is all modality we should have. It was strong enough results that if you're not doing power based movements, agility, jump style training, Olympic style lifting, you should get that included into your clinical practice for older adults that are trying to improve their bone density. It is clear that it should be part of the approach. Now I will say if you're looking at the overall results, the two different, levels of quality here. We've got a systematic review, which way trumps the randomized control trials I'm about to reference. But if you look at this multi-modal approach, because the systematic review really did not have just high-velocity resistance training, there was strength training, there was balance, there was functional training. There were all these different modalities. It wasn't just high velocity resistance training included in the study. So it was really a mixed modal approach, but a common thread was that high-velocity resistance training was included. Now, some former studies of a lower level of evidence, if we're looking at the Lift-More or the Lift-More-M trials, those are both free access to the public, you can Google those very easily, use this mixed modal approach, but it had a much more specific dialed-in approach to loading. So there was high resistance training, 80% plus of a one rep max included and power training included. That mixed modal approach with a higher percentage of resistance seemed to be very beneficial when we're looking at the Lift-More and Lift-More-M trials. I would say that's one thing that's different from the systematic review is the criteria did not include a minimum threshold of resistance. Now those are my caveats from reading this and kind of thinking about the body of research. SUMMARY So if we're gonna boil this down, we're gonna ask, does high velocity resistance training help build better bones? We would simply say yes. Dosage that we need, two times a week. We know that there's a detraining effect if people stop this training for more than six months. So fitness is forever. We need those training methods, those modalities to continue. Considerations for clinical practice. Can we hang our hat on just high velocity resistance training? No. This was not strong enough to rule out just heavy resistance training. The body of research is larger there for making changes in bone mineral density just in general. It should probably include some power training like Olympic style lifting or agility training as well. That's also going to be beneficial. No clear winner on the type of modality, whether we're going to use dumbbells, kettlebells, barbells, resistance bands. All of those things are on the table, which is actually great because we don't always have those same exercise modalities. So it seems to be more important to hit those thresholds for power training, to hit those thresholds for resistance training, but maybe it's not so important that we just have X equipment in our clinic or at our disposal, which is actually great news. Team, I hope you enjoyed this review. I will have the the DOI listed if you want to look at this article more in depth on your own as well as the ones for the Lift More and Lift More M trials. If you found this interesting and you're interested in coming to see us on the road, I tell you what, live is a great place if you are new to loading bones or maybe you want some new Method styles to load your bones for your older adults. We have a whole impact training lab Lots of resistance training labs where we can help you dial in the dosage for the person in front of you From the ICU all the way up to fitness and masters Athletes, which is wonderful in our older adult live course. The next ones are going to be in Santa Rosa, California That'll be January as well as you can catch us in Marysville, Ohio on the 13th and 14th of January, then we're going to have Clearwater, Florida just a week or so after. If you're looking to continue your journey towards getting your MMOA cert, if you want to catch us in the L1, Previously Essential Foundations, that will kick off on January 10th. In the L2 course, which prior was called Advanced Concepts, is gonna be kicking off on January 11th. I hope you have or are still enjoying your holidays. Love to get your thoughts, comments on this super interesting systematic review. And that is it for now, team. Catch you later. 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. Zac Morgan // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses recent research supporting the effectiveness of conservative care compared to invasive care, but in particular, the efficacy of chiropractic care compared to physical therapy care. Zac postulates that being hung up on the concept of spinal manipulation is often to blame for reduced PT outcomes when it comes to spine pain. He challenges listeners that the majority of patients are going to seek out & receive spinal manipulation for their pain, so the best course of action is to learn spinal manipulation, practice daily, and understand how to explain treatment to patients in a manner that does not facilitate dependence. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course, our Cervical Spine Management course, or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 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. ZAC MORGANAll right, good morning PT on Ice Daily Show. I'm Zach Morgan. I'm lead faculty here with the cervical and lumbar spine management courses and lead that spine division as well. Wanted to bring forward some content this morning. So the title of this episode is the deck chair on the Titanic or deck chairs on the Titanic. But before we jump into the actual content and kind of unpack what we're, what I'm talking about with that metaphor, I wanted to start out by kind of pointing you all in the direction of the next courses that you can jump into from the spine management side. So we're wrapped up for the year, but if you're looking for next year, two options in the middle of the country for cervical spine on the weekend of February 3rd and 4th, we've got Wichita, Kansas, as well as Hazlet, Texas. So if you're in the middle of the country looking for cervical spine, those will be good options. At the end of that month, we'll be in Simi Valley, California on February 24th and 25th. If Lumbar is the one that you're looking for, there's one in January. So Rome, Georgia, 27th and 28th of January. And then March 9th and 10th, Cincinnati, Ohio. And then March 23rd and 24th over in Brookfield, Wisconsin or right outside of Milwaukee. So several offerings there to start the new year for cervical and lumbar. If you haven't looked into the ice ortho cert, do so. So we've, we've revamped our website and you can go on there and kind of look at what all is included. Um, but that cert is kicking off. We're testing people out on the weekends already and it's been a really good kind of, uh, initial rollout here. So if you're looking for an orthopedic cert, um, check out the new ice cert and let us know if you have any questions. FIRST PROVIDER SEEN FOR ACUTE LOW BACK PAIN I just wanted to kick off today by actually unpacking an article. This article was published in the PT Journal back in September. It came out of the University of Pittsburgh, so that's probably the crew that does the most looking into back pain, at least in our profession. University of Pittsburgh is pretty famous for a lot of their back pain research. Essentially, this article was titled, First Provider Seen for an Episode of Acute Low Back Pain Influences Subsequent Healthcare Utilization. So definitely a bit of a wordy title, but essentially looking at who do people present to first and how does that influence downstream medical costs. And this was from Christopher Baez and his colleagues over there. Anthony Delito was on this paper as well. So if you're familiar with Anthony Delito, he's definitely done a ton in the low back space as well. So really good university, really well done study here, published in our journal here just very recently. So very recent data that we're looking at here. And let me just kind of talk briefly through what they did with this article with the method standpoint, and then we'll talk about the outcomes. And then we'll unpack the metaphor and end with some action items this morning. So really what was done for this article was a retrospective analysis. So they looked back at cases of acute low back pain, meaning that the person had not been to any sort of a medical provider within the last three months for back pain. So they looked at acute cases of low back pain and they looked at where they presented and then those downstream medical costs and how those things were affected based off of where they presented first. So they were looking at chiropractic care, physical therapy, primary care physician, emergency department, and so on, and basically comparing the outcomes downstream depending on where the person went from one of those professions. As far as outcomes, what were they looking into? They were looking into things like episode length, future CT MRI use, how often did those patients wind up getting that advanced medical imaging, how often did they opt for things like injections or opioid prescriptions, specialist referral downstream, getting to a spine surgeon, those types of referrals. Actual surgery was one of the outcomes they looked at, and then just unplanned care. So they looked at all these variables, retrospectively after these people had presented to the health care system one way or the other to see if there was any difference in the variables over the following year after they had that first episode of acute low back pain. And two things really jumped out to me as I was reading this article. So there's two very obvious things to me. CONSERVATIVE CARE OUTPERFORMS INVASIVE CARE First, conservative care definitely outperforms more invasive care when it comes to the reduction of those expenditures. So physical therapy and chiropractic would be the ones we would lump into conservative and physical therapy and chiropractic significantly outperformed basically the emergency department primary care physician any of the other places that patients would have presented, which makes a lot of sense to us as the conservative care crowd. We know that a lot of times getting that patho-anatomic diagnosis is not helpful at all and often drives a lot more care. So if a person ends up getting that type of a diagnosis early on, often they're going to end up in the health care system for longer. as physical therapists and then even often as chiropractic work, we're more targeting symptom behavior versus anatomical diagnosis, so it makes a bit of sense that conservative care outperformed non-conservative care. CHIROPRACTIC CARE OUTPERFORMS PHYSICAL THERAPY CARE But the second thing that jumped out to me as I was reading through this paper is that chiropractic care significantly outperformed physical therapy. Basically, at pretty much everything other than use of radiographs, which is not overly surprising. Chiropractors have the ability to prescribe radiographs. But if you look at things like episode length, they got us by a couple days. If you look at CT, MRI use, injections, opioids, surgical referrals, actual surgery and unplanned care, The chiropractic profession outperformed the physical therapy profession within that conservative care chump pretty significantly. I'm not really trying to pin our professions against one another. What I'm more trying to point out is they pulled their weight. Whenever we look at this data set and we see essentially how this course of care went through for the patients, it's clear the chiropractors pulled their weight. Yes, we helped from the physical therapy side as well, especially compared to non-conservative care, but within conservative care, I would say we left them stranded a bit and didn't do as good of a job as they did. And so I couldn't help but start to think about why wow, we've really got to step it up as our profession. Like if we want to be in this conservative care battle, it's not enough for us to not contribute to that side of the fight. We have to step it up. We have to pull our weight in this fight. So let's talk a little bit about maybe some of the ideas as to why PT didn't do quite as well as chiropractic care in this study. Because they didn't postulate too much on that in the actual article, but I have some thoughts surrounding it. And so I just want to talk through those things a little bit. WHY ARE WE SO AGAINST SPINAL MANIPULATION? Let me just start by saying, team, every year since I've been a PT, even from school till now, things like spinal manipulation have always been super challenged within our profession. So it's very clear when you look at medical practice guidelines, when you look at our clinical practice guidelines, when you look at most of the clinical practice guidelines, especially for the management of acute low back pain, they have suggestions for spinal manipulation. But within our profession, what I've always witnessed is anytime we, as I put out posts about spinal manipulation, we get a decent amount of kickback from our own profession. we get all sorts of commentary on those posts suggesting potentially that it's not as safe as it should be or maybe it's going to create dependence or things of this nature and I think in our profession we argue about that a lot and it winds up plaguing us when it comes to the execution of those techniques or even feeling okay about using those techniques on patients and team This is something we have to get rid of if we're going to contribute our share to the fight with conservative care for the management of acute low back pain. ARGUING AGAINST MANIPULATION IS LIKE ARGUING OVER DECK CHAIRS ON THE TITANIC I don't remember when I first heard the metaphor about arguing over the deck chairs on the Titanic, but it really fits in my mind to this current conversation. It doesn't make any sense to argue over the deck chairs on the Titanic, right? But imagine that. Imagine the ship is sinking, it's dropping underwater, it's hit the iceberg, And you're up at the nose of that ship that's going to sink last, arguing about where the deck chairs go, which table they go out, how you want to orient those. That makes no sense, right? The ship is sinking. So I think in our profession, we tend to do this. We tend to argue over the deck chairs on the Titanic. Let me unpack that a little bit. What's the Titanic in this metaphor? The Titanic is that people are going to have their spines manipulated when they have acute pain. You can like that or not like that, but the fact is true that patients or just our communities seek that intervention out in relatively high volume when they have acute pain. That's happening. What are the deck chairs that we're arguing about as a profession? That's where these things like Will it create dependence? Does it work? Is it safe? These types of questions are arguing over the deck chairs. We know it's safe, right? Like that has become very clear. If you look through the literature, when spinal manipulation is done well, it's a very safe and effective technique, especially relative to other techniques that people might would choose or even other medications that people might would choose for the management of their acute pain. So we know it's safe. We know it works well for acute pain. We've got enough data to show that it works well. Also, I mean, I would say even empirically, just looking at how many people are driven towards that intervention, I think empirically we know it works. And then, does it create dependence? I think that comes a lot more from the narrative for how it is presented to the patient than it does from the actual technique. So I don't think it has to create dependence. And we sit here and argue over these types of variables. Meanwhile, people are going to have their back manipulated regardless of whether we come to some sort of a conclusion or not. And that conclusion doesn't really influence the end result of those people seeking out that intervention because they think it'll be helpful to absolve some of their pain scenario. So it's very clear to me that we need to start pulling our weight here. We're too busy arguing over meaningless variables. START LENDING A HAND What we actually need to do is lend a hand in this fight to our chiropractic colleagues who are doing a very good job managing things conservatively. It's time that we take some action here. So team, I wanted to end this podcast by talking about what that action might would look like as a profession and hope that over the coming years we can start to shift to the profession in this direction. I do feel the wave of that currently and it's really exciting to see that more and more therapists are starting to utilize interventions that their patients want to meet that patient expectation and help create a narrative surrounding it. But I wanted to leave you with just a few action points. So first things first, I think you have to learn how to thrust manipulate. I understand there's a lot of argument in this space, but if you aren't able to do the intervention, the patients will never hear these arguments. So if we leave them stranded, or even leave them to just seek out all sorts of other health care, when what they want is spinal manipulation and if you could provide that to them, you could then help them understand the mechanisms, those underlying mechanisms that might make them feel more robust about their body versus feeling weaker or feeling fragile. We want to learn to do it so that that way when patients need it, we can provide it and we can also provide a supportive narrative that creates independence, not dependence. And this is possible. And so I think we have to learn to manipulate, otherwise we have no fight. Nobody's going to listen to the data. They're going to need to see it empirically. And so I think for us, we've got to get them in and actually do these interventions with them. To get good at that, I think you have to practice daily. So first, learn to manipulate, then practice daily. So whether that's on your spouse, on a family friend, or practicing on patients that are in front of you with no contraindications and perhaps even some indications for doing those techniques, I think we should practice these techniques daily so that you can get good at the psychomotor skills. Once you've mastered them, of course, focus on other things. But if it's still a skill set that you're refining, I would do those speed drills that you pick up in classes. I would practice on your colleagues and friends and patients. And then lastly, I think we have to, while doing these techniques, support a better narrative surrounding why they work. We want our patients to feel more empowered by feeling better following thrust manipulation, not to feel dependent by feeling better. So I think changing that narrative requires the learning of techniques and ability to execute the techniques well. That way the patient is actually interested in what you have to say. If you can't do the technique and you tell the patient that the technique doesn't work, a lot of patients are going to leave feeling like, well of course they think that, they're not able to do it. So I really don't think we can win any sort of battle of decreasing the dependence on things like spinal thrust manipulation without being experts ourselves in doing it. SUMMARY So team, that is just kind of the overarching thoughts on that article. It just jumped out to me that It was really nice to see the conservative care on the whole did really, really well. But I was just disappointed because I feel like I would love to carry more of the load alongside of our chiropractic colleagues and not leave them out there to fight this battle on their own. And I think a decent amount of professional infighting creates challenges surrounding actually learning these techniques and then utilizing them on patients. And I think we have to stop the professional infighting. We have to stop arguing over the deck chairs on the Titanic and just accept the fact that the ship is sinking. And it doesn't matter the orientation of those chairs. We have got to quit arguing over these factors and we've got to get to where we can actually do these techniques to people that are in pain so that we can help the chiropractic profession start to reduce a lot of those long-term costs that get associated with also not just costs but worse outcomes for the humans in front of us. You can criticize it all you want, but at the end of the day, what we're trying to avoid are things like opioids, things like injections, things like advanced medical imaging. These things, not just within 12 months, create a lot of expenditure and a lot of disability, but within the rest of that person's life, they do the same thing. So that's all I've got for you this morning, team. Let's tackle this problem together. Let's get out of the way. As far as the profession is concerned, stop arguing over little things and start to add these valuable interventions to our patients with acute pain. Hit me up if you have any questions, comments, or concerns in the thread here. I'll be checking it all day. Happy to further the conversation. But that's all I've got for you this morning. Take it easy and have a good Tuesday, team. 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  https://journals.lww.com/nsca-jscr/fulltext/2019/12000/validity_and_reliability_of_the_rear_foot_elevated.9.aspx https://journals.lww.com/nsca-jscr/pages/articleviewer.aspx?year=9900&issue=00000&article=00300&type=Fulltext  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad". Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ALAN FREDENDALL Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today here on Fitness Athlete Friday, the best darn day of the week. I currently have the pleasure of serving as our Chief Operating Officer at Ice and a lead faculty member here in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things CrossFit, power limping, Olympic weight lifting. recreational bodybuilding, running, rowing, biking, swimming, triathletes, marathoners, anybody who's out there getting after it on a regular basis, we address all things relevant to that population. Some courses coming your way really quick from the Fitness Athlete Division. Your last chance to catch us online for our eight-week online entry-level course, Clinical Management Fitness Athlete Level 1 Online will begin November 6th. So that's just two weeks away. That'll be our last cohort of the year. That class will take us right through the holidays. and then we'll take a little break. The next cohort after that will be available sometime in the spring. So if you've been hoping to join us for that class, November 6th is your last chance for the next couple months. Live courses coming your way between now and the end of the year as we get into the back half here of quarter four. You can catch Zach Long down in Birmingham, Alabama. That'll be the weekend of November 4th and 5th. That same weekend, Mitch Babcock will be in San Antonio, Texas. The weekend of November 18th and 19th, Mitch will be in Holmes Beach, Florida. Beautiful place, just actually took a vacation there a couple weeks ago. Wonderful place to get to, especially in mid-November if you're from the Northeast or the Midwest, Florida's a great spot that time of year. That class just has one seat left, so if you've been looking to get baby both to Florida and to fitness athlete, that is your chance. And then our very last live course of the year from the fitness athlete division will be December 9th and 10th. That will be out in Colorado Springs, Colorado. That course will also be with Mitch Babcock. So check us out online, check us out live. We'd love to have you here at the end of the year before we get into the holidays. 02:16 - DOES FORM MATTER? Today's topic, we're going to take a deep dive into form and mechanics. Does form matter? How much does it matter? We hear this question a lot in our courses as we're introducing movements, instructing the basics of how to perform some of the most basic movements, your squats, your deadlifts, your presses. This may be a question that you get from athletes or patients in the clinic and for a long time and even right now this is kind of a very dogmatic campy approach to this topic of yes form is the most important thing or no form has no application at all we've even heard things like Sheer force is an artificial construct created by physical therapists to scare people away from moving. Physics doesn't matter as much as we thought it did. That movement, however it happens, is normal, natural, and that's how the human chooses to move, and there is no right or wrong way to move. So, where's the magic lie? Where's the evidence lie? What actually works in practice in the gym with real human beings? And what are some pearls to take away from the discussion on form? So often we get questions of does it really matter if the low back rounds during a squat or a deadlift? Does it really matter if the back hyper extends with overhead lifting? Who cares if someone catches a snatch with a bent elbow or they never reach full extension of the elbow at the bottom of maybe a pull-up? If someone presses their jerks or snatches out, is it really that big of a deal? So today I want to approach this topic from a couple different directions. I want you to go back and watch last Thursday's episode or listen to it on evidence-based medicine about making sure we're addressing all of the facets of evidence-based medicine when we approach a really hot topic like this that also has a room for a lot of interpretation one way or the other. We need to look at what does the evidence say, we need to look at what does our friend physics say, what does our clinical experience say as far as What is our anecdotal experience with clinical pattern recognition with actual patients and athletes? And then what does the patient say? What matters to the patient? Patient expectation and input matters. So let's start from the top. 04:42 - WHAT DOES THE EVIDENCE SAY? What does the evidence say? As much as we don't want to hear this, we don't have a lot of strong evidence either way in this discussion about form. When we talk about what does the evidence say, we have nothing concrete or strong for or against poor mechanics and lifting. We have a ton of research out of the functional movement screen space that looks at movement quality and its association to injury. And time and time again, I have to declare my bias. I hate that test. I think that test is total garbage. I think the research supports that that test is total garbage. And when we look at does particularly unweighted movement transfer to predicting injury, we have stacks and stacks and stacks of research across a wide variety of populations, recreational athletes, tactical athletes, first responders, professional athletes, that shows the association between quality and injury prediction or injury risk reduction is simply not there. We do have some research that looks at the effects of lifting, and I'll put lifting in air quotes here for those of you listening on the podcast, that lifting with a rounded back does not seem to cause low back pain or make current low back pain worse with the caveat of when we look at that systematic review and meta-analysis from O'Sullivan and colleagues a couple years ago, that the papers they included did not have any patient lifting more than 25 reps across the span of a day at a weight heavier than 25 pounds. It's really hard to take research like that and extrapolate it to our population who might be deadlifting two or three times their body weight, cleaning or snatching their body weight, doing dozens or hundreds of things like pull-ups and handstand push-ups and double-unders, really getting a lot of load through their body, running, crossfit, lifting, whatever. That research really has no application. It's really hard to even call that lifting, right? Those are just kind of activities of daily living. We can't take research like that and extrapolate it to somebody dead lifting with a low back and say these are the same. They are just simply not. We also need to be mindful of the research that we do have. When you look at papers on deadlifts with low back pain, on the effects of lumbar reversal with lifting, what you'll find in those studies is that one of the variables that the research authors always control for is the lifting mechanics themselves. You'll often see, if you actually read the full paper, not to harp on that, but when you read the full paper, when you read the methodology, what you will find is that very often those folks are instructed how we would instruct a movement in the gym, which is to try to maintain a brace-neutral spine, modifying the load or modifying the range of motion to maintain that, to therefore reduce that as a variable in the research study. That if we cannot control mechanics, that's one more variable that maybe takes a little bit away from our conclusion when we look at the data. Of trying to standardize the mechanics as much as possible is how we can narrow down the focus of that research study on whatever the intervention is and whatever the outcome and feel really confident that the association there is direct and that other variables aren't at play. If we can't say deadlifts are safe, deadlifts increase low back strength, deadlifts improve low back pain, if we look at a study and there was no control on how the deadlift was performed or how the mechanics were performed through those deadlifts. One study does sumo deadlifts, another does conventional, one does trap bar, one allows back rounding, one does not. You'll see when you read those studies that controlling for those variables, controlling for those mechanics, is one of the ways that variables are reduced. And so it's hard to look at those studies as well and extrapolate to altered mechanics, what we might call a movement fault, and translate that to the population that we're working with. It's hard to take research and say, you know what? I'm gonna do everything this study did except change everything about it, right? That doesn't mean you're implementing that research and practice. You're taking the general idea and you're kind of going your own way with it. You no longer have that evidence base to stand on. From the research, we do know that symmetry can be objectively quantified, we can assess it, and we can intervene on it. Very often, physical therapists are very comfortable at calling out and identifying qualitative faults without really understanding what might be going on, how to assess it, how to measure it, how to track it, or how to change it. But if we look at some really nice research papers, a great one came out this year, I'm gonna butcher this name, I'm so sorry, Yuja Kovic and Sarah Bond came out this year, looking specifically at asymmetries and change of direction in basketball athletes and finding that there are ways that we can objectively quantify things like asymmetries, strength, speed, motion, quality, asymmetries, that we can also intervene on them. This study in particular sought to reduce the change of direction asymmetry by overloading the slower slash weaker limb with three times as much training volume compared to the stronger or faster side. That looking at an 11% or so difference in change of direction speed, able to reduce that down to just 4% simply by overloading the volume on the weaker, slower, basically problem area. In this case, it was the lower extremity. A very simple study, just using some lower extremity strengthening, three times as much volume as the contralateral limb. We know we don't need a biodex or some other form of fancy isokinetic testing or force plates in our clinic to have ways to objectively identify and assess maybe quality that is associated with asymmetry that is maybe the cause of pain, aggravating current pain, aggravating past pain and or limiting performance. Great study by Helm and colleagues 2019. wanted to validate the five rep max rear foot elevated split squat. Maybe you have heard of this as the Bulgarian split squat, but essentially kicking up that back leg, doing a five rep max on each leg. In this study, they used a barbell. In the clinic, you can use dumbbells as well, trying to find a five rep max per side, and then quantifying and objectifying the asymmetry side to side. Finding it's a very reliable, very valid way as compared to things like Biodex, and force plates to develop an idea of asymmetry from side to side. I would argue a paper like that we can extrapolate to the upper extremity, we can do something like a landmine press, we can do something with our lats or back with something like a bent over row and really start to think if we're seeing movement faults that we think are the cause of symptoms or some sort of performance issue to start getting more objective in how we assess, reassess, and intervene on these things. So that's what the evidence says. It doesn't say a lot. Besides that, we need to help people get stronger and we need to quantify where their strength is at as they're starting their rehab program and then reassess it as they're finishing in order to be sure that person actually got stronger and actually closed the gap on any sort of perceived or actual asymmetries that we found. 11:38 - WHAT DOES PHYSICS SAY? What does physics say? This is something that we tend to ignore a lot, that we exist as human beings on a planet with things like gravity, and that we are subject to certain physical characteristics that we can't avoid. Physics would say that the shortest route between two points is a straight line, and anything else, any other extraneous movement is a force leak. Any amount of force leak doesn't matter what your sport is. If you're an Olympic weightlifter, a powerlifter, a crossfitter, a gymnast, a swimmer, a runner, The more inefficient your mechanics, the more extraneous movement, the more your leg kicks out into circumduction in your run, the more your lower back rounds and extends back and forth as you go through deadlift reps, the more you bend your knees or bend your elbow in your pull-ups, it doesn't matter. The more extraneous movement you have, the more you're leaking force out of your system, the more you're limiting your top end performance. I have yet to this day see anybody break the deadlift world record by doing a Jefferson Curl. Yes, under extreme loads we might see a little bit of low back rounding, but we don't see people intentionally initiating a 1500-pound deadlift with a Jefferson curl mechanic. They tend to approach the barbell over and over again in a similar fashion, either setting up in a conventional or sumo deadlift and really doing everything they can, again, to minimize extraneous movement, put the maximum amount of weight through the ground to lift the highest load up in the air. That is performance, that is physics. We have to remember, unless we can invent some sort of technology or better understand physics, we can't get around that. So that's the evidence, that's the math. What does our personal experience say? Our clinical experience, maybe some of you would say this is anecdotal, but remember, part of evidence-based medicine is our clinical experience. 13:59 - WHAT DOES CLINICAL EXPERIENCE SAY? Our clinical experience would say that those folks in the gym that we see performing pull-ups, overhead movements with things like a constantly bent elbow, tend to be the people that we most often see over in the PT clinic for stuff like elbow pain. That the folks who rock up on their toes, catching their cleans, their snatches, because they lack ankle dorsiflexion, are the folks that we tend to see coming into the clinic with things like knee pain. That those folks who always quarter squats, no matter how much we try to help them get to a deeper range of motion, a greater range of motion, whether it's working on their mobility, elevating their heels, giving them a squat to target, whatever our coaching cues corrections are, those tend to be the folks in the clinic with things like knee pain and hip pain. And those folks who show up with lumbar rounding in the bottom of their deadlifts, as they're pulling the deadlift off the floor, the bottom of their squat, catching a clean, catching a snatch, those tend to be the people who come to see us for low back pain and hip pain in the clinic. 18:01 - WHAT DOES THE PATIENT SAY? And that connects really well to the third part of evidence based medicine of what matters to the patient. We have to understand these folks are often aware of their faults, especially the more they've been training, the less faults they tend to have, and they're more acutely aware of the ones they have left, and they also know the association between the faults they have and maybe aggravation of symptoms, re-aggravation of symptoms with maybe a previous injury. Understanding as well that we don't just always work with the lead athletes, that our goal is to introduce movement to everybody who comes into our clinic. How hard is it to introduce movements, even basic movements like the squat or deadlift, to patients who maybe never done this in their life before? Not even with a barbell. Maybe we just hand Doris a kettlebell for a goblet squat, or we have Frank just deadlifting a kettlebell off the ground. How tough is it for that person who is a complete novice to this If our instruction is, hey, Frank, you know what? Mechanics don't matter. Points of performance are arbitrary constructs created by rehab providers and fitness professionals to scare people like you into purchasing more care than you need. How helpful is that to teach movement to somebody new? What are they going to say? Uh, okay. So like, is there a way I should do this? Is there a best way? Well, Frank, it doesn't matter. All human movement is good and natural movement. Just do whatever feels good. That's not very helpful, right? And you would never do that in the clinic with a patient. You would never do that in the gym with an athlete. If you do actually do that, I challenge you to film that and send it to me because my gut tells me that nobody actually does that because you know how stupid you would sound and how likely it is for the patient to be successful if that's your approach to instructing movement. Likewise, if we do have that more experienced athlete, what good does it do to tell that person who has extreme low back pain, when their spine rounds in the bottom of the squat, there may be somebody who's filming their lifts to try to figure out why do my squats bother me? And our answer is, hey, there's no evidence to support that your spine flexing is a source of your pain. Same issue, right? Same outcome, entirely different patient population, but same outcome. Okay, that's not very helpful. I can see my tail tucking here, and I notice that when that happens, that's when I feel my extreme low back pain. That person has already associated that in their mind. What good does it do to tell them that there's no evidence to support that that's what's happening? They're experiencing it firsthand, right? We need to be mindful of the way that we instruct this, both with new and experienced athletes, patients in the gym and the clinic, that mechanics do seem to matter. People seem to have a natural awareness that at least some sort of standardization of performing a movement seems natural and that some sort of association exists between maybe symptoms and faults. We always acknowledge the resiliency of the human body, that yes, it can develop tolerance in different positions, such as lifting with a rounded back, but we can also still do stuff at the same time to limit pain with lifting. We can modify the range of motion. We can modify the load, the volume, whatever, to a more tolerable level. We need to get a lot more comfortable living in the gray area. Yes, we can recognize injuries multifactorial. Yes, the body's capacity can be temporarily reduced by things like sleep, stress, illness, nutrition, but we can also still manipulate movement to be more comfortable and enjoyable and also help that person work on strengthening in a manner that we know is very evidence supported that's going to reduce the likelihood of future injury. I have an athlete on my caseload right now, very, very impressive athlete, been doing CrossFit a long time. every time she's under an extreme amount of cardiovascular fatigue, or she's doing something like a 10 rep max with a back squat or a three rep max clean or something like that. Usually under a high amount of fatigue, she demonstrates some lumbar reversal associated with that lumbar reversal is always extreme low back pain. She is aware of that. She's somebody that films her lifts. She knows every time she rounds her low back in the bottom of her squat, that is what usually will kick up an episode of low back pain that could last short term, a couple of days, or could really set her back weeks or maybe months. So she's very aware of her spine rounding, the association of form with the development of symptoms, and aware of how bad those symptoms can get. So what are solutions with that in regards to does form matter or not? Well, the first thing we can always do is help reduce that pain acutely, right? Of that person is an extraordinary pain in our clinic, regardless of what we're going to do with them in the gym, regardless of how we're going to address their form, we have ways to reduce their acute pain. We can modify those squats, we can do things like belt squats, we can do lightweight, high tempo squats, tempo squats at maybe 30 or 40% of her max where she's maybe taking three, five, seven seconds to sit down to that squat to maintain or continue to build strength in a way that doesn't aggravate her symptoms. We can do alternate movements if a squat pattern is not tolerable at all, hip thrusts, deadlifts, et cetera, to train lower extremity general strengthening. Yes, we can build up general strength and endurance of the low back, the legs, the posterior chain as we're getting more comfortable, but we can also spend some time working with that athlete on their mechanics of what's going to probably help you the most is that under extreme fatigue, you know how to breathe embrace, you know when to call it for the day when you know you're extremely fatigued, so you don't find yourself in this position again and again. And yes, the final step there is probably to layer in some intentional lifting in that what we would say poor mechanical position, right? Let's also add in some rounded back lifting so that we expose ourselves to the movement so the only time we encounter it is not under a 10 rep max on the 10th rep where we tend to encounter our symptoms. So let's do things like sandbag cleans and sandbag squats and yes, Jefferson curls and other things like reverse hyper extensions. Let's do all the things. We don't have to focus just on form but also form matters. We need to train in that position so that when we get into that compromised form position, it is going to have a less likelihood to be symptomatic and set that athlete back. 21:09 - MECHANICS & PERFORMANCE And finally, we need to go beyond pain into performance. What does the evidence say? What does physics say? What do we say? What does the patient say? What does performance say? What can you possibly help an athlete with who comes into your clinic, who wants to pay you $150 an hour to improve their snatch, and you say there are no optimal mechanics to complete the snatch. We know that's not true, right? People who win gold medals in clean and jerks and snatches tend to lift a certain way. They tend to all show relatively the same mechanics. That tells us that mechanics seems to matter a lot in regards to high level performance. There's a reason those Olympic weightlifters tend to initiate their pull off the floor in the same fashion, going through their first pull, their second pull, their receiving position, the jerk overhead or the catching of the snatch. There's a reason that it looks pretty much textbook no matter who the athlete is, how tall or short or big or small they are or what their race or gender is. They all tend to show the same mechanics time and time again. It seems like it's physics at the end of the day. We don't see anybody breaking the snatch world record with a rounded back deadlift to a muscle snatch, do we? And I think that tells us a lot of now beginning to shift towards using mechanics to push performance. And again, as long as we can be objective about it, I think that is the way to go. 24:41 - SUMMARY So what does the evidence say? We have nothing strongly for or against poor mechanics and lifting. is it relates to people actually performing resistance training not just picking up pins off the floor with a rounded back. We need to be mindful that research studies tend to standardize points performance for lifts such that everyone is performing the same thing the same way every time. What does physics tell us? It will always tell us unless something miracle happens with a change in physics that the shortest route between two points is a straight line Mechanics matter in performance. Straight lines are strong lines. What does our clinical experience tell us? That people who tend to move like crap, especially under increasing amounts of load and or volume, whether it's due to poor mobility, going too heavy, going too fast, those tend to also be the people who need a lot of healthcare treatment, right? Those folks who tend to move quite well tend to have maybe one particular fault, that they're usually aware of, and that they're usually also aware of being associated with their symptoms, and we need to be mindful of that. And what do those patients say? People who are already active are usually aware of that fault, they're usually aware of when and how they demonstrate it, and they are usually aware of that it's associated with some sort of symptom, development of a new symptom, re-aggravation of a previous injury, that sort of thing. We know the group of people we probably need to help the most are inactive patients. The other 90% of the population, right? The majority of the people in our caseload. Inactive patients, people who are complete novices to movement, can't learn things in a structured manner that they're going to be able to repeat them on their own in the gym or at home in the garage or whatever. if our approach is that physics, points of performance, faults, are just artificial constructs that we create to scare them and somehow fleece the general public out of their money. And then also finally, something to remember is that you'll be stuck on a hamster wheel in your clinic forever just treating people in pain if you're not able to transition people to the lifelong fitness and performance side of what we can offer them. At a certain point, mechanics do matter as it relates to top end performance, as it relates to goal setting. And you're crazy if you think, quote unquote, normal people don't want to increase the amount of weight they can snatch, or how fast they can run their mile. We need to be mindful that with top end performance, when people want to see their 5K time come down, or their one rep max back squat go up, that mechanics really, really, really do matter. So mechanics, do they matter? It depends, but there's probably more to be said for mechanics mattering for a performance aspect, for instruction aspect, and for overall higher quality and the ability to perform more movement more often, which is the goal. If we are aware of mechanics, but also being mindful that sometimes they don't matter, especially if we're not being objective about assessing them, reassessing them, and what we're doing to intervene on maybe trying to improve mechanics. Tough discussion, but I think it's worth one having. I hope you all have a fantastic Friday. If you're gonna be at a live course this weekend, I hope you have a great time. We'll see you all next week. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

SUMMARY: So much for the housing crash as home prices hit a new all-time high in May, inventory levels fall for the first time in 10 weeks, and North Carolina is the top state to do business in for the 2nd year in a row...SHOW NOTES:Home Prices Hit New Record High in MayHousing Inventory Falls For First Time in 10 WeeksNorth Carolina is top place to do business according to CNBCDISCLAIMER: TowneBank Mortgage, NMLS #512138, is an equal housing lender. This website is for informational purposes only. Hosted by Tyler Cralle #2028201

Summary:So much free advice and guidance can be offered to us as we grieve. It is important, therefore, to be able to decide what might be helpful and what we just have to learn for ourselves. Gary Roe is the perfect resource to help and guide us as we grieve.Notes:Gary Roe is the multiple award-winning author of more than a dozen books including Comfort for the Grieving Spouse's Heart, Shattered: Surviving the Loss of a Child, and Aftermath: Picking Up the Pieces After a Suicide. Gary's books have won three international book awards and have been named as finalists eight times. He has been featured on Dr. Laura, The Daily Positive, Wellness, BeliefNet, Thrive Global, and other national media. A trusted and compassionate voice in grief recovery, Gary currently serves as a hospice chaplain and grief counselor for Hospice Brazos Valley in central Texas. Known for his engaging style and sense of humor, he is also a popular speaker at a wide variety of venues. Contact: www.asiliveandgrieve.cominfo@asiliveandgrieve.com Facebook:  As I Live and Grieve Instagram:  @asiliveandgrieve To Reach Gary Roe: Website:  https://www.garyroe.com/  Credits: Music by Kevin MacLeod Support the show

Episode Highlights: mental wealth, mission, meaning, purpose, healing outside pharma, astrology, manifestation, quantum physics, subconscious wounds   Summary:   So excited for you all to listen to my conversation with Krista from Wild Remedies. She is a previous high achieving client and a fucking rad human who is awake, intelligent and has such great energy!   In this episode we talk about: What is mental wealth Why having a mission is so important Finding your purpose Taking a holistic approach to healing Astrology, quantum physics, mediums and all the things that haven't fully been explained by science yet So much more!   Big thank you to Krysta for having Kaylor on the show and for letting us share this with the Mental Wealth audience!   Host's Bio:   Krysta Francoeur began her career as a designer and brand builder, working in the personal growth industry with the world's top leaders like Mindvalley, T. Harv Eker, The Shift Network, and Deepak Chopra.   After a series of mystical events in 2015, she followed her intuition and created Wild Remedies - a functional tea company focused on creating unique, flavourful, and beneficial botanical blends to help humanity and the planet heal.   Krysta's lifelong journey of healing her chronic illness is the driving-force behind the products developed at Wild Remedies. And she now shares her fascinating healing experiences and interviews experts varying from nutritionists to psychic mediums, who have helped her along her path, on the Wild Remedies Podcast.   Through the use of education, plant medicine, botanicals, and ancient wisdom, Krysta hopes to help other people reconnect with themselves so they too can heal and reignite the beauty and magic in their own lives.   If you enjoyed the episode, please be sure to take a screenshot and share it out on Instagram and tag @thekaylorbetts. Also, please make sure to give us a review and a five star rating if you're loving what we are doing! _____________________________   RESOURCES & LINKS MENTIONED IN THIS EPISODE:   Wild Remedies Magick Lattes: http://wildremediesshop.com Instagram: https://www.instagram.com/wild_remedies/ Wild Remedies Podcast: https://wildremediesshop.com/blogs/podcast Krysta's Design work: https://kfconsulting.biz/ _____________________________   IMPORTANT UPDATES:   Apply to work 1:1 with Kaylor | https://buildmentalwealth.co/ Follow Kaylor on Instagram | https://www.instagram.com/thekaylorbetts/ _____________________________  

Summary:So, you've decided you are ready to put yourself out there, or maybe you are already in love again after losing your special someone. Listen in as John Polo offers advice and insight into dating a widowed person. Notes:John Polo is a coach, author and speaker. In January of 2016, John lost his wife, Michelle, to cancer. From the rubble of everything that he once knew, consumed by desperation and despair, John held on long enough until he found his hope. And he slowly rebuilt. Today John helps others through his social media, books, coaching, workshops, speeches and podcasts. From grief to dating, self-growth and everything in between, John offers a style of coaching that is not only effective, but also very personal and unique.  John is the author of three books, host of two podcasts and has worked with clients on thousands of coaching sessions. He has been featured on People.com, NBC, The Huffington Post, Yahoo, Fox and more. "Don't just accept the fact she will always love her husband - but LOVE the fact that she will always love her husband. For his love & his loss - have BOTH helped shape the woman - that you so claim to love, today."Contact: www.asiliveandgrieve.cominfo@asiliveandgrieve.com Facebook:  As I Live and Grieve Instagram:  @asiliveandgrieve To Reach John: Email:  john@johpolocoaching.comWebsite:  johnpolocoaching.com Credits: Music by Kevin MacLeod 

Summary: So many Realtors are not getting out of their house. Many ask me how I've created success. We talk all about what I do from social media to the way I build relationships, and we've often talked about Vincent Pugliese's book, The Wealth of Connection, and just doing business backward. It's all about relationships. It's all about caring about people. When I speak to Realtors that are struggling, I will kind of ask them what their routine looks like, what they do on a daily basis. If it's on a phone call, it's normally awkward silence. If it's on Zoom, it is a blank stare on their face. Sort of like, “What do you mean, what do I do every day? I sit here at my computer and I try to get business.” And I'm all about sitting at your computer trying to get business, but you need to be getting out of your house. You might be sitting in your house, listening to this. And you're gonna sit in your house all day today and all day tomorrow and all day, the next day, wondering why you don't have any business. That's what this episode is about. Today, I'm going to talk to you about how to get out and make those connections you need to build your business. Podcast is edited by Kenny Carfagno. Show notes and blog posts are created by Jennifer Harshman and RealtorEmails.com John Schuchman is a licensed REALTOR® in Lancaster, PA with Berkshire Hathaway HomeServices Homesale Realty and a part of the Andrew Welk Group. The opinions shared on this show represent the opinions & values of John Schuchman and do not necessarily represent the opinions & values of Berkshire Hathaway HomeServices Homesale Realty. The opinions & ideas shared in this podcast do not guarantee or promise any results of success to the listener. 

Summary: So you want to be a big player. I'm constantly intrigued by the people that want to build something big from their real estate business, like a podcast, membership or community, so many different things. Yes, absolutely. Build the things that you want to build. Build a real estate business, build a podcast, build a community or whatever you're building. But I think one of the things people are missing is to support the people already doing it. I've mentioned how I was at Podfest at the end of May in Orlando, Florida. It was amazing. What I saw was so many people supporting others. I saw people that you would think should be too big to do that. They've already built their thing. They've achieved success. And I learned so much watching them. I had multiple conversations with people who have built something incredible with their platform or podcast, and guess what? They still support the other people. They still support their friends that they've met along this podcasting journey. So many people at Podfest had recently released new books. Their friends and fellow podcasters were there supporting them, buying their books, posting about the books on social media, and supporting what they are doing. In this episode, I talk to you about some people I met for the first time at Podfest that have built incredible platforms and how, if you want to have success in your podcast and your real estate business, you support the other players, even if you are already a big player yourself. I hope you think about this and apply this to your real estate business. Podcast edited by Kenny Carfagno Show notes and blog posts created by https://www.harshmanservices.com/content-repurposing-service/ (Jennifer Harshman) and RealtorEmails.com John Schuchman is a licensed REALTOR® in Lancaster, PA, with Berkshire Hathaway HomeServices Homesale Realty and a part of the Andrew Welk Group. The opinions shared on this show represent the opinions & values of John Schuchman and do not necessarily represent the opinions & values of Berkshire Hathaway HomeServices Homesale Realty. The opinions & ideas shared in this podcast do not guarantee or promise any results of success to the listener.

Summary  “So, you're telling me you want to give me $1000 to NOT return to school?” That's right, Gappers! In celebration of our 5th anniversary, CanGap is giving away $5000 in Gap Year Scholarships this year to 5 gap year students and gap year alum. Our first round of spring scholarships will award $1000 to two 2022/23 gap year students and one gap year student finishing their gap year this year. In this episode, Michelle dives into how to fill out your application, what we're looking for and application deadlines. Listen in to learn how to write a winning application before Friday, May 27, 2022! Topics Discussed Announcing our CanGap Gap Year Scholarships and what to expect. What scholarship funding can be used for. The application process for our spring and fall 2022 scholarships. Who qualifies for a CanGap Gap Year Scholarship. Three pro tips for writing a winning application. Resources Mentioned In This Episode CanGap Gap Year Scholarship - https://www.cangap.ca/scholarship Connect With The Canadian Gap Year Association Join “Gapper Connect” on Discord to connect with students thinking about a gap year, current Gappers, and alum all in one place! https://www.cangap.ca/gapperconnect Find more resources at the Can Gap website https://www.cangap.ca/ Follow on Instagram http://www.instagram.com/cangapassociation/ Follow on Facebook https://www.facebook.com/ucangap Follow on Twitter https://twitter.com/ucangap Follow on YouTube https://www.youtube.com/channel/UCuBit8gLXEOxaBggoGmykjQ

Balancing Work And Family How to Let Go of Working-Mom Guilt by Sheryl G. Ziegler September 04, 2020 Harvard Business Review  https://hbr.org/2020/09/how-to-let-go-of-working-mom-guilt   Summary.    Working moms are chasing the balance of working a job that they want and being the mom that they envisioned. They feel bad about letting their kids, team, or boss down, and also feel guilt about practicing self-care, remorse for not helping aging parents enough, or embarrassment about admitting their stress. Additionally, the COVID-19 pandemic has left working parents — and in particular mothers, who still disproportionately take care of the housework and children — having to find solutions for education and childcare. If you're a working mother, you must let go of this guilt. Consider these five tips. First, forgive yourself for your choices and circumstances. Second, revisit your values and make them your top priorities. Third, ask for help from those around you. Fourth, remember the basics of being a good parent and let yourself be “good enough.” Finally, unfollow those on social media that bring you down.   Forget "Having It All": How America Messed Up Motherhood--and How to Fix It  by Amy Westervelt  https://www.amazon.com/Forget-Having-All-America-Motherhood/dp/1580057861   “We still ask women to work like they don't have kids and parent like they don't work.It's well past time to change all that.”   What Exactly IS Mom Guilt Anyway? A Clinical Psychotherapist Explains by Lori Mihalich-Levin | Oct 21, 2017 | Working Mom https://www.mindfulreturn.com/mom-guilt/   Summary: So-called “mom-guilt” is pervasive among mothers.  It can strike at any time and can show itself in any number of “mom” situations.  There are enormous expectations from society, media, family and friends about what mothers “should be like” and what we “should do.”  Should a mom return to work or not?  Breastfeed or not?  Be happy she is a mom?   Unreasonable expectations of happiness are also commonly drilled into new mothers.  However, at least 1 in 7 mothers experience postpartum depression or anxiety following the birth of a baby. Voicing true feelings may lead to judgement, though and then guilt begins to take a toll.    Being a mother can be filled with anxiety, stress, chaos, and can feel like one of the worst jobs on the planet. But we don't have to let guilt shame and fear control our experiences, but rather work towards self-acceptance and letting go of guilt. 

Summary: So divisive have American politics become that conservatives and liberals now openly talk about “national divorce,” meaning dissolving the existing union to allow red and blue states to either govern themselves or join smaller, likeminded federations. While there is nothing wrong with considering this solution, one less daunting may be staring Americans in the face. Suzanne Sherman lays it out in her new book, https://www.amazon.com/gp/product/B09SY98H9X/ref=as_li_tl?ie=UTF8&camp=1789&creative=9325&creativeASIN=B09SY98H9X&linkCode=as2&tag=tomusbl-20&linkId=16b0bdf9df04da7ea64f6c61c6530c65 (FEDERALISM: How Decentralization Can Save America). Guest bio: Suzanne Sherman was raised in California and having spent most of her life there, she moved to Utah to live a life of preparedness and self-reliance. You may know her as the “Red Hot Chilly Prepper” and host of the Wasatch Report. She's also a recovering attorney previously licensed to practice in California for several years. In addition to her work on preparedness, Suzanne has done significant writing on history and the Constitution. More information can be found at her website at https://www.suzannecsherman.com/ (https://www.suzannecsherman.com/) Book discussed: https://www.amazon.com/gp/product/B09SY98H9X/ref=as_li_tl?ie=UTF8&camp=1789&creative=9325&creativeASIN=B09SY98H9X&linkCode=as2&tag=tomusbl-20&linkId=16b0bdf9df04da7ea64f6c61c6530c65 (FEDERALISM: How Decentralization Can Save America) by Suzanne Sherman Free Gift from Tom: Download a free copy of Tom's new e-book, It's the Fed, Stupid, at https://forms.aweber.com/form/87/2092395087.html (itsthefedstupid.com). It's also available in paperback https://amzn.to/3HTYSYh (here). It's priced at a pre-hyperinflation level so grab a few copies for friends if you can. It makes a great introduction to the government's most economically damaging institution for liberals, conservatives, libertarians, socialists, and independents alike. Like the music on Tom Mullen Talks Freedom? You can hear more at https://skepticsongs.com/ (tommullensings.com)!

                               ESEE/RAT Pack Podcast Show NotesIntro and MissionDate Recorded:  2/9/22Duration:  6:38 Hosts:Shane Adams            Summary:So we kinda got the cart before the horse.  This BRIEF podcast is an Intro to the ESEE / RAT Pack podcast and a quick layout of our purpose and mission.    Instagram Accounts:@patrickrollins230@shaneadams90@eseeknives Links:www.eseeknives.comwww.randallsadventure.comwww.ratsar.orgESEE ForumPODCAST Link:  (PLEASE SHARE THIS)https://eseeratpack.buzzsprout.comYouTube Accounts:ESEE Knives/ Randall's Adventure & TrainingFaceWaste:Randall's Adventure & Training / ESEE KnivesOfficial FaceWaste Group 

Summary So you lived through birth…now what? Despite the popular image of the Middle Ages putting children to work the instant they were capable of holding a tool, Medieval childhood was actually pretty similar to modern childhood. No iPads, but people bought cute clothes for their kids, lots of different types of toys, sent them … Continue reading "Episode 36: Sweet Child of Mine"

McAnally's Pubcast - A Dresden Files PodcastThis Episode discusses Chapter 26 and 27 in which Dresden battles Victor and manages to win! Storm Front Chapter 26 Summary:The Beckitts leave to bring the car sound and Victor calls up the toad demon and Harry hides behind a kitchen counter for cover. Harry intercedes and cuts Vic's control over the demon, leaving it free to go after the Shadowman, but also effectively trapping both humans in the burning, beastie-infested house. The two men grapple again, overbalancing over the railing into the sunken living room-turned-scorpion-pit below. Harry remembers that Murphy's cuffs are still on him and snaps the free end around one of the railing spindles to prevent him falling all the way, but Victor isn't so lucky. Exhausted and injured, Harry dangles there figuring that the end is nigh and that if demons and giant bugs don't devour him, then the raging fire surely will. Defeated and hungry, he wonders if he isn't hallucinating when he sees Morgan approaching, sword drawn, and figures it won't be death by fire or flaying after all. Just great. Storm Front Chapter 27 Summary:So… turns out Morgan wasn't bringing his sword down on Harry's neck, but rather the chain linking the bracelets of the handcuffs. Go figure. After blacking out in the smoke-filled house, Harry awakens to Morgan performing CPR on him and realizes that Morgan has saved his life. Harry is more than a little surprised by this, but Morgan had seen how things had played out and that Harry was ultimately not responsible for the rash of mystical murders, and, despite still not particularly liking or trusting Harry, Morgan's personal code of conduct would not allow him to stand by and let Harry die for the actions of another. Although grateful for the rescue, Harry still doesn't harbour a lot of affection for Morgan, either, and takes some pleasure in knowing that Morgan will have to defend Harry and his actions at the council meeting that Morgan originally convened for the purpose of doing the exact opposite. Harry himself misses the conclave, as he is busy recuperating in the hospital, as is Murphy, who has survived her scorpion poison overdose.  The police find the remains of the ThirdEye stash at the burned-out lake house, Victor is deemed the bad guy, Monica and her family disappear into witness protection and Marcone makes it known that Dresden was working at his behest to deal with the rival drug lord wanna-be. Bob returns from his shore leave, Susan prints an article about the events of her hijacked date with Dresden, Harry keeps his word to send pizza to Toot-Toot and Co., and makes some peace with himself about power and temptation. For the moment things are quiet again, and as they should be... But if not….Harry Dresden is in the book.

Do you care whether your taxes go up? Do you care if the cost of everything in your life increases? Have you read the stimulus bill? We didn't learn from the first round and this time is worse.****Check out my website www.everything.money if you want to get a copy of our free Lifestyle Strategy Template and take control of the direction of your life!Summary: So out of this entire mess, we are sacrificing the future of our lives and our childrens' lives to inflation and out of all of all of this, pretend the number was just $190,000 to spend on COVID, then only approximately $66,100 is going directly to bailing out individuals, helping health care systems, funding the vaccine effort and funding agriculture to keep food on the tables. Here's a summary of what is in it since I doubt I'll get you to read the full 5,000 page report.Line item #1 – The individual mandate is $1400 checks for individuals making less than $75,000 annually and phases out for people with higher incomes. Married couples can get up to $2800 if they have a combined income of less than $150,000. Problem: $1,400 is not the $2,000 that Biden and Harris promised. Also, it's not enough period for people who have been laid off for months and still can't return to work due to shutdowns. This is not about laziness. This is about the government banning people from working. We should be giving $10,000-$40,000 checks to individuals who are unemployed based on how many weeks they've been unemployed. Problem #2 – Why are we bailing out the millions of people who have been able to keep doing their jobs remotely? They aren't hurting. This money should be re-routed to those who need it or not used at all. This is going to contribute to inflation as the economy rebounds.Estimated Cost – This part ONLY takes up $422B of the entire $1.9T bill. That's less than 23% of the entire bill!!! So what is the rest of the money for Line item #2 - Expand Child Tax Credit, Child Care Tax Credit, and Earned Income Tax Credit mostly for one year. The plan would raise the $2,000 Child Tax Credit to $3,000, set the credit at $3,600 for parents of children under age 6 and make parents of 17-year-olds eligible. It would also make the credit fully refundable, so low-income households would get the full benefit, no matter how little they earn, according to the Wall Street Journal. Problem – None. This is actually a good idea and a TARGETED way to get relief to people who need it.Estimated cost: $143 billion Line item #3 - Provide grants to multi-employer pension plans and change single-employer pension funding rules. Estimated cost: $58 billionLine item #4 - Repeal rule allowing multinational corporations to calculate their interest expenses including foreign subsidiaries. Problem: As far as I can tell, this has no bearing on the outcome of COVID-19 and providing relief to those who need it and getting people vaccinated. Therefore, its pork and shouldn't be included.And the list goes on!

A Yuri on Ice Fanfic. Summary: “So, as my regular viewers will probably know,” he says, folding his hands together on the counter as though to stop himself fidgeting, “this is not my usual kitchen. But I'm visiting the boyfriend this week so we're in his rather lovely kitchen today. Obviously I had to do a big shop on arrival as Victor lives like the drama queen he is and mostly orders out.” “Hey!” a voice says, and moments later a taller, very attractive silver haired man wanders into view and flicks Yuuri on the nose affectionately. “I only apply as much drama as is necessary at any given time or place.” [Third in the YouTubers AU. Yuuri hosts a live stream of Katsu's Kitchen at Victor's. Shenanigans ensue.] Download the full fic from my website, HERE & My AO3, HERE .  Also, be sure to check out my YouTube channel, HERE. You can read this fic for yourself, HERE.  

Summary: So pleased to introduce you to my friend, Reagan Smoker. Reagan has been a retail and hospitality manager for over a decade. She's worked from brands like Jos A. Bank, Lacoste, Calypso St Barth. Noe she's the GM of a quaint inn and restaurant in Sturgeon Bay, Wisconsin. I wanted to bring Reagan on to talk about her perspective on being a great human and how that applies to selling people on her. Her story doesn't disappoint! You'll learn some practical things from her stories working with difficult customers, challenging employees, and also from her over 12 year battle with breast cancer. Reagan truly leads with love in everything she does. This episode will show you how she does it and how you might be able to bring these approaches into your own interactions with others. Key Takeaways by Time! 6:02: Reagan's story of growing up and learning to read a room from a very early age - 6:02 8:00: "I'm still a human being, I just have a touch of cancer" 8:52: Lead with Love - You don't knw what's going on with people's lives. Power of a genuine compliment. 12:15: If you can't feel someone's pain, we've all seen movies or books where we can think of someone's pain. Channel that. 31:00 - Having difficult conversations and how to approach people in a useful way. Connect with Reagan (Show her some love)! https://www.linkedin.com/in/reagan-smoker-64361630/ (Reagan's LinkedIN) https://www.instagram.com/regs311/ (Instagram) https://www.innatcedarcrossing.com/ (Inn At Cedar Crossing) Connect with Us! https://www.linkedin.com/company/53108426/admin/ (LinkedIN: ) https://stories-of-selling-human.captivate.fm/ (Website: )

SUMMARY:So many believe they've hit a ceiling and are lost on where to go beyond being an admin, yet they still love admin responsibilities.INTENTION:Offer inspiration and ideas on how to elevate ones career while still staying true to what makes you feel whole.EXCERPT:"I wrote a list of things I was interested and passionate about to move my career forward." - ReneeRESOURCES:Discover: WebsiteOutreach: LinkedIn CommunitySponsor: feals

Building A Dream Job Building A Dream Job Isn't Really Possible is the discussion on today's guest joining us on the Steve Jobs inspired Join Up Dots business podcast. This has been inspired by a message that we recieved into the Join Up Dots email inbox from a great guy from Denver Colorado. Lukas has been in contact with us over the last few years, as he looks to keep building a dream job around photography - his huge passion. His question is based around the concept of do you keep building a dream job and struggle in the beginning, or do something else to make it easier to get there later? The Building A Dream Job Question Hi David, I hope life is treating you well. I've started an electrical business and I've been focusing more on that lately then my passion of being a photographer. I still do photography, but the electrical business is way more lucrative. I don't hate electrical work, but I also don't love it. My question is, should I build the electrical company so I can do amazing things in the future or should I struggle in the beginning and do what I love? Our Building A Dream Job Answer  I can answer this one hundred percent.......bring in the money mate. Be pragmatic about it. You see nobody ends up having a business that they truly love. I used to think that was the case, but now I see it otherwise otherwise it would be called a hobby. With Join Up Dots i would say there is seventy percent that I love and thirty percent that is a hassle. But it is as it is. What it does give me is 1: no boss, 2: no fixed timescales 3: the ability to travel when and where i want. I actually found a vision board that I created six years ago, and i forgot about it, and I had achieved everything i wanted and they were all based around being free, not being told what to do etc So i would say think this...... can YOU build the electrical company until you become the OWNER and not working in the business? If you can ( and i know you can) then you have income coming in passively which means then you can do what you want to do. For example, I now own a car parts shop and Im having to work in it three days per week UNTIL i get the issues sorted and we start making good money and then I am out of here....but the money will be coming with me Does that make sense pal??? Summary So what do you think? Is this the right way to go? Should we spend our time doing anything that we dont like in life, if it makes the majority of our time amazing? Let us know by connecting with us below and you can help others move forward to building a dream job, and of course a life. How To Connect With Join Up Dots Website LinkedIn Facebook Return To The Top Of Building A Dream Job If you enjoyed this episode with Building A Dream Job, why not check out other inspirational chat with Caroline Casey, Festival Pass, Shane Foss and the amazing Jack Canfield You can also check our extensive podcast archive by clicking here – enjoy

Summary So many people don’t want to think about tax until it’s too late, but once you’ve listened to Brian Goodridge you’ll be positively inspired to do something about your tax situation! Brian is a different kind of accountant. He’s great at explaining the various different angles you can exploit to make yourself tax efficient and profitable in the long term. See some of Brian’s top tips below: ** Don’t get too hung up on avoiding tax. You can cost yourself money in the process. ** Tax planning is much more than just something you do in April and May. You should work it into your whole year. ** Beware of using savings indefinitely. Be honest with yourself with when you want to use the money. ** Don’t think about tax as a one-year thing. So many people do everything they can to save tax in year one, but they end up paying more in year two as a result. ** Do you really have a ‘tax problem’ or do you have a ‘cashflow problem’? Don’t blame it all on the tax! In this episode of Business Brain Food you will learn: ** The difference between tax minimisation and tax avoidance ** How to manage your accountant properly ** The right length for your goals ** How to manage your super balance ** Tax-efficient investments ** Instant asset write-offs explained Resources mentioned in this episode: ** If you’re a business coach, business adviser or would like to become one, go to: https://maxmyprofit.com.au/business-exceleration.html ** Brian is offering a free 15-minute strategy session exclusively to BBF listeners. Contact him through his website: https://goodridgeadvisory.com.au/ ** All previous BBF episodes & show notes can be found at http://www.businessbrainfood.com.au ** Join the Business Brain Food Facebook Group: https://www.facebook.com/groups/BusinessBrainFood/ ** Twitter: https://twitter.com/bfewtrell Call to action: DON’T LEAVE YOUR TAX PLANNING TO THE LAST MINUTE!!! People like Brian can help you get on top of your tax the whole year round. Also, if you are enjoying these Business Brain Food podcasts, then make sure to share them via social media sites or email the links to family and friends. A lot of time and effort goes into producing each of these podcasts with the goal in mind of the more people we can inspire about business the better. You can help us do just that! Until next time, have a profitable day! Cheers, Ben Fewtrell 02 8808 5500

SUMMARY:So many people set resolutions at the beginning of the year but then fall off from following through...why is this?INTENTION:Offer inspiration and a though provoking moment...what's stopping you from committing to the goals you put to paper to take care of yourself?EXCERPT:"Why not put off your fitness goals until the 2nd quarter and use the 1st quarter to get your mind right." - HilaniRESOURCES:Discover: WebsiteOutreach: LinkedIn CommunityLearning Corner: Why New Year's Resolutions Fail

Summary: So what is Visualization? From great achievers comes the prospect of visualizing or imagining what you want and having that become a reality. From Arnold Schwarzenegger to Jim Carry, to Kirk Duncan, to Will Smith, and the list goes on – all have talked about having a vision of a goal that motivates you. […] The post UYG 003 : What is Visualization? appeared first on Heralds of Life.

SUMMARY:So many struggle, talking to themselves often, "Is this it, is there nothing else coming - am I stuck?" So many professionals want to know what's to come, what's the purpose of this current situation, and/or prior situation(s), so the future is known and clear. This episode offers a great story that will help many, Trust the Process.INTENTION:To take the pain out of not knowing what's coming and to embrace whatever is in front of you knowing things can work out if you keep your thoughts and energy right.EXCERPT:"The way I gained this confidence in the past two years is by just doing it and not being afraid to do it." - LynnRESOURCES:Discover: WebsiteOutreach: LinkedIn CommunitySponsor : Clove and Twine

In this episode of the Better Golf Academy, I discuss why it is so important in golf to be in the moment. I truly believe in order to conquer this game to play our very best, we have to control our thoughts. It’s really true what they say, this game is 90% mental and 10% mental. And I so much believe that if we get this part right, it can really change our game. Mindfulness is a mental state achieved by focusing one’s awareness on the present moment. Is this easy to do?  It’s Not Easy No one said it was easy. Staying focus and not allowing your mind to wander is not easy. It takes discipline. It takes practice like everything else. And most of all it takes confidence. What do you mean by confidence? It takes confidence to know and believe and have a conviction that this really works. And, thinking back...I was teeter-tottering. I didn’t think seriously enough about it. Maybe, even though I preach it, I didn’t entirely believe it. I was thinking that if I had the physical talent and ability to shoot well, that I would automatically shoot well and the score will show it at the end of the day. NOT. It takes mental discipline every hole, every shot. Full focus. Being in the moment.  It’s a Journey How do we get there? I am not there yet. Obviously. But, I believe our pursuit of getting there is the goal, not just getting there. Okay, this reminds me of a quote, I know...sometimes introducing quotes in a podcast is a bit cliche-ish and corny but I think this really applies to what we are talking about today.  “Success is a journey, not a destination. The doing is often more important than the outcome”.  This quote is by Arthur Ashe. Who is Arthur Ashe? He was an American Professional tennis player who won 3 grand slam titles. He was the first black player selected to the US Davis Cup team and the only black man ever to win the singles title at Wimbledon, The US Open and the Australian Open. He was also an author and mostly known for being a crusader for equality. He really lived with intention and impact. So, for me, I can look at this event as a total failure. Which, I actually called it that on my dreadful drive back home in my head. But, nah...I don’t believe that anymore. It’s all part of the journey and it’s never about the outcome, or the end result, or the certificate, or whatever's in your life...I truly believe it’s about our attitude, discipline, will and our struggle and fight in getting there. Look Up When I started my podcast, my friend Charlton messaged me and said dude, this podcast is for me. I am your poster child. Do you know how many books I’ve read on golf? Every single one. Do you know how many videos I’ve watched? Workshops I’ve attended? He’s a learner. A seeker who’s hungry for knowledge, a true student of the game. When we are playing golf together several months back, I asked him, hey...just curious, from all the books you’ve read, videos you’ve watched and the workshops and lessons you’ve received, what’s the one thing, one main thing that has impacted you the most in your game? He said. “Look up” huh? So, I went home and looked it up. Yeah, the book Zen Golf talks about the expansive awareness. It’s a practice of Mindfulness. “When you have a difficult tee shot or short putt and you are waiting your turn, it’s not very helpful to stare at it, think about it, and let your mind get very small...instead, look up and breathe out, opening to the awareness around you. He says “in life..as in golf, you give it your best shot when you’re free of tension and self-consciousness.” In life as in golf...lol. That’s my line.  Summary: So, here’s the deal. It’s not easy. It’s a journey and you gotta remember to look up. Take a breath. Don’t get stuck on the small stuff. Be grateful. You are out here, on a beautiful day, on this beautiful course, with awesome people, playing golf. Look up. Enjoy. Have Fun. And be in the moment.

Summary - So let no one boast in men. For all things are yours, whether Paul or Apollos or Cephas or the world or life or death or the present or the future—all are yours, and you are Christ's, and Christ is God's. This is how one should regard us, as servants of Christ and stewards of the mysteries of God. Moreover, it is required of stewards that they be found faithful. But with me it is a very small thing that I should be judged by you or by any human court. In fact, I do not even judge myself. For I am not aware of anything against myself, but I am not thereby acquitted. It is the Lord who judges me. Therefore do not pronounce judgment before the time, before the Lord comes, who will bring to light the things now hidden in darkness and will disclose the purposes of the heart. Then each one will receive his commendation from God. I have applied all these things to myself and Apollos for your benefit, brothers, that you may learn by us not to go beyond what is written, that none of you may be puffed up in favor of one against another. For who sees anything different in you? What do you have that you did not receive? If then you received it, why do you boast as if you did not receive it? 1 Corinthians 3:21-4:7

PRINCE HANDLEY PODCAST REVELATION WITH DIRECTIONA MIRACLE PODCAST PRODUCTION ~ ~ ~ PRINCE HANDLEY PORTAL 1,000's of FREE ResourcesWWW.REALMIRACLES.ORG ~ ~ ~ INTERNATIONAL Geopolitics | Intelligence | Prophecy WWW.UOFE.ORG CLIMATE LEGISLATION THE INCONVENIENT UNTRUTH You can listen to the above message NOW. Click on the pod circle at top left. (Click “BACK” to return.) OR … LISTEN NOW >>> LISTEN HERE 24/7 release of Prince Handley teachings, BLOGS and podcasts > STREAM Twitter: princehandley ___________________________________________________________ DESCRIPTION OF THIS TEACHING In this podcast teaching we will discuss two postulates concerning Climate Change that are never covered by environmentalists, the media, or authors on the subject. Also, several resources are available for further study. Hopefully, IF you are involved in environmentalism―expending time or money―you may find another way to be more effective in helping Planet Earth and its inhabitants. ___________________________________________________________   CLIMATE LEGISLATION THE INCONVENIENT UNTRUTH First, let me say that I am NOT against Environmental Protection and basic Green initiatives: especially clean water, air and crops (or food) … and solid energy conservation. BUT … maybe I can save you some money and time in your efforts. So … let’s start here >>> Most, if not all, of the assumptions ... in Al Gore's movie, The Inconvenient Truth, are NOT accurate, and represent an "ad-hoc" system of statistical prevarication. In short, it's a BIG LIE. For example the "seeming" correlation of temperature to CO2 in the atmosphere. Gore states ... and thereby presupposes ... that the CO2 present in the atmosphere is causal to the rise or fall of temperature. When, the reverse is true: it is the temperature―the sun has a lot to do with this!!!―which is the casual effect for the amount of CO2 present in the atmosphere. If I were to tell you that 90% of the people in Hicksville who drink "Pollute Pop" soda have NO dental cavities, would that be impressive? Would you advocate for "Pollute Pop?" Would you also be an activist for the cause of everyone drinking "Pollute Pop?" What if the truth were - and you didn't know, or didn't take time to investigate - that 90% of the population in Hicksville have NO teeth! CHECK OUT THE SCIENCE During the first 3 months of 2017, over 150 papers had already been published in scientific journals that cast doubt on the position that anthropogenic CO2 emissions function as the climate’s fundamental control knob. AND … in only a few weeks during June of 2017, another 20 scientific papers were identified which linked solar variations to climate changes, which means 58 papers had already been published by that time just in 2017. Since solar activity does vary, it kind of makes more intuitive sense that this might affect climate more than the level of CO2 in the atmosphere. Since 2016 over 650 scientific papers have been published warning against global warming theory. Cutting edge research now works against the “Warmists!” As an engineer who worked in a chemical laboratory for years (I wrote my thesis in a chemical laboratory) it is easy to discern that if such an inconvenient UNtruth is being presented to people (including little children in schools) that, just maybe, there might be something more to Gore's―and other “Climate Change” advocates'—purpose in advocating for climate change. Could it be that they might be set to make billions of dollars with his green and eco-friendly climate companies and investments? Also, most ... if not all ... of the tendencies for "supposed" climate change (rise of sea level, melting ice caps, temperature rise) are not only exaggerated, but IF they WERE true, would take 50 to 100 years to show any marked effect. It's interesting to note that the terminology "Global Warming" has been replaced with "Climate Change." PRINCE HANDLEY POSTULATES THE FOLLOWING 1. Planet Earth will not be around that long. Even if it is, there will be such sulphuration in the atmosphere due to warfare that any attempts at climate control will be negligible ... nada!2. Scientifically, because of coming earthquakes and the comcomitant volcanic activity due to tectonic plate shifts, AND the resultant sulfuration of the atmosphere, Planet Earth should be shielded to some extent from sun rays and temperature should be lowered. However, we know this is NOT the case because we read in Scripture prophecy―which has always been fulfilled precisely and accurately―the following: "And the fourth angel poured out his vial upon the sun; and power was given unto Him to scorch men with fire.And men were scorched with great heat, and blasphemed the name of God, which has power over these plagues: and they repented not to give Him glory." (Brit Chadashah (The Hebrew New Testament): Revelation 16:8-9) My friend, there is coming such a rise in temperature as a result of the judgment of God, that NO amount of climate control could have even a minuscule effect on the temperature of Planet Earth. SUMMARY So … just in case you have been expending lots of your time and money on extreme (or, NON-practical) energy or green initiatives … WHY NOT turn those efforts around helping people in your community and around the world with things like clean water (or wells) … medicine, Bibles, and those things they urgently need NOW. And just in case YOU don’t know the LORD―so YOU can plan for life beyond Planet Earth―ask Him to come into your life today, and He will help YOU to “clean up your world.” Just pray this prayer: “God, if Yeshua (Jesus) is really your Son … IF He is really the Messiah … reveal Him to me and I will serve you the rest of my life. Amen” OK, my friend, have a SUPER BLESSED day and the rest of your life! Baruch haba b'Shem Adonai. Your friend, Prince Handley President / RegentUniversity of Excellence Podcast time: 8 minutes, 16 seconds. _________________________ Rabbinical & Biblical Studies The Believers’ Intelligentsia Prince Handley Portal (1,000’s of FREE resources)Prince Handley Books NOTICE If you would like to partner with Prince Handley and help him do the Spirit exploits the LORD has assigned him, Click the secure DONATE you see below. God will reward you abundantly on earth … and in Heaven! DONATE A TAX DEDUCTIBLE RECEIPT WILL BE SENT TO YOU ___________________________ SUGGESTED READING: Part 1. Natural Mechanisms Of Weather, Climate Change Solar Influence On Climate (38)ENSO, NAO, AMO, PDO Climate Influence (20)Modern Climate In Phase With Natural Variability (8)Cloud/Aerosol Climate Influence (3)Volcanic/Tectonic Climate Influence (1) Part 2. Unsettled Science, Failed Climate Modeling Climate Model Unreliability/Biases/Errors and the Pause (12)Failing Renewable Energy, Climate Policies (2)Warming Beneficial, Does Not Harm Humans, Wildlife (3)No Trends In Extreme, Unstable Weather In Recent Decades (3)Natural CO2 Sources Out-Emit Humans (2)Fires, Anthropogenic Climate Change Disconnect (1)Miscellaneous (5) Part 3. Natural Climate Change Observation, Reconstruction Lack Of Anthropogenic/CO2 Signal In Sea Level Rise (9)No Net Warming During 20th (21st) Century (10)A Warmer Past: Non-Hockey Stick Reconstructions (21)Abrupt, Degrees-Per-Decade Natural Global Warming (1)A Model-Defying Cryosphere, Polar Ice (10)  

Gay And Bisexual Pride Month And How To Support Your LGBT Friends, Relatives And Co-Workers #88: Daily Mentoring with Trevor Crane on GreatnessQuest.com SUMMARY: So it's Pride Month and today we’ll talk about what you need to know to support your LGBT friends, relatives and co-workers. Look, I don’t care what you call it, gay pride month, pride month, LGBT month, the pride parade… whatever. Pride Month offers numerous events where members of the LGBT community can celebrate who they are. But June also is a good time for straight people to show support for their LGBT friends, relatives and co-workers. About LGBT History Month This is a month long annual observance and celebration for gay pride, gay men, gay women, bisexual and transgender history, and its related to one of our most important civil rights movements. Wikipedia 1. Ask what’s going on 2. Attend and have the time of your life Pride events are geared toward anyone who feels like their sexual identity falls outside the mainstream -- although many straight people join in, too. LGBT is an acronym meaning lesbian, gay, bisexual and transgender. The term sometimes is extended to LGBTQ, or even LGBTQIA, to include queer, intersex and asexual groups. Queer is an umbrella term for non-straight people; intersex refers to those whose sex is not clearly defined because of genetic, hormonal or biological differences; and asexual describes those who don't experience sexual attraction. These terms may also include gender fluid people, or those whose gender identity shifts over time or depending on the situation. 3. Listen without judgement 4. Love everybody MORE ABOUT LGBT MONTH: Lesbian, Gay, Bisexual and Transgender Pride Month (LGBT Pride Month) is currently celebrated each year in the month of June to honor the 1969 Stonewall riots in Manhattan. Today, celebrations include pride parades, picnics, parties, workshops, symposia and concerts, and LGBT Pride Month events attract millions of participants around the world. Memorials are held during this month for those members of the community who have been lost to hate crimes or HIV/AIDS. The purpose of the commemorative month is to recognize the impact that lesbian, gay, bisexual and transgender individuals have had on history locally, nationally, and internationally. In 1994, a coalition of education-based organizations in the United States designated October as LGBT History Month. In 1995, a resolution passed by the General Assembly of the National Education Association included LGBT History Month within a list of commemorative months. LGBT History Month is also celebrated with annual month-long observances of lesbian, gay, bisexual and transgender history, along with the history of the gay rights and related civil rights movements. National Coming Out Day (October 11), as well as the first “March on Washington” in 1979, are commemorated in the LGBT community during LGBT History Month. IN NYC & LGBTQIA+ As Pride Month continues, things are slated to get even more exciting with the 2018 New York City (NYC) Pride March aiming to celebrate members of the LGBTQIA+ community Sunday. The first-ever gay pride parade in American history was held in NYC's Central Park on June 28, 1970. It occurred one year after the 1969 Stonewall Riots, which were multiple violent protests organized by members of the LGBT community after the NYPD raided known gay club Stonewall Inn. The parade served as a launching pad for other cities across the United States to hold their own respective marches. It's now commemorated annually, ultimately becoming an important civil rights movement. OUTSIDE LINKS: CNN Article: “How to be an ally to your LGBT friends, relatives and co-workers” https://www.cnn.com/2018/06/22/health/lgbt-how-to-be-an-ally-trnd/index.html Wikipedia has a great description of Gay Pride. https://en.wikipedia.org/wiki/Gay_pride Gay pride or LGBT pride is the positive stance against discrimination and violence toward lesbian, gay, bisexual, and transgender (LGBT)people to promote their self-affirmation, dignity, equality rights, increase their visibility as a social group, build community, and celebrate sexual diversity and gender variance. Pride, as opposed to shame and social stigma, is the predominant outlook that bolsters most LGBT rightsmovements throughout the world. Pride has lent its name to LGBT-themed organizations, institutes, foundations, book titles, periodicals and even a cable TV station and the Pride Library. GET THE APP: Text: TREVOR To: 36260 #greatnessquest #trevorcrane #unstoppable #idealbusiness #ideallife

Billionaire Vs. Bieber #35: Daily Mentoring with Trevor Crane on GreatnessQuest.com SUMMARY: So far, I’ve met 3 Billionaires. And let me tell you, they are a breed-apart. Recently I met a billionaire, Mr. Naveen Jain (founder of Moon Express and viome.com), and “The Biebs” (Mr. Justin Bieber) on the same day in Beverly Hills, CA. To be clear, I bumped into Justin Bieber in the elevator. And, I got to hangout with the Billionaire. But by-far, the BIGGER highlight for me, was meeting Naveen Jain. Yes, The Biebs smiled and cooed at my little 2-month old son, Maverick. And, yes I was so caught-up in how cute my son was, I hardly even realized it was, “The Biebs...” but on today’s show, I talk about the SIMILARITIES between these guys. And... I share a little of what I learned by hanging out with a man worth 8 Billion Dollars. IN SHORT: Has me re-thinking my goals, and what I want to do with my life. Perhaps, this insight will help you too. GET THE APP: Text: TREVOR To: 36260 #greatnessquest #trevorcrane #unstoppable #idealbusiness #ideallife      

Summary So much awesome stuff happened last week from exploding phones, to the new Guardians of the Galaxy Vol. 2 trailer, and Nintendo finally dropping a trailer for their new system. These and so much more on this AWESOME episode of the Pondering Nerdcast.

We all want to create profitable products but aren't sure where to start. We hope for some amazing formula, when all you really need are three core questions. When you are clear about the answers to the three questions, you can take an amazingly pedestrian, everyday concept and make it hugely profitable. So what are the three questions you need to have in place and how can you get started today? ----------------------- How to Create a Profitable Idea for Business Around July 2000, I was made redundant from my job at a web design firm. Life wasn’t supposed to unfold this way. I’d just moved to Auckland, New Zealand from Mumbai, India a few months prior. And here I was, barely a few months later, without a job and with a mortgage that hovered around $200,000 (yes, we’d just bought a house). What do you do when you’re hurled into such a situation? I turned to Photoshop, but not quite. There’s a story behind the Photoshop story and it began back in India, in July. Back in Mumbai, I freelanced as a cartoonist and work was pretty steady through the year, except around July. For some inexplicable reason, the phones would stop ringing at that point in the year. At first, it drove me crazy and I’d do everything I could to drum up business. I’d rant and rave and complain about the fickle nature of July when my mother pointed out that things were always quiet for me in July. From that point on, we’d use July to learn how to use Photoshop One of the big games at the office (yes, I had staff) was to learn to use Photoshop in Tab, F mode. If you were to turn on Photoshop and hit the Tab key and press F (full screen) you’d find that all your toolbars disappear. The game at the office was to keep working in Photoshop without any toolbars. A bystander would look in awe as you were able to use the brush tool, increase opacity, decrease brush sizes etc. You could do almost anything in Photoshop without needing the tool bar. It looked like pure magic. It’s this magic that I had to use when I was made redundant The moment I was made redundant, I went back to trying to get work as a cartoonist. Since most cartoonists at the time were still using pen, ink and paint, my work in Photoshop stood out when I went to meet art directors at the advertising agencies. One particular art director got a bit chatty and as we talked she realised that she too could use the magic of Photoshop in her work. And so, while I started out trying to sell cartoons, I ended up charging $60 an hour, teaching art directors how to use the core tools of Photoshop without the tool bar. Notice something very interesting in the last sentence? I wasn’t teaching them Photoshop. I wasn’t going into the 2,459 rabbit holes that Photoshop presents to a beginner. Instead I was just teaching them a subset—the core tools of Photoshop without the need for a tool bar. And this is precisely the kind of advice I’d give to a client if they called me up and asked how they should start a profitable business. I’d say you need to ask yourself three questions: who, what and when. So why do these three questions matter? Why Who Matters I’ve been pretty good at drawing since a very young age. Like every other kid around me, I did the usual doodles and scribbling, and when the rest of the kids decided to give up drawing at the age of four or five, I kept at it. So you can say I’d be pretty good at drawing after all these years, wouldn’t you? And you’d be right because I’ve never really stopped drawing for a day. But drawing is a bit like cooking. Just because you’re good at cooking Italian food doesn’t mean you’re going to be any good at Japanese food Over the years I became exceptionally good at drawing cartoons, loved the structure of buildings and architecture, even dabbled in a bit of caricatures. But there’s one thing I avoided: drawing animals. I’d decided very early in my life that I wasn’t too good at drawing animals. Then, recently, I was saddled with about 400 amazing envelopes. There’s a story behind those envelopes, but for now let’s just say it was much too hard to throw away those envelopes. So I started drawing animals on them, tentatively at first, but then with a sense of a mission. The moment I started posting the photos of these envelopes online, there was a flurry of interest People from different parts of the globe started giving me advice on what I should do with them. You should print them, said one. You could create a collector’s item box set said another. And the advice kept pouring in, and did exactly what advice usually does: it confuses you beyond belief. The reason you’re hearing this story is to give you a framework of how a profitable idea doesn’t arise from an ability to do something well. A profitable idea arises from the first question you need to ask: Who. The envelope art I just started working on in early June 2016. So why is who so important? Without the “who” in mind, struggle is almost inevitable. Think about the boxed set of envelopes, for example. There’s no doubt that they make a great product, but well intended as the suggestions were, there’s no clue who would buy it. Or why they would buy it? Yet if we took the Photoshop example, we notice there’s an enormous amount of clarity. Sure, the clarity came about by a fluke discussion, but as we’ll find out a lot of profitable ideas are pure fluke. To get back to the art director, I now had a clear person (what we call in The Brain Audit as the target profile). That one job of teaching the art director not only went on for several months, but led to another job—with the daughter of another art director. I didn’t go down the path of teaching Photoshop to other art directors, but you could clearly see how the “who” helped. The “who” matters whether you’re writing an article or creating a product or service Let’s say you’re creating an online product on storytelling. Before you start writing a word, you are peripherally aware of the volumes of story-related material in books, videos and audio. To write another series on storytelling would be nice, but how would it stand out. Now let’s be fair: there’s a lot of terribly average material online and offline that is very profitable regardless of uniqueness. All the same, when uniqueness is relatively easy, why would you want a me-too product when you can have one that’s clearly outstanding? When you create a product or service for someone in particular, they give you their own specific bent on the problem they’re facing. Take for example a service on presentations There are hundreds of books on presentations and services that promise to show you how to be amazing on stage. Yet, when I spoke to this presenter, she felt competent, but not quite. She felt she needed that last 10% that would take her from good to great. And there you have it. That subset is what gives you the clue. Instead of writing a book, creating a course, inventing a service on “presentations”, you work on the subset of how the “last 10% can take you from a good to great speaker.” Fluke plays an incredibly important part in this game of finding the “who” We’re so hell-bent on finding the right person, the right target profile that we don’t dare venture far from our computer screens. When I ran into that chatty art director, I had no clue that she’d talk about Photoshop. When I spoke to that presenter, I had no idea that a cup of coffee would lead to an idea about “the last 10%”. It may appear that a lot of products or services are built around strategy, but they’re often built around a person. The mistake we make is we hope we run into the ideal “who” right away And more often than not, the “who” is a complete fluke. At first, almost every product or service is like Version 1.0. And the feedback you get from that person is going to be relatively limited. Even if you were to create a product or service for “last 10% presenter”, the product would need refinement to get to Version 1.1 and from there to 1.2 and so on. With every product or service that’s been profitable, we’ve had a Version 1.0 and then moved along refining as we go along. Every time you fix things, your product becomes better and more profitable and there’s always a “who” who’ll give you feedback and help you take the product to another level. But even if there’s a “who” in place, how do you deal with the “what?” The what depends on a simple concept: the idea of a superpower.   Why When Matters 1838 1840 1845 1849 1853 1859 For over 20 years Charles Darwin postponed the publishing of his theory Then, on 24 November, 1859, Darwin published his theory on, “Origin of Species”. Priced at fifteen shillings, 1250 copies were sold. Yet, Darwin wasn’t keen on the book being published until his death. In a letter to his religious wife, Darwin asked that 400 pound be set aside and enough promotion of his book be done after his death. Yet, Alfred Russel Wallace got in the way of these plans Alfred Wallace, a naturalist, spent eight years in Singapore and South East Asia between the years of 1854 and 1862 and is known to have discovered evolution by natural selection as well. He wrote an essay while in Indonesia (while living on the island of Ternate) and sent it to Darwin in 1858. When Darwin saw the contents of the letter, he knew the “Origin of Species” couldn’t wait any longer. It needed to be published right away or all of Darwin’s work would be attributed to another man. We are similar to Darwin in many ways Our work may seem insignificant when compared with the work of Darwin, but if your work changes a single person’s day, it’s significant. You know from your own experience how a single line in a book may have caused you to stop and reexamine what you were doing. Or a random comment that may have changed the way you went about your life or business. Our work seems insignificant only because we know it so well. For others it can be a major moment in their lives. Which is why you need to start now As you’ve probably heard or read elsewhere on the Psychotactics site, most of our work started out unpolished. At this very moment, as I’m writing this article, Renuka is laughing at one of my articles that I wrote several years ago. However the best example of the unpolished nature of our work must be attributed to The Brain Audit itself. As you’v probably heard before, the “book” started out as just 16 pages of notes. We made over $50,000 selling that book simply because we got pushed into selling it. And when we sold it offline we weren’t ready to sell it online. Again, someone pushed us and our online business got underway. If you think your work is crappy, there’s a good reason why Your work is crappy. The Brain Audit was crappy at the start. All our courses and workshops were crappy at the start. Not by choice, of course. We did the best we could but now I can’t even bear to go back and look at the early versions. You too will need to bolster up your confidence and get your work going whether it’s through text, audio, video or presentations. Because if you don’t do it, someone else will. Darwin had all the material he needed but was still reluctant to publish his work And here I am giving you this advice but I’m reluctant as well. I’ve been working on the concept of talent since 2008 or earlier. So many years have passed and while I’ve written the odd article here and there, there’s no program, no book, no webinar, no podcast. Let me ask you this question: Would you like to read about how to become talented in just about any field? Would you like to read about what holds us back?(and no it’s not genes). It’s not like I’m comparing my work to Darwin’s or any one else for that matter. But as a reader or listener, would the information be important to you? Your work is more important than ever It may appear raw to you, but you need to start and fix it later. You’re hoping for that one great idea but you need to start with a little idea. Will the little idea fail? It might, but from those failures you keep moving ahead and fixing things.  Even Darwin’s work was just the start of his journey. During Darwin’s lifetime the book went through six editions, with cumulative changes and revisions to deal with counter-arguments raised. In 1871 he examined human evolution and sexual selection in The Descent of Man, and Selection in Relation to Sex, followed by The Expression of the Emotions in Man and Animals. His research on plants was published in a series of books. His final book, The Formation of Vegetable Mould, through the Actions of Worms (published 1881), he examined earthworms and their effect on soil. When he died he was honoured by a burial in Westminster Abbey where only royals, generals, admirals, politicians, doctors and important scientists are buried. And to think Darwin almost never started on his journey. Do you still want to wait? Or are you going to start today?   Summary So how do you create a profitable idea for business? When you started reading this information, you may have thought there’d be a formula. And that’s the formula you’ve been missing. The formula is so simple that somehow you feel like there’s something wrong. Like as if you have to pay $2000 to some Internet guru to get the formula. But think about it for a second. Let’s say you’ve got a really good way to grow tomatoes. You can grow thousands of tomatoes in an extremely small space. Is that a superpower? Sure it is. So let’s start with the who: Who is going to be interested in your tomato idea? Then let’s get to what: The “what” is about growing thousands of tomatoes in a very small space. Then let’s get to the when: And this is where it all falls apart, isn’t it? You should start now, but there are reasons why you can’t start now. If Darwin could have reasons, so can you and I. We can all have our reasons. The biggest problem isn’t necessarily that you need a great idea for business You just need to start but there’s something holding you back. And we’ll explore what holds you back—yes we will. But understand that there isn’t going to be a moment when you’ll get a great idea. The Brain Audit was not a great idea, it was just a presentation. Every product or service you’ve experienced at Psychotactics wasn’t a great idea and even today is just work in progress. Most ideas are half-baked when they start and it’s in your interest to get started. Start now! Identify whom you think will buy the idea, then work on the what you’re going to sell. Make it a superpower, as far as possible. And start now. If you keep at it, the road will change along the way. You’ll make mistakes and you’ll get smarter too. And that’s when the profit will roll in. Teaching Photoshop wasn’t a new idea. It wasn’t even a great idea. Heck, you could even borrow the idea by learning Photoshop and finding art directors. And the best way to get started is to get started. You’re a member of 5000bc aren’t you? Well, get to the Taking Action forum where others just like you have decided to take their ideas and run with it. They’re on their way and so should you. Useful Resources: 1) How A 3-Step Pre-Sell Creates Product Irresistibilityhttp://www.psychotactics.com/presell-creates-irresistibility/ 2) Three Unknown Secrets of Riveting Story Telling http://www.psychotactics.com/three-elements-storytelling/ 3) The Brain Audit http://www.psychotactics.com/products/the-brain-audit-32-marketing-strategy-and-structure/

Summary-So almost since I started the channel I have known Victor and Liam from Fatshark games. They were my first ever real interview and game coverage and honestly couldn't be too brighter and cooler guys. So I invited them to a casual talk. While we do talk about Vermintide we discuss all manner of things like technology, hobbies, when we first met, and what its like to travel to conferences. I also ask them some Patron Questions I am also pretty sure someone is told to choose their favorite child. Use the following links if buying this game or other games. It helps my channel ►My Amazon Affiliate Link http://amzn.to/1Lzl37q ►https://www.changetip.com/tipme/acg ►paypal.me/ACGsponsor ►G2A link for buying titles https://www.g2a.com/r/karak Social Stuff & Reddit ►My Twitter: https://twitter.com/JeremyPenter ►Subreddit: https://www.reddit.com/r/ACGVids/ ►My Itunes: https://itunes.apple.com/la/podcast/angrycentaurgaming/id966781846?mt=2 Patreon Stuff ►https://www.patreon.com/AngryCentaurGaming ►http://fbit.co/u/AngryCentaurGaming Steam Stuff: ►ACG Steam Curator Page http://store.steampowered.com/curator/6233509-Angry-Centaur-Gaming/ Buy, wait for a sale, rent, or never touch it. The Patented Karak review system to see if a game is worth a buy. --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/acg/support

This blog post is written by Ben Greenfield and Narrated by Brock Armstrong. I will be the first to admit that I spent most of my life not really understanding the difference between a “regular” sauna and an infrared sauna. While I’ve certainly covered wet saunas vs. dry saunas on a , and I’ve thoroughly discussed the myriad of benefits from heat exposure (from dry saunas to steam rooms to those dorky sauna suits) in ... ...until the recent show I’d never really delved into the concept of infrared saunas on the podcast either. But now that I’m spending at least two and, , as many as five days per week in an infrared sauna, I figured it was high time I filled you in on what I’m doing with infrared, why, and three ways to biohack your sauna for more heat, more sweat, and bigger benefits. ---------------------------------- Why You Should Use A Far Infrared Sauna First, you should know that this article isn’t really going to delve into the nitty-gritty of why heat therapy and saunas are beneficial, because . But before learning how to biohack your sauna experience, it is important for you to have a basic idea of what an infrared sauna is, and how it differs from dry saunas or steam rooms, especially if you haven’t jumped on the sauna bandwagon yet. Basically, an infrared sauna is a type of sauna that uses light to create heat. These saunas are sometimes also called far-infrared saunas, and the "far” simply describes where the infrared waves fall on the light spectrum. A traditional "dry sauna" uses heat from rocks or other heating elements to warm the air, which in turn warms your body. So a dry sauna must rely only on indirect means of heat: first, convection (air currents) and then, conduction (direct contact of hot air with the skin) to produce its heating effect. But because an infrared sauna instead relies upon light, it can heat your body directly without significantly warming the air around you, and the light waves from the infrared sauna penetrate deep (2-6 inches) into your body for a heating effect that allows more activation of your sweat glands compared to dry sauna. So an infrared sauna doesn't feel as hot as a dry sauna, but you sweat as much or more. In the book , Dr. Michael A. Schmidt explains the benefits of the slightly lower temperature of an infrared sauna like this: "Saunas are being used by some doctors to stimulate the release of toxins from the bodies of their patients. They have found that a lower temperature (105º-130ºF) sauna taken for a longer duration is most beneficial. These low temperatures stimulate a fat sweat, which eliminates toxins stored in fat, as opposed to the high temperature sauna, which encourages a water sweat.” Interestingly, the far infrared rays you get in an infrared sauna consist of similar wavelengths that are emitted naturally by the human body (yes, ). This is one potential explanation of why many people feel so energetically rejuvenated and balanced from contact with far infrared waves in an infrared sauna compared to feeling "drained and dehydrated" after a dry sauna experience. Tests have shown that the energy output in an infrared sauna is tuned so closely to your body’s own infrared radiation that you . So how does a far infrared sauna actually generate heat and invisible light? Far infrared saunas typically use either a carbon or ceramic heater, which do not turn red hot like the heating elements inside a conventional dry sauna, but instead produce invisible, far infrared heat. This is the same type of heat as produced by the sun, but without any of the effects of solar radiation. For years, many folks in the alternative health community have sworn by using infrared heat lamps as a source of far infrared heat, but these lamps can be cumbersome, they can get extremely hot to the touch and they  can be difficult to maintain at a constant temperature compared to an infrared sauna. So basically, an infrared sauna is like having a tiny little temperature-controlled sunshine inside an enclosed room, without the UV radiation. In an infrared sauna, only 20 percent of the energy from the light is used to heat the air, leaving the rest of the energy to heat the body. The temperature inside a typical infrared sauna is adjustable and averages about 100°F to 140°F, depending on how long you warm the sauna up before getting in, and what you put the temperature setting at. Many people actually find the lower levels of heat in an infrared to be more comfortable than a dry sauna. But although the temperature is slightly lower, you still sweat a ton in an infrared sauna, which is why they’re so popular for detoxification. However, a typical infrared sauna is still not quite hot enough for me, because I'm not just in there to detoxify, but also to produce a crap-ton of heat shock proteins, stress resilience and cardiovascular blood flow, so you’ll find out what I do about the need for more heat shortly. So do the things actually work? As the , several studies have looked at using infrared saunas in the treatment of chronic health problems, such as high blood pressure, congestive heart failure and rheumatoid arthritis, and these studies have indeed found some evidence of benefit. For athletes using a sauna post-exercise, those benefits can extend to being . No adverse effects have ever been reported with infrared saunas, and until I recently began using an infrared sauna, I’d already been using infrared therapy with a heating mat called a “” for the past two years. But even though a Biomat offers you a relaxing, warm surface to curl-up on for something like a soothing afternoon nap, it doesn’t hold a candle to the biohacked sauna experience you’re about to discover. ------------------------------- The Problem With Infrared Saunas Unfortunately, for most people, it's not the slightly lower levels of heat that tend to be the problem with an infrared sauna. Instead, it's the fact that most infrared saunas are concentrated hothouses chock full of Electromagnetic Fields (EMF), basically turning what is supposed to be a detoxification and longevity-enhancing experience into the equivalent of hanging out in a a microwave or perched inside a giant WiFi router, leaving you with cell damage, brain fog and inflammation after your sauna session. You’ve probably heard of EMF before, but here's a quick reminder: EMF are energy waves with frequencies below 300 hertz or cycles per second. Unless you live on a pristine Himalayan mountaintop, the electromagnetic fields you probably encounter daily are from things such as power lines, radar and microwave towers, television and computer screens, motors, fluorescent lights, microwave ovens, cell phones, electric blankets, house wiring and hundreds of other common electrical devices. For more detail on common environmental EMF’s lurking in your home and office, and also practical instructions on how to mitigate them, I'd recommend you check out my book “”. Anyways, deleterious health effects associated with EMF include: Memory Loss Depression Loss of Energy Irritability Inability To Concentrate Weakened Immune System Chronic Fatigue Headaches In case you want to investigate this more for yourself, the following are links to more information about the effects of EMF: 1) 2) 3) 4) 5) 6) Also, here’s an excerpt from Peter Asmus's book “”: “Remember when people who spoke of cigarettes causing cancer were derided as being alarmist nuts? (If you do remember that, you are at least 55 years old!) Today people who assert that there could be, let alone that there is, a risk associated with cell phone use are viewed as a bit wacky. Well, the Marlboro man died of lung cancer and it appears there is a growing body of information to suggest that the Nokia man might be saddled with dementia or Alzheimers (among others) for the privilege! Consider the following findings: • 3% of the population may have severe reactions to electromagnetic fields (EMFs) thought by some to shorten life expectancy. • Young people who start using cell phones before the age of 20 have a five-fold increase in brain cancer risk. • Up to one-third of the population may suffer from electrical hypersensitivity from EMF exposure.” And finally, for the ultimate guide to EMF, I'd recommend the book "". Anyways, it can be touch to generate infrared light without also generating EMF. As I’ve mentioned before on a podcast, this is the reason the  that I use comes with a built-in EMF blocker between the wall outlet and the controller device. And I’d settle for nothing less on an infrared sauna. So for my own personal infrared sauna, I chose a model that has a type of heater called a "True Wave II”, which contains a carbon based infrared heater with virtually no EMF. It’s made by a company called “Clearlight”, using a manufacturing process that allows them to cancel out EMF to levels that are nearly undetectable. Using ultra-sensitive EMF testing equipment, all of the True Wave heaters inside a Clearlight sauna are tested to ensure low and safe levels of EMF. EMF is measured in milligauss (mG), and when measuring with a gauss meter (), your exposure to EMF should not exceed 3 milligauss. This level is based on recommendations from both the (U.S. Environmental Protection Agency) and also the . Now I'm not really comfortable even getting very close to 3mG, so I was pretty pleased to find out that the EMF levels measured inside my Clearlight Infrared Sauna all around my seated position are at nearly 0mG. If I use a and measure directly on top of the heaters (and I'm definitely not sitting on top of the heaters!), the heaters have an average EMF output of about 2.5mG. That’s compared to over 100mg for other carbon based heaters in standard infrared saunas. You can see the testing below performed by EMF testing lab "VitaTech Electromagnetics". It’s pretty shocking how high the levels of EMF are in some saunas. You can . The EMF readings below are measured directly on the heater, and again, it's important to understand that where you are seated in the sauna, the levels are virtually zero, since you do not sit on top of the heater. Since I like to move around, exercise, do Bikram yoga, and even occasionally drag an exercise bike or a kettlebell into my sauna, the Clearlight model I chose is the "Sanctuary Y model" which is is the only combination personal hot yoga room and infrared sauna available on the market. You can leave in the two 35″ benches and you have a state-of-the-art full spectrum infrared sauna for lounging and reading, or you can remove the benches and have your own private hot yoga room with built-in heated yoga mat floor. Even though the EMF levels are rock bottom, the True Wave Full Spectrum heater system in the Clearlight delivers over 20 times the power of any other infrared sauna, but that’s still not enough for me, so I’ll fill you in on my hacks in just a moment. Anyways, before we move on, here’s how to get a fat discount at the same place I bought my Clearlight sauna: 1. Go to . This is the same site my guest Alex Tarris and I discussed in the recent podcast  Good deals on health equipment. 2. Once you’re there or in contact with them, mention my name, or when you order, use code "bengreen15".  3. That code, which you can use anytime, as much as you want will actually give you 15% off anything on the  site (like portable saunas, lay-down saunas, home detox equipment, etc.), but in terms of EMF, yoga capabilities, heat, etc. I can't personally vouch for any sauna except the Clearlight. If that seems like too much trouble to go through, or you want to get your sauna direct from the manufacturer, you can also . OK, let's summarize what we know so far. 1) Infrared saunas are a great way to heat your body “from the inside out”, which gives you not just heat and sweat benefits, but also detox benefits. 2) Most infrared saunas are concentrated sources of EMF, so I use the low-EMF “Clearlight” brand. 3) My sauna still isn't hot enough for my personal preferences. Now it’s time to move on to the fun stuff: three ways to biohack your sauna experience. This is where things get really interesting. ------------------------------------ Sauna Biohack #1. Hack Your Sauna Hotter Even though far infared saunas do a dang good job heating you “from the inside out” and producing the subsequent detoxification effect, there is one problem: even you sweat more quickly in an infrared sauna than you will in a dry sauna, and you will keep on sweating for a longer period of time, infrared saunas simply don’t get as hot inside as a traditional dry sauna. Most of the heat escapes the sauna by rising and escaping out the ceiling. And I don’t know about you, but I certainly don’t want to miss out on many of the positive physiological responses to uncomfortable heat, such as the production of heat shock proteins and stress resilience, the production of nitric oxide and enhanced blood flow, the increase in cardiovascular performance, the increase in brain derived neurotrophic factor and all the other cool (or hot?) things I discuss in my podcast episode with Dr. Rhonda Patrick ." So you're about to learn how you can get an extra 10 degrees out of your sauna, and save a lot of electricity as a bonus. It’s important to understand that most of the heat escapes an infrared sauna by rising and escaping out of the ceiling. The most important first step you can take when biohacking your infrared sauna is to insulate the ceiling. My friend Brett, a fellow biohacker who first put this idea in my head, charted his infrared sauna temperature and his sweat volume during a typical sauna session and found that after insulating it with the technique you’re about to learn, he got ten extra fahrenheit degrees of heat and nearly 30% more sweat volume! Instructions for insulating your sauna ceiling: Step 1: Remove plywood from the top of your sauna. Measure distance from the top of sauna to bottom of where the plywood was. This will determine the maximum amount of insulation board you can use to replace the plywood. Some people insulate it even thicker and leave the plywood completely off, but this can detract from the aesthetic pleasantness of a nice plywood ceiling, so it’s completely our call how thick you want to go with the insulation. Step 2: Once you determine your desired insulation depth, go to your local hardware or building supply store and get a sheet of the highest R value foam board that you can find for that thickness. If you do one layer, a 4 by 8 sheet will easily have enough volume to insulate any sauna. You might find that two layers of thin board fits better or gives you better R value. Also get a good roll of quality duct type tape. You will need a sharp long and stiff kitchen knife and a straight edge with which to cut and mark the foam board. Some small metal staples can also be handy for holding wires in place, but are not necessary. A roll of tape and screws or nails might prove helpful as well. Step 3: Measure the largest exposed sections of the sauna roof and cut the foam boards to fit the largest spaces. To cut foam board, simply mark it with a straight edge and a pen and then cut the marked area with your kitchen knife. Of course, it’s better to make your foam board a little bit too big than too small, since you can always cut off a little more later if you need to. Be sure to note where the vents are on the sauna roof and make sure that you plan to keep these clear when you put your foam board up, or drill or cut holes in the foam board to match the location of the vents. Also move any and all wires to the edges of the sauna top, and then staple or tape the wires in place if necessary. Step 4: Make holes in your foam board for thermostat, vents, speakers and lights (if your infrared sauna has these). Here’s an easy way to do this: make a loop of tape, adhesive side out, and place the tape on the spots of the ceiling you need have uncovered, such as over a vent. Then place the foam board in position on the ceiling, and the tape will stick on the board. Then remove the board, and you now know the location on the board to cut out! If you have a sounds system in your sauna, the tape won’t stick too well to the speakers, so for the speakers you can place screws on the perimeter of the magnet facing up. Then press the board down over those areas and the screws will stick in foam board. You then simply cut a circle in the foam board and chisel out the approximate amount of depth. I wouldn’t cut all the way through as this could allow air flow and heat loss. You just want it thin enough to where the speaker sound can come through. For the lights, you will want to check to see if they are LED or incandescent. If they are LED, then you can cut out a small cavity and it will work fine. If the lights are incandescent or fluorescent you will want to allow an adequate hole for cooling of the lights. Make sure not to insulate on top of the control mechanism, which is usually a stainless steel box on the top of the sauna. Step 5: After placing the large pieces of foam board, follow the same process and fill in the smaller areas on the ceiling with small pieces of foam board. Duct tape all of the seams, replace the plywood top, verify that all vent holes are vacant, then duct tape the perimeter and seams of the plywood top. Boom. Now you have a super efficient sauna that heats up quickly and allows you to create lots more heat and sweat. Here are a few photos of my heat biohacked sauna: The roof...using some basic 10lb weight plates to hold insulation down... Another view of the roof...   A close up of the roof and how the insulation is slightly cut to fit siding... The cork placed in the inside hole next to the speaker to hold heat in... How the sauna sits in my home gym... ----------------------------------- Sauna Biohack #2. Add Extra Heaters OK, so now you’ve got your sauna ceiling insulated. This is going to significantly jack up the heat levels. I must emphasize that the Clearlight saunas have excellent low-EMF heaters and get pretty hot, but I also realize that some of my readers are really masochistic heat-hacking ninjas, and may want to get a really, really intense sweat on. But I found that I wanted my sauna to get even warmer. Perhaps I’m a glutton for punishment, perhaps I’ve grown too accustomed to heat because to all my racing in the extreme heat of places like Hawaii and Thailand, or perhaps my body just has a lot of heat shock proteins and good cardiovascular cooling mechanisms, but I like my sauna really, really hot. Again, I could just use an extremely hot dry sauna, but I’d still be missing out on all the benefits of infrared, and I want the best of both worlds. So here’s the next step I took to get my sauna even hotter: I added two 2000 watt heaters to my sauna. Now, before you rush out to Google the best price on space heaters, you should now that just like most infrared saunas, most space heaters are notoriously annoying sources of EMF. My friend Brett, the guy I mentioned earlier who first put the idea in my head of insulating my sauna, actually purchased several different space heaters and tested them all for EMF. He found the space heater to be both affordable and have very low EMF. But the problem is that a space heater shuts off at around 120 degrees, so it is only useful for pre-heating your sauna (helping it to heat up faster if you want to accelerate the pre-heating process). There is no space heater that Brett or I have found that doesn't have this annoying high temperature shut off feature. It's probably some stupid fire code regulation or something. But you can think outside the box... ...and this is where a portable stove burner comes in. Yes, a stove burner is normally used for cooking food, but portable stove burners also don't have high temp shut offs, and they put out plenty of heat. Before choosing a portable stove burner, I’d recommend you first check your breaker to see how strong a stove burner you can get. If you have a 15 amp breaker, then your stove burner can be 1500 watts, and if you have a 20 amp breaker, then you can go step up 2000 watts. To check your breaker amps (if your breaker isn't labeled), you can simply call your local neighborhood electrician, or you can overload the circuit with a couple of space heaters or hair dryers and see which breaker trips. Or . So, what did I find to be the best portable stove burner heaters? For a nice, cast-iron 1500 watt, I recommend the . The fact that this burner is cast-iron means that it is very heavy, which gives you a bit of built in safety, since it won't easily tip over. And if you want to step up to 2000 watts, then you will need two of the . For added safety and to avoid the heaters moving or tipping, you should create a sturdy base for your stove burner. To do this, you can mount the burner(s) to a thick, heavy piece of wood such as a short 2x12 or a piece of plywood. I’d recommend you also create a protective barrier over the top of your stove burners. You can do this by surrounding the burner with some thick wire like over the top of the burner and a couple inches around the sides. You can then attach the wire screen to the wood base. And for Pete's sake: if you have young children running around, know where those stove burners and kids are at all times unless you want some free hot branding tattoos for your young ones. Will these stove burners put out a little EMF? Ultimately, yes. But the important thing to know about EMF’s is that they follow the inverse square law, which, simply put, means the amount of EMF reduces very quickly as distance from the EMF increases. This is why overhead high voltage power lines will give you far less EMF exposure than a very low voltage electric blanket, since the blanket is very close, but the power lines are far away. For example, when I tested my portable stove burner, I had to be 12 inches away to get below 2 milligauss, a completely safe acceptable level of EMF. So if you put portable stove burners or space heaters in your sauna, just make sure you hang out about a foot or more away from them, which is easy enough to do. ----------------------------------- Sauna Biohack #3. Detox With Niacin Detoxification is a topic I’ve covered many times before in other articles, and probably the best resources for you in this regard for you are the Get-Fit Guy episodes "" and “”. My friend Brett (the same guy I've mentioned twice already who figured out how to hack his sauna and introducted me to the strategies above) has also spent the past 20 years experimenting with detox strategies from herbal tea, to colonics, to enemas. I’d never heard of this particular niacin+sauna strategy, but a few weeks ago, Brett sent me this very interesting anecdote: "About 8 years ago I discovered a book called . The book was written many decades ago and the purpose of the book was to teach the reader how to clear toxins from drug use by using a sauna for long periods of time, combined with niacin and other special supplements. What was different about this book is that it had the actual research and data to prove its claims, along with numerous accounts of high levels of toxins in the blood being dramatically reduced by this protocol, and continuing to reduce for weeks after the protocol was completed. Then I learned that most detox experts, from Dr. Yu to David Root, say that Hubbard's protocol is the most effective detoxification protocol there is. Period. It is so effective that doing this protocol. The basic idea behind the protocol is this: high dose niacin causes lipolysis, or rupturing, of the fat cells (the same thing happens with extreme, rapid weight loss). This rupturing is what releases the toxins from fat cells (you can read exactly about how that whole process works in my article “Does Fat Loss Cause A Toxin Release?). The running/exercise part of the protocol (which you’ll learn about in a second) increases circulation, especially in the lymphatic system where fat cells are carried. Then the sweating in the sauna releases these toxins through your body’s primary and largest detoxification organ: your skin. Later, even more of the toxins are eliminated through the stool. Supplements that you take during the protocol are primarily designed to replace lost minerals, electrolytes and fats, and to help to absorb the mobilized toxins in the gastrointestinal tract. I will give a summarized version of the protocol in the subsequent paragraphs, but first, a big warning: do not do this protocol without a full and comprehensive understanding of it. If you mobilize high amounts of toxins and do not completely include all the other aspects of the protocol you will suffer from hypertoxemia. So to get a full understanding of the protocol, you need to read the book . You must get the 1987 or prior copyright date of the book, and will help you get a used copy very affordably (the new editions of the book have been oversimplified and lack crucial valuable information). The protocol lasts about 30 days, but can be customized to fit your schedule. The sauna duration is directly correlated to your toxicity. If you’ve been living healthy for a long time (e.g. a decade or more), then reduced sauna time is needed. If you have been exposed to chemicals and eaten a standard American diet and taken drugs of any kind legal or illegal then you will need to increase the sauna duration." Brett then went on to explain this basic protocol: "First, heat up your sauna long before you go for your run. You want it roasting hot. I have the best far infared sauna made (Clearlight) and I still have insulated the ceiling and I put a space heater in it to keep it even hotter. In addition, I blocked the hole where the thermostats is with a cork so that the heaters stay on the entire time. Because of this, I purchased a separate thermometer to monitor temperatures. These steps increased my sweat volume dramatically. Next, take high dose niacin right before your run. A dosing chart is in the book. Follow it. Then, go for a run for 20-30 minutes. If you can’t run, ride a bike, use an elliptical trainer, jump on a mini-trampoline, etc. The primary goal is to raise body heat and to increase lymph and blood flow. I also turn the sauna timer back on to make sure it is still warming up when I run. For the exercise, I recommend dressing as warm as you can tolerate to raise your core temperature. When I did this, I sweated much more while I was in the sauna. Next, get in the sauna and stay in the sauna for as long as you can tolerate. Around an hour works for most people depending on toxicity - the more toxic, the more time, the less toxic, the less time. Finally, cool yourself with a lukewarm or cold shower, then take appropriate doses of mineral, electrolytes and fats and oils as described in the book. Repeat daily for 30 days. When you finish, you will have eliminated years of toxins and you will benefit tremendously in numerous ways from this protocol. This protocol is usually administered by professionals. If you decide to do this without supervision, then you need to have complete knowledge of the protocol and access to others for support and questions and answers. I have a support group for this at Facebook called "”." It turns out that Dr. Joseph Mercola recently learned about this protocol. This guy has heard about every detox method there is, and he was shocked and amazed. Check out his reaction in the video below. It is only 3 minutes long but it will give you an idea of the validity of the program from one of the most trusted natural health experts on the internet. The idea behind combining the niacin, the exercise and the heat is that the niacin and the heat causes a "", meaning that the niacin first tries to prevent lipolysis and then after one to two hours, it rebounds and leads to massive  such as BPA, PCB's, pharmaceutical byproducts, etc. Clearlight has a very helpful .pdf that you can Now here’s the deal: I don’t live a very toxic lifestyle. And I haven’t for over a decade. So I didn’t do the exact protocol above per se, but instead simplified into the following steps: 1. I modified my sauna using both the insulation and stove burner hacks you learned earlier in the article. I must emphasize that the stove burners aren't completely necessary because the sauna does get pretty hot by itself, and you may want to forego the stove burners altogether if you have kids around. 2. I read the book and for 30 days, I followed the niacin dosing chart prior to my pre-sauna exercise. I used  and for me it came out to 500mg week 1, 1000mg week 2, 2000mg week 3, 3000mg week 4. I chose the because it's in a safer form of niacin called "Inositol Hexaniacinate". This is important because the side effects of high amounts of niacin range from flushing and itching to liver toxicity and impaired glucose tolerance. I didn't take any of other supplements in the book, because I already get plenty of healthy fats and oils and take a . 3. During the entire protocol, I used the following simple sauna + exercise strategy: after my hardest workout of each day, I sat, read, stretched, did yoga, and foam rolled in the sauna for 30-45 minutes, depending on my available amount of time. This may seem like a big chunk of time, but to maximize productivity I simply saved all my reading and stretching and foam rolling and yoga for my sauna time.  Although I did not measure sweat volume, the amount of sweat pouring from my skin dwarfed any “normal” dry sauna session I've ever done. I already eat plenty of fats and oils, but I included plenty of in the water I consumed after each session, along with hefty amounts of water and generous portions of sea salt with dinner. Although my eyeballs literally feel as though they’re going to pop out of my head during these sessions, once I get my post-session cold shower in, I feel absolutely amazing. Again, I’m not sure how many toxins I dumped during my initial 30 day niacin phase, since I’m not very “toxic” in the first place, but for the rest of the day after my sauna session, I noticed marked improvements in skin tone, clarity of thought, calm and focus. And even though now that I'm done with the 30 day protocol and I'm no longer doing the daily niacin sauna protocol, I'm still using my sauna nearly every day. You could probably say that I am now officially addicted to heat therapy. And yes, I am aware of L. Ron Hubbard's affiliations and I am not a member of the Church of Scientology. I just like to get high on niacin and do kettlebell swings in my sauna. ----------------------------------- Summary So that’s it! What do you think? Do you plan on using any of these sauna biohacks? Leave your comments, thoughts and feedback below. If you want a Clearlight sauna - the same I am using and same Alex Tarris and I discussed in the episode , you can simply go to  and when you call or write them, mention my name, or use code bengreen15, and you'll get 15% off anything on the site. You can use that code anytime, as much as you want. Or you can . Oh, and below are some fancy photos and specs for the Clearlight Sanctuary Y model that I personally use. You'll notice that the specs show that the ceiling includes something called "color therapy", also known as "chromotherapy". I didn't even tap into that concept in this article but am working on an article about that for you too. It's a very slick and helpful feature for fixing and aligning your sleep cycles. Enjoy, and leave any questions or thoughts in the comments section.

Summary:So far in our project, we've mostly spoken to people who were involved in startups that went public in the dot com era. But as I've said many times, that's only part of the story. I very much wanted to speak to someone involved with a successful startup that was acquired by a larger "portal" site. So, I reached out to Ted Barnett, who was one of the founders of the early web calendar site, When.com, which was eventually acquired by AOL. In this episode, we talk about the economics and strategic considerations of a 90s startup that found overnight success, but could not scale in a way that would allow it to continue to grow without hooking up with a larger, deeper-pocketed partner.But Ted's career is so interesting and varied, we also got to delve into a bunch of other fascinating topics: what it was like to work at Apple in the late 80s, early 90s John Sculley-era; the pre-web "bubble" of pen-computing startups; working at AOL at the height of its late-90s powers; how a company like Kodak dealt with technological disruption completely decimating its 100-year old business; and even the current prospects for Virtual Reality technology.Because our discussion with Ted paints such a well-rounded picture of a technology career lived in full... recounting how a young technologist can work their way up the ranks, all the way to founder and CEO... I would go so far as to say this is absolutely an essential listen for young people who are starting out in Tech today. See acast.com/privacy for privacy and opt-out information.

A couple weeks ago, I caught a lot of online flak for publishing about how professional basketball player Lebron James' constant use of a cell phone held up to his head probably contributed heavily to his recent development of mouth cancer. And then, just yesterday, here on , I visited the home of another professional basketball player - (the photo above is of me and Doron in his backyard garden as I interview him). Doron was an amazing basketball player. He was an achiever. A hard-charger. A professional person. As a guard for the dominant college basketball team UConn, he fed the ball to star teammates like Ray Allen (recently with the NBA’s Miami Heat) and played for legendary coach Jim Calhoun. Sheffer averaged five assists and thirteen points per game, he hit 40 percent of his three-point attempts and he led the Uconn Huskies to a brilliant 89-13 record, along with NCAA tournament appearances in each of his three seasons. He was the first Israeli ever drafted by the NBA (the Los Angeles Clippers selected him in the second round in 1996), but he instead signed a lucrative contract with the Israeli professional basketball team, Maccabi Tel Aviv - which he then led to four consecutive national championships. But then Doron got cancer. Testicular cancer. All the tremendous pressure, tension, difficulties, frustrations pent-up emotions and stress from the life of a hard-charging professional athlete eventually built up inside him and culminated in disease. --------------------------- Stress Causes Cancer Indeed, that emotional stress similar to what Doron experienced can be a trigger for the growth of tumors. As a matter of fact, any sort of trauma, emotional or physical stress, can act as a literal pathway between cancerous mutations, bringing them together in a potentially fatal combination. In other words, your risk for developing cancer can be positively or negatively affected by your emotional environment, including everyday work, physical, emotional and relationship stress. Now here's the deal: I'm personally a very hard-charging guy focused on personal and professional excellence in everything I do. And as I noted to Doron in the audio that accompanies this article, I truly believe that unless you are able to relax, to breathe, to de-stress and to simply stop and smell the roses, you're going to be the kind of person who eventually develops a disease that puts your fast-forward life into slow-motion. So you have to put the brakes on before your body puts the brakes on and forces you to stop, perhaps with the flu, perhaps with back pain, or perhaps with cancer. Make sense? ----------------------------- How To Slow Down Before Your Body Forces You To Slow Down (Audio And Video) The ultimate question is: how can you do this? How can you slow down before your body forces you to slow down? How can you somehow dig yourself out of a hole of a constant barrage of e-mails, text messages, phone calls, over-exercising, eating to train and training to eat, going to bed late, 24-7 self-quantified biohacking, trying to "have everything", getting up early and still somehow managing to squeeze in some semblance of quality in your friend and family relationships? This is exactly what Doron figured out, and this man's new approach to life, his answers, and his new aura of peace and calm spoke heavily to me, which is why I'm now sharing his story with you. He defied conventional medicine and naturally healed his body of cancer, and his approach to life is now refreshing, relaxed and incredibly peaceful. Myself and the team from visited Doron at his in Amirim, in the mountains of Northern Israel. Amirim was founded in 1958 as a retreat for vegetarians, and it now serves as a residence and hotspot for a community of aromatherapists, massage therapists, herb gardens, spas, a health food shop, an organic olive oil shop, art galleries, restaurants and wellness bed and breakfasts. These mountains are where Doron reinvigorated his body and underwent his own "spiritual cleanse" after winning his battle against testicular cancer. These mountains are also where Doron talked to us for 30 minutes about his new perspective on life - 30 minutes of some of the most valuable content you'll ever listen to or watch (if you're serious about living happy and disease-free). Just do me a favor: don't listen to or watch this one while you're out pounding the pavement, punishing the gym, or doing hardcore intervals on your bicycle. Instead, go sit in your backyard, or at the park, or in a comfortable chair in your living room and just breathe and soak in the message. Ready? Click here to listen to the audio of our talk with Doron, which was recorded in his backyard garden looking over the beautiful hills of Amirim, and eating organic figs, goji berries and sweet local almonds. , or watch below (video may not yet be fully uploaded). ----------------------------- Summary So that's it. What do you think after listening to the audio or watching the video? What can you change in your own hard-charging life so that you can slow down before you're forced to? Leave your questions, comments and feedback at . , which is actually open for visitations and retreats for people who want to find the same kind of peace that Doron found, and engage in therapies like Tai Chi, Yoga, Qigong, farming, water treatment, solar healing and simply...playing.

The following is a guest post by Dr. Andrew Hill, Lead Neuroscientist at . Click here for a fascinating audio podcast that accompanies this article. featuring Ben Greenfield and Dr. Hill. Dr. Hill received his PhD in Cognitive Neuroscience from UCLA in 2012, studying how attention operates in the brain. He has been employed as a Lecturer at UCLA over the past few years, teaching multidisciplinary courses on both Healthy Brain Aging and courses in Neuroscience and Psychology. Dr. Hill has published chapters on measuring and modulating human attention, and continues to research self regulation. Prior to UCLA, Dr. Hill obtained extensive experience working with both psychiatric and developmental populations as well as gaining experience in high technology areas. He received his B.S. in Psychology/Neuroscience from UMass Amherst, and is a key adviser in the formulation of the (get 20% off on your purchase with the code BEN20). --------------------------------- The Limitless Pill In the , Bradley Cooper’s character gets his hands on a smart drug (NZT-48) that enables him to be cognitively super human. The only known side effect is that his eyes change color while he is on the drug, but that changes over the course of the movie as side effects, including withdrawal symptoms, begin to get worse and worse. It’s a sci-fi thriller with a not-so-feel-good message about addiction and performance enhancing substances. And goons chasing you. Makes smart drugs sound dangerous, right? Like any good sci-fi , this movie questions our assumption on the limits of science. And some of what it is suggesting is not science fiction today. Smart drugs and nootropics are a current reality, being used more and more not to treat or remediate any active condition or complaint but towards boosting already typical or superior performance, in colleges, board rooms, military theatres, and by forward thinking gerontologists. With the wide variety of compounds available today that have some research support for cognitive effects, it is important for you to understand the risks and benefits associated with usage, or at least how to choose smarter, when choosing things that affect your brain. For example, one of the most popular misconceptions about smart drugs is that they are the same as nootropics. This may be due to similar benefits that people use them for, but ultimately they do not share the same range of effects, mechanisms of action, safety and side effects. So - what are smart drugs? What are nootropics? How do we know if something is safe or effective? What are these drugs actually doing to my brain? Why am I asking so many questions without answering them? Keep reading to get this and more information you need to understand these questions, and start formulating your own answers - and your own strategies for selecting nootropics. --------------------------------------- Smart Drugs vs. Nootropics A smart drug is generally a prescribed medication or off-label drug used primarily to treat some kind of mental or cognitive disorder. The most common are drugs such as Adderall (dextroamphetamine) or Ritalin (methylphenidate) in the stimulant class used to treat symptoms related to ADHD - although legal and illegal off-label use is rampant. And while they may promote focus and energy in some people, others have dramatic side effect, to body and brain. Smart drugs in the stimulant class also tend to be reinforcing, producing spikes in dopamine and norepinephrine. This leads to tolerance and habit formation, including adverse effects on appetite, mood stability, cardiac function, stress levels and possibly many other unwanted effects - especially on younger brains such as teens and young adults. Irritability and mood swings, anxiety, sleep issues, and other forms of emotional or cognitive regulation problems can crop up over time with stimulant use, as well. A popular atypical stimulant “smart drug” includes the narcolepsy agents Modafinil / Adrafinil, although their effects on cognition beyond wakefulness are unproven, and side effects - while rare - can be life threatening. If attention problems are already present the side effect risk appears to be significant increased, as well. (). In contrast to a smart drug, a nootropic is generally a non-prescribed compound, including vitamins, herb, other supplements, natural or synthetic compound that may increase or protect cognition in some way. The preponderance of research in the past 40 years shows some effects on focus, attention, effects on aging, and possibly cellular metabolism. To paraphrase the definition of “nootropic” as , it is something that improves cognition without appreciable side effects, or provides from protection to the brain. In a modern context we think of nootropics as something used not to treat any mental condition or pathology directly, but instead to provide support to peak function, protect against long term risk, and provide daily boost. Across the field, true nootropic ingredients and full blends can now be found largely sourced from natural ingredients. Nootropic blends are designed to leverage synergy effects suggested in the research and subjective experiences. The goals with nootropics should always be to allow for greater and more consistent cognitive effort and flow, without the side effects of a stimulant or other harsh substance. ------------------------------ How Do I Know If A Smart Drug Is Safe? As a rule of thumb, it is the nature of science to be wrong at times. We’ve come a long way since we accepted that the theory behind the Earth being the center of the universe was wrong. We understand that new research may overturn old knowledge. So how can we truly know the risks and benefits of long term use of nootropics or smart drugs? A red flag in understanding the harm of a substance is the body’s ability to handle an overabundance of this substance. Small amounts of toxic substances may be beneficial in the short term, but the magic happens when we look at what is happening in the body when we get too much. Something as simple as a cup of coffee may seem harmless, but caffeine in high amounts can cause dizziness, anxiety, and even cardiac arrest or death. Caffeine mimics the action of the neuromodulator adenosine in the body. This leads to higher adrenaline and cortisol levels. Even in typical doses caffeine can deeply affect our sleep and cause heart arrhythmias for some people. Alcohol has even worse short and long term toxicity symptoms at non-moderate doses, and some people struggle to keep their dosing moderate. In better doses - perhaps a couple cups of coffee a day (without sugar) and a drink or so per day on average, these substance are actively health promoting, and reduce risk for many brain and cardiac diseases. When you are picking substances and compounds, dosing should be cautious at first. From this, a couple rules come out - 1) don’t take any compounds, substance, or blends of substances that don’t list all their ingredients out in plain amounts. Proprietary blends with lump-sum amount hiding buzzword-compliant list of magical ingredients known as “fairy dusting” in the supplement industry. Don’t be fooled. Read the ingredients. Figure out why and what is in there, and if you want it. 2) don’t chase suspicious research chemicals without much history of use or safety profile. Experiment on yourself if you like, but you only have one brain - make rational and cautious choices. There are nootropic, smart drug, and cognitive enhancers that have been around for decades - something released last week as a “Research Chemical” with a bunch of numbers and letters for a name and no human studies isn’t worth the risk to you. Not for years. ------------------------------- What About Adderall & Modafinil Safety? Smart drugs such as Adderall can cause dangerous lows, psychosis with extreme use, rebound fatigue, and depression, even at lower use levels. As an amphetamine, Adderall can act as a reuptake inhibitor, meaning that it can compete with other neurotransmitters for reuptake. Specifically it is thought to block the uptake of dopamine and norepinephrine, which are associated with reward behaviors and our nervous system functions, respectively. This causes a flood of these neurotransmitters onto multiple receptors, causing neurotransmitter depletion and overexcited receiving neurons. This large “signal” is the reason for the focus, but also responsible for some of the side effects that go along with this class of prescription drugs. Existing research is also a bit weak on any improvement that Adderall or other stimulants may have on short term memory or cognitive function, and some actually may impair function. Modafinil, also known as Provigil, is an example of a smart drug that has been used like a nootropic. Modafinil is prescribed to treat sleep disorders, but when combined with a normal functioning brain, can potentially cause increases in cognition and awareness. Just like Adderall, the use of these drugs outside the medical field does not make them a nootropic. Modafinil is also a reuptake inhibitor for dopamine, causing the same type of neurotrasmitter flood as Adderall. However, Modafinil may also affect the histaminergic pathway, which deals with wakefulness and the delicate immune response of the body. Histaminergic neurons in the brain are more active during wakefulness and slow their firing pattern as we rest or sleep. Modafinil’s “beneficial” side effects may come from this heightened histaminergic neuronal activation, but too much activation can cause apoptosis, or cell death. In addition, this has been shown to cause adverse skin reactions that required hospitalization since the histamine pathway also deals with our immune system. Modafinil may increase your intelligence, but can be extremely dangerous to the health of your brain and body. ------------------------------- Enter Nootropics Nootropics, , and a few other products on the market, have dose-toxicity levels much lower than salt, caffeine, and especially Adderall. There doesn’t seem to be any neurotransmitter depletion, tolerance or habit forming potential, adverse body side effects, or impaired brain function, from most true nootropics, by Girugea’s definition. The mechanisms for nootropics lie within the structural connectivity of the brain, the optimization of blood flow and oxygenation, and the fortification of brain regions over long term consistency. Nootropics act more as a super supplement to protecting the brain. Girugea’s own first synthesized nootropic (in 1964) is still in use today and has been shown to have effects on mitochondrial metabolism, cell membrane fluidity, and functional connectivity in the brain. Piracetam is this poster child for nootropics, and one of the main ingredients in . It is one of the only compounds used in that formulation that can not be found in nature, however it was originally derived from - and has structural similarities to - the neurotransmitter GABA. Since Girugea bought piracetam to light in 1964, there has been lots of research to support the benefits of piracetam. It has been shown to positively affect our cell membranes and to have neuroprotective and pro-metabolism effects on cells. The fluidity in our membranes changes with stress and old age, as well as moment to moment as one method of regulating receptor activity. By keeping our membranes healthy we can promote the cells ability to communicate. For example, combines other membrane oriented supplements - including choline. The cell membrane - especially in the brain - relays ongoing control signals and messages from other cells to the inner processes of the cell. Neurons’ membranes in the axon (wiring) and soma (cell body) help generate and propagate electrical signals, sum distant signals, and even have computational and complex learning functions related to changes in membrane function.Healthier and more active cell membranes bring us increased activity and cell communication, and hopefully better cognition. Piracetam along with other ingredients such as magnesium, choline, and DHA, increases in brain plasticity and are designed to improve cognition and efficiency under processing load - or peak performance, versus remediation. Nootropics may support increased cognitive potential as well as long term protection. The team added L-Theanine and L-Tyrosine to support neurotransmitters of GABA and Dopamine, respectively. You can use a similar or different strategy when building your own nootropic regimen, but use a strategy. Know why you are putting an ingredient in, know how it might interact with the others, and be sure that dosing is safe. When you are planning your nootropic or nutraceutical regimen, think in terms of nutrition support to cell metabolism and function, amino acids, natural or near-natural compounds, and avoid bad fats and harsh chemicals that give a momentary boost at the cost of later crashing or having other more serious side effects, such as excess sugars and caffeine. And don’t forget what else you put in your mouth - additional DHA and other omega-3 fatty acids (in grass fed meats, deep sea fish) are excellent for brain health. Craft your diet like you craft your brain supplement regimen - or have both catered / curated for you in a high end product. If you do create your own blend, think precise selection, not shotgun approach, and add slowly to your regimen. -------------------------------- The Problem With Instant Gratification As a culture, we often hear false marketing claims or create mindsets about what is possible with our health. We see ads that advertise a pill that gets rid of “stomach fat fast”. Truthfully, fat is lost uniformly in the body and the fastest and healthiest way to lose weight it about 1-2 pounds uniformly a week. So we eat poorly and don’t exercise for 2 years and then criticize our healthy workout plans and diet 1 month in when we don’t get the results we want. The healthiest and most effective things in life are often the ones that we do routinely. Consistency is key. This is true if you are talking about athletic performance, academic or intellectual training, or nutrition and supplement support. While not “necessary” like supplements or medicines, nootropic use follows this principle as well. There is another rule, emerging. If something is strongly “felt” dose to dose - if it gets you high, or wired, or sedated...it’s a smart drug, recreational drug, or something that may enhancing some aspect of performance (perhaps at the expense of another), but is definitely not a nootropic. And finally, nootropics should be sustainable. With some nootropics there is an initial loading phase followed by a maintenance phase, and while subtle, results can be felt fairly quickly on the timescale of a few days. The contrasting quick highs / crashes of coffee, alcohol, smart drugs, and even quickly digesting carbs are definitely experienced more immediately, but have consequences that make them unsustainable for many people. ------------------------------ Summary So in summary - here are a few initial rules to help select your own nootropic or cognitive enhancing blend: Know your ingredients, and their amounts. Don’t spend your money on obfuscate fairy dusting or expensive blends that are full of caffeine or random research chemicals. It’s not a nootropic if it has side effects. Your nootropic solutions should focus on mild nutritive and metabolic support, for long term gains and protection. Break the cycle peak and crash that you get with too many stimulants, and avoid the more serious side effects that you risk with smart drugs. Nootropics don’t get you high, altered, or wired. And don’t forget the other accessible and evidence-based brain and cognition improving methodologies we have at our disposal today: meditation, yoga, and other contemplative (attention training) practices, biofeedback and neurofeedback, diets high in good fats, and other modifiable behaviors you can implement to take control of your brain health and performance. So take care of your brain - the tools are out there, to support health and shift performance. Leave your questions, comments and feedback at . Also, if you want to try the nootropic that Dr. Hill helped design, and get 20% off on your purchase with the code BEN20.

2 years ago, I decided I was fed up with supplements. Just freakin' tired of all the tablets, capsules, pills, powders and oils. And bottles. Lots and lots of plastic bottles scattered everywhere. I distinctly remember the day I finally decided something needed to change. It was when I swung open the door of my refrigerator to dive into my daily regimen of vitamins, antioxidants, nutrients, micronutrients, fish oils... ...and I realized it was getting overwhelming. Sure, it was better living through science, but it was anything but simple. I'm sure you've experienced the same thing. You open what seems like nearly a dozen different bottles to launch into your morning supplement regimen.... ...or you pack your suitcase to travel and struggle to prioritize which bottles to shove into your limited suitcase space... ...or you spend an inordinate amount of your precious time tracking, ordering and restocking your vitamin D or your fish oil, or your greens, or your multi-vitamin or your minerals or your antioxidants or your amino acids... You get the idea. Supplement clutter, supplement confusion and utter lack of supplement simplicity. ------------------------------------ 9 Reasons You May Not Want To Throw Out All Your Supplements Now don't get me wrong. I don't think supplements are an inconvenient and unnecessary curse that should simply all be tossed out. There is certainly evidence that , but even if you're eating a “healthy” diet, studies have shown that it is nearly impossible in our modern era to get all our nutrients, vitamins and minerals only from food. For example, a : "Large portions of the population had total usual intakes below the estimated average requirement for vitamins A (35%), C (31%), D (74%), and E (67%) as well as calcium (39%) and magnesium (46%). Only 0%, 8%, and 33% of the population had total usual intakes of potassium, choline, and vitamin K above the adequate intake when food and multivitamin use was considered. The percentage of the population with total intakes greater than the tolerable upper intake level (UL) was very low for all nutrients..." "...Conclusions: In large proportions of the population, micronutrient sufficiency is currently not being achieved through food solutions for several essential vitamins and minerals. Use of age- and gender-specific multivitamin supplements may serve as a practical means to increase the micronutrient status in subpopulations of Americans while not increasing intakes above the upper intake level." So how on earth could this be? Is the planet broken or something? There's actually nine reasons for the failure of modern diets to supply our bodies with all the nutrients we need. First, modern commercial farming practices strip our precious soil of nutrients. When plants are repeatedly grown on the same land for year-after-year (a relatively new phenomenon in agriculture that beats up our land but gives us lots and lots of calories), the overused soil loses it's nutrients faster than they can be replaced.  Over time, the plants have fewer nutrients to grow, so the farmers are forced to fertilize.  Fertilizer does indeed contain enough nutrition for a plant to survive until harvesting, but not enough nutrients to support your body's nutrient needs. As discussed in the excellent book "", this results in plants that up to 75% fewer micronutrients. This problem is compounded by the fact that most plants are not harvested fresh, and the nutrients degrade as they often sit on airplanes, trucks, shelves, and counters for weeks before they arrive on your plate. Second, most , and not maximum nutrients, and because of this much of your fresh produce that us humans would have historically relied upon for nutrients are instead .  And of course, this is all passed on to the animals (including you!) that are eating the plants. For example,  found copper levels have dropped by 90% in dairy, 55% in meat, and 76% in vegetables! Third, pesticides are making this problem even worse.  Because polyphenols are produced as a defense against bugs and pathogens, . To make matters even more frustrating, even if you buy organic plants,  So unless you're going out of your way to grow your own fresh fruits and vegetables in a pristine backyard garden which contains soil that you've treated with added minerals, you are at a huge risk for malnourishment and nutrient deficiency that adversely affects your performance, fat loss, recovery, digestion, brain, sleep, and hormone balance. Fourth, it's not just nutrient-poor plants that are affecting the nutrient status of the actual animals we rely upon for food, but it's also what many of those animals are being fed - especially grains. Compared to grass-fed meat, grain-fed meat is , but unfortunately, eating high-quality, organic grass-fed (and grass-finished) meat, pastured pork and naturally raised poultry is simply not a reality for many people living in urban environments or frequently traveling. Fifth, the nutrients in your food aren't the only things that are disappearing - your liquids are being affected too. Unless you're drinking from your own well, or relying upon fancy mineralized water such as Pellegrino, Perrier and Gerolsteiner, your bottled water, filter water and tap water is also  - and if does indeed contain adequate minerals, these are typically accompanied by enormous levels of flouride and chlorine. So this means that unless you want to spend lots and lots of money on fancy water, you are stuck in a situation where you must filter your water to get rid of the dangerous stuff, then figure out other methods, such as supplementation, to get the minerals you'd normally be getting from the water. Unfortunately, milk is not much better than water. The majority of nutrients in milk are found in the fat, so while , most of us simply don't have ready access to it, especially at the typical grocery store.  In addition, pasteurization can destroy many of the nutrients in both skim and full fat milk.  , which increases your nutrient needs even more, creating a vicious cycle. So whether it's due to nutrient-poor plants, nutrient-poor animals, nutrient-poor milk, or nutrient-poor water, most diets are now so micronutrient deficient that they require on average . In other words, in our modern era, you would need to be stuffing your face all day long to actually get what your body needs, and this does not into account the fact that if you are trying to lose weight by restricting calories or if you are a physically active person like a triathlete, marathoner, Crossfitter, weightlifter, or other exercise enthusiast, then your risk of nutrient deficiency is going to be even higher!  In other words, if you are A) trying to lose weight by not stuffing your body full of excessive calories or B) an athlete  or physically active person, then you're pretty much guaranteed to be at a constantly malnourished nutrient deficit (unless you figure out a way to somehow squeeze in all those added nutrients). The older you get, the fewer nutrients you absorb, so as you age, the worse things become. And that's reasons six (weight loss), seven (exercise) and eight (age) that you may need a little help over and above what you'd get from food. So let's say you dig a well, grow your own produce, milk your own goats, eat strictly grass-fed meat and wild-caught fish, you're relatively young and you avoid excessive physical activity or calorie restriction for weight loss. Then you're safe, right? No added nutrients necessary, right? The unfortunate ninth fact is that unless you live on a pristine mountaintop in the Himalayas, you're exposed every day to airborne pollutants, xenoestrogens from plastics and BPA, environmental toxins, mold, industrial solvents, electromagnetic fields, heavy metals, fluorescent lighting, constant stress, sleep disruption and a host of other modern-day assailants upon your biology. Your body simply wasn't mean to deal with these physiological stressors - all of which vastly increase your need for nutrients to help you fight the daily battle. So for the nine reasons above - depleted soil, nutrient-poor produce, pesticides, conventional meat, subpar water and milk, weight loss, physical activity, age, and our modern post-industrial living environment, you definitely shouldn't throw out all your supplements. --------------------------------------- Is It Possible For Supplements To Be Simpler? So this was the conundrum I found myself in two years ago as I stood in front of my refrigerator door and sighed in frustration at the dizzying array of supplements and bottles. I knew that because of my extremely active lifestyle and the other reasons I just listed that I couldn't and shouldn't just throw out all my supplements. I knew that I needed to keep my precious nutrients topped off for better performance, faster recovery, optimized fat burning, clean digestion, superior mental focus, better sleep and hormone balance... ...but I also knew that I was sick and tired of having to lug around a bunch of bottles, painstakingly use a weekly pill box to keep track of my supplements like an old man tracks his medication, and constantly be headed over to Amazon or some other website to re-order something I was running low in.  And then there was that gnawing worry at the back of my mind that any of these supplements I was ingesting could be laced with something like chemicals, toxins, metals or illegal-performance enhancing drugs that could potentially damage my body, put pie in my face and get me banned from competing in a sanctioned sport like triathlon. I wanted better living through science. But I also desperately needed more simplicity. And I knew that somewhere, somehow, there must be a way to have both: the ultimate combination of science and simplicity. --------------------------------------- Seven Criteria a Multivitamin Must Have At that point, I embarked upon my quest to discover the greatest multivitamin on the face of the planet - something that could cover all my bases from a nutrient standpoint without requiring a dizzying, inconvenient and exhausting array of pills, bottles and packets. After all, that's kind of the definition of a multivitamin, right? It supposed to cover multiple needs. As a nutritionist, personal trainer, exercise physiologist and strength and conditioning coach with strict standards about what I find acceptable for myself or my clients to ingest, I also had a very distinct set of criteria that I knew a multivitamin must have - seven criteria to be precise... --------------------------------------- My Multivitamin Criteria #1: Capsules, Not Tablets Before completely shoving tablets under the bus, I'll acknowledge the two benefits tablets possess. First, because tablets are pressed together so hard, more nutrients can fill the same amount of space than you can put into a capsule. Second, it’s cheaper to make tablets than capsules. There are several drawbacks, however, to using tablets. First, tablets are much harder to digest. Because tablets are packed together so tightly and need far more binders and diluents to keep them together, it takes much longer for them to break down in the digestive system. A capsule, on the other hand, breaks down within just minutes of hitting your digestive tract. This is important because of the little known fact that most of the nutrients in a multivitamin actually need to be absorbed in your stomach. When a tablet takes too long to break down in the stomach, and passes on to your intestinal tract, its content will be far less broken down and absorbed. And that means expensive pee. Tablets also need lots of extra nasty ingredients, such as binders, lubricants, coatings, disintegrants, and other excipients. These ingredients must be added to make the tablet stay together, to make the tablet shiny, and to make the tablet break apart. Tablet press machines compact the powdered nutrients together (that have already been mixed with binders and lubricants) with a tremendous amount of force. Then, to make the tablets shiny and easier to swallow, the tablets are often sprayed with coatings such as shellac (just like the shellac found on furniture but instead labeled “pharmaceutical glaze”) or coated with “vegetable protein,” (most often a protein derived from GMO corn). Yuk. I'll take a capsule, please. --------------------------------------- My Multivitamin Criteria #2: One Morning Dose & One Evening Dose Your body needs nutrients throughout the course of the day, not just one huge shotgun dose when you get out of bed in the morning or before you go to bed at night. So I needed to find a multivitamin designed in such a way that it delivered important nutrients for daily metabolism and activity in the morning dose, and important nutrients for recovery, rest, and sleep in the evening dose, but without a dizzying array of capsules. I'll admit that it does take slightly more discipline to take a multivitamin twice a day – once in the morning and once in the evening – but it’s a much better way to deliver the optimal nutrients at the optimal times throughout the day. After all, you'd rarely eat only breakfast or only dinner, right? I figure if I can handle at least two meals, I can handle two supplement doses - as long it's not a dozen different bottles of stuff. --------------------------------------- My Multivitamin Criteria #3: Low Number of Capsules One extremely inconvenient factor in most multivitamin formulas out there is the number of capsules necessary for daily use if you truly are going to be able to get all the nutrients that you need from a single formula. I think that taking three capsules in the morning and three capsules in the evening is practical and doable for me. Anything less than the six capsules per day can significantly reduce the efficacy of a multivitamin formula, but once you get over six capsules, it becomes a pain to manage, difficult to swallow, and a hassle to travel with. --------------------------------------- My Multivitamin Criteria #4: Vegan & Vegetarian Friendly Capsules Most capsule-based multivitamins use capsules made from bovine gelatin - that's cow. And although I do not personally eat a plant-based diet, I have many clients who are either vegan or vegetarian. So I wanted the actual capsule material to be made from the best alternative to cattle-based bovine gelatin. The ideal answer would be a capsule made of cellulose, which is a natural, vegetable-based material, and is pure plant fiber (usually from pine trees). In other words, I know it's important to many of my clients and friends that no animals be harmed in the formulation of a good multivitamin. --------------------------------------- My Multivitamin Criteria #5: No Magnesium Stearate or Other Nasty Fillers Magnesium stearate is probably the most common flowing agent that you will find in the “Other Ingredients” section on the Supplement Facts box on any multivitamin label. Magnesium stearate is a lubricant that is used to manufacture nutritional supplements to help powders flow through manufacturing equipment faster. It allows more tablets to be manufactured per hour and is therefore a cost-savings choice for a manufacturer. However, studies have shown that magnesium stearate can reduce the absorption rate of some nutrients. It literally wraps around nutrients and keeps them from being absorbed in the digestive tract. So although magnesium stearate is not necessarily harmful, it can vastly reduce the effectiveness of the nutritional supplements that you are taking. Instead, I'd rather see a multivitamin use something like calcium laurate, which helps powders flow through the manufacturing equipment, but is a completely naturally-occurring material that does not inhibit absorption. Calcium laurate is not as effective of a flowing agent as magnesium stearate is, so products can’t be manufactured as fast, but it can certainly get the job done without the need to use magnesium stearate. When it is necessary to fill the capsule with something in addition to a nutrient or botanical, I'd rather see a multivitamin manufacturer use magnesium citrate, a the pure element reacted with pure citric acid; cellulose, a pure plant fiber, magnesium citrate-laurate, a pure element reacted with citric acid and lauric acid (a small fat molecule that does not inhibit absorption), silica, a pure element found in sand, and the amino acid leucine. Any of these fillers are completely natural and allow you to take a multivitamin without worrying about unnatural or harmful ingredients you might be ingesting. --------------------------------------- My Multivitamin Criteria #6: No GMO's For  personal health and longevity reasons, and for consideration of the earth's environment, I avoid like the plague any product that contains Genetically Modified Organisms (known as GMOs). Unfortunately, most multivitamins contain GMO-laden ingredients - as well as corn, gluten, and some of the other nasty fillers mentioned earlier. This requires that any multivitamin I would ever use would need to closely analyzed by the manufacturer and guaranteed to be absolutely certain that none of ingredients are derived from GMO sources nor that they utilize GMOs in their production. --------------------------------------- My Multivitamin Criteria #7: Certified to Have No Banned Ingredients As I mentioned, it's very important to me that any supplement I take is not only CGMP certified (manufactured in a certified good manufacturing practices facility to ensure purity), but is also free of any ingredients that would get me banned from competing in triathlons, or taint my body with unnatural steroids or hormones. For years, I've been under the impression that something called an "NSF For Sport" certification was the strictest, third-party verification standard by which to judge whether a supplement contains these potentially illegal or banned ingredients. Turns out, I was wrong.   There's something even more strict than NSF. And that is Australia’s Therapeutic Goods Administration (TGA), the pharmaceutical regulatory agency of Australia. Considered the toughest regulatory agency in the world, the TGA inspection and certification is conducted at a pharmaceutical level standard. Yes, that means the supplements certified by the TGA are verified to be as pure as an actual pharmaceutical drug. For me to hold a multivitamin to as strict a standard as a TGA certification would be tough. Only a handful of U.S. companies are able to achieve the status of holding a TGA certification and there is really only one dietary supplement company in the U.S. that ever has completed all three strict levels of a TGA certification, since the certification requires not only a review of Good Manufacturing Practices (GMPs) every two years, but also on-site inspection of every aspect of a multivitamin's quality control, laboratory procedures, pharmaceutical good manufacturing practices, and standard operating procedures. But that's not all. I'd also prefer for a multivitamin to be certified by Informed Choice. Informed Choice requires five samples from three different production runs of product to be tested, which would further guarantee, because of extremely rigid raw material and finished product testing and production procedures, absolutely no ingredient banned by any amateur or professional organization. In other words, I want rock-solid, bulletproof confidence that I can hand any multivitamin that I endorse or personally use to the best athlete on the face of the planet with zero reservations about whether or not the multivitamin is pure or might get them banned. --------------------------------------- Notoriously Neglected Ingredients That A Multivitamin Must Have I also know that there are notoriously neglected ingredients in most multivitamin complexes that make them barely scratch the surface of your true nutrient needs, especially if you're a hard charging athlete, exercise enthusiast, an aging person, a busy professional living a CEO-esque lifestyle, or anyone else with advanced nutrient needs. Take Vitamin D, for example. The 200-400IU of Vitamin D found in most popular multivitamins is basically enough to keep a child from getting rickets. This is not even close enough to support optimal hormonal balance and physical or mental performance. Problem is, the multivitamins that actually do indeed have the 2000+IU per day of Vitamin D that I like to see do not include optimal amounts of Vitamin A or Vitamin K to allow for ideal absorption and utilization of Vitamin D, or reduced risk of Vitamin D toxicity. Or take Vitamin K - a crucial fat soluble vitamin usually found in complete zero amounts in a multivitamin. The body actually needs nearly 400mcg per day of Vitamin K to support bone health, calcium and magnesium balance, and vitamin D absorption, among a host of other metabolic and immune-boosting functions. Yet strangely enough, it's not included at all in most multivitamins. So what else is neglected in most multivitamins that I searched for on my quest to find the greatest multivitamin on the face of the planet? 1. Vitamin B6, B12 and B2 In The Correct Form The bioactive form of Vitamin B6 is Pyridoxal 5’-Phosphate. But the most common form found in most multivitamins is Pyridoxine HCl, which is not the active form of Vitamin B6. So the Pyridoxal 5’-Phosphate is a must-have in my opinion. The most common form of Vitamin B12 used in nutritional supplements and processed foods is cyanocobalamin. Cyanocobalamin, however, is absorbed at a much lower rate than methylcobalamin, which is the form of vitamin B12 that a multivitamin should actually have. Riboflavin 5’-Phosphate is the bioactive form of vitamin B2, but unfortunately Riboflavin HCl is the form commonly used in multivitamins, and that form needs to be converted in an extra step in the liver to the active form. Why do most multivitamins cut corners on these forms of Vitamin B? They're either uninformed, or going for the cheap alternative. 2. Folate In The Correct Form  Folic acid is the most common form of folate used in nutritional supplements and fortified foods. However, a significant percentage of the population has trouble converting folic acid to folate, which is the natural form found in foods and in the body. A good multivitamin should use a form of folate called  l-5-methyltetrahydrofolate to ensure folate is absorbed. It does cost considerably more than folic acid, but again, I only want a multivitamin with ingredients that work - not that just look pretty on a label and then give me expensive pee. 3. Minerals That Are Actually Absorbable Minerals by themselves are poorly absorbed, but when bound to an amino acid (also called a "mineral chelate") they are absorbed much better. Technically the most absorbable form of a mineral is the bisglycinate chelate form, and to avoid the minerals in a multivitamin simply creating expensive pee, I would specifically like to see calcium, magnesium, copper, zinc, manganese, chromium, and molybdenum minerals in a chelated form. 4. Curcumin That Is Actually Absorbable Curcumin is one of my favorite supplements, and has received a lot of attention recently as a potent natural anti-inflammatory nutrient that can control brain and muscle inflammation, positively affect muscle health, joint structure and function, and antioxidant activity in the gut, liver, and heart. But the trouble with most curcumin ingredients is that they are extremely poorly absorbed. However, there is one form of curcumin called the phytosome form which was developed by the researchers in Milan, Italy, and has been shown to be absorbed 29 times better than a standard curcumin extract. This is the only form of curcumin that I'd like to see in a multivitamin. 5. Green Tea Extract That Is Actually Absorbable Green tea is another powerful antioxidant that has been shown to have a mild effect on raising metabolic rate and improving fat oxidation. But like standard curcumin extracts, standard green tea extracts are not well absorbed either. But the same researchers who discovered the curcumin phyotosome have also developed green tea phytosome, which provides a much better absorbed form of green tea extract, and would also ideally be in a multivitamin. 6. Adaptogens Stress-fighting adaptogens are another notoriously missing component of most multivitamins, but in our hectic era are a must-have for sleep, de-stressing and hormone balance. One of the most potent adaptogenic compounds that I discovered in my multivitamin research to both lower cortisol levels and raise testosterone levels is called "Relora", and is a blend of magnolia officinalis and phellodendron amurense. If added to a multivitamin, it could also help curb cravings and stress-related eating, and help calm the mind and support rest and relaxation prior to bedtime. As a high intensity guy, this addition would be a very important to me as a necessary multivitamin ingredient. Remember - this all comes down to simplicity. This means that if you or I can't get our hands on a capsule-based, pure and safe, minimalist and simple multivitamin that provides everything I just described above... ...then it means we are instead forced to buy 6, 8, 10 or 12 different supplements to supply our daily nutrient needs and fill in all the "holes" the multivitamin isn't giving. --------------------------------------- Where A Tiny Town In North Idaho Fits In So that's what I've been doing over the past two years. I have been taking a deep, deep dive into educating myself on the wide world of nutrients, supplements, ingredients, fillers, formulations, encapsulation technology and every aspect that goes into creating a multivitamin. And I have literally been pulling my hair out and hitting dead-end after dead-end as I have been trying to hunt down something that meets my strict quality criteria for a multivitamin. Of course, I have also found it incredibly frustrating when my clients, or readers, or podcast listeners or me have to simply keep on taking a crazy number of supplements or buying an unbelievable number of bottles and spending inordinate amounts of money when it's so straightforward to see what a multivitamin that meets all our daily nutrients needs should really have (and not have!) in it. I've even gone so far as to consider simply hunting down the raw ingredients and formulating my own multivitamin. But frankly, I'm an author, an athlete and a teacher - and don't fancy myself as a supplement manufacturer. I just don't have a desire to get into that business.  I simply want a multivitamin that I can, with a clear conscience, recommend to you and also take myself. Is that asking too much? And then it happened. During one of the dozens and dozens of phone calls I made and countless hours attempting to hunt down the perfect multivitamin formulation, a raw ingredient manufacturer informed me of the existence of a new multivitamin formulation created by a company called "Thorne Research", in Dover, Idaho. That's right - just 60 miles from the front door of my house, in the tiny town of Dover, Idaho, are the Thorne Research facilities (pictured below). After months and months of searching, it turns out the solution could possibly be right in my own backyard. For over 30 years, Thorne Research has set the standard for exceptional formulations, quality and purity in the dietary supplement industry - and is considered the most respected nutritional supplements brand in the healthcare practitioner space. That's right - this is is the stuff physicians use with their patients. I'd actually heard of Thorne before, but always knew it was just for the fancy doctors and clinicians so I couldn't really access it or use it. So until recently, none of the coveted Thorne Research products were available for me or any other personal trainer to actually recommend to our clients, readers or listeners. Instead, these high-quality, private formulations were only available for physicians or dietitians to use with their patients, and only for certified health care providers to use with their clients. But then, in January 2014, Thorne Research created a new branch called "". ThorneFX was specifically designed to address the growing demand of fitness experts like me who are seeking a solution for our clients, but don't have the privileged access to the fancy formulations that normally only a doctor or clinician would be able to prescribe or order. --------------------------------------- The Greatest Multivitamin On The Face Of The Planet So I thought it was pretty interesting (and exciting) that I now had access to some of the highest quality formulations on the face of the planet, produced in a facility just an hour's drive from my house. But it turned out there was even more good news. I also discovered that when Thorne Research created the ThorneFX branch, they had not just created a multivitamin formulation but they had specifically left no stone unturned to launch the most powerful, absorbable multivitamin on the face of the planet. This was a multivitamin that possibly met all of my strict criteria, but that previously had never been available to the general population unless their doctor or dietitian knew about it. It's called the , and I immediately got my hands on it. Upon closer inspection and using it for 30 days, I instantly knew that this is not your typical multivitamin. Formulated with superior forms of vitamins and minerals,  is actually two unique formulations - an AM formula is designed to support daytime energy, and a PM formula designed to support better rest and recovery in the evening. Some of the key differentiators in  include: -Vitamins K1 and K2 (most use only K1 or no K2 at all).  -Natural folate (5-MTHF) instead of folic acid.  -Methylcobalamin instead of cyancobalamin.  -Chelated minerals to ensure optimal absorption. -Higher dose of magnesium and calcium than typically found in a multivitamin. -Curcumin Phytosome (curcumin complexed with phosphatidylcholine for superior bioavailability) -Green Tea Phytosome (green tea complexed with phosphatidylcholine for superior bioavailability) -Relora, a blend of adaptogenic plant extracts to aid in relaxation, curb late-night cravings, and balance cortisol, testosterone and DHEA levels.  The  (pictured below) literally satisfies every criteria I require in a multivitamin: all the notoriously neglected ingredients, a TGA and Informed Choice certification, no GMO's, no nasty fillers and ingredients, a capsule instead of a tablet...everything. I couldn't believe when I first found out about the new formulation. Three easy capsules in the morning, three in the evening. Boom. Simple science. My quest was over. Mission accomplished. See for yourself - below are the label and full ingredients. Morning dose - three capsules contain: Vitamin A (3,000 IU as Beta Carotene and 2,000 IU as Palmitate) 5,000 IU Vitamin C (as Ascorbic Acid) 250 mg Vitamin D (as Vitamin D3) 2,000 IU Vitamin E (as d-Alpha Tocopheryl Acid Succinate) 20 IU Vitamin K (100 mcg as Vitamin K1 and 100 mcg as Vitamin K2) 200 mcg Thiamin (as Thiamin HCl) 50 mg Riboflavin (as Riboflavin 5’-Phosphate Sodium)  12 mg Niacin (as Niacinamide)  60 mg Vitamin B6 (as Pyridoxal 5’-Phosphate)  20 mg Folate (as L-5-Methyltetrahydrofolate from L-5-Methyltetrahydrofolic Acid, Glucosamine Salt)*  600 mcg Vitamin B12 (as Methylcobalamin)  600 mcg Biotin  500 mcg Pantothenic Acid (as Calcium Pantothenate)  45 mg Calcium (as Calcium Bisglycinate Chelate)  38 mg Iodine (as Potassium Iodide)  75 mcg Magnesium (as Magnesium Bisglycinate Chelate)  63 mg Zinc (as Zinc Bisglycinate Chelate)  10 mg Selenium (as L-Selenomethionine)  100 mcg Copper (as Copper (II) Bisglycinate Chelate)  750 mcg Manganese  (as Manganese (II) Bisglycinate Chelate)  1.5 mg Chromium  (as Chromium Nicotinate Glycinate Chelate) 200 mcg Molybdenum  (as Molybdenum (II) Glycinate Chelate)  50 mcg Curcumin Phytosome** (Curcuma longa extract  (root) / Phosphatidylcholine complex)  200 mg Green Tea Phytosome** (Camellia sinensis  extract (leaf) decaffeinated / Phosphatidylcholine complex)  75 mg Choline Citrate  50 mg d-Gamma Tocopherol (from Mixed Tocopherols)  24 mg Boron (as Bororganic™ Glycine)  1 mg Lutein (from Aztec Marigold extract (flower) (Tagetes erecta))  300 mcg Evening dose, three capsules contain: Vitamin A (600 IU as Beta Carotene and 400 IU as Palmitate)  1,000 IU Vitamin C (as Ascorbic Acid)  150 mg Vitamin D (as Vitamin D3)  500 IU Vitamin E (as d-Alpha Tocopheryl Acid Succinate)  20 IU Vitamin K (100 mcg as Vitamin K1 and 100 mcg as Vitamin K2)  200 mcg Folate (as L-5-Methyltetrahydrofolate from L-5-Methyltetrahydrofolic Acid, Glucosamine Salt)*  400 mcg Biotin  500 mcg Calcium (as Calcium Bisglycinate Chelate)  50 mg Iodine (as Potassium Iodide)  75 mcg Magnesium (as Magnesium Bisglycinate Chelate)  107 mg Zinc (as Zinc Bisglycinate Chelate)  20 mg Selenium (as L-Selenomethionine)  100 mcg Copper (as Copper (II) Bisglycinate Chelate)  750 mcg Manganese  (as Manganese (II) Bisglycinate Chelate)  1.5 mg Chromium  (as Chromium Nicotinate Glycinate Chelate) 200 mcg Molybdenum (as Molybdenum (II) Glycinate Chelate)  50 mcg Proprietary Blend**  200 mg Magnolia officinalis (bark) extract   Phellodendron amurense (bark) extract   Choline Citrate  100 mg d-Gamma Tocopherol (from Mixed Tocopherols)  24 mg Boron (as Bororganic™ Glycine)  2 mg Lutein (from Aztec Marigold extract (flower) (Tagetes erecta)) 600 mcg The science is obviously there - every nutrient your body needs. But the simplicity is so amazingly refreshing - especially when I pack to travel and literally have one morning bottle and one evening bottle to toss into my suitcase - and of course, a heck of a lot of extra space in my refrigerator. Better yet, if you need some icing on the cake - such as anything extra added in like some , , , a , a , a ,  - , with the same huge, unparalleled quality that I've never been able to find before. It's like a one-stop shop for everything I have ever looked for or wanted in a nutrition supplements line. --------------------------------------- Summary So that's it: pure and simple. I have never before been able to recommend a complete multivitamin that satisfies all my criteria. And I have always had a refrigerator full of a bunch of bottles. But now the problem is solved. And yes, this means that the ThorneFX  is now my recommended, go-to source for the ultimate combination of science and simplicity. Furthermore, the  is now something I back, endorse, vouch for and am now using in my own personal daily routine with great success. And the best thing yet?  An entire month of the  is just 34 bucks. You heard me right: 34 dollars. So rather than forking over hundred of dollars for bottle after bottle of fancy supplements, powders, tablets, pills, and oils, you get one multivitamin that hits all your needs for a mere fraction of the price. Go ahead - spend that extra money you were blowing on 10 different supplements on a fancy steak dinner or chock it away for your kid's college or your next car. Of course, if you're familiar with me, my podcast, or articles I've written in the past, then you may be wondering... ...what about the other supplements I've previously recommended? What about ? What about ? What about my ? The good news is that all of these are still available and still consist of specific ingredients that I may use with certain clients or recommend in certain situations when the need arises. After all, everything I have recommended in the past is all excellent, extremely high-quality stuff, and if you're happy with what you're currently using...then that's fine! But for science, simplicity, peace of mind, and some extra room in my refrigerator and my suitcase, I am moving in the direction of shifting nearly my entire personal supplement protocol to  - and specifically what I have discovered to be the greatest multivitamin on the face of the planet: the . , feel free to ask me about how to use or implement  into your current protocol, and leave any questions about any substitutions or replacements for other supplements you're currently taking. I promise to personally respond and walk you through everything. Enjoy the new simplicity in your life!