Podcast appearances and mentions of zach long

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Fitness Athlete Division lead faculty member Zach Long delves into the effectiveness of lighter weightlifting for athletes aiming to enhance their Olympic weightlifting skills. Drawing from a recent research study and insights from the Soviet Union's Olympic weightlifting team in the 1980s, Zach offers valuable strategies for CrossFit athletes and Olympic weightlifters. Tune in to learn how these approaches can improve your clinical practice and athletic performance! 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 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.

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 anatomical & clinical considerations of the deltoid muscle in functional fitness, as well as the best ways to begin to train the deltoid in the gym. 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 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 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. ALAN FREDENDALL Good morning, PTonICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan, happy to be your host today here on the PT on ICE Daily Show. It is Fitness Athlete Friday. We talk all things CrossFit, powerlifting, Olympic weightlifting, endurance athletes. For that patient, athlete or client of yours that is recreationally active, Fridays are all about topics for that person. We are finishing out deltoid week here at ICE, so we're talking all things shoulder, in particular the deltoid muscle, exercises for the deltoid, manual therapy for the deltoid, so go back if you haven't been listening the rest of this week to all the episodes from all the other faculty, Monday, Tuesday, Wednesday, Thursday, dry needling techniques, cupping techniques, exercises, modifications, importance of deltoid exercises for pregnant and postpartum moms, we've got it all. Plus, we have a whole bunch of great content on our Instagram page as well, related to the deltoid and all of those topics. Today on Fitness Athlete Friday, we're going to tackle the deltoid from its role in functional fitness. So in particular, we're going to be talking about vertical pressing. So we're going to talk about anatomical considerations of the deltoid as it relates to lifting weights overhead. We're going to talk about clinical considerations of why do we care about someone's deltoid when they come in for physical therapy treatment. And then we're going to finish talking about how we think you should actually train the deltoid with these patients and athletes in the clinic. THE DELTOID: ANATOMICAL CONSIDERATIONS So a brief anatomy overview to start. What are our considerations for the anatomy of the deltoid? We need to understand and recognize the deltoid muscle is large, it is designed, it is built for blunt force trauma. If we come away from social media and computers, and the past 2000 plus years of human progress, and we go back to ancient man and even before we became humans and we were walking around on all fours, understanding the role of deltoid, but as we're crawling around on all fours, we have hip extension from our hip, we have glutes and quads as our primary lower extremity muscles, and in the upper body, we are pulling ourselves along the ground. We are designed for vertical pulling in particular, We all understand the importance of the lat. There's probably not a single person, if you walked into a room and recommended that the average person could benefit from doing some strict pull-ups, there's probably nobody that would voice opposition or concerns. But yet, when we start to talk about vertical pressing, all of a sudden, the conversation changes. Whoa, don't lift your arm overhead. That's dangerous. We've heard things, and I've heard things, like even when I was in school, that the shoulder is so mobile, it's just really not optimal to lift your arm overhead. Which, if we go back to our history and our evolution, doesn't really seem practical. And I think it's a fundamental misunderstanding. of how the deltoid functions and its role in providing that stability to the shoulder joint. So being quadruped, now bipedal organisms, now standing up resisting gravity, great at vertical pulling, not great at vertical pressing, especially when we don't do it. Why? The shoulder is inherently mobile, it is inherently unstable. It does not have a lot of bony support. The deltoid is the primary muscle that gives us that stability. throughout the whole range of motion of the shoulder. The deltoid is primarily responsible for flexion and abduction. It is the prime mover of shoulder elevation. And in particular, as we begin to approach 90 degrees of flexion and abduction and move up towards 120 degrees and beyond, the deltoid really becomes the only mover. A lot of the other smaller muscles, upper traps, rotator cuff muscles, whatever, really fall off and the deltoid stands alone as moving things overhead. And so we see that that does not happen. That does not happen in a lot of people. We already know most people are sedentary. They're not lifting weight overhead, pushing or pulling. But for those folks that are, we need to get them doing probably more vertical pressing to train that deltoid to really understand and respect the anatomy that we need to have a really strong deltoid if we really want to have a strong and stable shoulder. Really great evidence on the importance of the deltoid as the prime mover of the shoulder. An article back from 2021, the Journal of Elbow and Shoulder Surgery, Hecker and colleagues, Really cool study. They took people, they gave them an axillary nerve block on one side, and then they gave them nothing on the other side. And they tested maximal isometric strength. And what they wanted to find out is how much strength comes from each of the shoulder muscles, at what degree of shoulder flexion, shoulder abduction, internal or external rotation, adduction and abduction. And what they found is when they blocked the axillary nerve, and they tested isometric strength, instantly with the arm still at rest, moving into flexion, the shoulder strength was reduced to 76%. In flexion and in abduction, it was reduced to 64%. And now again, as we elevate that shoulder further up towards 90 to 120 degrees, the strength fall off was even more significant. Flexion now at only 25% strength, and abduction at 30 strength. So the deltoid is involved in the entire range of motion of primarily flexion and abduction. But in particular, as we get up towards 90, and as we start to bring our arm all the way overhead, it is primarily deltoid, which means we need to be training the full range of motion, and we need to be training more pressing patterns, and not so much laying on our back or laying on our stomach and doing prone rotator cuff work, trap work, whatever. That stuff is great early on in therapy, but if we really want to get the deltoid strong, we need to move it through the range of motion that it controls, which is all of it, and in particular, all the way up and overhead. THE DELTOID: CLINICAL CONSIDERATIONS So discussing clinical considerations, who might we see with a deltoid problem? How could we pick up that somebody might need to get stronger deltoids? I would argue just like with glutes or quads, it's every human being, right? There's no one that is checking the box on strong enough muscles. I don't think you'll find a single elite athlete who thinks, I don't need to train anymore. I've made it. They're probably always aware of their weaknesses and things they need to train. and I would argue vertical pressing, training the deltoid is true for every single person. But we do see these presentations come in. where we start to think, hmm, what I'm seeing, I think I'm treating the symptom of a bigger problem. So when the deltoid isn't doing its job, that's when the other smaller muscles of the shoulder complex take over. That's when we have people with upper trap stiffness or upper trap pain or headaches or posterior cuff pain or issues up in their neck, trouble with rotation, side bending, whatever. those smaller muscles that can act to elevate the shoulder are taking over because the deltoid isn't pulling its weight. The long-term solution isn't to only train those muscles, it's to train those muscles if it makes the person feel better, but again, get back to training the deltoid. So when we see those patients come in the clinic, oh, my traps, my traps, my traps, my traps, my neck is stiff, I've got a headache, and we start to dig into the subjective, what have you been doing? Oh, we've been doing a handstand push-up cycle at my gym. Oh, we've been doing a split jerk cycle, a clean and jerk cycle, a snatch cycle, whatever. you start to hear that this person has increased their volume and overhead lifting and they're complaining of all of these secondary symptoms of upper trap, neck, headache, whatever. When I hear that, I'm thinking this person, this person, yes, needs my help. reducing pain, restoring range of motion, but I'm also thinking, I need to get this person on a vertical pressing program. Especially a functional fitness athlete, I need to be getting them doing strict press, I need to be getting them doing handstand pushups, strict handstand pushups, whatever they can tolerate, wherever they're at in their fitness journey, maybe it's handstand pushup, eccentrics, whatever, but I'm thinking, we need to start integrating some vertical pressing in this person's program, because yes, while we're treating their symptoms short term, the way they're presenting tells me they would benefit a lot from stronger shoulders. These symptoms are probably going to be less likely to show up in the future if we do that. And so as we're reducing the symptoms, resolving the symptoms in the local tissue, we then need to evaluate if the deltoid needs strengthening. A lot of folks ask, how strong should your shoulders be? We have a lot of really great evidence on bodyweight normalized exercise in the lower extremity. We know the stronger your squat gets relative to your bodyweight, the less likely you are to develop lower extremity injuries. So the stronger a 1x bodyweight back squat, a double bodyweight back squat, stronger, stronger, stronger, less, less, less injury. We don't have a lot of that research in the upper extremities, but I would say that a strong person should be able to press 50-100% of their bodyweight overhead. Now that's going to depend on a lot of things. Training age, right? Somebody that just started lifting overhead six months ago is probably a very long time, like years or decades away from achieving a bodyweight strict press. Somebody that has been training a lot and is close is obviously going to get there a lot closer. But we don't necessarily need to get there with a strict press. Somebody that can push press their body weight, somebody that can jerk their body weight, somebody that can show me a strict handstand push up, that person really tells me that they have really strong shoulders. Arm length plays a big role here. Those of you with longer arms, I know you're listening right now, nodding your head. I'm five foot seven. I have these little T-Rex arms. I don't have a lot of range of motion before my arms are locked out overhead. Someone built like me. isn't actually going to have a stronger press, a stronger handstand push up capacity than someone that is six foot six and their fingertips touch the middle of their fibula, right? So consider that as well. Don't hold people's feet to the fire on that too much. But no, we want to see people getting a strong press, we want to see them move towards a 50% bodyweight press, and then continue to train that as much as possible. We have a number of different tools we can use as well to look for asymmetries in the clinic. I love to just stick with a dumbbell strip press in the front rack. Hey, let's try a five to eight rep max. Let's see if we have an asymmetry. If somebody can't tolerate that due to pain, I love to go to a landmine press and try to find a five to eight rep max there, and then try to see if I can observe any asymmetry. And then we know if we talked here on the past on the Daily Show, to clear up asymmetries, we need to be training the weaker side three to four times the volume. So that person needs to be doing maybe four to five sets of pressing work for every set that the strong side does. So that's always a consideration as well. When we look at ratios in the upper body, we need to understand the upper body is or at least should be a little bit weaker compared to our lower body. Humans are primarily legs. We do have those people out there. You probably all have a friend that has a 400 pound bench press and a 200 pound back squat. They're just built. They're built different, right? They love upper body, skip leg day a lot. But in general, our legs should be stronger than our upper body. How strong? About 40-60, maybe 30-70 at the most. But when you start to get to a ratio of 80% of my strength is in my legs and 20% is in my upper body, we really get into an issue where now our lower body can generate more power than our upper body strength can handle. And so we have some really cool research, Matt Sura and colleagues, 2023 Journal of Science and Medicine and Sport followed swimmers and asked that question in their research. Hey, is there a ratio where lower body strength leads to upper body injury? And the answer seems to be yes, which is really interesting research. So this study followed 48 competitive swimmers across six months. At the start of the study, these swimmers had no pain. Across the six months of training, 20 swimmers developed pain and the researchers testing baselines and reassessments throughout the study wanted to pick up on how can we determine who's most likely to develop a shoulder injury across a season of competitive swimming. And so finding that folks who developed a stiffer shoulder across those six months, worse posterior deltoid range of motion, And those folks who had higher ratios of lower extremity strength to upper extremity strength went on to develop pain. Their legs were able to generate so much power in the water that their shoulders were too weak to keep up. And over time, we're assuming and carrying forward that that led to overtraining essentially of the upper body. We can see that in the gym, with movements like push press or push jerk, we know the legs provide the majority of the motion and the power for those movements. And if our shoulders are not strong enough, yes, our legs can help us get that weight overhead. But if we're doing that a lot, and our shoulders are just not inherently stable, because we have a weak deltoid, then we can run into trouble where the ratio becomes so skewed that it can now be harmful. So I like to think of this is the legs begin to write checks that the shoulders can't cash, right, the shoulder is not moving through the full range of motion. And now those other muscles have to take over because that ratio is so skewed. And that's who shows up in your clinic door, right? I have stiff traps, I have a headache, I can't turn my head, I did a bunch of push jerk, I did a bunch of kipping handstand push ups, whatever, we need to treat that person's symptoms, we need to get their shoulders stronger, we need to control that ratio a little bit better. THE DELTOID: TRAINING So as we finish up here, how do we do that? How do we train the deltoid? A lot of people think they're training the deltoid, they think they're training shoulders, but they're not really doing it effectively, which is why they don't see a lot of results in whatever their goal might be for the shoulder, even if it's just to not have shoulder pain during exercise. And so we see a lot of what we might call bro shoulder press, right people sitting or standing in the gym. That arm is cocked out to 90 degrees of abduction and then they're kind of just pumping that weight up and down overhead, right? They're in a neutral grip. They're in a small amount of abduction They are technically in no flexion in a small amount of external rotation so in that movement that kind of seated or standing dumbbell press where the weight is just floating out in space is EMG studies would say that person is primarily training the triceps. If you ask that person in the moment, where do you feel this, they would probably tell you their triceps. And so getting people to understand what does deltoid training look like. is very important because some folks may think they're doing it, they may think they're doing a lot of it, and they're not. They're probably training triceps, they're probably primarily overloading a different muscle, which is just exacerbating the whole problem. They're probably allowing a dip in their legs in the strict press. So again, the legs are primarily generating the momentum for the movement. And they're probably just not performing full range of motion. And again, The deltoid is on the whole range of motion, especially at and above 120 degrees. So we need to be training full range of motion if we want a really strong, robust deltoid. Most people skip deltoid training completely, which is another factor, right? Coming into the gym and doing five by five strict press is not fun. It's not sexy. It's not as cool as ring muscle ups or a heavy deadlift or a heavy power clean or something like that, or even just doing push press or push jerk. It's more momentum. It feels cooler. You can lift more weight. And so strict press often gets left behind, which is the thing that some athletes and patients need to be training the most. Other athletes might be thinking, hey, I bench press a lot, I have strong shoulders, but when we look at studies of what muscles are active at what degrees of incline in a bench press, we see that we have to elevate that bench to almost 60 degrees just to begin to get a little bit of anterior delt work. And that we have to incline it to 90 degrees, which is, you know what, no longer a bench press, you are sitting upright, to begin to target the lateral and posterior heads of the deltoid. We had a cool study from Rodriguez, Redallo, and colleagues in the Journal of Environmental Research and Public Health in 2020 that looked specifically at that and said, hey, primarily in the bench press, even at an incline, you are still primarily targeting the pec muscles. Yes, at 60 degrees of incline, you begin to get more anterior delt, but bench press is for the chest, which some of you are saying, Alan, I knew that already before I listened to this podcast, but others out there might be thinking, hey, I thought that was also getting my delts. It's not. So we need to recognize that we cannot bench press our way to stronger deltoids. That will certainly get you a stronger chest, better push-up capacity and ability, but it will not do anything to really train your deltoids, and if that's a weakness area for you, help shore up that weakness. And so we need to get folks training shoulder flexion and shoulder abduction through the fullest range of motion possible, training them together. Yes, barbell strict press, alternating dumbbell press, standing, sitting, Z press, whatever. And in really, really being sticklers for people that they work the full range of motion. If you're going to use dumbbells, they need to start in the front rack position where the head of the dumbbell is on the shoulder, and you are pressing through 180 and 180 degrees of shoulder flexion and abduction. and you're not hanging out here and just giving it that little tricep hump that people like to do. Train the full range of motion. For those folks who are needing or wanting to do handstand pushups, handstand pushups are also a great way to train the vertical pressing pattern. If folks already have strict handstand pushup capacity, working at it as accessory work is great. Adding things like plates for a deficit will challenge bigger ranges of motion that will develop and continue to progress in a linear fashion vertical pressing, and deltoid strength. If they can't do strict, but they can kip, we can have them kick up to the wall, lower themselves through that range of motion, and do a handstand pushup negative. That is a great shoulder strengthener. I have a lot of athletes do that for accessory work. Even athletes that have strict handstand pushups and have good strict handstand pushup capacity, working that time under tension, especially if they can tolerate a deficit, is gonna make really robust shoulders, a really strong, healthy shoulder, And because they're training a deficit so often, when a workout shows up with regular handstand pushups or regular strict handstand pushups, those athletes fly through those workouts because their capacity has increased so much. At all costs with those folks, we want them to avoid kipping unless they're doing an eccentric, because again, that's the same as if they were standing up and doing a push press or a push jerk. We want to avoid having the legs help us train the shoulders. When we need to get strong shoulders, we should be training the shoulders. Folks can benefit a lot from complexes, things like doing a bunch of strict press followed by push press or push jerk. That is a great way to train the deltoid under fatigue, which relates a lot, especially to those athletes who are going to be using a lot of vertical pressing under cardiovascular fatigue. So one of my favorite ways to do that is 3 sets of 3 strict press, add some weight, 3 sets of 3 push press, add some weight, 3 sets of 3 push jerk. Starting fresh, working the deltoid, sets of 3, very heavy load, getting stronger. is the deltoid fatigues, using the legs a little bit to help it out with the push press, and as it gets really tired, using the legs even more in our push jerk. You'll find if you do a big complex like that, that your shoulders are tired, your shoulders are sore the next couple days, and that is really a unique feeling to have soreness in the deltoid that a lot of people don't experience because they're primarily not training the deltoid, or other muscles are taking over for them because their deltoid is so weak. For accessory work, the EMG exercise with the largest deltoid activation is a prone Y with the arm unsupported, moving in and out of 120 degrees of flexion abduction with the hand wound up and as much external rotation as possible. So that's from Mike Reinhold and colleagues, they have a bunch of research on EMG activation in the shoulder muscles. That's where the delt works the most out of a number of different exercises. So after training is done, after we've got our strict press or handstand push ups in, we can go to that prone Y do some burnout sets, something like that, and really begin to overload the deltoid in a way that facilitates a lot of strength. SUMMARY So the deltoid, largest or should be largest, strongest muscle in the shoulder built for work, built to move the shoulder through the whole range of motion, but only if we train it. Otherwise, those smaller muscles are going to take over. The shoulder is inherently unstable, that full 180 degrees of freedom. It doesn't have bony approximations that give it support as much as the hip or other joints, which means we need strong muscles, in particular, a strong deltoid to act as the stabilizers for us. In the clinic, we're primarily treating the aftermath of what happens to people when their shoulders are not as strong as other parts of their body, their legs, their traps, their posterior cuff, whatever. We need to clear up those local symptoms and then get that person on some sort of deltoid strengthening program so that the deltoid begins to do the work. Most folks will find that their capacity in the gym, in their fitness, often increases with overhead lifting, and they have less symptoms, less stiff traps, stiff neck, headaches, so on and so forth. A lot of folks have no issue doing vertical pulling. They might be doing vertical pulling multiple times per week, really training the lats, pull-downs, pull-ups, chin-ups, muscle-ups, whatever, but often they are avoiding vertical pressing, or they're using a variation of a vertical press where their legs help them a lot when they should be focusing on strict movements. Strict movements like strict press, strict handstand push-ups, and training the full range of motion. Remind these folks they are welcome to do as much bench press as they like, but you cannot bench press your way to a stronger deltoid. And when in doubt, again, keep it strict. So I hope this was helpful. I hope you have a wonderful Friday, a great weekend. If you want to join us online, our next cohort of fitness athlete level one online starts August 2nd. Fitness athlete level two online starts September 2nd. And then a couple chances to catch us out on the road. Zach Long will be teaching this weekend in Raleigh, North Carolina. And then in two weeks, we have the fitness athlete summit here in Fenton, Michigan at CrossFit Fenton. We'll have all four lead faculty from the division here, as well as our four teaching assistants, so our full staff will be on hand for that course. That's gonna be a lot of fun, so we hope to see you in two weeks here in Fenton. Have a great Friday, have a great weekend, bye everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the principle of Specific Adaptations to Imposed Demands (SAID), the principle of Somewhat Humdrum Adaptations to Rehab Treatment (SHART), and how to help patients & athletes reach & meet specific goals. 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 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 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.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 Good morning, PT on ICE Daily Show. Happy Friday morning. I hope your day is off to a great start. Welcome to the PT on ICE Daily Show. It is Fitness Athlete Friday. I'm your host, Alan. I currently have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader in our Fitness Athlete Division. We're here on Friday, Fitness Athlete Fridays. We talk all things CrossFit, Functional Fitness, Endurance Athletes. If you have a patient or client who is active on a regular basis, Fridays are for you. We have an exciting announcement next week you'll see on our social media. An entire week, thanks to dry needling faculty member Paul Killoren, an entire week dedicated to the deltoid. So you'll see the podcast next week, all the episodes will be about the deltoid, and you'll see all of our social media posts next week focused on educating you, everything related to the deltoid muscle. If you've taken our upper body dry needling course with Paul, you know that he has quite the obsession with the deltoid muscle. So we're really excited to see just how much shoulder content we can give you all next week. So tune in beginning June 3rd for an entire week of deltoid themed content. Today, the topic for Fitness Athlete Friday, what are we talking about? The SAID principle, specific adaptations to impose demands. You may have heard of this principle at some point in your life. You probably heard a very generalized definition of this term that maybe did not really help you understand what it is or how it could possibly apply. to exercise or to clinical practice. WHAT IS THE SAID PRINCIPLE? So the SAID principle, really, again, very basic definition that training a particular movement pattern, training a particular skill, training a particular time domain or energy system will result in the most efficient adaptation to that imposed stimulus that imposed demand on the body. And when we uncover, when we unpack the definition of the said principle a little bit more, we talk about actually the two ways that we see changes from this. The first being structural, that we see muscle size and shape takes place, and the other being neuro or neuromuscular, that we get a more efficient recruitment of muscle fibers, that we're able to recruit more fibers, larger fibers, recruit them in a more efficient sequence, so on and so forth. So that's the said principle in a nutshell. Today we're gonna talk about why it matters, give you a practical example from the gym, give you a practical example from the clinic and kind of wrap up why maybe we need to reconsider this. Maybe if we did learn this back in high school or undergrad or grad school or maybe all of them, maybe why we need to consider this more often in our practice, whether we're working with patients in the clinic or athletes out in the gym or a more active setting. So when we interact with folks in the clinic, whether they're patients for physical therapy, whether they're athletes coming to us maybe even for performance help, they don't necessarily need help with a physical therapy related issue. They come in and they may complain about a plateau about not making progress with their physical therapy about not making progress with their performance in the gym in their running plan or whatever. And if we take the time to unpack, and if we take the time to assess a couple things, what we usually find with these folks is they seem to be at a plateau, but it's really because they're not doing things specific enough to create the adaptation that they're wanting from the stimulus that they're giving themselves. Their rehab exercises, their exercises in the gym, their strength training, their endurance training, whatever that might be. WHY DOES THE SAID PRINCIPLE MATTER? And so why does the said principle matter? Training similar things may result in some carryover, but people I think fail to understand that it won't result in the most efficient, time-wise, in the most efficient carryover to develop a specific skill, a specific movement pattern, a specific progress towards a goal. So we often say, hey, well, doing a bunch of strict pull-ups make you better at strict pull-ups. Yes, of course. Will doing a bunch of strict pull-ups make you better at free climbing El Capitan? Well, there's gonna be some carryover, right? But probably the best thing to do to get really better at free climbing is to do free climbing. And arguably, we would say and not or. The best thing to do would be to practice the thing you want to get better at and then do accessory stuff like strength training to further enhance your way onto goals. We see this a lot. In the gym and CrossFit, folks always complain about not being great at running. We do run in CrossFit, but often lower volume, shorter distances than someone who would consider themselves a runner would consider running. And so when folks want to improve their 5k time, or they want to run a 10k or a half marathon, or maybe even become a marathon runner, They often say, I'm not getting better at running. And when we ask, okay, how often are you running? And they say, oh, well, I hate running. Running bothers my shins. So every time there's running, I just row or bike. Again, is there going to be carryover from rowing or biking or doing some other cardiovascular modality to running? Yes, of course, but not as specific, not as great as if you did running training to improve your goal of getting better at running. There are certain things that happen when you run more, You get an improved running economy. You get more efficient in that movement pattern because you're spending time in that movement pattern. And yes. We can get cardiovascular adaptations from rowing or biking, but it's just not gonna translate 100% to that specific thing. So that is why the said principle matters. PRACTICAL EXAMPLE: "GRACE" When we look at our practical example in the gym, we just had a benchmark workout last week at our gym called Grace. You may have heard of this CrossFit benchmark workout. 30 clean and jerks for time at a standard barbell weight of 135.95. And talking to members that day, people asking, hey, like, what is the world record on this? Do you know? I do know it's it's 59 seconds, right? With some people completing it, CrossFit Games athletes under 90 seconds. And so the conversation began, okay, If this takes me eight minutes, and it takes them 90 seconds, what is the difference between them and me? And I think a really lazy answer when people want to improve their performance when they want to break through a plateau, whether that's in the clinic, whether that's in the gym is well, they're just in better shape than you, right? That's a very lazy answer. When we break down why is that person better at doing that workout than you, we can start to unpack some characteristics, some specific characteristics of why their performance is higher than yours. We look at somebody like Matt Frazier, five time CrossFit Games champion, a minute 18 clean and jerk, grace time 30 clean and jerks for time, which is faster than a clean and jerk every two seconds. So moving fast, moving unbroken for 30 clean and jerks, what do we know about that athlete? Again, the lazy answer would be, well, he's been doing CrossFit a long time and he's just in better shape than you. Yes, but why? And the why matters, the specifics matter because that can turn into a training program for a person who wants to maybe cut 15 or 30 seconds off their grace time. or cut time off their 5K, or get better at strict pull-ups, or rock climbing, or whatever, right? When we look at Matt Frazier, why is he better at that workout? A long history of Olympic weightlifting, very familiar with a movement like the clean and jerk, very efficient in the clean and jerk, very strong, not only in the clean and jerk, but the movements that support the clean and jerk, the front squat and the strict press, an athlete who can strict press above his body weight, an athlete who front squats several times his body weight, and an athlete who has a 425 pound clean and jerk, right? So when we look at 135 pound barbell compared to a 425 pound clean and jerk, a 500 pound front squat, a 250 pound strict press, we say, okay, this is a very strong individual and specifically related to things like the SAID principle, he is very well trained in this specific movement pattern. It makes sense that because this is an incredibly light barbell for him, but he can hang on to it for 30 reps, move it touch and go unbroken, and get that workout done in 90 seconds that might take you five minutes. Why? You don't have as strong of a clean and jerk. You don't have as strong of a strict press. You don't have as strong of a front squat. You aren't as efficient at cycling that barbell because you have not been doing CrossFit as well. And in specific, we also look at time domain, right? He is getting a workout done while he is still in the anaerobic glycolysis time domain. He still has a lot of high power output. versus when you transition, when it starts to take you more to two to three minutes, we know your power output goes down. We know you're transitioning into your aerobic energy system. He's getting it done because he's more efficient at it before he runs out of gas. And so, how do we take that and translate that to a training program for that athlete? Well, of course, we need to work on your front squat. We need to work on your strict press so that your clean and jerk gets stronger. We also need to train your clean and jerk so you get more efficient at clean and jerks. We need to train your clean and jerk where you do touch and go reps at a light to moderate weight so you get efficient in the endurance of the clean and jerk, not just the strength. And we need to train a very fast, explosive time domain for you, right? That is a great athlete where we might say, hey, every minute on the minute, I want you to do five clean and jerks, seven clean and jerks, 10 clean and jerks, progress it and make them work in the time domain in the movement they want to get better at, right? This is what endurance athletes do all day long. They progress their volume, they progress their time domain, and they get very specific in what they're doing, right running, biking, swimming, maybe all three of those, maybe just one of those, but spending a lot of time in the movement pattern you want to get better at spending a lot of time in the time domain you want to get better at. THE SAID PRINCIPLE IN THE CLINIC Switching gears, we see this happen in the clinic as well. Just like somebody is plateaued maybe on a workout like Grace, we have patients who are maybe plateaued in their plan of care. And if we're not careful, if we're not specific, if we're not assessing in the clinic, if we're not using our clinical reasoning, we can develop a very high quality loading program, a very high quality accessory program for the wrong area, for the wrong athlete, for the wrong time domain. I call this the specific humdrum adaptation to rehab treatment or the sharp principle, right? A very boring adaptation that serves no purpose, because that person in rehab was forced to do what we told them to do. And maybe we weren't giving them specific enough of a treatment. So without proper assessment, we may not know what people need to work on. And so we're often surprised and curious and maybe upset when Gladys comes in and she hasn't improved her 30 seconds sit to stand. She is still only getting four reps done in 30 seconds. She's been here for six weeks and we look back at her treatment plan and most of her treatments consist of coming into PT and riding the new step at zone one heart rate for 30 minutes or most of her session. We should not be surprised when we reflect back on the said principle that Gladys is making no meaningful improvement, right? She is struggling with a high power, short time domain demand, a 30 second sit to stand, and her treatment almost entirely consists of relatively low intensity, long duration endurance activity. Again, specifics matter. What we have our patients do, they will adapt to. If we give them the wrong stuff, or maybe just not as effective stuff to do, we should not be surprised when we do not see them make a lot of meaningful progress. We can see the same thing with patients who are symptomatic. Why are we surprised when Mark comes to the clinic, he's made no progress on his lateral elbow pain, and all we're giving him in PT is high volume, low load, banded, or lightly resisted exercises. We know that's a tendinopathy, we know it needs load, specifically it needs time under tension, and it needs progressive loading. Giving that person a high volume, low load dose is likely what caused that condition in the first place, so we should not be surprised that that person is not making any meaningful progress. So getting specific, adopting the said principle matters. Avoid the sharp principle. We can make people pretty averagely better at stuff they don't need to get better at or don't want to get better at if we're not careful with our rehab treatment. I truly believe we have a lot to offer patients and clients from both a rehab and performance perspective, but only if we take time to assess where is this person weak in their game? What is the most important thing or the maybe most important two or three things they need to work on? That's what our rehab plan, maybe that's what our accessory program for the training they're already doing should look like. Keep it specific, especially if that person needs or wants a specific result. We can be very good at giving a lot of general treatment that gives a lot of general improvements, but if it's not helping that person meet their specific goals, then it's not as effective as it could be. SUMMARY So remember, what is the said principle? Specific adaptations to impose demands, train in the time domain, exercise in the time domain they want to get better at, you want them to get better at, train the movement patterns they need to get better at, and you'll be surprised at how quickly somebody makes progress. Avoid the sharp principle. Avoid just giving a general exercise prescription. We see this a lot in students who are so happy to walk in and write down a 30-minute AMRAP on the board or 24-minute REMOM and sometimes we have to stop them. We appreciate the enthusiasm, but we have to let them know, hey, you're just giving that person a bunch of general stuff that may not translate to them getting specifically better at the stuff they need or want to get better at to meet their goals. We have a lot to offer, but we have to make sure that we're assessing, reassessing, and we're being specific. So I hope this was helpful. If you want to learn more from us in the fitness athlete division, we'd love to have you. A couple chances coming up in the month of June. Zach Long will be down in Raleigh, North Carolina, the weekend of June 8th and 9th. And then we have our Fitness Athlete Live Summit here in Fenton, Michigan. That's the weekend of June 22nd and 23rd. We'll have all of our lead faculty, all of our teaching assistants here. That's gonna be a really fun weekend. Online, our next cohort of fitness athlete level one online starts July 29th. That course always sells out. And then our next cohort of fitness athlete level two online begins September 2nd. So, I hope this was helpful. Remember, keep it specific. Assess, reassess, keep it specific. Have a great Friday, have a great weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the science and practical application behind hydration & recovery drinks. 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 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, 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. ALAN FREDENDALL Good morning, PT on 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 is the best darn day of the week. Today we're gonna be talking about salty science. No, we're not gonna be talking about how upset Drake fans are by how badly they're getting beaten by Kendrick Lamar's diss drops. We are talking about the new era of salt-based hydration and what that means and how that compares to previous eras of things you might be more familiar with. Gatorade, Powerade, those sorts of things. So today we're going to talk about the origin of hydration in recovery drinks. We're going to talk about the pros and cons of what we might call the first generation of those recovery drinks. And then we will move in and talk about the new era of sodium-based drinks that may or may not have any sugar included in them. THE HISTORY OF RECOVERY DRINKS So recovery drinks really started as we know it a long time ago back in the 1960s, actually 1962 at the University of Florida. Researchers created a recovery drink for the Florida Gators. You now know that is Gatorade, A-D-E. Back then it was spelled Gator dash A-I-D like a band-aid, Gatorade. And this formula was rather simple. It was water, sodium, and some lemon juice. And when we look at the macronutrient breakdown of the original formula of Gatorade, if you're old enough, you may, even if you were a kid in the 80s or maybe even 90s, you remember it used to come in that glass bottle and it really had nothing in it. It had 50 calories total, it had 14 grams of carbohydrates, it had some sodium, and that was essentially it. And that was a 20 ounce bottle, 20 ounce serving. So a little bit of sugar, a little bit of sodium, and that was it. A lot of credit went to Gatorade in the 60s and 70s when the Florida Gators went on to win and many other collegiate and professional teams went on to win sporting events, they maybe sarcastically credited Gatorade with their success, and at that point Gatorade took off into orbit. That is very different from the Gatorade of today. The current formula of Gatorade is significantly different. It has a lot more calories, as you may be aware, that is primarily sugar. So for the same serving, a 20 ounce serving, a 20 ounce now plastic bottle that you might find in the store or the gas station, 160 calories, so over three times as much. caloric density, way more carbohydrates, three times the carbs, 42 grams of sugar, which is a lot. More sodium now, giving credit, 10 times more sodium, 300 milligrams of sodium, but also a lot more potassium, 90 milligrams of potassium. What's changed from the 60s to today? Pepsi bought Gatorade, Pepsi sells Gatorade, You may know Pepsi owning a lot of the snack brands and soda drinks that we are very familiar with. So it's not really surprising when you find out that Gatorade is now owned by Pepsi that it's just kind of pumped full of sugar and it's essentially turned into a soda drink. THE CRITICISM OF SUGAR-BASED RECOVERY So that being said, what is the main criticism of Gatorade? as it relates to its functionality as a recovery drink or not. The first thing to consider is just looking at it from a molecular level, it's sugar water. The primary ingredient is sugar. It's a bunch of calories. Yes, it has a little bit of sodium. Yes, it has a little bit of potassium. But it is primarily sugar water. Now, we may think, okay, we know we sweat, we know we burn calories when we work out, surely we can put that sugar to good use. But it's really important to know that the majority of people drinking these drinks are perhaps not exercising at all. They might be sitting at a computer desk and or they may not be exercising to the level that they are losing that much sweat and that much glycogen from their system. Certainly somebody running, cycling, doing a long endurance activity, 90 minutes, 120 minutes, longer, running a marathon, ultramarathon, triathlon, Ironman, that sort of thing, that person does need to consume glycogen to keep their aerobic energy system running. But those folks just recreationally active, going to CrossFit for an hour, going to run a couple miles, working out in an air-conditioned gym where they may not be sweating at all, don't really need that amount of caloric replenishment and sugar during their workout to keep their workout intensity high. Go way back to episode 1552 of the PTA Nice Daily Show if you want to learn a little bit more about fueling during exercise, we talk about how the human body has about 400 grams of glycogen stored inside of it, inside of our muscles, and about another 100 grams in our liver. So we have the ability to go 90 to 120 minutes before we dig deep enough into those reserves that we need to consider drinking glycogen, drinking glucose to sustain our energy system. And again, the argument and the largest criticism, especially in the past 10 to 15 years or so of Gatorade and similar drinks Is it simply too much sugar? Some really good papers here. Zimmerman colleagues way back from 2012, sports drinks, not just sodas, drive up weights in teens, looking at 11,000 kids aged nine to 15 and finding that kids gained two pounds for every two years in which they drank a can of soda per day. So if they drink a can of soda per day for two years, they would have gained two pounds per year. If they drank two cans, they would have gained four pounds, three cans, six pounds, and so on. And so we say, yeah, Alan, we know that. We know soda is bad. But what is really, really, really interesting about this study is they also looked at sports drinks. They looked at things like Gatorade and Powerade. And this is kind of shocking that they found the same level of consumption, one bottle of a sports drink, two bottles of a sports drink, et cetera, following that same scheme for every one bottle consumed per day. kids gained three and a half pounds per year, two bottles per day, seven pounds, three bottles per day, so on and so forth, 10 and a half, 14, all the way up. And so, recognizing that these drinks actually contain as much or more sugar per ounce of basically table sugar than a can of soda, a can of Coca-Cola or Pepsi or something like that. I love the conclusion from this paper, sports drinks fly under the radar, The danger is that they're sold as part of a healthy and active lifestyle, and it's just part of something you do being active. Most kids are not getting the two hours of high-intensity exercise needed every day to justify refueling with a sports drink. And so, finding that because they have so much more sugar per serving, and that it is so much more acceptable to drink a Gatorade versus to drink a Mountain Dew or something like that. Shout out to Brian Melrose, the Mountain Dew King. that these kind of fly under the radar, and there might be kids that drink these every day in their lunch. They might drink one for lunch and one after school, after playing outside, and it's not surprising that we're racking our brains to figure out why we have a childhood obesity and type 2 diabetes epidemic when it's right in front of our face. Gatorade just simply has too much sugar for the folks who are drinking it on a regular basis. Now, if you're out there, you're running marathons, triathlons, Ironmans, whatever, you're working out for hours at a time, you're working in the heat, you're sweating a lot, ignore me. But for most of our patients, for most of our athletes, we need to understand why that criticism of Gatorade is there and that it's pretty cemented that it is simply too much sugar for the small bit of electrolytes that you might get out of Gatorade. And so that's maybe what we call the first generation of recovery drinks. THE ERA OF SODIUM-BASED RECOVERY The new generation you may have heard of a product called LMNT Element. There are a lot of similar brands now. A sodium based recovery drink that has no sugar. This high sodium drink, which also faces criticism of, isn't salt bad? Doesn't that give us high blood pressure? But really finding that these drinks are entirely different on a molecular level from something like Gatorade or Powerade. That again, they have no sugar. They have 10 times more sodium, a thousand milligrams, one gram of sodium. They have a little bit more potassium, usually around 200 to 250 grams. And they also come with some magnesium. What is the scientific argument for drinking something like Element or similar compared to something like Gatorade or similar? Understanding that individuals that are active and exercising may not be using muscle glycogen to the point where they need to drink sugar during or immediately after their workout, but also recognizing they are sweating, which means they are losing especially salt from their system, and that if we replenish that salt, people will probably feel better without feeling the need to go and drink 50 grams of liquid table sugar during or after their workout. A really good article, Sharif and Sawaka, 2011, the Journal of Sports Science, finding that folks can lose up to seven grams of sodium out of their body through sweat per day. If they're active with exercise, if they're maybe somebody outside working, whether that's for a job or just active in the garden for a couple hours on weekend days, that sort of thing. And so we are losing a lot of sodium. And there's kind of a catch-22 here of active individuals don't tend to eat a lot of processed food. And so active folks are not naturally taking in a lot of sodium yet, because they are active, they are losing a lot of sodium at the same time. They're sweating in the gym, they're sweating out running, biking, whatever. Maybe they're sweating outside at work or in the garden or doing lawn work or whatever, and they're simply not replenishing it unless they happen to be somebody that really salts a lot of their food to taste at home. which again may not be the case. So this argument for high sodium, isn't sodium dangerous? Not if you're losing seven grams. Replenishing with just one gram is really just trying to bring you back to balance. We're not as concerned that somebody drinking a sodium based recovery drink is going to run into issues with maybe their blood pressure or any sort of cardiac issues because they're not drinking seven grams at a time. But again, also they're losing it by being active. Why does this matter? What is the science behind a sodium based drink? It's the sodium potassium pump. Way back in like sixth grade biology, you probably remember the pictures of the cell. It looked like a little half sandwich with some ridges in it or something and little circles were moving around. We probably learned about it again in exercise physiology in undergrad and maybe you heard about it again in PT school, but the sodium potassium pump in the membranes of your cells does a lot of work. It is responsible for a lot of body functions. It powers muscular contraction. It transports glucose into your cells to power those contractions, power that cellular activity. It regulates neuronal activity, the actual firing of our nervous system, our synapses. It regulates our body temperature, and overall it maintains our physical performance. of a workout where you sweat a lot, it was really hot, you felt terrible, low energy, you may have even felt cold even though you knew you were really hot, your sodium potassium pump was running out of the sodium needed to power itself. Three molecules of sodium come in, two molecules of potassium come out. So that is the rationale behind a high dose of sodium compared to a relatively smaller dose of potassium. maintaining that sodium potassium pump. And the end goal is, without consuming a lot of sugar that you probably don't need, we can help sustain your current activity or the activity you're about to do, or feel better and recover from the activity you've already done by drinking one of these sodium-based energy drinks. PRACTICAL APPLICATION FOR PATIENTS AND ATHLETES Now, the history of Gatorade, the history of sugar-based recovery, element in similar, the new era of sodium-based recovery, what is the practical application at the end of the day for our patients, for our athletes? For those folks who are not already active in exercise program, which is statistically 90% of the human race, they don't really need to be drinking Gatorade. They probably should never be drinking Gatorade because they're not expending enough calories, they're not burning enough glycogen to really justify housing 50 grams of liquid table sugar. That being said, even folks who are active, if they are not active for 90 to 120 minutes of higher intensity exercise, they probably also don't need that much Gatorade. Certainly if you go out for a run for an hour on a warm day or maybe 90 minutes, You might want to cut that Gatorade with some water and dilute it down. That can be beneficial to maintain your energy levels, maintain your hydration, but you don't necessarily need to take two full bottles of Gatorade out on your run and house 500 calories and 50 grams of table sugar. I'm sorry, 100 grams of table sugar while you're out on that run. Now what about our athletes who are training really hard folks who might be in the gym for a couple hours, folks who are long endurance athletes, I would argue those folks probably already have their fueling plan dialed in for what they're going to be drinking, what they're going to be eating. So just leave those folks alone. They probably already know what they want. They probably already know what they like, and they probably already know what their body can handle as far as digestive system issues. So if it's not broke, don't fix it, right? Leave those people be. However, you can give the recommendation of if you're not already drinking something sodium-based, you might want to consider that. Why? Because if they are using things like Gatorade or Powerade, whether it's the pre-liquid version already sold in the store, or whether it's the mix, that stuff just simply does not have a lot of sodium or potassium anyways. Again, it's primarily sugar. So recommending to those folks, even if they feel like they have their fueling plan dialed in, of hey you might want to consider a packet of element or something similar before your long run or your long bike or whatever or maybe during maybe after whatever and just see how you feel feel if you feel that you're able to perform better you're able to recover better maybe both And then what about our regular folks? Our folks who we maybe say, you don't really need Gatorade or Powerade, but we can feel very optimistic and very comfortable recommending something like Element to them, even if they're only going to the gym an hour a day, even if they're only going to run a couple miles or bike a couple miles or something like that. Why? There's no sugar in it, right? It's just sodium. We know they're going to sweat it out anyways. And so really it's about their body maintaining balance and they're not going to be worried about extra weight gain or anything like that from drinking more calories than they're expending. So in general, these new sodium-based recovery drinks can be a really safe recommendation for folks to improve their hydration, improve potentially their performance, and also improve how they feel and how they recover after. So that is salty science for this Fitness Athlete Friday. SUMMARY If you want to learn more from us out on the road, we have a couple chances coming up for a Fitness Athlete Live course this summer. Zach Long, aka The Barbell Physio, will be down in Raleigh, North Carolina. That will be the weekend of June 8th and 9th. You can join all of the faculty all of the teaching assistants from the Fitness Athlete Division, June 22nd and 23rd. That'll be right here at CrossFit Fenton, here in Fenton, Michigan. That's gonna be a fantastic weekend. If you've been looking to take Fitness Athlete Live, that's the one you wanna be at. Online, if you wanna learn from us online, our next Fitness Athlete Level 1 course starts on July 29th. That course sells out every cohort. That course sells out every cohort. Don't be that person emailing us the Tuesday after asking to get in. It won't be possible. And our next cohort of Fitness Athlete Level 2 Online begins after Labor Day. That will be September 2nd. You must have taken Fitness Athlete Level 1 to get into Fitness Athlete Level 2 Online. Just like Level 1, that class always sells out every cohort as well. So I hope this was helpful. I hope this is a great resource for yourself, for your own exercise, but also a great resource for you, your patients, and your athletes. Have a great Friday. Have a wonderful Memorial Day weekend. See you next time. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko tackles the difference between grip endurance & maximal grip strength. Joe also provides several programming examples to help clinicians know what to program, who to program it for, and when to program it. 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 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 slash switch. And if you decide to make the switch, don't forget to use the code icept1mo at sign up to receive a one month free grace period on your new Jane. JOE HANISKGood morning crew. This is Dr. Joe and it's going to One of the lead faculty of the fitness athlete division here at ICE. Coming off a great weekend last weekend out in Carson City, Nevada at the Sampler. It was fantastic to see 150 or more PTs from the ICE community there. Great times, great learning, and looking forward to next year as well, which I think is sold out. So if you are interested in going, hop on and grab a waitlist ticket. Pay attention. Jeff will be throwing out some dates for hopping on that waitlist as well. So today, though, team, my plan is to cover… One second, I got a camera issue here. My plan is to cover advanced grip strength. So about a year or so ago I did a podcast on grip strength and it predominantly focused on what I would say is the nuances of grip strength using more of accessory training to build a grip strength within a fitness athlete or just an individual specifically who was looking to build grip strength. But the more I've sat back and thought about it, The more I've independently tried to train my own grip strength, which I find to be one of my weaknesses in the sport of CrossFit, I really believe that there's two versions of grip strength, strength that we need to focus on, depending on what our athlete or our person is looking for to develop there. Basically, what I'm going to get at today is specificity of advanced grip strength. And what we're breaking this down to essentially is two categories. Either someone is looking to build grip strength from more of an endurance perspective, and in the world of CrossFit, I would say that would be like in the gymnastics world. we're often really taxed on endurance grip strength. That is, while we are on the bar doing things like pull-ups, toast the bar, or possibly on the rings doing more than likely ring muscle-ups of some kind. That is typically what we're going to hear athletes complain is one of their breaking points is that they just couldn't hang on or that their grip strength was weakening and therefore when we know through a lot of research now that when the grip goes so do a lot of the other power producing muscles because the energy transfer is just not as clean and clear there. So when I think about endurance grip strength, we're thinking about gymnastics grip strength training. So that's one silo. The second silo is going to be more in our weightlifting world of CrossFit, moving maximum loads. But I think that the thing that we haven't really thought about as much is that when we move max loads, we're not doing it for long durations. The bar is in our hands for only a few seconds or fraction of a second from the time that the bar leaves the floor until the weight lifting movement, the clean or the snatch, for example, is complete. In other movements like the deadlift, we have strategies like a mixed grip that seems to not be a limiting factor for most once they've figured it out, meaning that many people can deadlift their maximum capability with a mixed grip on the bar and their posterior chair and their legs their back are not though are the limiting factor I should say that their grip strength is not the limiting factor so we have a resolution to that in the deadlift but when it comes to the clean and the snatch which require hopefully a hook grip position oftentimes people's grip strength can be a limiter they may not realize it but often again similar to the gymnastics world when the grip goes our power and our connection to the bar is dampened and when we're looking to create speed through that mid zone through that second pull of the olympic lifts Often people lose that torque, that grab on the bar, and they lose power production, and the lift may eventually be failed because of that. So certainly it's not the only thing to consider with weightlifting, but when we're talking about grip strength, we're going to look at max grip strength on the barbell as a separate training thought process than we would look at max grip on a gymnastics movement, which tends to be more endurance based. GRIP ENDURANCE Let's talk about endurance first. When I think of endurance-based grip training movements, the one that jumps to me right off the bat is just long-duration bar holds, dead hang or active hang holds on the bar or on the ring. That would be the most obvious one because it's the most specific to the gymnastics positions and that we are moving on the bars or on the rings. You could add in some dynamic challenges like hip swings or beat swings while doing long duration grip and hold. We could add weight or loaded holds active and dead hang holds from the bar and maybe you would even consider things like farmer's carries in this group where you're sustaining a grip on an object for long durations but often the load tends to be relatively moderate compared to our maximum effort, meaning that if you're hanging from a bar for a minute, that clearly wasn't, it may have been a max effort for that one minute, but it wasn't a max effort overall in total grip, like max grip strength there. So those are some of the ideas of how we might choose certain movements, but they're certainly going to look more like the movement itself, meaning the gymnastics movement as the basis. I wanted to give an example in each of these categories as like a programming idea that we could use so that it kind of comes into play. So lately what I've been playing around with on my grip strength training for endurance in the gymnastics world is mechanical drop sets basically, or even just loaded dropsets I guess would be the better word here because we're not changing the movement as much, but a drop set. Meaning that we're going to start with something that is significantly more challenging. and then we're going to try to maintain work output throughout the following sets but we're manipulating a variable in this case it'll be load so that even though we're fatiguing we're able to maintain high work output over the span so A drop set of active hangs for me lately has looked like this. I have determined what my maximum effort of around 60 to 70 seconds of a hang is loaded, and I picked that one minute mark for a couple reasons. I feel like it's an easy trackable number that we can repeat over and over again. It is a long enough time in the bar where very rarely are we going to see an athlete maintain more than a minute on any type of gymnastics movement that would be kind of at the peak. So I chose that 60 to 70 second mark and I've over time I've tested what my max ability to hang in that one minute mark is with adding load onto my body. So let's say in this situation that I can do a 45 pound plate hang for 60 seconds. That would be set number one. I would then give myself about a minute of rest following that 45 pound hang. I'll let the grip recover, but not too long. We're thinking endurance here. We want to repeat this again and I'm hopping back on the bar, but this time I'm dropping by, we'll say maybe 10 to 15 pounds. So we go from 45 to maybe a 30 pound a dumbbell or a kettlebell that we're now hanging from. Repeat that one minute. There's the drop set that we dropped load, but we're still doing one minute of output here. Rest 45 to 60 seconds. Then maybe we go to a 20 or 25 pound weight. And ultimately I've been doing anywhere between four to five sets. So if I start at 45 pounds, my very last set over those four or five sets is going to be just my body weight and I'm trying to hang. My goal is 60 seconds. But often what I'm doing here now is just providing a opportunity for me to really test my max grip hold on the bar or on the rings at body weight after hyperloading it in the three to four sets prior to that. So this is an example of grip strengthening for the endurance training of gymnastics, but you could do a whole lot of other things. But again, as a summary for the endurance grip strength, we're looking at moderately challenging loads, for longer durations, simulating ultimately the experience of having to hang on to the rings or the bar for long periods of time. We could consider dynamic movements as well, like kipping to challenge the grip or load. Those would be my two best suggestions. And if you're really, you know, in a bind, we could consider things like farmer's walks or carries as well too. MAXIMAL GRIP STRENGTH So now this has to directly, sort of oppose the next scenario in which we talked about silo number two being grip strength training on a barbell we're looking to move maximum weight the literally the the absolute max of load that we can hang on to and move effectively and then how we change our ability to have a stronger grip during those movements and So for me personally, I mentioned this briefly before, I believe and I feel myself that often if my grip is going, it's not that I physically couldn't necessarily hang on to the bar, it was that it was starting to break my ability to hang on to the bar effectively and energy was leaking out of my hands and therefore as I was trying to create speed on a clean or snatch, once I got past the knees more than likely in that second pull, into triple extension through the following third pull movement that I wasn't able to create enough energy through the bar to keep it accelerating upward at the appropriate speed or height and I was failing to get my arms up and under it. So I've been working on training grip strength on the barbell in really heavy positions on the bar and not only incorporating load but also considering speed because i think speed will challenge the grip as you start to move upwards and everything in the world is trying to push that bar back down towards the floor that has a unique dynamic that needs to be offset by incredible grip strength so here in the olympic lifting world i like to treat this more like strength training max strength training. If I were trying to improve a one rep max back squat, bench press, whatever, I want to kind of treat grip strength training in this scenario very similar. So this could be movements like Simply put, maybe even if you're warming up your deadlift, we start working on deadlifting with a regular grip, not even a hook grip, just a regular hand over hand grip, which is often going to be the most limiting, but this is a great opportunity that as you're working from 135 to 225 to 275 and maybe into that 300 pound range as you're warming yourself up for your heavy loaded deadlifts that you're just doing a regular grip. That is one option of training grip strength on the barbell. You're only getting those three or four seconds of each movement. If you're doing multiple reps in a row, you may have to re-grip the bar and you'll also realize how quickly that fatigue in the grip comes into play with that. But it's certainly an option that we could think about building grip strength on the barbell during our deadlift and our deadlift warmups. If you are a trained deadlifter, you will probably run into the scenario that eventually Your body could move more, but your hands can't hang on to it. And that's usually when we go to a hook grip, a mixed grip, or possibly straps. But more recently, the way I've been going after this is doing rack pulls or heavy barbell holds with rack pulls. So in a rack pull, I can set the barbell height to be starting at around the knee level, which is right after that transition zone of the Olympic lifts. And what I'm often looking to do here is pick a load that I can regular grip that i can move with some sort of speed and intent and i'm moving through that second pull position quickly but just from the rack so grabbing the bar really gripping it standing up with good technique good form and pulling into that essentially hip crease position that power position taking the bar right back to the rack letting go and then repeating it is a short burst a short intentional burst of grip strength that I'm looking to train at loads that are often similar to the amount of weight or even slightly heavier, we'll say 90 to 110% of what I could clean or snatch. You could do this in a wide grip or more on your clean grip, either one would be fine. But essentially what we're doing is doing short bursts at high loads. So if we're thinking about building out like a working set for somebody, I've lately been doing anywhere between six or seven, upwards of maybe 10 sets, depending on how I'm feeling, of just sometimes one to two or three reps in a set. So let's say I have 300 pounds on a bar in that rack position. I grab the bar, squeeze it like hell, pull to power position, set the bar back down, and depending on how that load is feeling, I'd either re-grip and repeat for rep number two, or possibly three, or maybe I'm just doing eight to 10 sets of singles at my max effort. It's unique in that it won't be overly taxing from a stamina standpoint, but it certainly will start to train the grip from a speed, power production, and we'll just call it an integrity position, where it really has to commit to doing what you're wanting it to do, which is hang onto that bar as it's moving fast through your transition zone. So that's an example of a working set that I would do, six to 10 sets, one to maybe two or three reps total at anywhere between 90 to 100, 110% of your Olympic lifting capabilities to start to build confidence and strength in that second pull, or possibly off the floor if that's where you feel like you're weakest, but the second pull seems to be where that speed change is occurring, which will challenge the grip the most. The third phase of grip strengthening, I guess, would be back to my original podcast that I'd done a while ago now, which I think a lot of us are becoming more familiar with, which is just accessory grip strength training. And this is the things like, you know, doing forearm work, doing plate pinches, doing spherical or dumbbell head holds, where you're grabbing on the top of a dumbbell, training our grip in different positions, narrow to fat grip. There's so many different ways we can go after that. But if we're only focusing on the unique, accessory grip strength training, I think we're missing the ability to be more specific and whether that specific need is in endurance, long duration, moderate holds, or if it's in more of a strength world where it's maximum loads, quick, fast bursts, I think we need to be thinking about what our athlete is looking for, what we're looking for as individuals and starting to train within that bubble. So hopefully that was helpful guys. It's been certainly helpful for me to train this way. I've been really putting some time into it. I'm hoping to see some changes because I've worked on a lot of grip work for years on and off and I felt like, you know, pound for pound, my grip was okay, but it was starting to inhibit my ability to move barbells faster. So I've been putting a lot more of my energy into this max barbell grip and hold position. Um, Good luck with it. It's challenging. I think you'll learn from giving it a go. And it certainly fits that mold of specificity, which is always important in our strength training world. SUMMARY So last thing before signing off, CMFA live courses coming up here in May. I think Mitch is out in Bozeman, Montana. I'll be in the Duluth, Minnesota area here in the next few weeks. So if you're looking to get a course last minute and you're out in Montana or you're in Minnesota, Michigan, Midwest area, that Duluth course would be awesome. It's a cool town. We're already filling up out there. And then in Fenton in June, the third weekend of June, we are doing a fitness athlete summit, which we are pumped about. It is going to be myself. It'll be Mitch Babcock, Zach Long, Kelly Benfield will be there, Guillermo will be there, Jenna will be there, Tucker, all of our lead faculty and TA are gonna be there. We're gonna try to implement more fitness, but you'll have tons and tons of opportunity to learn from some of the best in the business, so I would absolutely get onto that course. It is filling up super fast, people are excited about it. Mitch's Gym, CrossFit Fitness is an amazing place to be. It'll be a great time, so if you're looking for anything this summer to get into, I would say don't miss your opportunity there. Have a great weekend, we'll talk to 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 CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the why behind the footwear recommendations they make and why minimalist footwear may not be the best choice for many fitness athletes to start with as well as how proper footwear can have an added benefit of improved strength, hypertrophy and fitness 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. GUILLERMO CONTRERAS Here we go. Good morning, fitness athlete crew. Good morning, PT on Ice Daily Show. Welcome to the PT on Ice Daily Show and the best day of the Fitness Athlete Division of the Institute of Clinical Excellence. Super happy to be with you here this Friday morning. fitness athlete footwear. And that's a little teaser there. Hopefully you get excited for that. Before I start jumping though, I want to say anybody headed to Reno, Nevada, in Reno, Nevada for the ice sampler, have an awesome time. Have an epic time. A little bit of FOMO not being able to be there, but hope you all have a wonderful time. Take so much out of that weekend. It's such a great weekend. So much to learn. So many to learn from. And I've done this topic in the past. I've talked about my shoe recommendations for fitness athletes, whether it be the Rad One Trainer, the Strike Movement Trainer, the Nano, the Metcon. I've gone deep dive almost too long into episodes with that in the past. And today's actually a more of a, let's call it a response, a response PT on this episode, discussing why we don't, or why I don't personally recommend barefoot in the fitness athlete, whether it's the level one or the live course, we get asked, hey, what are your thoughts on barefoot shoes? Or why aren't you recommending minimalist shoes to allow the foot and the ankle to naturally do what the foot and ankle should be able to do? And this is where we're going to dive into, right? This is the topic I'm discussing because we know there's different shoes out there, right? I have somewhere in front of me right here. This would be a minimalist shoe, right? This is a zero drop shoe. it allows the foot display so a really nice wide toe box. It allows the foot to move naturally, allows the ankle to move through a broad range of motion. Why is that foot, why is that shoe wear not something we recommend to the majority of fitness athletes? to explore that full, broad range of motion that we wanna see with squats, squat cleans, wall balls, air squats, you name it. Why is that? when we look at shoe wear, we know that there's aspects to it, right? There's the forefoot, there's the midfoot, there's the heel, and we have something called a heel drop. And the heel drop, essentially, I'm gonna grab another pair here, is the amount of drop a four millimeter heel drop from the back of the shoe to the front of the shoe. That means that when I put this shoe on, my heel is lifted up just a little bit, just about four millimeters difference. What that does for me as an athlete, when I am squatting, is that it gives something we like to coin a dorsiflexion buffer. on board so that when I squat, I have maybe a little bit more available ankle dorsiflexion range of motion for me to squat with. When we take that away, when we go into that minimalist where we have a flat, fully flat shoe, if I am limited at all in ankle mobility, ankle dorsiflexion, that shoe is not going to allow me to have as much anterior transition to that tibia. it's then going to reduce the depth with which I can get into my squat, or it's going to push me into some more funky motor patterns, what we call the immature squat pattern, where my shin moves forward, but then it stops, which means my hips can't go any further without me losing balance or falling backwards, which means my torso needs to dive much further forward, which leads typically to a significant increase in stress on the posterior We're going to increase the loading, uh, the, the, the, the torque on the hips and the posterior chain when we significantly limit that anterior translation of the tibia. We know that from research, right? We know that it's no longer recommended or should be recommended to teach to restrict amount of increased stress to the lumbar spine, the posterior chain, and the hips when we do that with a very minimal decrease in stress to the knee. If you look at the data from the research, it's about a 53% decrease in the knee. 1,000% increase in torque to the low back, hips, and posterior chain, right? That's a huge trade-off. Whereas if we allow that tibia to translate forward, that knee to move forward, it allows for a more upright torso, a more vertical descend into that squat, and improved motor pattern there. So all that to say, when we give minimalist footwear, and we don't know what the individual's mobility is like, or we do know, like, hey, I know this person has really stiff ankles, And what we see both anecdotally and pretty much everywhere is that the ankle is one of the most difficult joints in the body to create mobility. And it can take years to improve ankle dorsiflexion range of motion. If you don't believe me, you can talk to our COO, Alan Fredendahl, uh, who's been working on ankle dorsiflexion for darn near a decade now, probably. And he's, he's doing much, much better now, but it's, it's been a journey for him to try and improve his ankle dorsiflexion. that athlete's ability to sit deeper into that squat with that more mature vertical squat pattern. And when we're talking about CrossFit or fitness athletes, that means that we're limiting the squat, including the back squat, the front squat, the overhead squat, squat cleans, squat snatches, pistol squats, wall balls. There's all these movements where we want to have a vertical torso, a more upright torso when we're performing it or receiving And when we take away mobility from the ankle, we restrict that motion because we're saying you need to go barefoot at all times to really work on it. You need to work on your mobility. Okay, you're not gonna go to depth until you can have better ankle mobility. We are significantly reducing that athlete's ability. to improve, strengthen the knees, strengthen the hips, strengthen the trunk because they can't load that barbell as much. We're reducing fitness level because now they're doing less work in the same amount of time as maybe their counterparts in the same classes or following the same programming and such. So we use the shoe to allow for that dorsiflexion buffer to allow for a deeper squat. We also recommend TO Slide a pair of VersaLifts, of heel lifts underneath the insole, they sit in there. Now instead of a four millimeter, maybe they have more like, I believe VersaLifts are eight millimeter or so. So it'd be like a 12 millimeter, which is, it's pretty high up, right? But it gives so much more mobility in that ankle to allow them to sit deep into a squat with good mechanics, with good motor pattern, and really, really hit the deep ranges that are gonna allow them to train a greater amount of the glute max, a greater amount of their quad to a broader range of motion, right? powerful hip extender that most people don't realize only really gets targeted when we're hitting those deep ranges below parallel to the squat. Again, this is not me saying barefoot or minimalist shoes aren't for nobody, right? There are individuals who have fantastic mobility in their ankles, great mobility in their hips. By all means, if they want to wear a two millimeter heel drop like Vans or Chuck Taylors, or do you want to wear a New Balance Minimus or the, I think the Xero, X-E-R-O, whatever those are. Those are fine for those individuals if they have the adequate prerequisite mobility in their ankle, their hips to be able to perform these movements are really good quality patterns. But for those of us who might have a limitation in the hip or limitation in the ankle, we have should be recommended. right? The two I have right in front of me, right? The strength movement, his trainer, four millimeter heel drop. This is someone who maybe has pretty good hip mobility. Um, and they can make up for a little bit of lack in ankle mobility with that, but they still have more than like 10, 15 degrees of ankle dorsiflexion. Um, me personally, I have like 30, 35 degrees of ankle dorsiflexion. I have decent hips. These work really, really well for me. These are my favorite training shoe for They fit more true to size than they used to. This has, uh, the rad one trainer, um, has a seven millimeter heel drop. Uh, and it is much larger. It's different. The heel is really good for lifting. It's good for Metcons. I have a lot of people at our gym who love these shoes. Uh, really high recommend these for those who maybe need a little bit more ankle dorsiflexion buffer or limited in their ankle mobility because of that. And one I don't have with me right now, if you have more of Um, and you don't like your toes display a whole lot, uh, tier T Y R their tier one trainer has a nine millimeter heel drop. So the biggest heel drop and they just standard training shoe that you can find. And that is the one I recommend to my individuals who like, Hey, I have horrible ankle mobility. Um, I always struggle to hit squatting full depth without my either my ankles kicking in or my going up on my toes. What do you recommend? Um, that's uh that's tier one trainer um excuse me first ones are called oh i'm sorry these are the uh strike movement haze trainer strike movement haze trainer so there is a strike movement right there uh strike movement without any vowels in the movement um so the haze trainer uh good quality shoe really really solid uh great for med cons i love them for weight lifting as well um and again nice and like a wider toe box not too wide but not too narrow at all either so really comfortable i love these for So hopefully that answers your question. And if you're looking for the evidence, right? Like, oh, well, like you gotta be able to use your feet. You gotta be able to use your ankles. In 2022, a study from the Journal of Strength and Conditioning Research came out on the effects of footwear and biomechanics of the loaded back squat to exhaustion in skilled lifters. So these are people who are already lifting, who probably already have really good mechanics and strength and everything on board. And they made one group lift barefoot or minimalist as barefoot style shoes. One group had to lift in like heel elevated shoes. And what they found was there's no difference more in like a novice athlete or beginner athlete or maybe people who maybe don't have that same mobility but in these skilled lifters people have been doing it for a while there was no significant difference in that either shoe reduced joint loading or improved joint range of motion for them they already had the adequates on board so the reason I even always emphasize, more than anything else, in the level one, in the live course, when people ask about shoe wear, about are we going to restrict someone from squatting until they have adequate ankle mobility, do we give them a shoe like this, is this okay, or do we give them a minimalist shoe right away, and if they can't do it, do we let them do it? It's always and, not for. I'm going to recommend something like a Rad1, and if they need it, a Rad1 with a heel insert, a VersaLift in there, while they work on ankle mobility, while they work on their hip strength, to work on their squat, to continue being a part, a participant in their CrossFit class, in their group fitness class, without needing to worry about scaling every single time, without needing to worry about modifying every movement every single time, and then they are also going to continue working on their ankle mobility diligently to get to a point where maybe they can take that heel insert out and they feel really comfortable here, and they can move to something like this, and then they can move to minimalistic. That is their end goal. It's always and, not, or with this type of If you want to learn more, if you want to ask this person live and really have a debate with me one-on-one, we have courses coming up where you can meet us on the road, where you can talk all things shoe. Like I love talking shoes. I love talking footwear, worn them, almost all of them. Love doing it. SUMMARY But we have courses coming up. Our CMFA online level one just sold out. So if you've been looking to take an online level one course with Fitness Athlete, we are not having another one until fall of 2024, but you can sign up for that now. So if you want to register for that now, this course always sells out. We always sell out before we start the course. We have a course in the fall. You can sign up now. You can wait until the summer to sign up whenever you want to. Our next level one one if you've taken the live course and you just have the level two to finish up your CMFA cert or if you just want to continue down the path of that CMFA cert we have CMFA level two starting up in September uh on to a year. So again, if you're looking to get that certification, if you're looking to learn more about Olympic weightlifting, programming, modification, even some business type things, check out the level two CMFA course on September 3rd. That one also always sells out before it starts. So if you're looking to take that, sign up sooner rather than later. If you want to hit us up on the road, you're looking where we're at. CMFA Live is going to be on May 18th and 19th in two different locations. Proctor, Minnesota. I believe Joe Hnisko will be leading that one up in Proctor, Minnesota. And then that same weekend, I'll be hanging out with Mitch Babcock in Bozeman, Montana. That is, again, the weekend of May 18th and 19th. And that's all we have right now in May. And then June, on June 8th and 9th, you can hang out with the barbell physio, Zach Long, in Raleigh, North Carolina. And then on June 22nd and 23rd, we have the first ever annual Fitness Athlete Summit. You're going to see every single faculty and TA and every member of the fitness athlete crew. You have Mitch, Zach, Joe, myself, Kelly, Jenna, Tucker. We're all going to be coming together in Fenton, Michigan at CrossFit Fenton for an epic weekend, more fitness and fun and sweating and learning than any course you've ever done in your career. So we would love to see you at the Fitness Athlete Summit on June 22nd and 23rd. I believe it's about 45 minutes, an hour, something like that away from Detroit. null: So quick flight in. You can also SPEAKER_00: to fly into Flint, I believe, which is a shorter, even shorter drive from there. But we would love to see you there and have you join us for the Fitness Athlete Summit in June of, June 22nd and 23rd. Gang, thanks so much for tuning in this morning. Have a wonderful weekend. Again, if you are at Sampler, have an absolute blast. Enjoy yourself for me as well. And we will catch you on Monday for the PTNX Daily Show. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

Kirkland Signature Sonoma Old Vine Zinfandel- Costco's excellent $10 ZinThe winemaker is  Zach Long who has worked at Kunde  Family Wiery for the last 10 years.Kunde is a 5th generation winery that has been around for 117 harvests.Zach is also involved with Vintage Wine Estates which has a first-class portfolio.This Old Vine Sonoma ZIn has a strong resume.For more information check out https://cheapwinefinder.com/ and also listen to the best value-price wine PODCAST!!Check us out at www.cheapwinefinder.comor email us at podcast@cheapwinefinder.com

This week Bryce sits down with Zach Long AKA the Barbell Physio! Today's guest is a PT, a DPT, a strength and conditioning specialist and he's the co-founder of the performance plus program where he helps people with mobility, gymnastics and strength accessory workouts.-Learn more about Zach - HERE-Smiths build things.Smiths get the job done.We are all smiths. -Trident Coffee -  Use code "ALLSMITH" to get 20% off online and in TapRooms (https://bit.ly/3fzbBDx)RX Smart Gear - Use code "ALLSMITH" to get 10% off full ropes and grip (https://bit.ly/34RQt9g)LSKD - Use code "ALLSMITH" to get 10% off (https://www.lskd.co/?ref=5E4za_te51Ty9o)Thank you for Listening! Learn more below.ALLSMITH IG ALLSMITH YouTubeBryce Smith IG

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.

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 current state of the insurance-based healthcare systems, alternative practice styles, and the "magic" behind building a sustainable practice. 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 INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL All right, good morning, PT On ICE Daily Show. Happy Thursday morning, I hope your day is off to a great start. My name is Alan, I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at Ice, and the Division Leader in our Fitness Athlete Division. It is Thursday, it is Leadership Thursday, that means it is also Gut Check Thursday. This week's Gut Check Thursday is another qualifier workout, so it's on the more aggressive end. So we have every four minutes for four sets. You're basically going to go through one workout of the Hero Workout DT. You're going to do 12 deadlifts. You're going to go 9 hang cleans. The caveat this week is that they're hang squat cleans. So they're going to take longer to cycle and they're definitely going to take more out of your legs than the traditional power clean we find in DT. Then you're going to finish with six shoulder to overhead. So for most folks, that's going to be a push jerk. The weight there is 155-105 on the barbell. Ideally, we're finishing one round of that complex in about two minutes. And then in any remaining time in that four-minute window, we're doing as many wall balls as we can. Guys are going to throw a 20-pound ball to a 10-foot target. Ladies, a 14-pound ball to a 9-foot target. The goal of that workout is to get through the barbell and get to the wall balls and accrue some wall balls. Great scores are going to be really anything above 50 reps. Exceeding 100, making your way towards 150 is definitely going to be an exceptional score. Modify the weight on that barbell, modify the reps if you need to make sure that you get off the barbell in about two minutes and that you have time for wall balls. There is no rest between sets, so keep that in mind as well. You probably don't want to be doing wall balls right until the whistle and need to turn and pick up that barbell without a break. You're probably going to want to allow yourself maybe 15 to 20 seconds of rest on the last set of wall balls and then go and pick up that barbell when the clock beeps. So have fun with that one. That's from a qualifier workout for a really awesome competition we have here in Michigan out on the west coast of Michigan out near Grand Rapids called Fresh Coast Fit Fest. Really fun CrossFit workout two day event on the beach. So some of our teams here from our gym at CrossFit and Fenton are going to be doing that. So have fun with that qualifier workout. THE CURRENT STATE OF THE PT INDUSTRY Today what are we talking about? We are talking about cash-based practice, insurance-based practice, or maybe in between what we call a hybrid-based practice, where is the magic? So today I want to make a couple points. I want to really have a candid discussion on insurance and really the physical therapy profession in general. I want to talk about what it means to open a sustainable and ethical practice. I want to talk about the down-low with payment methods and payment amounts as far as how much we get paid. and I want to talk about the concept that I call the golden rule of private practice. So let's start with that discussion on insurance. So Kaiser Foundation back in 2022 published that about 95% of Americans have health insurance. Why do I bring that up? I bring that up because if you only get information from social media, which unfortunately many folks now do, you might have this perception that cash-based therapy, cash-based medicine in general, concierge medicine, has taken off and that if you still accept insurance, you are somehow maybe 100 years behind what's currently happening. and it could not be further from the truth. Most Americans, most consumers have insurance. Again, 95% of people. So certainly while folks are getting more used to maybe their high deductible plan and that they do probably need to pay out of pocket for some or maybe all of their health care, Certainly that's not the case for everybody. In this idea, this mantra on social media that Americans have just rebelled against health insurance and none of them have it anymore and everybody is totally willing to pay cash for everything and you can charge whatever you want is the name of the game could not be further from the truth. In fact, 33% of Americans have Blue Cross Blue Shield PPO insurance which means they carry pretty nice insurance that they probably pay a lot of money for. So I say all that to say this, we need to be realistic that most of us will probably come and go from this profession before we really see a significant shift in how patients interact with the healthcare system, most notably from how they pay for their healthcare. Why does that matter? And why is that unlikely to change? I think looking at the state of the economy in general, again, if you get a lot of your news from social media, you may believe that the economy is on the edge of being destroyed at any minute. But again, that could not be further from the truth. We dodged the depression that was forecasted. The economy is at an all-time high. And that is shown if we look at insurance company profits. So let's go down this list. I love to look at data like this. Blue Cross Blue Shield last year, $457 billion. Almost half a trillion dollars. UnitedHealthcare right behind them, $414 billion. Anthem Blue Cross Blue Shield, so kind of a conglomerate of a bunch of different state Blue Cross Blue Shield associations, $109 billion. Cigna, that's a private commercial insurance, $76 billion. Humana is another private insurer, $55 billion. If we look at just the five largest health insurance providers in the country, they comprise 5% of the country's total GDP. All of the money that we essentially generate and spend across the span of a year. We also need to recognize as we've talked on here before that by 2030, 70% of Americans will be Medicare eligible. So if anything, what we see over time is that more people are carrying insurance, more people have nicer insurance, whether they're paying for that themselves or whether they're just being provided nicer insurance through their employer and that more and more Americans are also going to be carrying Medicare insurance as they turn 65 or whatever that age becomes over the next couple years. So why are we unlikely to see a significant shift in payment methodology in physical therapy or in health care in general? Look at all of that money, right? If we include all the other health insurers, we're looking about one-tenth of all of our money coming and being generated by health insurance providers. If we include what's being spent on health care, both through insurance and through private pay, that is beginning to comprise almost a quarter of our economy. What does that translate to practically? What can we glean from that? It really says that the chief product that the United States produces is sick, injured people in pain, and that our primary export is dealing with the subsequent secondary issues that come with a sedentary lifestyle that produces really sick people. So I think we're really unlikely to see things shift because a lot of people are making a lot of money either being on the health insurance side of the equation or being on the health care system side of the equation. And I think we are living in denial if we don't think that those giant companies that are making half a trillion dollars a year aren't making sure that some of that money goes to lobbying members of Congress to make sure that there are laws that require health insurance to make sure that we build brand new headquarters buildings that employ a lot of people where case adjusters and claims adjusters and all these folks that run a health insurance company can work and that that company can say to the government, look how many jobs we're creating. And when you really see that these companies are starting to take in nearing a trillion dollars, you recognize how much money is truly in this system. INSURANCE IS WEIRD & NEEDS TO CHANGE That being said, we need to be honest that insurance is totally weird. Health insurance is so weird. It is the most inefficient, weird thing that we probably do, right? We're used to having auto insurance. If you've ever had to make an auto insurance claim, you would probably say that by comparison to health insurance, it was a pretty easy process, right? If you've ever wrecked your car, somebody came out and probably said, Oh dude, that car is wrecked. Yeah, we're going to get you a new car. So we'll do some paperwork. And then you'll get a check and you can go get a new car, right? I just had a windshield crack. It was really cold here in Michigan. It was negative 20 degrees. Made a call. Somebody came out and said, yep, dude, your windshield is indeed cracked to the point where it's probably dangerous for you to be driving. Drop your car off here and in an hour somebody will fix your windshield. We don't see that smooth process with healthcare. We see a really weird process filled with a lot of paperwork, a lot of limitations on access to service, and otherwise, the health insurance company trying to hold on to the money that they're getting from patients. It would be totally weird to have insurance in a lot of the other things we do, right? Imagine you need to get your hair cut. I need to get my hair cut really bad. Imagine I go to get a haircut and they tell me, hey, your haircut insurance will only pay to cut half of your head today. You'll have to wait six months, and they'll cut the other half of your head. How impractical would that be? Yet, that's how healthcare insurance functions. So we need to acknowledge the dichotomy here. There's a lot of money in this system. It's probably not changing anytime soon. That being said, it's very weird and inefficient, and it's not working for a lot of people. So that being said, if this is the current state of our healthcare system, and our industry is physical therapists, how do we navigate this? NAME THE ENEMY We navigate this by naming the enemy, right? Corporate physical therapy with hundreds or thousands of locations, employing thousands or tens of thousands of therapists, overbilling patients, seeing multiple patients an hour, driving up that revenue for both their businesses and the health insurance companies, and really delivering low-quality care. We will never win against those folks one-on-one. We'll never be able to go toe-to-toe with them. If you missed Virtual Ice on Tuesday with Jeff Moore, our CEO, you missed a really good discussion on effortless clinical practice. And he really touched on the idea of the solution to high volume, low quality is not to try even more volume with even less quality. That is a losing game. We can certainly try the same strategy to win. What's probably going to happen is that It's not going to last very long, you're probably going to burn yourself out, and you're just going to become another clinic that gets bought up by one of those big chains. So we need to name that enemy, we need to recognize what's being provided, and we need to begin to chip away at them. We need to hit them where it counts, which is to take their patients away from them. How do we do that? We need to fundamentally understand and recognize and be comfortable with what an hour of our time is worth. WHAT IS AN HOUR OF YOUR TIME WORTH? This is something I heard many, many years now, almost a decade ago now from Zach Long, of no matter what you're doing, you should know what an hour of your time is worth and you should be trying to get that. It doesn't matter if you're treating a patient, it doesn't matter if you're doing back-end work, It doesn't matter if you're doing marketing for your clinic, you should be getting relatively the same amount per hour, and you should have a really good understanding of what an hour of your time is worth. Building upon that is how we build a successful, sustainable practice. We just crossed the halfway point in our most recent cohort of Brick by Brick, our practice management course, and this is something I really hammer on people with how to establish your practice, that before you launch, before you start seeing patients, Now is the time to make sure that you set your practice up so that you have a successful, sustainable practice because that is the only way that we're going to chip away at all of these high volume, low quality establishments in a way that we might actually turn this ship around. What's not going to work is doing the same thing of seeing and taking insurance that does not pay well, seeing two, three, four people an hour and getting stuck in the same volume trap that all of these clinics are already stuck in. $40 a visit is profitable if you see four of those visits per hour, right? We can't get caught up trying to fight fire with fire here. We need to go a different route. We need five high-quality, independent, private practices around every chain clinic to provide really quality service to take those patients away over time from the chain clinic and drive them out. And we need to replicate that across the country. The worst possible outcome of fighting fire with fire is that after a couple years, you decide that you're done and you sell your practice to one of those corporate chains, right? You become the enemy. you turn your practice into another version of something that already exists, the volume goes up, the quality goes down, you just become another cog in the machine. That is the worst possible outcome if you do not think about starting your practice sustainably. How do we do that? PAYMENT METHOD: THE PATIENT'S PROBLEM My third point is that it comes down to payment method. We need to understand and recognize that Some people want to use our insurance, but that some insurance simply doesn't pay us a living wage such that we can pay ourselves what we think we're worth. We can pay the people who may work with us what they're worth, cover our expenses and still turn a profit. We need to really think about sustainability. That means that you probably should not accept every insurance possible and that depending on where you live and depending on what an hour of your time is worth, maybe no insurance is good enough for you. And that's also okay, right? Hence, cash-based physical therapy. And that for the majority of folks, the magic is going to probably lie somewhere in the middle. Taking a handful of insurances that let you reach a moderate amount of patients, and everybody else is going to have to pay cash. With that comes the hard truth that not every patient is going to be able to see us. And that at the end of the day, how a patient pays for their service, their physical therapy, is really their responsibility. There are certainly ways we can help. We can offer cheaper rates. We can offer pro bono. And that's a topic for a different day. But at the end of the day, how they pay needs to be in a form that is sustainable for us to take. And I don't think we consider that enough when we're about to launch a practice. I think we go full spectrum. How many people can we reach? Let's take every insurance. Doesn't matter how terrible it pays. Doesn't matter how much paperwork is involved with seeing those patients. Let's take it all and then we'll deal with it later. And then later becomes, I'm tired of doing this and I'm going to sell my clinic to one of the big chains. Again, the worst possible outcome. We need to recognize that if we accept more insurance and we provide lower quality, higher volume care, that we're going to have a minimal impact overall, not only on our patients' lives, but on the profession in general. PAYMENT AMOUNT: THE OWNER'S PROBLEM Looking at payment amount, we need to recognize that there's a natural give and take between employer and employed. And at the end of the day, for those folks in management positions or leadership positions, We need to recognize and truly embrace the idea that the staff physical therapist, the person who comes to work every day and treats patients, is our frontline worker, and that they need to be supported more so than anybody else. Far and away in our industry, far and away across healthcare, the people who see patients are often treated the worst. They are the people who have been told, guess what? There's no money for a raise this year. Guess what? We're taking away your Con Ed money. Guess what? We were going to give you an extra week of vacation. We can't afford that now, right? We continually strip money and benefits and autonomy away from our frontline workers and then we're totally shocked that they leave and open up their own practice, right? Attrition is one of the worst things that can happen to your clinic and we need to understand that while payment method is the patient's responsibility, Payment amount is the owner, the leader's responsibility of controlling what we get paid is ultimately, for me here at our clinic, my responsibility. I need to make sure that we take in enough money, that the frontline workers are supported, and whatever's left is for the ownership. And far too often in clinics, it is the other way around. If the insurances you take aren't paying you enough to take care of your people, you should probably stop taking that insurance. If the insurances you take require you to hire another staff member to do all of their authorizations and certifications, you should probably stop taking that insurance. And if working with an insurance company requires you to reduce your quality or increase your volume and become a detriment to the healthcare system instead of a positive influence, you should probably stop taking that insurance. THE GOLDEN RULE TO SUSTAINABLE PRACTICE The golden rule, my last point here, what do I think the golden rule is? Is that you should only work with organizations that value and reward high quality physical therapy that pay you at or above what your desired rate per hour is. Folks often ask us, hey Alan, hey Mitch, why do you guys take insurance? Well, we only take three of them. We take our Blue Cross Blue Shield state PPO. we take Medicare and TRICARE. Why? Because they don't have any documentation authorization requirements, they pay at or above our desired rate, and they have a really quick turnaround on payment, usually 48 hours for Medicare TRICARE and about 10 days total for Blue Cross, about five to seven business days. So we have relatively no turnaround on payment and it pays at or above what we want to get paid. And I don't think enough clinics appreciate how important that simple rule is. SUMMARY So I think, will things be fixed? Probably not anytime soon. We need to recognize that most Americans have insurance. They want to use insurance. Cash-based therapy is getting more popular, but is widely dependent on geographic area and local socioeconomics. We cannot fall into the traps on social media where we see all of these paid ads maybe from cash-based physical therapy owners that tell you you need to be 100% cash-based or you're behind the times. We need to have some sort of compromise as long as that compromise doesn't require us to sacrifice quality in order to obtain really good outcomes at a volume of patient care that is sustainable for our therapists and ourselves in a manner that rewards them for the work that we put in. We need to recognize how much money is in the health insurance and the healthcare industry, and how little of it those of us going to work every day and treating patients are actually seeing. I laugh every time somebody lets me know they just scored a sick $500 quarterly bonus for treating 80 patients a week. Because I know that clinic probably made hundreds of thousands of dollars off those patients that quarter, and the staff physical therapist got $500. Whoopee, that means nothing, right? We need to acknowledge that amount of money, excuse me, and we need to know that that is part of the reason why things may not be changing as quickly as we want them to change. If we're thinking about opening our own practice, we need to make sure we do the things necessary to make it sustainable. We need to take a really long, hard look at our local socioeconomics, our population, In Brick by Brick, we have people do a SWOT analysis, strengths, weaknesses, opportunities, and threats. And one of the things we encourage students to do is who are the biggest employers in your area and what insurance do they carry. If you work in a town where 80% of the people are employed by the same employer and they have Blue Cross Blue Shield PPO or it's a military base and they have TRICARE, it's probably in your best interest to take those insurances provided it pays you what you want and the documentation requirements are acceptable to you. If not, we need to also recognize it's okay to not take every insurance and that hybrid practice is probably long term the best solution moving forward until we can make significant changes in the insurance market or until we can shift enough folks over to the cash based side of healthcare practice. So cash-based, insurance-based, hybrid-based, where's the magic? Probably somewhere in the middle as with most things, right? And not or, but also recognizing that we're on the same team, right? If you are operating a cash-based practice, if you are operating insurance practice or hybrid practice, and you are providing really high quality care, you are doing your part to chip away at the problem. And if you're working for a company that is not doing that, or you are part of the management leadership team at a company that is not, you do need to acknowledge that you are providing a negative impact on the healthcare system. and you need to be understanding and recognizing of that fact. So, I love this topic. I think about this topic literally a thousand times a day. So I'd love to hear your discussion, your comments on this. Have fun with Gut Check Thursday. I hope you all have a fantastic weekend. If you're gonna be at Fitness Athlete Live this weekend with Mitch, Don, and Raleigh, have a great time. Have a fun Super Bowl. Go Chiefs. 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. Paul Killoren // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren discusses key research supporting using dry needling with electrical stimulation to target peripheral nerves to reduce pain and improve muscular function. 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. PAUL KILLOREN Good morning team. We've got YouTube up. We've got Instagram live. Happy to kick off the PT on ICEDaily Show this morning. If we've never met, my name is Paul Killoren. I'm the current division lead for the dry needling division with ice. And this week you actually have a dry needling double header coming at you. On Thursday, our lead faculty, Ellie Melrose, is going to dive into technique Thursday. with some subscap tips. Zach Long, barbell physio, hit subscap pretty hard last week. So we want to bring you the dry needling tips for subscap on Thursday. That's with Ellie. Catch it live in the morning or catch the recording. Today is clinical Tuesday, and we're actually going to kick off a topic that really celebrates our advanced dry needling course. As a division, we have two courses going down this weekend. One of them is myself hitting the advanced dry needling course in Bellingham, which is really cool for all of the reasons. It's an advanced course, it's kind of the last part of our dry needling trilogy, our three course series, which will build out our dry needling cert with ice. It's really cool in Washington that that third course is what gives our kind of our inaugural group the 75 hours, which as of last week, the word is that in Washington, PTs will be able to dry needle patients as early as July. So really cool stuff happening this weekend. And the advanced course is really my direct segue into the topic this morning. PERIPHERAL NERVE STIMULATION If you saw the teaser yesterday, we're going to talk peripheral nerve stim. And I guess first to qualify our advanced course, the first half of the course is treating more technical or slightly higher risk targets. Muscles around the scapula, around the thorax, we treat the suboccipitals, we treat some more technical muscular targets. That's the first half of the advanced course. But the second half of the advanced course, we stop having intramuscular interactions with our needles and e-stim. And what I mean by that is we do tendon needling, we do scar needling, but we do peripheral nerve stim techniques. So I figured it'd be worth at least having a little teaser topic on the podcast to discuss What are we doing with all that? And really, this is a short format this morning. So what I'm not going to do is dive deep into all of the things and all of the reasons and all of the research as to why we might intentionally, directly interact with a peripheral nerve with our needling and e-stem. But I wanted to give you some research teasers, kind of a little sampler platter, a little charcuterie board of research when it comes to peripheral nerve stem. And again, without getting into all of the reasons we might do it, it might be obvious for me to say that there's actually some pretty sound research that says if we have a true nerve injury, it was injured in surgery or there's a degeneration or a palsy or a tractioning, but if there's a direct trauma to a nerve and we're trying to regenerate or we're trying to improve the nerve health, It might sound kind of obvious that there's quite a bit of research that says if we can directly stimulate that nerve with our needle and e-stim, that there's great benefit there. I mean, that's obvious, that's a home run. Treat the tissue that was injured, all of that stuff. What you might not necessarily immediately assume is that there's actually pretty solid research when it comes to direct nerve stim being the sciatic nerve for low back pain or for improving muscular performance. even some neuropopulation stuff. That might not be the immediate thought when we talk about influencing a nerve with e-stim. And again, what I'm not going to get into today is all of the stratifying, the decision-making process of when we might stim a nerve versus when we do our intramuscular stuff. I really just want to tease you with some research because these techniques are out there. These percutaneous neuromodulation therapies are actually becoming much more popular. whether it's for pain relief as an alternative to pharmaceuticals, whether it's post-surgical pain modulation or improving muscular performance. These techniques are growing in the rehab realm, in the sports medicine realm. So I want to tease you with some research. THE RESEARCH BEHIND PERIPHERAL NERVE STIMULATION The first one, it's kind of a pilot research study from 2019. The author is Alvarez-Pretz. That's a hyphenated last name. And what they did was basically did one bout, it was 10 trains of 10 hertz frequency, but one session of femoral nerve stim. And what they looked at, these are patients with unilateral knee pain, they looked at immediately before and immediately after strength output. So max isometric strength for the quads before and after femoral nerve stim. And it improved. Not only did it improve statistically significantly from pre to post, but it outperformed a healthy control. So pretty cool stuff. Again, I'm just giving you these little nuggets today. But here's the first citation that says femoral nerve stem improved quad performance. And these are knee pain patients. So again, you can get deeper into the inhibition mechanisms and why that might be, but immediate change in max strength output of the quads with femoral nerve stem. Since I brought up the femoral nerve stem, let me tease you with one more. It's a 2020 publication by Paola Garcia Barmejo. Again, she's looking at anterior knee pain. One bout of ultrasound guided femoral nerve stem improved knee pain, but also range of motion, functionality, and there was a crossover. So they did it on one side, and they saw changes on both. So again, femoral nerve stim, we have changes in not just quad strength, but knee pain, functionality, range of motion, all the things. But let's talk back pain. Or let's frame it this way. Let's talk sciatic nerve stim for a moment. Because the first research publication, 2008, it's by an O, Fascinating stuff. Because again, it might be kind of obvious for me to say if we wanted to improve blood flow to the sciatic nerve, if we wanted to send blood into the vasonevorum, like engorge the vessels to the nerve, improve blood flow to that nerve tissue, it might be pretty obvious for me to say that doing direct sciatic stim does that. And it does. But here's a research article that's fascinating and gives context as to other interactions. Because for this research, they're looking at blood flow to the sciatic nerve, and they had three groups. Group one, they actually did lumbar muscle pumping e-stim. So they didn't necessarily say multifidus, but they did that muscular motor response e-stim to the lumbar paraspinals, and then they looked at blood flow to the sciatic nerve. Group two, they did the sciatic nerve stim. They put a peripheral nerve stem directly on the sciatic nerve and they looked at blood flow. Group three, they actually did e-stem to the pudendal nerve. So a separate nerve, but again, they're looking at blood flow to the sciatic nerve. Here are the fascinating findings. 57% of the folks in that lumbar paraspinal group saw improved blood flow to the nerve. So whether you want to say that that pushes us kind of towards the the changan, the radiculopathic influence, or like the segmental influence of nerves, the myotomal influence you could say, 57% of the folks that got lumbar paraspinal e-stim saw improved blood flow to the sciatic nerve. But here's the rest of the fascinating findings. 100% of the folks that received sciatic nerve stim saw improved blood flow to the sciatic nerve. That was almost their control and it worked. But the last piece here is that 100% of the folks that received e-stim to the pudendal nerve, also 100% of them saw increased blood flow to the sciatic nerve. Fascinating. So we do have an influence approximately from that muscle pump of the lumbar paraspinals, but it's almost like we don't have to be nerve specific because we can put some e-stim on the pudendal nerve and we saw improved blood flow in the sciatic nerve. Again, I'm just going to tease you with more research. The next publication by San Mitro Iglesia in 2021. Love these names. I mean, I will say most of the research being done right now is overseas, international. For this research, they had folks with low back pain and they had three groups. Those three groups all received sciatic nerve e-stem. but they were in three separate anatomical locations. So group A, they put e-stim on the sciatic nerve proximally, so near the issue of tuberosity. Group B, they put e-stim mid-hamstring, so mid-thigh, just a different anatomical location for a sciatic nerve. And then the last one was actually the popliteal fossa, so you wanna call that tibial nerve, whatever. But they're stimming the sciatic nerve or sciatic components in three separate anatomical locations. Fascinating outcomes, these are folks with low back pain. Every single group that received eSTIM to a nerve improved in low back pain, in range of motion, actually in their balance tests, and in their functional scales. And there was no difference between these three groups. So with those last two kind of research nuggets, I'm calling them, it almost seems like we can have a profound impact with nerve stem, peripheral nerve stem, and maybe we don't need to be nerve specific and we certainly don't need to be location specific, meaning we're having a global impact here. And if you've, and if you're out there and you've taken one of our upper or lower courses already, hopefully you gathered that the nervous system influence is really the driver of our contemporary understanding for the therapeutic benefit, the therapeutic mechanisms of dry needling. Now that we're interacting with a nerve, a peripheral nerve, early indications are that we're having a very similar, but maybe a more profound, more substantial nervous system interaction. Maybe it's everything we talk about, muscle spindle and motor unit loop interactions up to the dorsal horn and then, you know, supraspinal centers going to the cortex and somatosensory, all of that stuff. We're now interacting with a much more sensitive much more nervous peripheral nerve structure, and that nervous system influence has to be times 10. So again, today I really just wanted to tease you with that. We do cover peripheral nerve stim techniques on our advanced course. Again, the first half of the course, we keep doing muscular interactions. We do the rest of the muscles that you didn't get in upper and lower, the more advanced, the higher technical muscles. But then the second half of our advanced course, we do peripheral nerve stem, tendon needling, and scar needling. And maybe we can grab a few more of these podcast spots throughout the rest of this year to say, why would we interact with a peripheral nerve? Today, I just set for you a little charcuterie board of research that says we can change, not just nerve health, not just nerve blood flow or neuro regeneration, but we can improve muscle function. We can change strength. We can change pain. And maybe there are patients like low back pain where the initial strategies of conservative therapy, maybe even our, our typical paraspinal or multifidus estim isn't working. We now have one more strategy, one more tissue interaction to consider. But again, that's all I wanted to jump on today was to give you a quick snapshot of nerve stim research. Not gonna give away all of our secrets on how we stim nerves. It's probably fair to say or fair to acknowledge that all of the research I just went through, almost all of the percutaneous neuromodulation, so peripheral nerve stim with needles, fair to say that almost all of that research is done under ultrasound. And that's to ensure safety kind of, but also ensure that it is a direct peripheral nerve interaction. We're not going to use ultrasound on the course. So really the beauty of the technique is how do we interact with it safely again, for sure, but consistently and effectively. So peripheral nerve stim is a big topic on our advanced course. We have a couple that will be popping up. Again, the first one is this weekend in Bellingham. If we're not sold out, we're nearly sold out. We have one in December in Colorado, and there'll probably be one or two more that pop up Q2 and Q3. Hopefully we're targeting the Midwest. We are probably going to be back here in Washington, because again, we need that for our 75 hours to treat patients. But peripheral nerve stim, if anything, I wanted to put that in your mind today. And I mean, big picture before we continue this podcast series about why and how and when for peripheral nerve stim. At the very least, I want to keep throwing out this topic because on the ground floor, if nothing else changes in your mind, I'd like to kind of decrease the paranoia or the concern of needling near a peripheral nerve. Or if you use eSTIM, I'm sure you've had that interaction where the needle goes in, all of the words from the patient are normal, achy, crampy, sore, no nerve words. But then you add yeast into the equation and clearly you're near a peripheral nerve and you generate a different response. At the very least, I'd like to turn off some of the alarm bells that we're so paranoid of interacting with a peripheral nerve that we don't acknowledge there's benefit there. Again, upper and lower, our goal is just to treat muscular targets. We're not intentionally trying to interact with a nerve, but advanced we will. So on the ground floor, I'd love for just The, we always respect nerves for sure, but we don't want to respect them so much that we don't see that there's benefit there. Again, you should be trained in a technique. We're not trying to intentionally or accidentally interact with the nerve. We need to know where they live. If you took a level one or a level two course from somewhere else, I'm sure they mapped the large vessels, the large nerves, and we want to avoid them at all costs. And you should do that to start with. I mean, there's, There's something very precise and very safe about knowing how to not interact with it directly with the needle. But then there is another layer on top of that, that eventually, especially when we use e-stim, so we're going to piston much less, we're going to use e-stim, there's value to knowing where these tissues live and interacting with them directly. So for now, I just want to put that thought in your mind. I want to decrease some of the paranoia, some of the nervousness of being around a nerve, and hopefully I can keep teasing you with certain research. We'll throw some stuff up on Instagram. If you've taken upper or lower through us, you can look for the advanced courses popping up. To complete the CERT for ice, it is upper, lower, and advanced, but you only need to take one of them to show up on the advanced course. So let me know what you think. I mean, do you have questions on peripheral nerve stem? Throw them on Instagram. Hit me up directly on Instagram if you'd like, at dptwithneedles. Otherwise, stay tuned for Thursday. Ellie is going to jump on and show you some subscap tips. Such a key muscle for your shoulder, folks. Again, go back and listen to Zach Long's episode from last week. and how he assesses it and how important it is to treat and how he loads it because Thursday Ellie's just going to bring the dry needling smoke. She's going to teach you how to get in there safely, consistently and effectively. It's a key target. So that's what we got coming at you. Thanks for joining. 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. Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty discusses treating the subscapularis muscle for the fitness athlete. Zach discusses modifications for pressing, pulling, and Olympic weightlifting. In addition, Zach discusses go-to exercises to use for HEP with these individuals. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show, where it is not only the PT on Ice Daily Show, but it is the best day of the week here on the PT on Ice Daily Show, and that is Fitness Athlete Friday. I'm excited to be with you all this week. My name is Dr. Zach Long. I'm a faculty member inside of the Fitness Athlete Division, teaching both our live and advanced concepts course with the rest of the team there. Today, we are going to talk about subscapularis treatment with the fitness athlete. So the subscapularis muscle, I think, gets commonly overlooked in the fitness athlete's shoulder. Alan talked about it last week, so I'm going to follow up his discussion last week with a few other things. But like Alan said last week, this is the largest and strongest of the rotator cuff muscles, and I think it commonly gets overlooked when people are dealing with shoulder pain. And so we're gonna jump into kind of some of the different modifications and treatment strategies that I use when patients have subscapularis pain. Make sure you listen to last week's episode as well. A little quick recap of last week's for you just to set the stage here. SUBJECTIVE EXAM FOR THE SUBSCAPULARIS Subjectively, what I hear most frequently when people are dealing with subscapularis strains are that they have pain with dips, pushups, and the bench press, so with shoulder extension-based pushing motions. And then things like snatches, overhead squats, and kipping pull-ups, where their arms being really stretched overhead in that position. OBJECTIVE EXAM FOR THE SUBSCAPULARIS Alan talked quite a bit last week about testing positions for the subscapularis, and those were absolute gold for ruling in and out the subscapularis. I'm going to throw one more test at you before I move on to more of the treatment stuff. And I like this test because As Alan talked about last week, when you do like IR at neutral, the pecs are such a big muscle working right there that it's not going to be sensitive enough on your subscap. So that's why he talked about like the liftoff test in your arm. The one kind of issue that I have with the liftoff test, I use it with all my subscap people, is for those that are highly sensitive and you know that they're already really irritable, I find at times that just getting into that position really lights them up. So the test that I prefer to start with is that internal rotation at neutral, but we get rid of the pec involvement a little bit. So imagine somebody standing with their elbow right at their side, elbow bent to 90 degrees. You then put one of your hands outside of their lateral elbow and you have them push out like they're doing a lateral raise. You don't let them actually push away from their body, but they're trying to. And then you test internal rotation resistance with the other hand. And you'll find that that little lateral raise push gets rid of a lot of the peck involvement in there and will let you get a positive test for a lot of people that have a subscap strain that your standard IR at neutral would not. SUBSCAPULARIS TREATMENT So let's jump into treatment a little bit and modification. I'm going to say number one, from a manual perspective, like if you made me choose only one area of the body to needle for the rest of my life, and you said you can only needle one thing for forever, choose what muscle. Now this might just be because I treat primarily shoulders, hips, and knees in the clinic, but I would choose subscapularis dry needling over every other area of the body. It has just been the area that I find most frequently gets huge improvements in their symptoms after a quick dry needling session. So if you're not familiar with that, look up Paul iDryNeedle. Paul runs our dry needling division along with Ellie. and the great faculty that we're building over there, but check out their coursework. That is just a money technique to have. From a treatment perspective, so much of my treatment with this comes down to the combination of wanting to build the subscap up, but also wanting to make sure we're not continually overloading the subscap. So I have a lot of conversation with my patients on what sort of modifications they need to be making to their training to not further aggravate the subscapularis. And so, All of these are obviously based on somebody's irritability. So when they strain their subscap, if it's very, very minor, I'm not pulling all of these levers, but if it's very major, I might be. And as y'all know, our goal with the fitness athletes and all of our people in general is to keep them active. We don't want to tell them, stop benching, stop doing pushups, stop doing dips. We want to find ways for them to do those movements or similar movement patterns with less pain. So that's breakout kind of where I kind of go with modifications. MODIFYING HORIZONTAL PRESSING So if we start with like our horizontal pressing motions, which I think are the most common things that I hear people with subscap strains discuss subjectively, that's the dips, pushups, and bench press. I think the reason why those hurt so much is as we take the shoulder into extension, I think you can appreciate as your shoulder goes into extension that you're gonna create a little bit of compression on that anterior shoulder. And as we know, tendons don't like compression. So I think that's why extension is so irritable for these individuals. So one thing that I find myself doing more than anything else in people with subscapularis strains is I actually have them stop doing dips. And we end up replacing dips with, with push-ups or banded push-ups or some variation that doesn't take the shoulder into quite as much extension. When push-ups are pain-free, then we start moving back to dips. But generally, I find that dips are going to be really painful if the push-ups still hurt at all. So that's kind of a general rule of thumb for progression there on the dips. In terms of the pushup and bench press, I find that the most valuable thing we can do for people in terms of modifying is to just adjust the range of motion a little bit. So for the pushup, kind of the two modification, three modifications I make there are a lot of times I have individuals do a pushup down to an ab mat. So that ab mat's just gonna, they touch their chest to the ab mat instead of the floor. We reduce that range of motion, maybe an inch and a half or so with the ab mat there. And so frequently that is enough that we can now still do the prescribed workout with just that slight modification to the range of motion. Other times I find that having them really torque their hands into the ground or keep those elbows close to their side and making it a little bit more like a close grip pushup can help them out quite a bit. From a bench press perspective, very similar. So maybe instead of bench pressing, we do a floor press or a board press. So a floor press is simply a bench press where we're laying on the ground. So when the elbows get to our side, they hit the ground and you can't actually take the arm into extension. That can usually be enough that people can still press really heavy. The floor press is one of the best exercises you can do by far to improve your bench press strength, so it's a great modification in this time period. We can also do a board press where they're on a bench, but they go down and they touch one, two, or three 2x4 boards that are placed on their chest to reduce the range of motion. And then very frequently I also have, especially with more like my power lifters or people that care about bench pressing a lot, I'll use accommodating resistance. So maybe with a lightweight, they can touch their chest and not have that much pain, but if it's really heavy and they touch your chest, they get pain. So that's resist the bench press with bands so that at the bottom, those bands are unloaded a little bit, and then that weight increases as they go towards lockout. So that's a great way to really challenge the lockout, still train full range of motion, but not irritate that already irritated subscapularis. So the big key there is to probably reduce the range of motion a little bit and play with some of those variations to see if you can get people to not continually aggravate the subscapularis but still get in that horizontal pressing stimulus. MODIFYING KIPPING When it comes to kipping-based movements, so toes-to-bars are one that really tend to aggravate the subscapularis, I see quite a bit. I will Usually prefer to just get people to do a really tight kip where they maintain a lot of tension and they don't go into as aggressive an arch position. That is actually a performance advantage in the toes to bar. People will cycle their toes to bar reps a lot faster. So this is a great time to make people do smaller sets because a lot of times they'll fatigue more rapidly with this. but to actually work on a technique improvement that will help them out long-term. So those quick cycled reps with a little bit more tension. If it's more irritated, then we might just do an active hang, knee raise of some sort so that we're still getting the hanging stimulus. We're still getting the ab stimulus, but we're just reducing a little bit of the shoulder demands. And then when it comes to things like kipping pull-ups, if it's highly irritable and I don't feel like kipping is in their best benefit right now, we just turn that into strict band-assisted pull-ups that we maintain that high volume of the vertical pulling stimulus. We maintain those fast reps that keep our cardiovascular system up if we're talking about prescribing kipping pull-ups in a Metcon, but it will unload the shoulder just a little bit to do a strict band-assisted pull-ups versus kipping when somebody has a subscapularis strain. MODIFYING OLYMPIC LIFTING And then the final thing that I often modify is their snatches. So frequently, it's the turnover and the catch of the snatch that really irritate these individual symptoms. So at times, that just means we move to variations where we're not doing the turnover or the catch. So we're doing snatch grip deadlifts, snatch grip high pulls, snatch grip pulls, exercises like that. So we're still building their technique. and working on things that will help their snatch overall. But again, we're just not adding more fuel to the fire there. So that's the main modifications that I make when somebody has subscapularis pain. TREATING THE SUBSCAPULARIS: LESS IS MORE Let's jump now into treatment. And I think from a home exercise perspective, one thing that I'm really big on is that less for your HEP is more. We don't want to overload our patients. So a huge percentage of my patient population at this time are people that are seeing me for a second opinion. And I kind of see three things most commonly pop up when people see me as a second opinion. Number one, they were just underloaded. They didn't get a sufficient enough stimulus, their therapist was on the right diagnosis, but they didn't challenge them enough to actually build tissue strength up. Number two is they're on the wrong diagnosis, which we all see all the time. Somebody thought, you know, that because this person's pain was on the back of their shoulder radiating down to the tricep, they assumed that it was a posterior rotator cuff pain and they didn't do a great job screening out the subscapularis with the tests that Alan talked about last week and I talked about earlier. And so they're treating posterior rotator cuff when it's really the subscapularis instead. And then the third thing is people come in and they have an HEP list of eight exercises that they're doing for three sets. And I look at that and I'm like, man, that's going to take 40 minutes to get done. Less is more here, folks. So the rule of thumb I have here is that my goal, sort of like your post-op ACL that needs a full strength program, My goal with most of my individuals is to try to limit their HEP to 10 or 15 minutes or less, four-ish days a week. I think that that's pretty manageable for most of our people. It gets really crazy when you're asking people to do 30 minutes of work every single day. So to get this done in 10 minutes or less, that usually means that I'm trying to stick to three exercises, maybe four. So in the subscapularis, maybe they do some soft tissue work on their subscapularis. That's one minute. And then we do a nine minute EMOP. So that's 10 total minutes of work. We add in grabbing equipment. They get this done in less than 15 minutes. Less is more with these individuals. Try to really stick to that. And I think you'll see your HEP compliance go up quite a bit. So three exercises, less than 15 minutes, preferably less than 10 minutes is my goal. When I'm looking for exercises, I kind of have four different exercises that we might have in those three of their HEP. Number one is going to be obvious. Like if they have a subscapular strain, we're doing something to try to build that muscle and tendon backup. It would be way too hard for me to really describe these exercises here on the podcast, but if you go to my YouTube channel, Barbell Physio, you can search for all of these exercises. But kind of my general progression here, highly irritable. I'm doing internal rotation at neutral, but I'm going to do it similar to how I did the testing. So I take one band and I'll put it around their arms. So one big resistance band going around both arms. So they have to do that little lateral raise before they do the internal rotation. I'll find that that again isolates the subscap a little bit more than the pecs. Progress that to an IR punch. Progress that to an IR diagonal. Progress that to IR at 90 degrees. That's my general philosophies there. So number one, load the subscap. Number two thing to have in that HEP is to look at any mobility limitations that they might have. Like is their overhead positioning stiff? Is their Tyler test for that posterior shoulder capsule stiff? Do they lack shoulder extension? Does their thoracic spine suck? Does something as far away as their ankle mobility suck? And that's putting them in suboptimal positions for things like overhead squats or snatches. So the second component there is to dial in their mobility, The third component is lat strength. So the subscap and lats have a lot of similarities in terms of their function, but I'd say overall for the athlete doing rig-based gymnastic skills, when they have lat weakness on board, the rotator cuff ends up taking on more of the stress of those movements. I call the lats the glutes of the upper extremity. What happens when somebody has weak glutes in athletic performance? They strain their hamstrings more. They tweak their back a little bit more. Their performance overall goes down. Strong lats are so important to the fitness athlete population. So make sure you're thinking of that with individuals. That's number three on people with subscap strains is to load their lats up. 4. Something to pump a ton of blood into the shoulder tendinopathy, whatever you want to call it. And lateral raises don't bother their shoulders. So we do something like an internal rotation diagonal to directly load the subscapularis. Now lateral raises don't hurt, but we know lateral raises are going to challenge the deltoid quite a bit. They're going to challenge the supraspinatus. Those muscles are all around the subscapularis. So if I then have them do a set of 15 to 20 lateral raises, I'm going to pump a bunch of blood to the shoulder. What happens when we pump blood to an area that's currently injured? We help with inflammatory chemicals that are sitting out in that area. We help with, you know, an overall endorphin release. We just make everything feel better when we add a little bit of blood pump to an irritated area. So that's make that be our final exercise in that little EMOM for them. So I hope those modifications and HEP discussion help you out a little bit more when you see subscaps. Again, make sure you go back and check out Alan's episode. He did a great job discussing internal rotation and shoulder extension and why that's so important in this population as well. Hope y'all have a great Friday and a great weekend, and we'll see you here next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long discusses Testosterone Replacement Therapy, including research supporting its use, side effects, understanding dosing, and common clinical presentations related to TRT use. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show. It is Fitness Athlete Friday, the best day of the week here on the podcast. I'm excited to be with you as your host, Dr. Zach Long. And today we're going to talk about a topic that's a little out there, like it's not something we talk about a whole lot in the profession, and that is testosterone replacement therapy. And we're going to discuss four or five things that I really believe that those of us in outpatient orthopedics need to understand about testosterone replacement therapy because you are for sure seeing these patients in your clinic with certain conditions and being aware of a few things will help you out clinically. Before we jump into that topic, upcoming courses that we have inside the fitness athlete division. Our live course is, we have one more for the end of the year. That's Colorado Springs, Colorado this weekend. Mitch will be teaching that. If you can't make it to that in quarter one, we will be in Portland, Oregon, Richmond, Virginia, Charlotte, North Carolina, and Boise, Idaho. So check out those courses, pglnice.com. We also have our advanced concepts course. We'll be going live at the beginning of the year. That course always sells out. If you've already taken level one, you can jump into the online level two, but that sells out. So you want to look at jumping in and booking your spot as quickly as possible. TESTOSTERONE REPLACEMENT THERAPY Let's jump into testosterone replacement therapy and what physical therapists need to know about that. Testosterone replacement therapy is injecting testosterone into your body, which is the male sex hormone, prescribed by doctors at times to treat hypogonadism. We've seen a giant increase in the number of people and the acceptance of people being on TRT in the past few years and I think that's why it's so important for us to understand that because so many individuals are now when they you know get into that 35 40 50 year old age range where their libido goes down a little bit. They stop improving quite as much in the gym as they used to. They start to have a little bit more general fatigue, anxiety, et cetera. We're seeing more and more men jump on TRT. I found a research study from 2017 looking at the rates in the US population of people being on TRT. And in 2017, they estimated that between 1% to 3% of men were on testosterone replacement therapy. which that number was a threefold increase in the number of prescriptions of TRT from 2007 to 2017. So threefold increase in those 10 years. And I would even say since then, in my opinion, it has become more popular or at the very least more accepted. Back in 2017, you wouldn't hear a whole lot of people talk about being on TRT. And now I feel like I see it all the time. I see big time influencers talking about being on TRT. all the time on social media, when I'm talking to people at the gym, they're regularly talking about their doctor just put them on TRT, whatever. So there's a lot less stigma around it and there's a lot more people getting on it. And I think that's really important for us to understand because there are gonna be a few things that we see in the clinic in people that are on TRT. And so asking this question more frequently to your male patients, especially that are between the ages of say 30 and 50 years old, is going to change a few things that you might be thinking of clinically. So three-fold increase in those 10 years and probably a little bit more than that. Another really interesting study that I found with testosterone replacement therapy was this study called Testosterone Dose Response Relationships in Healthy Young Men. So this was a really cool study where they took individuals that had previous resistance training experience and they told them that they weren't allowed to exercise during this six-month study. So If they've done previous resistance training, we kind of know that they're going to be through their beginner gains, their newbie gains in the gym where they would have really easily put on several pounds of muscle. So these aren't people that you're going to expect to see drastic increases in muscle mass in a short period of time. especially when they're not working out. But what they did in this study was for six months, they put these men on testosterone replacement therapy at different dosages. So the dosages were 25, 50, 125, 300, and 600 milligrams of testosterone for 20 weeks. So a wide range of doses from 25 milligrams a week to 600 milligrams a week. And they looked at a number of different things, such as their fat-free mass and their leg press strength, and then a number of other different physiological factors. But I'm gonna focus on those two, mostly muscle mass here. So again, we wouldn't expect these individuals when they're not resistance training, but having had previous resistance training experience to gain a lot of muscle mass in this time period. But what they found was that the group on 125 milligrams a week during those six months gained six pounds of muscle on average. The group at 300 a week gained 12 pounds of muscle mass on average and the group at 600 milligrams a week gained on average 19.5 pounds. So a lot of increase in muscle mass during that time period, especially when people aren't doing any resistance training. UNDERSTANDING TRT DOSAGE And so I bring those dosages up because I think that's one really important thing when you have a patient on testosterone replacement therapy, I want to know what that dosage is. So when you're treating hypogonadism, less of this like people getting on TRT to try to improve their sports performance, their aesthetics, their strength, et cetera. What you tend to see is much lower doses in terms of testosterone replacement therapy. Like getting on those low doses under typically 200 milligrams a week is what you'll see a lot of doctors prescribe here. And that's going to do a lot to help improve libido and anxiety and other symptoms like that of hypogonadism. But when you get to that 125 milligrams a week, that's when we start to see a large increase in muscle mass. And what you'll often hear referenced by doctors prescribing TRT is sports TRT dosages versus hypogonadism dosages. And the cutoff there that you'll hear most people discuss will be 200 milligrams a week. So when you're taking 200 milligrams or more, that's when you're getting into a bit more of the sports performance arena than just purely addressing hypogonadism. And I think that's important because of the next studies that we'll talk about in a second here. But 200 milligrams a week, when people are on that, I'm thinking, all right, we're on a pretty good dosage. And if we go back to that study where the milligrams per week range from 25 to 600. It's important to note that testosterone is obviously a performance-enhancing drug. It can be used for medical reasons. It can be used for recreational and sports performance reasons. And when people typically do like a steroid cycle, not TRT, like trying to put on as much strength, muscle mass, sports performance as possible, the dosages that people will typically be at will be at 300 or more. Typical dosage that you'll hear a lot of people talk about doing a starter steroid cycle is like 500 milligrams a week So this study was really aggressive in the dosages that they did there like especially the group that was doing 600 milligrams a week for six months like they were doing a full-blown steroid cycle, but remember 200 milligrams a week is kind of your cutoff there in terms of sports TRT versus just standard TRT. THE RELATIONSHIP BETWEEN TRT DOSAGE AND TENDINOPATHY Why that's important and why I want to know the dosage that my patients are on if they're on TRT is because One thing that I clinically see quite a bit is that those individuals on TRT, I'm frequently finding them showing up to the clinic with tendinopathies more than any other injury out there. In fact, when I see a male between the ages of 30 and 50 years old that's coming to me with a tendinopathy and I know that they're exercising and they look relatively fit, this is a question that I will just straight up ask them. because I think it's valuable information to know. And the reason why it's valuable is that there are actually two research studies out there that have found, one of them found an increased risk of rotator cuff tears in men on testosterone replacement therapy, and another one found an increased risk of distal bicep tendon tears and increased risk of needing surgical intervention to repair that distal bicep tendon tear. And so if we know from these two research studies that these men on TRT are at increased risk of a tendon tear, that would suggest that there's likely some degeneration already happening to some tendons in men that are on TRT. Now, why that is? Can't for sure say though. One theory could be here when we go back to that dose-response relationship study where men taking 125 milligrams or more per week are putting on significant amounts of muscle mass in a six-month period. It could be. those muscles are responding really fast, and those tendons are responding a little bit lower. It could be that maybe these men had low energy, anxiety, depression, they get on TRT, now they're feeling better, and they go from a low amount of activity to getting more aggressive in the gym, so they see training load spikes that challenges those tendons more than they're able to recover from. Whatever reason that is, it happens. We're probably seeing degenerative changes in tendons of men on TRT. TENDON HEALTH ON TRT And we need to be aware of that because that might lead us to want to have more discussions with individuals. on taking care of their tendons if they're on TRT. Like maybe they need to spend a period of time every few months doing heavy, slow tempo work on their spots. Like if you're in CrossFit, maybe not always bouncing out of the bottom of the hole as aggressively as possible. Maybe they have to spend a period of one month every six months where that tempo's going really slow. Maybe we need to be prescribing some extra rotator cuff loading, tendon work, or maybe even different supplements that might have a positive effect on their tendons, such as taking Collagen and vitamin C. There's some research by Keith Barr on that potentially having some positive effects on our tendon health. But that's definitely something worth discussing and having in the back of your mind when you see men taking testosterone replacement therapy is what can you do to help improve their tendon health? INJECTION SITE MATTERS WITH TRT And then the final thing that I think is important for us to understand with TRT, I would have never thought of this unless Jordan Berry, my business partner at Onward Charlotte, also a faculty member for ice in our spine division, hadn't treated somebody that was on TRT and came into the clinic with incredibly debilitating neural tension. So this guy had previously been a bodybuilder that had abused performance enhancing drugs and now was on TRT, but the guy could barely walk, couldn't pick anything up off the ground, had a 10 degree straight leg raise. As Jordan evaluated the guy's lumbar spine, the lumbar spine was completely clear. And Jordan kind of recognizing in this guy's body type that he looked like somebody that may have previously or currently was on performance-enhancing drugs, Jordan went ahead and kind of broke out that with the individual, started talking to him about his previous performance-enhancing drug history. It turns out the guy was still injecting testosterone regularly. He was on TRT after years of being on more performance-enhancing drug dosages of that. And Jordan asked him where he was injecting. And the guy was injecting his TRT dead center in the middle of his… to inject TRT or the place that's safest to inject it is actually going to be glute med. So if I'm looking at your butt from behind, if I drew a line straight down the middle of your glute, both horizontally and vertically, we want to be in that upper outer quadrant or in the vastus lateralis. Those tend to be the safest areas to needle. When he was going dead center in the glute, he was constantly hitting his sciatic with his injections. And so hitting his sciatic nerve as he was giving himself TRT injections resulted in some scarring on that nerve. And that was what was leading to his intense sciatic and neural tension. So I hope that gives you some ideas and things to think of clinically when you see guys on TRT, or at least makes you more aware of the prevalence of this, and that when you see people with it, you might want to be thinking of some different strategies and different questions if they're coming in with things like tendinopathy or weird neural tension. Hope that helps. Hope we see you on the road at a future Fitness Athlete Live course. Have a great day, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad". Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALL All right. Good morning, folks. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. We're here a little bit early in the garage. We're going to be talking about some double unders today. Welcome to Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at the company, as well as the Division Leader in our Fitness Athlete Division. We love Fitness Athlete Friday. We would argue it's the best day of the week. On Fitness Athlete Friday, we talk all things relevant to the CrossFit athlete, Olympic weightlifting, powerlifting, bodybuilding, anybody that's recreationally active in the gym. We also talk about our endurance athletes, whether you're running, rowing, biking, swimming, triathletes, If you have a person that's getting after on a regular basis, Fitness Athlete Friday has a topic for you. Some courses coming your way from the Fitness Athlete Division. We have a couple live courses before the end of the year as we get ready to close out 2023. This weekend, as in tomorrow and Sunday, November 4th and 5th, both Mitch Babcock and Zach Long will be on the road teaching. Mitch will be down in San Antonio, Texas, and Zach will be in Hoover, Alabama. Even though it's last minute, both of those courses still have some seats. And then your final chance to catch Fitness Athlete Live will be the weekend of December 9th and 10th. That's gonna be out in Colorado Springs, Colorado, and that will be with Mitch as well. Online from the Fitness Athlete Division, our entry-level course, Clinical Management Fitness Athlete Level 1 Online, previously called Essential Foundations. The next cohort of that class begins November 6th. We love that class. That is a great entry-level experience into all of this stuff if you have not taken it yet. We take you through the very basics, back squats, front squats, deadlifts, presses. We get into some basic gymnastics with the pull-up and introduce you to Olympic weightlifting with the overhead squat. Along the way, we have case studies relevant to athletes with those particular issues that we discuss with those movements. We talk a lot about loading and we get you introduced to basic programming, both for injured athletes and also how to recognize CrossFit style programming, strength style programming to better prepare you for those folks who want to continue on to our level two online course, previously called Advanced Concepts, who really want to drill down into programming, advanced gymnastics, advanced Olympic weightlifting, and truly become the provider of choice for athletes in their region through the clinical management fitness athlete certification. So that's what's coming your way course-wise from us in the CMFA division. WHAT ARE WE DOING WITH THE DOUBLE UNDER? Today we're going to talk about double-unders. This is personally an issue I've struggled with for a long time and probably maybe aside from pull-ups and handstand push-ups, one of the more basic movements we see in the gym that still a lot of your membership base will struggle with, maybe you personally struggle with, and I want to talk about what are we actually trying to do with the Double Wonder, some tips and tricks and cues to think inside your mind as you're going through them. I want to spend some time talking about the equipment involved in jumping rope because I think there's two sides of the equation, people with very basic equipment and people with maybe equipment that they don't need that's maybe too expensive, too advanced, And then I also just want to talk about how to begin to better practice double unders so that you can work towards achieving them and being able to complete them during a workout, in large sets, when the CrossFit Open comes up, or just in your regular workouts at the gym. So first things first, with double-unders. When I ask a lot of athletes in the gym when I'm coaching, when they say, oh my gosh, I just did five double-unders in a row, I say, great, great, what were you thinking about? And overwhelmingly, the majority of the people say, I don't know. I couldn't tell you what I was thinking about. And that strikes me as very different from a lot of stuff that we do in the gym. People usually have maybe one cue or maybe even a couple cues in their mind when they're setting up for a heavy deadlift, when they're setting up for a clean and jerk or a snatch or a handstand pushup. They often don't kick up upside down or go to max out their snatch and tell you that they had nothing going on in your brain. But something about the double under, people think it's just magic, how you learn these and how you get better at them. And unfortunately, it's not magic. Fortunately, it's just physics. So I want to talk about really at a base level, at a nerdy physics mathematical level, what are we doing with the double under? We are translating linear force. We are creating force across the lever that then transforms into rotational force where your jump rope handle meets the bearing. FIX THE SET-UP If your jump rope is nice enough to have a bearing. So a lot of times the setup, even with just the handles is wrong of looking at a jump rope. Again, it's quite a basic piece of equipment. It's got some handles. you to hang on to in a rope. Even a cheap moderate jump rope of $20 should have some sort of bearing set up so that it spins a little bit. We are trying to create force at the end of the handle that as we flip that jump rope it turns into rotation through the rope and that by doing it both hands at a time with that flicking motion we spin the jump rope. What we're not trying to do is physically spin the rope ourselves with our shoulders, right? We're trying to create rotational force through a flick. So the first thing is making sure that you are even handling your jump rope appropriately. If you are cinched down with a full grip, right where the handles meet the bearing, first of all, you can physically block the bearing if you're not careful. If you hold right here with a depth grip, that bearing cannot spin anymore, right? It's going to be extraordinarily difficult to easily create rotational force here and you're going to naturally be that person who has to spin your arms to spin the jump rope. That's exhausting. It's not a great way to do single unders and it's an even worse way to do double unders. So first things first, where are you grabbing the handle? You should be grabbing further down the handle, ideally with a loose grip, as low on the handle as you can get, right? The longer the lever, the more force amplification we have, right? The more force is going to be transferred and transformed into rotation down here versus the higher we grab up towards that bearing. So a nice loose grip, thinking about flicking, creating linear force at the bottom of the handle that creates a spinning force for me up at the bearing. So that's number one of making sure that you're even using the jump rope correctly. The next thing is making sure it's sized correctly. I always laugh when I see people in the gym who I know are taller than me, which is not very useful because most human beings are taller than me, but I know someone is a couple inches taller than me and I see them using a rope shorter than a rope I would use and I think What the heck, why are they using such a short rope? It makes sense why trying to do double unders, they're bringing their knees up to their chest and bending their knee to try to clear the rope because the rope is so short. How do we sign the jump rope? We take the jump rope, we hold both handles, we step one foot, we try to even it out as much as possible, bring it towards our body, and the length of that rope should be at our nipple or maybe a little bit higher. If it's down at our stomach, it's too short. You're gonna have to do some really unnatural jumping things, like piking your hip, or kicking your legs back, or both, just to be able to clear that short rope. Likewise, being a little bit longer is okay, but this thing up to my chin or above my head, I have a lot of slack behind me now. I'm moving a lot of extra weight I don't need to, and that's all the more drag factor on the rope that's gonna mess up my timing as I try to learn double unders. So making sure we're holding the handles in the appropriate place and making sure that we understand how to measure our jump rope. A really nice jump rope will have maybe a nut or a screw here to adjust. This is a typical, what we call a class rope. This is just a $20 rope from Rogue. You'll often see these in the wall at a gym for everybody in class to use. These can't be adjusted. They go based on your height. There should be a table or a chart or the coach should know what color you should be using based on your height, assuming that you know what your own height is, to make sure that you're using a jump rope that is long enough with maybe a little bit of extra slack, but is not extraordinarily short or long. So that's first things first, using linear force to create rotational force, making sure the rope is sized to us correctly, and making sure we're holding the handles in the right spot so that we're not hampering ourselves from creating that rotational force. SOMETIMES IT'S THE WRENCH We have a saying, with jump rope, with most things in life, it's usually not the wrench, right? It's not the equipment, it's the mechanic. But sometimes it is the wrench. A lot of folks start trying double-unders with maybe the class rope they have, and I think that's a great place to start. Now the issue is a lot of folks will start trying double-unders, they'll look at people in the gym who are really great at double-unders, and not recognize that that person probably started with the class rope, and they'll immediately go out and buy a $200 competitive CrossFit game speed rope. There's a couple issues with the wrench itself of making sure you have the right wrench. We've already talked about length. A really nice jump rope, again, will have a way to adjust the length that you can undo a screw or a nut and make it longer or shorter and get it really dialed in. These ropes, again, are a fixed length but making sure the length is exactly correct. The next thing that most people don't consider is that this jump rope has some weight. Yes, the handles have weight, but that's going to be relatively fixed based on the brand that you have. So not considering the weight of the handles, what is the weight of this rope? This is a class rope. This is about 2.5 ounces or so, which I would call a medium weight rope. When we are doing jump rope, In learning double-unders, the best thing you can do is use a rope that's a little bit heavier. null: Why? Two reasons. SPEAKER_01: When you spin a heavier rope, you can hear it slapping on the ground in the gym, even over the loud music. That helps your brain learn the timing. A heavier rope also forces you to develop wrist speed. When we're doing double-unders, it's not about how fast you jump, it's about wrists. And a really light rope doesn't force you to learn that speed because it costs you almost no energy to go through that movement pattern. So for a lot of folks, they're trying to purchase the most lightweight rope ever, and I'm going to show you some different ropes here in a second, when in reality they should probably be working with a heavier rope. Again, this is a class rope. This is maybe two and a half to three and a half ounces, somewhere in the middle. What's going to help a lot of folks Smartgear brand rope. You can buy this from Rogue or from RX Smartgear directly. You can see just by looking at these two ropes, significantly thicker, right? This is a 4.1 ounce rope. The handles are different. Yes, they spin a little bit better. They have a little bit better hand grips. You can see here different spots to put your thumb along the handle. But most importantly, the cable is heavier. This is going to teach hand speed, this is going to build up endurance with the double under, and it's also both the sound and the feeling of this rope is going to help learn timing a lot better for our jump rope. So making sure that we have the right rope. Again, almost everyone trying to get good at double unders immediately goes and buys the $200 speed rope, when in reality they should probably buy this. Now the nice thing about these ropes, as you can see, I'll bring it up really close, is this is just a keychain type carabiner. When I'm ready for a lighter rope, the most expensive part of a jump rope are the handles. The cable is usually cheap or sometimes even free if it gets frayed. If you fray your actual rope, you can email Rogue, you can email RxSmart here, they'll send you a new cable that you can reattach to your handles and you can use the same handles forever. So as you get better, you can detach, put a lighter cable on, make it easier and more energy efficient as you actually start to string together double-unders. But early on, you're going to want a heavier rope, something around four ounces. That's the biggest recommendation I can make to folks who are trying to learn double-unders, and especially to those folks who have 19 different speed ropes at home. They've got a second mortgage on their house full of jump ropes just to pay for them all. and they're going lighter, lighter, lighter, thinking they need a lighter rope, a faster rope, lighter handles, diamond grip handles, when in reality they just need a heavier cable. So when in doubt, go heavier. Again, four ounce rope compared to maybe a two and a half or three ounce rope. Once you can start to turn over bigger sets of double unders, 25, 30, 50, you're able to start doing them in workouts, your efficiency, your endurance with them improves, now you're ready for a cable itself is basically non-existent. This is aircraft grade aluminum. This is about eight tenths of an ounce. So almost 500% lighter than that heavy rope I just showed you. This weighs almost nothing. It is very hard to feel when you jump rope with this cable and it's very hard to hear as well, especially if you're in a CrossFit style gym in the middle of workout with loud music playing. What's different about this besides the cable weight? The handles are so much nicer. They are diamond grip. My thumbs can lock on. I can hold very low on the rope. Again, I want to have as much time for that force to build up and transfer along the length of the handle as I can. I can hold just my index finger and my thumb and really develop that flicking motion. What's also very nice is look at the spin on this handle. right? That thing spins forever. Very, very, very efficient for large sets of double-unders, but only once you can actually do them. So this is kind of the in-stage progression of somebody who looks at a workout that has a couple rounds of 30 or 50 or maybe even 100 double-unders and says, no problem, I got These ropes are about $200. And again, the most expensive part arguably is the handle. If the cable frays, you can replace it. But a very, very, very high quality jump rope intended for folks who have already learned how to do big sets of double unders, ideally using a heavier, cheaper rope. So that is what we would call a speed rope. So that's the wrench. BUT IT'S USUALLY THE MECHANIC Now let's talk about the mechanics. because there are a lot of things we can do, a lot of cues we can give that can very quickly make double unders a lot better. The first thing is understanding, again, in a double under, what changes is my hand speed. Jump, spin, spin, jump, spin, spin. It is a double spin of the rope. It is not an increase in my jump rate. A lot of folks, off the ball of their foot. Because in a single-under, we're only clearing the rope once, we can get away with a very small jump and just clear that rope once. We see a lot of boxers do this. You see a lot of people in the gym who have jumped rope a lot in the past do this with single-unders. They can crank out 150 single-unders in one minute with that very fast, low jump. That's not gonna cut it for a double-under. Why? The rope has to pass twice. A lot of athletes in the gym will ask me, I have no problem getting it over the first time, but it gets caught the second time. The answer is yes. The rope has to come back around again twice and you have to be in the air the whole time. That's why it's called a double under. You're trapping the rope on the second time through, which is why you're not getting your double under. How and why are we trapping the rope? Most commonly, is we do not increase our jump height, we just now try to jump even faster. All we're gonna do there is trap the second pass of the rope that much more quickly. We're just getting more efficient at bad double-unders. We need to consider a smaller, taller, slower jump. We should practice single-unders on the ball of our foot, and we should practice a little bit taller jump, but not try to pick up our legs not jump speed. If you correspondingly increase your jump speed, you're going to trip because you're now trying to basically get in rhythm and jump twice for two rope swings. That doesn't make sense. Keep your jump speed the same. Stay tall, vertical on the ball of your foot, and jump a little bit higher. Practice single-unders that way. When you can begin to turn over 50 or 100 single-unders like that, now you know you have the jump height, the jump speed, to be able to begin to turn over double unders. Remember, wrist speed, not jump speed, and stay on the ball of your foot. A lot of folks will do some really dramatic stuff to get that rope over twice, and they will land on their heel. Again, the rope has to pass twice. If you land on your heel, there is no physical way that rope can pass under your foot for its second time through. You're going to track the rope underneath your foot. So small, short, sorry, tall, vertical jump. PRACTICING & DRILLING DOUBLE-UNDERS Make sure we're practicing wrist speed. A penguin drill is a great drill to give people, to have them practice maybe what's a new jump height and cadence for them. And at the top of their jump, have them slap their thighs twice to imitate the double flick of the jump rope. You'll find a lot of athletes who think they should be able to do double-unders, struggle a lot with that drill. They're used to that short, very fast jump cadence for single-unders. Asking them to slow down and jump a little bit higher wrecks them. It also messes them up mentally when now they have to focus on actually doing something with their hands. You'll find they're probably not as ready for double-unders as they thought they were. So double-unders, not magic, just physics. We are creating force across a lever, the handle of the jump rope. We're holding it as low as possible. We're trying to create rotational force where the rope meets the handle at the bearing. We're holding it as low with as loose of a grip as we can. We're thinking about flicking the wrist, not spinning the shoulders. Sometimes it is the wrench. Make sure the rope is the correct length. Make sure newer athletes who are beginning to experiment with double unders use a heavier rope, something three, four, maybe five ounces, and that we reserve those speed ropes for once we're actually able to string together bigger sets of double unders with a heavier rope. PROGRESSIVELY OVERLOADING DOUBLE UNDERS The final thing is how to progress these. A lot of folks want to be able to do more unbroken sets, Can you just practice more sets of double unders? Yes. The key thing though is that we practice that. We don't try to do it in the middle of the workout under an extreme amount of cardiovascular fatigue and that we consider double unders no different than a back squat or a clean and jerk or a deadlift. That we take principles of progressive overload and we carry it over to our body weight, cardiovascular stuff, especially higher scale, like double unders. How do we do that? Things like a Zeus Rope. or a drag rope are great. A drag rope is literally climbing rope with handles. It has, you can see the same handles as some of the other jump ropes I've shown you. The only difference now, there is no handle spin. The only way I'm going to rotate this rope is by being really aggressive and really fast with my hands. This is a nine ounce, I guess you'd call it cable. Again, it's technically just a length of climbing rope. This is nine ounces. So this is 900% heavier than the speed rope. So if I want to get better at double unders where I can look at a workout that has a couple rounds of maybe a hundred double unders and it has some other stuff in there too that's also going to make me tired from a cardiovascular perspective, how do I know when that workout shows up that I can blast through those with my speed rope? Well, when I go back and take class workouts that maybe have small sets of double unders 20 or 30 at a time, I bring my drag rope to class. And I do smaller sets with a heavier, slower rope that continues to progressively overload my double-unders so that when big sets do show up in different workouts, I can handle those no problem with my speed rope. So it takes practice, intentional practice. Folks are always disappointed that they don't magically learn double-unders 18 minutes into a 20-minute AMRAP. That's not how it works. Sometimes it does, but it usually doesn't. Practicing this stuff at home with a cheap jump rope from Rogue that's 20 bucks, practicing 10 minutes a couple times a week is really going to go a long way. I always tell folks when they're practicing double-unders the same way I tell them when they're practicing things like pull-ups. When you're learning to kip, when you're learning that motion, forget about getting your head over the bar. Just learn the rhythm. That's the most important thing you can do. I say the same thing to folks who are going to be going home and practicing double-unders. Don't focus on actually getting the double under. Focus on doing the mechanics correctly. Use a timer so that you're not just in your garage for an hour and you're breaking stuff because you're so frustrated or the neighbors are worried because you threw your jump rope into the street. Set a timer, do as many as you can, and then take a break for two minutes and do a couple sets of that. Make sure that you aren't treating it as a workout, but that you're treating it as practice and that you use different methods once you actually can do double unders. to continue to progressively overload your double unders. So double unders, not magic, physics, make sure your wrench is set up, but make sure your mechanics are dialed in as well. And make sure if you want to get better at these, that you actually spend diligent time to practice and make sure that it's actually practiced and it doesn't turn into a second workout that day. I hope this was helpful. I hope you have a fantastic Friday. If you're going to be at a live course this weekend, we have 10 of them going on, I believe. So I hope you have a fantastic weekend. We'll see you all next time. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses hip shifting in the squat. Zach emphasizes the need to ensure first and foremost, pain is in the hip or elsewhere in the body is not the cause of the shift. Second, Zach urges listeners to determine if the shift occurs under increasing loads or not. Finally, Zach discusses that if the squat is pain-free and that the movement pattern does not change under load, hip or ankle mobility is the final culprit. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ZACH LONG Hey everybody, welcome to the PT on Ice daily show. It is the best day of the week here on the podcast, and that is Fitness Athlete Friday. I am your host today, Dr. Zach Long. I'm lead faculty inside of the clinical management of the fitness athlete curriculum, teaching in our live weekend seminar, as well as our advanced concepts course. And today we're going to be chatting about assessing the individual that has a hip shift when they squat. what are the questions you should be asking, and what are the things that you should be looking at and programming for them to help address that hip shift in the squat before we dive into that topic. Upcoming courses that we have in the Fitness Athlete Live arena here. November 4th and 5th, I'll be in Hoover, Alabama, and Mitch will be in San Antonio, Texas. November 18th and 19th, we'll be in Holmes Beach, Florida, and in December, Colorado Springs, Colorado. If you can't make it to any of those courses, we are already filling up the 2024 calendar as well. And we have Portland, Charlotte, North Carolina, Boise, Idaho, Renton, Washington, Raleigh, North Carolina, and Fenton, Michigan on the map. So check out all of those courses, as always, at PTOnIce.com. If you want to get registered, learn how to better assess, treat, and help fitness athletes do the movements that they love, as well as how do we get those people that are not already getting their daily dose of physical activity, how do we start to get them involved in that sort of stuff as part of their plan of care when they come to see us for pain? So PTONICE.com there. 02:32 - ASSESSING THE HIP SHIFT All right, today's topic, the hip shift in the squat. What I mean by that is you watch somebody squat, and instead of their weight staying even side to side, you see them shift some of their weight more towards one side than the other. Why does that happen? What are the questions you need to be asking? And then what are the things that you need to be doing as part of their treatment? So I think there are two big questions to ask subjectively when somebody comes to see you for a hip shift or you notice that when you're watching videos or watching somebody actually lift in the clinic. Question number one is, does that individual currently have pain in regions of the body that are impacted by the squat? Question number two is, does that change under load? When you ask and answer those two questions, you'll have a much better idea of what interventions you need to do to help improve that squat pattern. 3 Different Pieces to That 1. If someone is having pain, That's kind of the end of the discussion on the hip shift in the squat. So if somebody comes in and they're dealing with really nasty patellar tendinopathy or they're dealing with an ankle that was just sprained and is very, very sensitive as we dorsiflex the ankle. or someone has really irritable hip impingement. As they squat down and those tissues start to get loaded more as we go through range of motion, if those tissues are really sensitive, the body is understandably going to want to unload those tissues and try to avoid further aggravating them. So, when pain is on board and I notice a hip shift, I don't really worry too much about the hip shift right now in terms of trying to correct that. Instead, my main focus is on doing everything I can to calm down that irritability, because until we calm down that pain, we're probably not gonna make a whole lot of progress on the hip shift. So if pain's on board, take care of the pain. Now, there are definitely things that you can do that might assist this a little bit, but to me, those are secondary to the pain portion of this. So you could have somebody do box squats where they limit their depth to where they don't hip shift. or some other variations of lifts that maybe load that tissue a little bit less so that they demonstrate less of that hip shift. I think that's a fine intervention to do so that maybe that hip shift doesn't become, you know, as much of an ingrained movement pattern to them. But overall, when pain's on board, just take care of the pain and don't worry quite as much about the hip shift. 04:29 - HIP SHIFTING UNDER LOAD The second component to that, the second question was, does this change under load? And this is the big one that I see missed quite a bit. So I've had a couple of these show up in the last few months in the clinic, which is why I decided to do this podcast. And of those that I've seen lately, most of them, I was a second opinion. So they'd already seen another physical therapist or a chiropractor. And they had already had a lot of mobility drills that they were working on to try to improve the hip shift but they weren't noticing a change with the mobility drills. And what was missed by that previous practitioner was the fact that the hip shift worsened with load. And if we think about like the mobility demands of a squat, those demands don't change drastically when they go from an air squat to a 45-pound barbell squat up to a 400-pound squat. What does change is the demands that we're putting on the muscles. And actually, it's a little different than that. It's a little opposite. When you put load on a bar, if you're a little stiff, that load will often help you move a little bit better. It'll help push you through a little bit of that stiffness. So the key thing here is that if you notice the hip shift gets worse under fatigue or under load, then it is probably not a mobility issue. It is much more likely to be a tissue capacity issue, a strength issue. That's the big turning point here. So two examples of this that I've seen lately. Number one, super high level power lifter. He started noticing when he looked at videos of his squat that his bar would get uneven, but that wouldn't happen until he got to weight over 400 pounds. Prior to that, it didn't happen. And if you watch a set of him squatting over 400 pounds for say a set of five, what you notice is rep one was a little bad, rep two a little worse, rep three worse, rep five was really, really bad in terms of that bar being uneven. And what I noticed when I started analyzing that was that as he came out of the bottom of the hole, you would see his one side of his leg, if you're watching that Instagram, I have no idea why fireworks just popped up on my background, but You saw one of his legs really extend rapidly and the other one slowly extend. And what that's called is a good morning squat fault. If you've taken the Fitness Athlete Live course, you've heard us discuss that squat fault, but he was doing it only on one leg. And that leg had previously had an ACL reconstruction. And when we went and measured his limb circumference on that leg, he had a significant quad muscle mass difference on that side compared to the other side. So it was a strength deficit. And what we ended up doing with him was we loaded up his quads, doing a lot of unilateral work. We'll talk about a few drills for that in just a second. And what we noticed is the more we built up that unilateral quad strength, the less that hip shift was present. Another example I saw was recently in a… very high level CrossFit athlete, like top 200 in the world. When he deadlifted, he lost a major competition because his deadlift was relatively weak compared to his level of fitness. And when we watched his deadlift, he kind of did the same thing. So he starts pressing off the ground and the side that he had previously had an ACL reconstruction on about a year and a half prior to this, he hyper extended that knee as soon as he started pressing off the ground because he was still had a little bit of top end quad weakness relative to the other side. So he locked that knee out and he tried to, on that surgical side, make it almost a straight leg deadlift and rely on his posterior chain rather than his quads. So if it changes under load, it is a strength issue, not a mobility issue. 09:26 - ANKLE & HIP MOBILITY If it doesn't change under load, then you're gonna shift your thinking towards it possibly being more likely to be a mobility issue. And so from a mobility perspective, a few things that we like to look at, Number one, I'd say the most common are ankle and foot limitations. So lack of ankle dorsiflexion, lateral tibial glide, or the ability of the midfoot to move as somebody drops down into a squat. In our Fitness Athlete Live course, we talk you through a couple different tests that we think really help you screen out the foot and ankle, and if that's the impacting factor on somebody's squat technique. The second one to that is going to be somebody's hip mobility. And then the third to that is sometimes you'll see knee flexion limitations, but typically you don't see knee flexion limitations unless somebody's had some really significant trauma to that knee or a recent surgery. Outside of that, it's typically the ankle or the hip from a mobility perspective that will be impacting somebody's squat, causing them to have a hip shift in the squat. So once you answer that, you kind of know what to do. If it's pain, take care of the pain. If it's mobility, work on mobility. If it's strength, then let's do some unilateral strength loading of whatever tissue it is that you identified was a little weaker on one side versus the other. Take care of that. But I also think that it's worthwhile to spend a little bit of time working on some drills that might help reinforce a better movement pattern. So that as you build up maybe that unilateral strength or as you open up that ankle mobility, now you start teaching them a little bit more of where they want to go. And there are two drills that I really frequently use for that. My favorite to use is what's called a sit squat. So what I do there is I get an individual sitting on a box, a bench, a chair, a medicine ball, whatever the lowest surface they can perform this drill on, and they're sitting on it. We pull their feet back underneath them. We lean over. I get them positioned exactly how I think they should look in the bottom of the squat. And then they're sitting there, and I've got everything lined up so that it's symmetrical or as close to symmetrical as I feel like we're gonna get or we need to get. And then what I do is I tell them, imagine that there's a scale underneath your butt. Right now it says 100% of your weight. I want you to make it say 50% of your weight. So they just unload that medicine ball a little bit. Now I say, I want you to lift up one inch and only one inch. So they barely lift off the medicine ball or chair. They go back down to 50% weight and they just cycle up and down. And if you do a set of five to 10 reps of that, it is gonna actually burn really, really good because most people don't spend a whole lot of time under tension down the bottom of the squat. because there's no load on it. It's not going to be very fatiguing or really eating to their recovery a lot. So I use this a ton as a warmup drill, but that is deceptively hard and is really good for getting people to evenly drive and press into the ground and get an even lift off. And then when they sit back down, what they should feel if they're on something like a medicine ball is that they have the same amount of butt cheek touching the ball. Like if they sit down and it's only left butt on the medicine ball and right butt is floating off the side, then they're not squatting evenly. They're demonstrating that hip shift so they also get some tactile feedback in terms of their positioning. The other thing that I really like to do at times with individuals is get them to do some tempo box squats. So we squat down to a medicine ball, a bench, a low box, whatever it is, and we're basically doing the same thing there. We're going down nice and slow and we're making sure when we touch that surface that we're squatting to that we feel an even amount of weight on both butts. so that we, again, know if we're hip shifting or not. Those can be two good drills to drill in moving a little bit away from that hip shift. So, again, your two questions to ask when you see a hip shift. Are they having pain? Does it change under load? When you answer those two questions, you'll have a much better idea of what to go to to get rid of the squat hip shift a little bit faster. So, hope that helps. Look forward to being back on here again in a few weeks with you all. Hope you all have a great Friday and a great weekend, and we'll see you on the road. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com   In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the concept of excessive humility and being overly open-minded, discussing how it can hinder individuals from taking action and being useful. While acknowledging the importance and benefits of open-mindedness in considering different perspectives and possibilities, Jeff also points out that excessive open-mindedness can render one unable to take stances or make decisions, rendering it useless. Jeff emphasizes the need to strike a balance between open-mindedness and the ability to take a stance. He cautions against being so open-minded that one loses their ability to make decisions and take action. Excessive open-mindedness, according to Jeff, can lead to a lack of direction and clarity, making it difficult to make progress or contribute effectively. Similarly, Jeff addresses the issue of excessive humility, particularly in relation to feeling inadequate to take action due to a lack of knowledge. While it is important to acknowledge and respect the limits of one's knowledge, Jeff argues that excessive humility can be detrimental. Constantly waiting for more information or certainty before taking action, they assert, can result in paralysis by analysis and prevent individuals from being useful in their professional careers. Jeff encourages individuals to have a level of humility that allows them to act even in the presence of uncertainty. Jeff highlights the importance of being willing to make choices and decisions, even if they may not always be perfect. By embracing the imperfection of action and remaining focused, individuals can gather data and fill the gaps in their knowledge. This approach allows for continuous improvement and growth while avoiding the pitfall of doing nothing. Take a listen to the podcast episode or read the full transcription below. 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 00:00 JEFF MOORE Okay, team, what's up? Welcome to Thursday. Welcome back to the PT on Ice Daily Show. I am Dr. Jeff Moore, currently serving as a CEO of Ice, and always thrilled to be here on Leadership Thursday. I cannot wait to jump into this topic about choice and the need to make one. Before we do, it's Gut Check Thursday. Let's not ignore the workout. Let's talk about it. Let's take it on head on. It's a doozy. We've got five rounds for time, okay? We've got 12 handstand pushups, nine toes-to-bar in six squat cleans. Okay, it's gonna be at 155, 105, so a little bit heavier than we usually encounter our cleans in Gut Check Thursday, but the volume's a little bit lower there on that set. Five rounds of that for time, bang that out, you're probably gonna have some rest on the handstand push-ups and the heavier squat cleans. Try to keep moving steady, make sure you tag Ice Physio, hashtag Ice Train, we love tracking those videos. Get it in, it's Thursday, get the work done. All right, upcoming courses, I want to highlight CMFA Live this week. We've got Newark, California coming up. I think there's only two spots left in that course. That's with Zach Long and crew. It's going to be September 30th, October 1st, so in a couple of weeks over in California. We've got Linwood, Washington coming up October 7th, 8th, and then down in Hoover, Alabama, November 4th, 5th. So if you want to get out on the road, learn all things barbell movements, get into some basic gymnastics, talk about programming, demystify a lot of things around resistance training. That is the course you need to be in. It is, of course, part of our CMFA certification, which includes Essential Foundations, Advanced Concepts, also known as Level 1 and Level 2 on the fitness athlete side. And, of course, during that live course, you get testing in person if you want to obtain that certification. So hit that up. PTonICE.com is where all that good stuff lives. 02:16 YOU HAVE TO CHOOSE Let's talk about the topic. You have to choose. Team, it has always driven me nuts. From the very, very first entrance into my professional career, this comment or idea of more research is needed has always driven me crazy. Now, I don't mean from the actual research side. Like, I get the idea of why that statement is made, at the end of papers, like, hey, to get to a certain level of statistical significance or confidence, we have to have more data, right? Totally understand where that comes from in the research world. But the ridiculous incorporation or discussion of that into patient care has always blown my mind, right? So you see so many folks saying that, we don't know, we don't know, we don't know, as though we can't do anything. This is absurd from a patient care perspective. Like, I always imagine these people, like, are you really sitting in front of your 8 a.m. and saying, hey Lynn, I know your shoulder's really bugging you. Problem is, the jury's still a little bit out on the best rehab for this until we know, we're gonna pause here, I'm gonna have you come back. Like, are you really doing this all day, every day, every 30 minutes with a new patient? Of course not, it's absurd. To be of any use, we must decide and act in the presence of uncertainty. This is true literally everywhere in our lives. It is obviously true in patient care, right? We've got to do something for Lynn, right? We know it's not gonna be perfect, but we've gotta act with the knowledge we have and do our best. We have got to decide and act in the presence of uncertainty. And this goes so far beyond patient care. This is true in every aspect of our professional journeys and lives. We've gotta be willing to say, we've gotta be willing to choose to say, From what I've learned and experienced thus far, I currently believe X. I don't care what domain you're talking about. I don't care if you're talking about business, sports, hobbies, patient care, nothing moves forward with waiting. I was thinking about this last weekend. So for those of you who haven't followed my recent journey, I'm getting into enduro motorcycling, right? So I'm signing up for some races next year and I'm terrible at it. So this weekend I'm up in the mountains and I'm flying down this trail, moderately out of control per usual, and having to choose lines in real time, right? So you're coming up on obstacles, going relatively fast, thinking I've got to do something in real time in this moment. I have to choose. Now, knowing full well in that moment that if I was to go back to that same trail two years from now, I have no doubt that I would choose a different and by different I mean better line because I'll be better at the activity. But that does not mean right now I don't have to choose. I just have to choose, thinking with the experience that I have, what is the best way to move forward, knowing full well it isn't going to be perfect. In a couple years when I come back, I'll choose something different. This is the process. Just because you know down the road, you will know more and do better, doesn't mean right now you do nothing. not in patient care, not in business, not in sport. Yet, people are always trying to remain neutral and I want to discuss a few of the reasons why they do this and I want to challenge them a little bit. So, number one, people are often proud of themselves for being open-minded. What I would say is excessively open-minded. Being open-minded is great. Always remaining vigilant that better options are out there and keeping an eye open that you're not missing them because you're so tunnel-visioned, that's great. But being excessively open-minded to the point where You say, yeah, I'm open to that, I'm open to that, I'm open to that, I'm open to that, I'm open to everything. 06:23 “AT SOME POINT, BEING SO OPEN-MINDED IS HAVING NO MIND AT ALL” Well, at some point, being that open-minded is having no mind at all. And having no mind at all isn't useful to anybody. Being open-minded is great. Being excessively open-minded to the point where you can't take any stances is useless. And you've gotta be careful of which side of that line you're on. Number two is excessive humility about what we don't know yet. People love to say, yeah, but we aren't sure yet. We will never be sure. That's the nature of the game. So while, again, some of that humility is useful, so you're not excessively betting on something that you truly don't have the requisite data for yet, understanding that we are never gonna hit a point where we say, we are absolutely certain about this, Knowing that and owning that will allow you to act even in the presence of some level of uncertainty. So this excessive humility of, we never know enough to do anything, again, simply isn't useful. Number three. People don't wanna be seen as falling into a guru camp, and there's some good reasons for that. Looking back historically, and again, speaking to physical therapy, it's the area I know the best, there have certainly been plenty of extremists in guru camps that have led the collective astray, no doubt, but don't be one of those. You don't have to be an extremist in a camp to go in and say, hey, I think most of what's going on here is pretty useful. There's no reason you can't go into it with that frame of mind. But people are so afraid of being labeled, of being in this camp, or that camp, or that camp, that they stay, again, doing nothing. And unfortunately, doing nothing doesn't serve anybody. Number four, they don't want to step on toes. Once you say, hey, I believe this, you are naturally going to rub some people the wrong way because now you've committed a bit. You've said, I kind of looked at everything that I could and I'm going to go this direction. I think this makes the most sense. Well, other people that made other commitments are going to be rubbed the wrong way by that. If that is not happening, you are not doing anything of merit. If you are never rubbing anybody the wrong way, I can promise you, you aren't moving anything forward in a relevant fashion. So reflection point number one of this episode is are you doing that? In the past couple years, have you rubbed some folks the wrong way? I mean, give this some serious thought. Like really think, have your stances, have your actions bothered some folks? If that answer is no, you're not standing for anything. And if you're not standing for anything, you're not being useful. So just give yourself a little pause today and really think, like, am I committing enough that people who have made contrary decisions are a bit bothered by that? That should be a constant in your life. As you're working through decisions and emerging and making choices, some people aren't gonna love those, and if you aren't feeling some of that pushback, I think you're holding yourself back and trusting yourself and making commitments that actually allow you to decide and move things forward. But the number one reason is I look at folks who are forever trying to stay in this kind of neutral ground that I really feel this static posture doesn't get anybody anywhere is because they don't want to be wrong. They don't want to be wrong. They don't want to look back in two years and know the line they took on that motorcycle trail was the worst one they could have chosen. They don't want to be wrong. They're perfectionists. Team action is always imperfect. Action is always imperfect, especially in hindsight. There is not a single action you are ever gonna take that you're gonna look back with five more years of data and say that was perfect across every domain. That's never going to happen. So if you can't embrace that you're gonna be wrong, at least in some percentage, every single time you make a choice, You are forever going to be paralyzed. It will be paralysis by analysis for the rest of your professional, business, patient care career. You've got to get over that. You've got to embrace that every single action will always be looked back as imperfect, and that is a beautiful part of the process. That's what allows you, as you recognize that, to alter it, shape it, and make it better. This is the process. 10:55 “IF YOU CAN'T CHOOSE IMPERFECT ACTION, YOU CAN'T CHOOSE ACTION. PERIOD.” But if you can't choose imperfect action, you can't choose action, period. And that's a problem if you're trying to be useful as you're moving forward. Bottom line is this, the people that I've observed who have been the most useful, and of course, the most useful meaning the most successful, because these two things tend to go together. You provide a lot of value, you're useful, success follows, are always those who took really deep dives. They said, I think this makes a bunch of sense, I'm going all in. Like I'm gonna learn as much about this as I can, I'm gonna try to replicate it, I'm gonna try to leverage it, I'm gonna try to use it. But as they're doing that, they're aware and okay with acknowledging the shortcomings of that model. So that they can in real time be seeking out solutions to fill those gaps. They're learning through action, which necessarily followed decisions, choosing. You have to do anything besides nothing. You have to do anything besides nothing, because if you don't get out there and go, you can't evaluate the shortcomings, because you aren't doing anything. The people that I see that act with the most, again, it's not arrogance, it's not even confidence, it's out of necessity to act. They know they have to say, I know this isn't perfect, but I have to go anyways. Those people that are willing to be in that space, first of all, provide the most value, and absolutely learn and refine at the highest rate of speed, simply because the data's now coming back at them because they're out there. And because they're out there, it's a bit vulnerable and emotional, and you tend to learn a ton in those phases. Now, all of that being said, Your decisions should always change. This is a critical part of this conversation, right? Your decisions should always change with emerging data. If they aren't, you're just being arrogant. And now you're falling into the other side of the problem, which is not having one eye open. If your decisions aren't changing consistently, if that's not just a part of your growth and process, where you look back and say, ooh, shoot, should've done, now that I know better, I'm definitely gonna do better because that was imperfect. If you are not regularly doing that, you are also going about this process wrong, but on the other side, right? Remaining blind and over-trusting your actions. So reflection point number two of the episode is have they? In the past couple years, Have you reversed course on a couple of key philosophies, beliefs, decisions, directions? If not, I think you're erring on the other side, where you're not keeping one eye open. You think your action's perfect. You aren't aware of the imperfection and looking for the gaps. You're going in blind. This is every bit as errant, maybe even more dangerously, than the former. In this case, not only are you probably not being as useful as possible, but you're probably leading folks excessively astray by not being aware of what's emerging. So reflection point number two is are you every couple years realizing something you believe strongly had some pretty significant flaws and are you willing to incorporate emerging data to change them? Team. If you aren't willing to embrace that action's always imperfect, you're never gonna choose, decide, and move forward. If you don't do that, you can never get the data that fills the gaps of what we don't know that you're so concerned about, it's holding you back from action to begin with. Trust that your intentions are good. Remain focused. Humble in the face of everything emerging, so you're not totally just tunnel visioned in one direction. Allow that to shape your actions, but make sure that you're actually playing the game. So when you get information, you can modulate in real time, forever become better, but always stay away from the pitfall of doing nothing. 14:49 “PARALYSIS BY ANALYSIS IS THE ONLY WAY TO ENSURE YOU'RE USELESS YOUR ENTIRE PROFESSIONAL CAREER.” Paralysis by analysis is the only way to ensure you're useless your entire professional career. Do anything besides nothing, stay humble, be ever evolving, but be willing to choose. You'll be wrong. I guarantee it. Me too. Let's be wrong bravely and let's adapt in real time. You have to choose. I hope it makes sense. Hit me up with questions, comments. Thanks for being here on Leadership Thursday. PTOnIce.com where everything lives. We'll see you next week. Cheers, team. 15:28 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.

When you exercise consistently and push your body past its limits, injuries can happen. The problem is, most guys don't know the best way to recover from current injuries and prevent future ones.  For example, most guys think passive stretching can reduce injuries, but this isn't exactly true. Stretching does provide relief, but without strengthening the underlying muscles, joints, and tendons around the injured body part, you won't prevent future injuries from happening.  The same is true for resting through an injury — in fact, staying active helps you recover from injuries faster than simply resting.  That's why I'm pumped that Zach Long, a personal trainer, owner of The Barbell Physio, and expert in injury prevention and recovery joins us on this episode.  We cover a ton of injury prevention and recovery information in this episode, including…  Why the “Rest” component of RICE is outdated (and how to exercise safely when you're injured)  Why technique isn't the most important aspect for injury prevention (even though it is important)  The weird way your nervous system can make you experience pain that isn't there  The 3 most common (and preventable) injuries for men 40+ And more! Listen now.  Show highlights include:  The easiest way to determine if your physical therapist is worth their salt or not (8:19)  Why resting after an injury can actually cause more problems than staying active (10:44)  The “PEACE & LOVE” injury rehabilitation method which is wildly more effective than the popular “RICE” method (11:43)  Why seeing a physical therapist before scheduling a surgery prevents you from having an unnecessary and costly surgery (20:39) The eye-opening “Surgery Placebo” experiment that may change your mind on whether or not you need surgery (21:52)   How to cut your risk of injury in half by simply sleeping 8 hours each night (26:57)  The “Red Light, Green Light” system to strengthen injured muscles without causing more severe injuries (30:54)  Why forgiving yourself for coming up short on your fitness goals actually increases your chances of reaching them (1:19:29)  Haven't hit your protein intake goal today? Here's a quick snack to help you eat enough protein every day (1:22:42)  Resources mentioned in this episode:  1. The Barbell Physio: Want to improve your performance while reducing injuries? Head to Zach's website here: https://thebarbellphysio.com/  2. Performance Plus Programming: Want to prevent injuring yourself in just 10 to 15 minutes per day? Check out Performance Plus Programming to find supplementary injury prevention programs for any part of your body here: https://performanceplusprogramming.com/ 3. Follow Zach Long on Instagram: Want to learn more about preventing injuries (without sacrificing your strength and fitness)? Follow Zach on Instagram at @thebarbellphysio 4. Rhone: Save 20% on all high-quality, long-lasting, and comfy workout gear from Rhone by using this link: https://manflowyoga.com/rhone  Other important links:  Want to improve your sexual wellness, get stronger erections, and last longer in bed? Then join the FREE 7-Day Sexual Wellness Challenge here: https://shrtlnk.co/uA27H  Want to unlock more flexibility and strength, reduce your risk of injury, and feel your absolute best over the next 7 days? Then join the FREE 7-Day Beginner's Yoga for Men Challenge here: https://ManFlowYoga.com/7dc.  Tired of doing a form of yoga that causes more injuries than it helps prevent? The cold, hard truth is men need yoga specifically designed for them. Well, here's some good news: You can start your 7-day free trial to Man Flow Yoga by visiting https://ManFlowYoga.com/join.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the role of carbohydrates, the relationship between carbohydrates & performance, carbohydrate loading, and carbohydrate consumption timing. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 02:14 ALAN FREDENDALL Good morning everybody. Welcome to the PT on ICE Daily Show. Glad to be back again. Hope your day is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and elite faculty in our fitness athlete division. It is fitness athlete Friday. We would say it's the best darn day of the week here on Friday, live on Instagram, live up here on YouTube, and wherever you get your podcasts. Thank you for joining us. Some announcements really quick. If you're looking to join us in the fitness athlete division, we have a couple chances online and about a dozen chances live before the end of the year to catch us out on the road. Our online courses, fitness athlete essential foundations, that's our eight week entry level online course. All things relevant to treating the recreational athlete, the cross fitter, the Olympic weight lifter, the power lifter, the orange theory athlete, the boot camper, so on and so forth. That is the course for you. That starts this coming Monday, September 11th. We still have room in that class. And our advanced concepts course, also eight weeks online. Pre-requisite for that class is essential foundations, our entry level course. Advanced concepts is only taught twice per year. It is taught spring and fall. So this is your last chance to catch it this year. That will kick off the week after September 17th. That class has just two seats remaining. So if you're looking to round out your fitness athlete certification, make sure that you get into fitness athlete advanced concepts this fall. Live courses coming your way between now and the end of the year. Your next chance will be September 30th on October 1st. That will be out on the West Coast in the Bay Area with Zach Long. Also on the West Coast, October 7th and 8th, you can catch Mitch up in Linwood, Washington. That's outside of the Seattle area. Also on the West Coast, October 21st and 22nd, Zach will be on the road again, this time up in Vancouver, British Columbia. You have two chances the weekend of November 4th and 5th. You can either catch Mitch down in San Antonio, Texas, or Zach will be down in Birmingham, Alabama. Mitch will again be on the road in November, November 18th and 19th. He'll be in Holmes Beach, Florida. That's right outside of the Tampa area on Anna Maria Island. You can catch Joe Hanisco in New Orleans. That'll be December 9th and 10th. And then our last course of the year will be December 9th and 10th as well. That'll be out in Colorado Springs with Mitch. So that's your chance to catch us on the road in the fitness athlete division. Today's topic, let's talk about carbohydrates. Let's take a deep dive into what a carbohydrate is, how it's relevant to us here in the fitness athlete division as far as exercise, energy and performance goes. And then let's talk a little bit about when and how to kind of dose out your carbohydrates, who needs to be eating them, who maybe needs to think about eating more. And let's talk about timing of getting those in to best suits whenever we're going to be exercising to maximize and optimize our performance. 04:18 WHAT IS A CARBOHYDRATE? So starting very basic, if you know nothing, what is a carbohydrate? It is a sugar, a starch or cellulose plant material. So commonly we know carbs traditionally are things made out of maybe table sugar, candy, soda, that sort of thing, potato chips, things that are maybe less than optimal carbohydrate choices but are overwhelmingly what is often consumed when people eat carbohydrates. We also think of fruit being fructose. We think of the sugar that's in milk, lactose. We also think of carbs as vegetables that we eat when we're primarily eating the cellulose in a vegetable, we're eating that plant matter, we're eating things like green leafy vegetables, broccoli, kale, asparagus, that sort of thing. So different ways we can consume carbohydrates. They're not all equal as far as content goes, but those are all kind of classified as carbohydrates. Why do we care about them? Well, we really care about carbohydrates because eventually they become glucose in our body, which is an energy currency, a way that we metabolize energy reactions and chemical reactions in our body, but we also store glucose as glycogen. We store glucose as glycogen both in our liver and in our muscles. At any given time, we only have about four grams of circulating glucose in our system. So we have a relatively small amount. Our body does not really like to have glucose moving around in our blood system. So when we tend to get beyond that four grams circulating throughout our body, that's when insulin is released, insulin is released, and at the end of the day converts that glucose into glycogen, either stored within our muscles or stored in our liver, or if we do have an incredible excess of glucose in our system, it can be also stored as body fat. 09:13 MUSCLE GLYCOGEN  Aside from the four grams circulating in our body, we have about 400 grams stored inside of our muscles, and we have about another hundred grams stored in our liver. For most people, a total of about 500 grams of muscle glycogen or about 2,000 calories worth of energy. And that's kind of where, if you ever wonder where is the recommendation that I should eat 2,000 calories a day to maintain a healthy weight, where does that recommendation come from? It comes from estimations of how much muscle glycogen we are storing and throughout the day using for regular physical activity, but also for exercise. And that if we deplete that glycogen throughout the day, we will need to eat 2,000 calories of food to replenish that glycogen back into our muscles and back into our liver. We can make glucose and then store muscle glycogen on demand. This is that process you may remember back from middle school or high school biology and chemistry called gluconeogenesis, gluconeogenesis, make new glucose. This is a very, very slow energy intensive process. We can only make about 30 grams of glucose per hour. Now this typically comes from our body fat. It's synthesized, made into glucose, and then is either stored as glycogen or pushed into circulation for energy. So this is kind of where the all day energy you have of being at work, maybe working around the yard, relatively low intensity activity. The energy, the glucose that supports that energy, those metabolic reactions comes from that process of taking body fat, turning into glucose in the liver, about 30 grams per hour. 11:17 GLYCOGEN DEPLETION DURING EXERCISE Now when intensity increases is really our concern in the relationship between carbohydrates, glucose, glycogen, and exercise. That when we start to exceed about 65% of our VO2 max, we start to use more glucose, use more glycogen than our body can produce per hour. So we start to dig into the reserves that are inside of our skeletal muscle and our liver. Now at very high intensities and very long durations, especially if heat, if temperature, is a factor as well, humans can use up to 150 grams or more per hour of that glycogen, which means at any given time, there are only about a couple hours of energy stored in our body for higher intensity activity. So above 65% of that VO2 max, what we call a low oxygen environment, we can no longer make enough glucose and glycogen to replenish what we are burning with that high intensity exercise. We are in a high oxygen environment, relatively low intensity activities. Our body can again make those carbohydrates, make those sugars from the fatty acids from our body fat, but as intensity increases, we start to dig into our reserves. Now that typically happens around the 90 to 120 minute mark. That is going to be a little bit different for every person. Bigger people, people with more muscle can store more muscle glycogen. Those who are better trained, who exercise at all, but especially those who are used to doing long endurance training, can store a little bit more muscle glycogen. And then certainly you've heard of the concept of carb loading, where if we taper our activity for two to three days and we increase our carbohydrate consumption accordingly, we can supersaturate our muscles with glycogen as well. And overall, we may have about 50% more glycogen reserves than the average person. We might have maybe 600 to 700 grams available. So maybe we can kind of flirt with having two hours of energy total for high intensity activity before we need to start thinking about eating, eating food, eating it to not only continue exercise, but feel better after, which is part of what we're going to talk about today. The relationship between carbohydrates and performance, especially if you want to be training multiple times a day or otherwise just not feel terrible the rest of the day after you finish exercise. Now it's not an all or nothing concept. It's not, I have a hundred percent of my muscle glycogen or I've used it all and I need to stop exercising and eat. We certainly know that we can consume food during long endurance activities, but also that as those reserves deplete, we feel a performance shift as we're doing different activities of we can feel maybe speed slow down on a run, maybe power slow down if we're out and we're on the assault bike or something like that. And we know we can run out. That's a concept that's called bonking of where we have depleted almost all of our muscle glycogen and our body is going to take us from that high intensity, low oxygen environment and say, Hey, you need to cool it. We need time to recover some of this energy and your body's going to stop you for you. And that's the concept of bonking of shifting you to a high oxygen environment by lowering your intensity in an uncomfortable manner, maybe even possibly losing consciousness, but definitely not feeling like exercising anymore. It's really important that we never hit that point. If we can avoid it, we've all we've all done it. I have a story of hiking in the smoky mountains of bonking at the top of a mountain, mainly because my wife ate all of our food on the way up and I had nothing to eat. So I had no choice and bonked at the top. But it's important to know that we don't want to get to that point. We never want to use all of our glycogen and hit that wall because there is a compensatory recovery point afterwards where for one to three days after we're going to feel really low energy as our body slowly recuperates and restores all of that glycogen in our body. We're not going to feel like pushing the pace. We may not feel like exercising at all. It's going to impact our training. And what you don't want to get into is kind of this weekend warrior phenomenon. Where maybe you go you go for a really hard run for two to three hours. You hit the wall and then you don't feel like exercising maybe for another week, right? Where you don't feel like you can work out again for a couple of days. That's not very productive training. So we want to avoid that. 13:58 CARBOHYDRATE CONSUMPTION And we'll talk about that now as we talk about when should I eat my carbohydrates. So it's really cool that technically a human being does not need to eat any carbohydrates at all. You may have heard of the keto diet of being low carb, maybe no carb, under 50 grams of carbohydrates, being in a state of ketoacidosis of only utilizing your own body fat as an energy source and the fat and protein that you consume. But it's cool that we don't technically need to eat carbohydrates. Yet almost all of the metabolic and chemical reactions in our body are fueled by carbohydrates. It's very, very interesting how our body operates. So you can go without eating carbs. So again, your body can make carbs about 30 grams per hour, but we need to understand that that takes time as we talked about. And especially if we are doing longer, harder events, we're thinking about maybe training twice a day, something like that. Then we need to understand that that process is slow and we need to give the body either a lot of time or we do need to consume carbohydrates. We also need to recognize at some point that eating carbohydrates is like consuming jet fuel for a mechanical engine. Of it's a very caustic chemical reaction to our body, a lot like burning gas inside of a gasoline engine, that it does create some low grade, low grade inflammation that's kind of always present as we're eating carbs and fueling our chemical reactions with the carbs. And so kind of the longevity side of the research would say, if you want to live as long as possible, avoid that. However, that's in direct conflict with the performance research, especially if you want to be a more competitive athlete. You want to do longer, more intense activities. You want to maybe train multiple times a day. You need to understand that those are two kind of diverging thoughts of longevity versus performance. At some point, those tend to dissect and not reconverge of needing to eat carbs to fuel your activity, especially multiple activities in a day or a busy workday after you exercise or avoiding carbs. Maybe even you may have a longevity physician who recommends you take metformin prophylactically to keep as much glucose out of your system as possible because of the inflammation that's present. But nonetheless, we need to talk about that relationship between eating carbs and performance. So it's that that longevity versus performance question that we have a need to eat carbohydrates if we are a long duration endurance athlete, that when you start to run 10 miles, 15 miles marathon, ultra marathon, when you start to do long trail runs, long bike rides, long hikes, that sort of thing. Again, you are using your reserves faster than your body can make more. And you either need to know that at some point you're going to hit that wall that we talked about or you're going to need to start consuming carbohydrates as you exercise. Higher level elite endurance athletes may eat 90 grams of carbohydrates per hour in the forms of liquid carbohydrates, gels, chews, that sort of thing. Folks who maybe are doing half marathon or marathon training may be eating less, maybe about 30 grams per hour. Our fitness athletes don't necessarily need to eat carbohydrates during exercise. We think about a typical one hour CrossFit class. We're not really at the level of intensity and duration long enough to need to eat carbs during that hour. We can get away with doing that hour of fitness and then worrying about carbohydrates after. But there's also a want, a need versus want. The want for carbohydrates is understanding that performance trade off, but also understanding that your body can only make about 30 grams per hour. So what does that mean? That means if you do go to that one hour CrossFit class, you don't technically need to eat carbohydrates before or during, but that you might want to front load your consumption afterwards, especially depending on the time of day in which you do your exercise. If you're like me and you like to get up and exercise first thing in the morning and then you might be looking at, hey, I have 8, 10, 12, 14, 16 hour day ahead of me. Those subjective feelings that you may feel your patients, your athletes may feel of, I feel tired all day after exercise. I feel like I just need to go home and go to bed. I feel weak. I feel like I can't do my work tasks. I can't take care of my kids. Maybe even feeling lightheaded or some sort of impaired cognitive function. Like my mind just feels cloudy. All of those are good subjective reports to tell you that you should probably eat some more carbohydrates after that exercise session or to recommend that to your patient or athlete. And then we get in now to how to do that of our long duration endurance athletes. We've already talked about they're probably going to be or hopefully should be consuming those carbohydrates as they're exercising, especially once they cross maybe that one hour mark of again, it's not an all or nothing equation of go until I can't anymore of as those reserves of muscle glycogen get depleted, I'm going to feel worse and worse and worse than my performance. And how I get ahead of that is eating, eating those carbohydrates while I'm exercising. So the combination of me eating them and my body making some more keeps them relatively high, keeps my performance, my output higher, keeps me away from feeling kind of that onset of losing power, losing speed, losing energy throughout my workout. 22:08 CARBOHYDRATE CONSUMPTION & TIMING How to eat those? Well, I'm still trying to figure that out. As I get more into long endurance training, I have tried chews and gels and my body doesn't really sit with those. I tend to do better with liquid nutrition like Gatorade. Every person is going to be different, but definitely those people who are going out for longer workouts, especially crossing an hour need to find a way to start to consume that as they're exercising. This is also relevant to our fitness athletes who may be doing a multi event day. Maybe they're doing a local CrossFit competition. Maybe they're a quarterfinals or a semi finals athlete where they have multiple events per day, multiple days in a row. I always laugh now when I go to a CrossFit competition and I see that person after workout eating chicken and salad, right? Just not enough carbohydrates in that meal to replenish what was used in that CrossFit workout in order to have those reserves restored and ready for the next workout, which might be two to three hours after the first one. They might have a third one two to three hours after that, right? Those are athletes who they don't necessarily need to eat carbs during the workout because it's a relatively short event, maybe 10, 20, 30 minutes. But if they have to workout again in three hours, they're definitely somebody who's going to want to eat higher carbohydrate food. That's the case. You see CrossFit Games athletes eating gummy bears and Snickers bars, just getting as much carbohydrates as they can. Again, they're trying to maybe replenish 200, 300, 400, 500 grams of carbohydrates within a two to three hour window to be ready to work out again. So understanding it's important to get those carbs back in if you're wanting to train or you have to exercise again in a relatively short amount of time. I hiked the Grand Canyon last year with Dustin Jones and Jeff Musgrave and we did it. It was about a 12 hour hike up and down about 20 miles and we did it almost exclusively on water, Gatorade and gummy bears, right? Just high carb food that's going to keep our reserves up because we're basically hiking and walking in a hot environment at moderate to high intensity for a very long period of time. I'm thinking I just ran 10, 800s this morning. I have a 12 hour day ahead of me. The first thing I did was eat three bananas, right? The first thing I did was house 100 grams of carbs to give my body that jump start on replenishing that glycogen, which was not entirely gone, but definitely mostly gone at the end of that running workout. And that's really going to determine how you recommend carbohydrate intake to that patient athlete in front of you of what does the rest of your day look like? When do you train and what does the rest of your day look like? If you work out at 5 a.m. and then you have to go to work all day and you're maybe a physical therapist, right? You have a relatively physically active job. You're getting your steps in. You have an eight to maybe 10 hour day in front of you. You'll probably feel a lot better if you eat the majority of your carbs earlier in the day to replenish those reserves. You will find yourself feeling subjectively better. If you work out early in the morning, maybe you run and you want to lift weights at lunch or go to CrossFit after work. How can we fuel our body to be able to do double sessions in a day, two a days, right? The same thing, we need to front load that carbohydrate consumption in the morning, at lunch, in the early afternoon so that by the time we are going to work out again, most of those reserves are back. They're probably not going to be 100% back where I can PR my 5K in the morning and go PR a CrossFit benchmark in the afternoon. It's probably not going to work out that way to be 100% ready to go for a second session in the same day. But you will feel better during the day subjectively and you will definitely perform better objectively in that second session if you eat a lot more carbohydrates in between. Now who is that person that maybe works out in the afternoon or evening and that's their only session of the day and then they go home and they basically watch some TV, get ready for bed and go to bed? That is maybe a person who can get away with maybe a lower carbohydrate or could maybe play with a keto diet, right? Of hey, I work out at 6 p.m. when I'm done with work, I get home around 7.30, take a shower, eat some dinner, go to bed. That is a person that they do not necessarily need to replenish as much of their glycogen as possible because of their schedule, right? They deplete their glycogen in the evening, they are going home consuming some with maybe a dinner meal and then they're going to bed. They're giving their body maybe 8 to 10 hours to replenish hundreds and hundreds and hundreds of grams of muscle glycogen overnight while they're asleep. So that is a person who maybe could get away with lower carbohydrate or no carbohydrate consumption between when they work out and when they wake up again. That's a person who's going to work out, have dinner, sleep, have breakfast and have lunch again before they work out again 24 hours later and they're in a really good position where maybe they don't need to worry about it as much. So carbohydrates, what, when and how? Understanding they're very important for performance, especially for longer duration exercisers, for long endurance athletes. They're definitely linked to performance, especially if you are wanting to train multiple times a day. You are in a competitive environment where maybe you're doing multiple events in a day and then we need to understand timing of when should I eat them. For most people, if they're working out in the morning, they're maybe doing multiple sessions in a day. They're going to work and they want to feel like they have high energy. They should probably eat a good portion of their carbohydrates earlier in the day, but there is that person who maybe trains later in the day who doesn't have a lot going on between when they train and when they're going to train again, who maybe can get away with not eating as much carbohydrates as somebody else. So understanding that food is our friend, food is fuel and understanding how your body creates, consumes and utilizes carbohydrates for energy can be a really big game changer for performance during and after exercise. We all probably have that patient who seems really active, really fit, but complains all the time of being tired, of feeling weak, of not hitting PRs. And that can be a good person, yes, to evaluate their protein consumption, to make sure that their muscles, their musculoskeletal system is recovering appropriately, but also to have a conversation of what their carbohydrate consumption looks like. If we can up our carbohydrate consumption a little bit, we'll often find that that subjective fatigue, weakness that comes after a training session, especially if we're going to train again later or we have a long day of work or whatever ahead of us, we can alleviate a lot of that just by tweaking our diet a little bit. So I hope this was helpful. If you're going to be on an ice course this weekend, I hope you have a fantastic weekend. Have a great Friday. Have a great weekend. Bye, everybody.  24:46 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

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

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

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

Do you NEED mobility? Does flexibility even matter? How do you rehab minor injuries from lifting weights? And what does “prehab”, to prevent lifting aches and pains, for the general population look like? ALL of this and more answered in this episode! Because we have The Barbell Physio, Zach Long, on the episode to drop some knowledge bombs and help us better understand proper movement, lifting, and injury prevention. And there’s truly nobody better, because he’s not just a physical therapist — he’s a coach to countless athletes AND a true lifter himself. Follow Zach on social media @thebarbellphysio and check out everything he offers at www.thebarbellphysio.com If you love this podcast, please do us a favor and share this episode with anyone you think would like it or benefit from it. Thank you!! —- To Apply For Coaching: Click Here Purchase Training Program On TrainHeroic: Click aHere To Get Your Questions Answered On The Podcast: Ask Us Here! Purchase Items From Tailored Life Apparel - HERE Download 1 (or ALL) Of Our FREE GUIDES: https://www.tailoredcoachingmethod.com/guides Giant Lifting Equipment (10% Off With Code “TCM10”): GiantLifting.com 1st Phorm Supps: https://www.1stphorm.com/tailoredcoachingmethod To Get Cody’s Amazon Recommendations, Click Here —- Timestamps: (2:30) - Who is Zach Long (4:30) - Dealing with specific injuries (7:40) - How to asses injuries (9:50) - Importance of mobility (23:40) - Most common complaint with patients (27:30) - Importance of Compounds lifts (36:10) - Full range of motion (39:00) - Lifting for ligaments and tendons (centric and eccentric) (42:20) - The BIG 3 (48:40) - Quad Training vs Hamstring Training (56:00) - Where you can find Zach and all of his services —- Social Links: Blog – http://www.tailoredcoachingmethod.com/blog
 Facebook - https://www.facebook.com/tailoredcoachingmethod
 Instagram -https://www.instagram.com/codymcbroom YouTube - https://www.youtube.com/codymcbroom1 Email – info@tailoredcoachingmethod.com Cody McBroom Has Also Been Featured On: Huffington Post, Bodybuilding.com, The PTDC, Dr. John Rusin, Muscle For Life, Barbell Shrugged, Strong By Design, OPEX Fitness and More…

On todays episode, Julie is joined by Dr. Zach Long to discuss growing @thebarbellphysio, his leadership in blending strength and conditioning with rehab, and why taking people “back to baseline” isn't enough. Simply put, the person that was your baseline got hurt, so why would we stop there? Zach is a physical therapist, educator, and coach who has helped tens of thousands of people optimize and understand performance through his courses, social media content, and fitness programming. We discuss strategies for building true tissue resilience, how to effectively dose exercise, and how much emphasis we should be placing on lifting technique. We also discuss the limitations place on us by the health care system and how we can maximize health & fitness despite these challenges. Shownotes: 03:00- The Barbell Physio Origin Story 05:35- “The person that was your baseline got hurt, so why do we want to get you back to that baseline?” 13:05- “It's about adaptive changes in the mind as well.” 18:05- Assessing capacity & physiological readiness to load 20:30- The value of Intentional Underdosing 21:50- “The intensity doesn't matter as much as setting the habit.” 29:10- Lifting technique- when does it matter most? 33:55- The empowering effect of a barbell  Zach's Links: www.instagram.com/thebarbellphysio https://thebarbellphysio.com/ https://onwardphysio.com/ www.ptonice.com Julie's Links: www.instagram.com/goalsetmindset_jb www.facebook/com/goalsetmindset

Physical Therapist Zach Long and Personal Trainer Bo Skitsko discuss how to have a life long fitness journey without injuries. How to progress in the gym and and not get hurt for beginners, experienced athletes, young and old fitness enthusiasts. Fitness longevity is very important for young and old to have a good quality of life! Questions discussed: Am I too old to workout? Should I stretch before workout? How to avoid injuries in the gym? Should I workout long or hard?Video version of this Episode: https://youtu.be/XMUyWmOCAJcDr. Zach Long, better known as The Barbell Physio, is an internationally known physical therapist and strength coach. Zach consults regularly with elite weightlifters, CrossFit games athletes, and professional athletes from a wide range of sports. His expertise is in improving sports performance while simultaneously decreasing injury risk factors.Special Guest: Dr. Zach Longhttps://www.instagram.com/thebarbellphysio/https://thebarbellphysio.com/https://performanceplusprogramming.com/More from your host Bo Skitsko:Check out our Store and Supplements :https://shop.bofitstudio.com/Get my Book

Kevin has a fun chat with Zach Rodgers, Editor-in-Chief and Co-Founder of Marketecture Media, a new media venture that helps people navigate the world of marketing technology. Zach also ran AdExchanger's editorial operations and supported programming strategy for the company's Programmatic IO and Industry Preview Events. Zach and Kevin discuss editorial independence, how Marketecture can help assist vendor conversations, and how Marketecture's products and offerings can help both ad tech and marketing executives.   Takeaways: [3:31] Zach believes in editorial independence and that there are still many strong journalists out there. [10:50] How can AdvertisingWeek get better? [13:32] What exactly is an oligarchy? [14:32] As the economy turns down, unfortunately, the people that get fired first are often the ones with the creative and inventive thinker-type titles. [20:35] Okay, what does it mean to be the Jenny to the industry's Forrest Gump? [22:43] Zach talks about Marketecture and how it cuts through the BS while providing people a platform to be curious and have genuine interactions. Marketecture can also help take the hocus pocus and hand waving away from the process, and help people understand the complex world of technology to make better vendor decisions. [23:49] Zach breaks down the Marketecture pricing and the overall subscription model. [28:48] What's the plan for the future of the business?   Quotes: “There are still strong journalists out there.” — 4:33 Zach “Long live editorial independence. I believe it will continue.” — 10:38 Zach   Mentioned in This Episode: Marketecture Zach Rodgers Star Wars: Be More Boba Fett: Always Get the Job Done, by Joseph Jay Franco

It was great to catch up with this guy in this weeks Strength Chat after last speaking with him back in episode 107. Today I was joined by The Barbell Physio, Zach Long. The content and information that Zach puts out there is awesome. He strikes that balance between still getting his clients and athletes to still train hard, but also work around, manage, and progress from their injuries or niggles. In this episode we chatted about adding mobility into your training, working on weak links to get stronger, as well as training around injuries. You can follow Zach via the following links: Instagram:  https://www.instagram.com/thebarbellphysio/?hl=en   Website: https://thebarbellphysio.com/           You can follow myself, Coach Cuthbert, via the following links: Website: https://www.coachcuthberttrainingsystems.co.uk/ Instagram: https://www.instagram.com/coach_cuthbert/?hl=en Facebook: https://www.facebook.com/coachcuthbert/   Check out the podcast affiliates: https://www.coachcuthberttrainingsystems.co.uk/affiliates

In this episode, we sit down with the owner and operator Zach Long of Craze Bottoms in Danville Alabama. We discuss future plans and endeavors with Craze Bottoms. We also talk about the exciting new partnership between Craze Bottoms and Old Dixie Kennels.We really appreciate you taking the time out of your day to listen in. If you enjoyed the show, share it with a friend and leave us a comment below. We look forward to seeing you in the timber! 

In this Episode Dr Zach Long discusses the importance of technique for performance, pain and injury. We covered changing a patient's technique and more importantly how to do that, when to do that and what words we should use when we do.Dr. Zach Long is a physical therapist and CrossFit coach located in Charlotte, NC. He majored in exercise and sport science, before doing his doctorate in Physical Therapy at East Carolina University. He specialises in improving athletic performance and injury rehab of athletes from Olympians to weekend warriors.Our host is Michael Rizk from Physio Network and iMoveU: https://cutt.ly/ojJEMZs

The editor of Time Out Chicago, Zach Long, joins Steve Bertrand on Chicago’s Afternoon News to highlight holiday events at the Time Out Market Chicago, including a VIP way to be the first to try Goose Island’s Bourbon County Stout 2021 offerings the day they are released. Follow Your Favorite Chicago’s Afternoon News Personalities on […]

Today we're excited to be joined by The Barbell Physio (@thebarbellphysio) for a great discussion about weighted loading, specificity, and where weight lifting plays in to the rehabilitations process.  A hot topic in rehab, Dr. Zach Long provides some great insight into the use of weights with rehab patients!  Enjoy Episode 25 of What The Cup!? A Podcast!

I've had the pleasure of knowing the two of the co-founders in Onward Physical Therapy for several years now - @thebarbellphysio Zach Long and Jordan Berry @jordanberrydpt. Both are certified DPTs and have created an amazing license model for physical therapists who want to get out of the rat race that the status-quo clinics have created. And not only do I know them as business colleagues in Charlotte, NC....but I'm also a client. And I can personally attest to the brand and client experience they've created and are continuing to grow across the country. Enjoy. www.onwardcharlotte.com IG @onwardclt --- Send in a voice message: https://anchor.fm/wtfgymtalk/message

On this episode Alex talks with Physio, Strength and conditioning coach and revolutionary within the health and fitness industry. They dive into positives and negatives of the current mindset around rehabilitation, functional fitness and strength and conditioning. I hope you enjoy this as much as we did!

Coaches, I always strive to bring you the best guests along with interesting and helpful topics for your businesses, and I've gotta spoil my upcoming lineup a bit: it's incredible. The fitness required for and neuroscience behind dance. The strength and empowerment of fitness for the pole. An extraordinary guest that talks to me about active aging. I am so excited to share what I've already recorded and the guests I have lined up. Today I have the pleasure and the privilege of sharing this interview that I conducted at the end of July with Dr. Zach Long. Like me, Zach is interested in and excited by preventative physical therapy and treatments. He operates a highly respected and trusted company and resource for other trainers and clinicians, and truly, it's a privilege having him on this podcast. In this episode, we dive into the key components of human movement and how he helps disciplined athletes. He also shares some tips on how to get quality sleep and what gadgets and apps he uses to track his clients performance while at the same time helping them to avoid injury. Zach and I dive into topics such as:- The importance of getting quality sleep.- How he assesses his clients virtually.- Heart Rate Variability (HRV). About Today's Guest Dr. Zach Long is a physical therapist in Charlotte, North Carolina and runs an industry leading fitness website called The Barbell Physio where he is a trusted resource to thousands of athletes, coaches, and health care professionals across the United States and beyond. Additionally, Zach teaches with the Institute of Clinical Excellence in their “Fitness Athlete” division where he helps medical professionals better understand the needs of CrossFitters, power lifters, and weightlifters. Zach is a Board Certified Sports Certified Specialist, Level One CrossFit Trainer, NASM Performance Enhancement Specialist, and certified SFMA practitioner. The Barbell PhysioDr. Zach Long on InstagramThe Barbell Physio on FacebookThe Barbell Physio on YouTube Join my Facebook community! Are you a new fitness entrepreneur looking to attract clients? Maybe you're looking to dial in your messaging? Or perhaps you'r

Lollapalooza asked fans arriving for the festival to bring a copy of their COVID vaccination card or negative test results. Time Out Chicago editor Zach Long joins Reset to tell us what that looked like, and more about the lineup.

Zach Long interviews Kathy Lassalle on episode 5 of the More Than Teachers Movement podcast. Through their conversation, we hear about the importance of life-long learning, growing over time in your teaching career, and building meaningful relationships with your co-workers. Focusing on these three areas will help teachers to create a career that they love.

We sit down with the barbell physio Zach Long talking all things barbell training. Zach is a PT out of North Carolina who teaches through ICE courses on barbell training for medical professionals. He also runs a very successful online platform called the barbell physio (www.barbellphysio.com). Check out his website for the references we refer in the talk. We review assessments, progressions/regressions, training de-loading, manual therapy, and more. Check it out!

Zach Long brings us a message on the power of the Spirit within and why we don't have as much in common with the underdog as we sometimes like to think.

Zach Long joins Patrick on this week's episode to discuss the importance of Kobe Bryant, his lasting legacy and why his career is so divisive, and why he is the most important player of the 21st Century in the NBA to date.

It was an absolute pleasure to have this guy as a guest for this weeks Strength Chat. In this episode I spoke with a physical therapist providing a trusted resource through The Barbell Physio, Zach Long. Having followed Zach’s work for such a long time, it was great to have the opportunity to pick his brains. We chatted about bulletproof programming and training to help reduce the risk of injury in sports that can have a wide variety of movements, such as CrossFit. You can follow Zach via the following links; Instagram: @thebarbellphysio Website:  https://thebarbellphysio.com/     You can follow myself, Coach Cuthbert, via the following links; Instagram: @coach_cuthbert Facebook: Coach Cuthbert Training Systems Website: http://www.coachcuthbert.co.uk/ JOIN THE NEWSLETTER:  https://forms.gle/cNRo6b37mqiQPQ8M7 COMPLETE ONLINE COACHING: https://docs.google.com/forms/d/1Q00Am67pl65nswCMsxyPwhJWCpeXvkigk3aAhVXfSYQ/edit 2 WEEK HOME WORKOUT PLAN: https://app.fitr.training/plan/2040 8 WEEK FAT LOSS BOOTCAMP: https://app.fitr.training/plan/1846

Today we welcome Dr. Zach Long to Health Coach Radio.  Zach is a Physical Therapist out of Charlotte, NC who runs an industry-leading fitness website, The Barbell Physio, where he is a trusted resource to thousands of athletes, coaches and healthcare professionals across the United States and beyond.  Zach also teaches for the Institute for Clinical Excellence in their Clinical Management of the Athlete division.  In this episode, we discuss communicating to clients in a language they understand, recycling content for your online business, the biggest thing he sees missed with athletes in his practice and how your vision should help drive the decisions you make in your business.  We really learned a lot about what fitness, movement, and mobility coaches need to know to get their clients functioning well.  If you are interested in the physical side of health coaching, this episode is for you! To learn how to become a health coach or to up-level your skills and credentials as a health coach, visit primalhealthcoach.com.

Dr. Zach Long (@thebarbellphysio) is a physical therapist and CrossFit coach located in Charlotte, NC. He attended the University of North Carolina at Chapel Hill, where he majored in exercise and sport science, and East Carolina University, where he earned his doctorate in physical therapy. He specializes in improving athletic performance and injury rehab of athletes from Olympians to weekend warriors. Zach is also an instructor for the institute of Clinical Excellence (@icephysio) where he teaches Clinical Management of the Fitness Athlete, he writes for CrossFit HQ, and he is an instructor for Stronger Experts (@strongerexperts), an online platform where 20 of the world's best S&C experts put out weekly content. In this episode we discuss: Zach's mission and philosophy What drives him to push the profession of physical therapy forward Zach's work in the continuing education worlds both in PT and S&C The importance of coaching in the clinical setting Blood flow restriction therapy (BFR) and more... Helpful Links: Zach's Website TheBarbellPhysio.com Stronger Experts TheBarbellPhysio.com/stronger Where to find us: (@betterfasterpodcast) Vertex Performance Training (@vptstrength) vertexpt.com (@vertexpt) Josh Jeffery (@joshjeffery5) Brandon Vaughn (@bvthept)Support the show (http://paypal.me/betterfasterpod)

Episode 21: What is "Tendinitis" and How to Fix it! with Dr. Zach Long, "The Barbell Physio" We delve into common causes of tendinitis, how to prevent it and how to fix it! Dr. Zach Long is an expert in weight lifting and training athletes, and has been instrumental in the evolution of providing PT to weightlifters. For more information or to contact Dr. Zach Long, please visit https://thebarbellphysio.com. Dr. Cameron Dennis hosted this episode but focuses professionally on training runners and running injuries. For more information or to contact Dr. Cameron Dennis, please visit https://backontracktherapy.com.

In this episode, Zach talks about analyzing and coaching human movement, how cross fit has impacted his career as a physical therapist, the CSCS vs SCS exam, and more. Check out his website here--> https://thebarbellphysio.com/ FB: https://www.facebook.com/thebarbellphysio IG: https://www.instagram.com/thebarbellphysio/ GRADitude Scholarship Fund: https://www.gofundme.com/graditude-podcast-student-scholarship --- Support this podcast: https://anchor.fm/graditude/support

This week's episode is the of the #MusingsTour2018 episodes! It ended in Charlotte, NC, with Zach Long. Zach is a Doctor of Physical Therapy and creator of The Barbell Physio. He's a teacher, lecturer, lifter, and fantastic host! William got the change to hangout with him in the clinic for a day followed by a lifting session in the unprecedented Barbell Physio garage. We hope you enjoy! Check out @thebarbellphysio on Instagram and Facebook, or www.thebarbellphysio.com for more content! For questions, comments, concerns, or collaboration, contact us at: info@thealineacollective.com

On this latest episode of the High Impact Health Podcast, I have with me the top Fitness Athlete Physical Therapist in the country, Dr. Zach Long, AKA The Barbell Physio. He is a mentor of mine and on this episode drops knowledge bombs all over the place! We discuss treating the fitness athletes, getting experience over credentials, and why you NEED to work on your squat mobility! Want to check out more of Dr. Zach's content? Interested in increasing your squat mobility and performance? Check below! Master the Squat Program: http://bit.ly/masterthesquat Website: https://thebarbellphysio.com/ Facebook Business Page: http://bit.ly/BBPHYSIOFB Instagram: http://bit.ly/bbphysio --- Support this podcast: https://anchor.fm/high-impact-health-podcast/support

In Episode 22 I get a chance to sit down with Dr. Zach Long, a Board Certified Sports Specialist and the creator of the industry leading fitness website, TheBarbellPhysio.com.I reached out to Zach after coming across some of his content online and was blown away at the amount of great insight and knowledge he puts out there. He has a really cool story about how he got involved in fitness and physical therapy and his path to starting and building upon his website, The Barbell Physio.His Dad was his high school football coach and probably the biggest influence on his life and had a great quote he used to say, “Don’t ask yourself what the world needs, ask yourself what makes you come alive”. Very fitting for this episode and the entire Just Get Started Podcast series!We get into a whole lot of different topics where we crush a few myths and learn a little bit about “Dry Needling”.I know you all with love this conversation and if you get a chance to listen I hope you enjoy!About Dr. Zach LongDr. Zach Long is a physical therapist and CrossFit coach located in Charlotte, NC. He attended the University of North Carolina at Chapel Hill, where he majored in exercise and sport science, and East Carolina University, where he earned his doctorate in physical therapy. He specializes in improving athletic performance and injury rehab of athletes from Olympians to weekend warriors.Find Zach Online:Fitness Website – https://thebarbellphysio.com/ Carolina Sports Clinic Website – https://carolinasportsclinic.com/Instagram – https://www.instagram.com/thebarbellphysio/ About the Host:It's hard to write these things about yourself but I'm just a very curious guy that wants to learn as much as I can about the world and the people in it. With a new found motivation many years ago to achieve certain goals and push beyond status quo, I wanted to speak with people that were breaking out of their comfort zones and try to capture how they were doing it and what insight could be shared to help others. I hope you all will continue along on the journey with me and share any feedback you have.If you enjoyed this episode or others please consider leaving a review on iTunes or whichever Podcast platform you listen on.Here's where you can find me:Website: https://www.brianondrako.com Instagram: https://www.instagram.com/brianondrako/Twitter: https://twitter.com/brianondrakoFacebook Page: https://www.facebook.com/justgetstartedpodcast/ Thank you very much!Brian The post Dr. Zach Long (Ep.22) – Creator of TheBarbellPhysio.com | Board Certified Sports Specialist appeared first on Just Get Started. See acast.com/privacy for privacy and opt-out information.

Dr. Zach Long (@thebarbellphysio) is a physical therapist and CrossFit coach located in Charlotte, NC. He attended the University of North Carolina at Chapel Hill, where he majored in exercise and sport science, and East Carolina University, where he earned his doctorate in physical therapy. He specializes in improving athletic performance and injury rehab of athletes from Olympians to weekend warriors. Zach is also an instructor for the institute of Clinical Excellence (@icephysio) where he teaches Clinical Management of the Fitness Athlete, he writes for CrossFit HQ, and he is an instructor for Stronger Experts (@strongerexperts), an online platform where 20 of the world's best S&C experts put out weekly content. In this episode we discuss: Zach's mission and philosophy What drives him to push the profession of physical therapy forward Zach's work in the continuing education worlds both in PT and S&C The importance of coaching in the clinical setting Blood flow restriction therapy (BFR) and more... Helpful Links: Zach's Website TheBarbellPhysio.com Stronger Experts TheBarbellPhysio.com/stronger Where to find us: betterfasterpodcast.com (@betterfasterpodcast) carolinaperformancetraining.com (@cpt_strength) vertexpt.com (@vertexpt) Josh Jeffery (@joshjeffery5) Brandon Vaughn (@bvthept)Support the show (http://paypal.me/betterfasterpod)

Episode 4

[Re-published because it wasn't showing on some platforms] Join Jared & Tyler as they finish reminiscing on their first year of podcasting (with clips from previous episodes). Part 2 features Aaron Perez, Zach Long, Ryan Michael Smith, Cruz Romero, Will Boyd, Jarod Carter, Quinn Henoch, Scotty Butcher, Danny Matta, Mark Powers, Jarod Hall, Jenna Kantor, Katie Schmitt, Fairy Tale Physical Therapy, Monique J Caruth, Alex Engar, Joses Ngugi, Casey Coleman, & Brianne Showman Brown. Thanks for riding with us on this journey. Let's make some shit happen in 2018. --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/duck-legs/message Support this podcast: https://anchor.fm/duck-legs/support

Mitch Babcock and Zach Long come on the show for an episode focusing on teaching and training the fitness athlete. They provide their insight on how to best teach/train fitness athletes, pros and cons of treating fitness athletes, how students and clinicians can become better at treating this group of people along with their favorite resources, how they teach management of the fitness athlete and much more! Mitch Bio: Dr Mitch Babcock is a Physical Therapist and CrossFit Level I Trainer with a primary purpose of helping others pursue a greater state of health through fitness. After receiving his bachelor's degree in exercise science, Mitch went on to receive his Doctorate in physical therapy at the University of Michigan-Flint and graduated in 2016 to better understand the human movement system and help others recover from the injuries & limitations hindering their performance. With personal training experience in CrossFit, as a NPC physique competitor & in endurance events, Mitch continues to test his physical potential daily in order to better help people reach theirs. He teaches the online class: Fitness Athlete: Essential Foundations & The Fitness Athlete: Live Seminar with Ryan Smith through the Institute of Clinical Excellence. CrossFit Level 1 Trainer Certified MobilityWOD Movement & Mobility Specialist Certified Functional Movement Screen Certified Selective Functional Movement Assessment  Certified RockTape Level 2 FMT   He is also the owner of FitnessTX: Aiding Elite Fitness which is in the town of Holly, Michigan which is about 20 miles south of Flint, Michigan. He offers rehabilitation, recovery, and post rehabilitation strength progression through a tailored program to help people get back to the PR numbers that they're accustomed to/ and eventually a new PR. FitnessTX's Website: https://fitnesstx.physio/  Mitch's Twitter Page: https://twitter.com/Babcock_DPT  Mitch's Facebook Page: https://www.facebook.com/mitch.babcock  Mitch's Instagram: https://www.instagram.com/dr.mitch.dpt/  Mitch's Interview on The Healthcare Disruption Podcast: https://itunes.apple.com/us/podcast/healthcare-disruption-15-launch-greatness-w-dr-mitch/id1139397173?i=1000380186058&mt=2  Mitch's Interview on The Knowbodies Podcast: https://itunes.apple.com/us/podcast/move-by-example-with-mitch-babcock-and-ryan-smith/id1142438407?i=1000394276924&mt=2  Mitch's Interview on The Duck Legs Podcast: https://itunes.apple.com/us/podcast/002-dr-mitch-babcock-pt-dpt-cf-1/id1176312012?i=1000379113578&mt=2  Mitch's Interview on The PT Entrepreneur Podcast: https://itunes.apple.com/us/podcast/e35-mitch-babcock/id1265979257?i=1000395072633&mt=2  Mitch's Interview on the Healthcare Reboot Podcast: https://itunes.apple.com/us/podcast/healthcare-reboot-mitch-babcock/id1217439525?i=1000388134512&mt=2  PTonICE Podcast: https://itunes.apple.com/us/podcast/ptonice/id1088698598?mt=2  Fitness Athlete: Essential Foundations online course taught by Mitch and Ryan Smith: http://ptonice.com/fitness-athlete  Fitness Athlete: Live Seminar course taught by Mitch and Ryan Smith: http://ptonice.com/fitness-athlete-live-seminar    Zach Bio: Dr. Zach Long is a physical therapist and CrossFit coach located in Charlotte, NC. He attended the University of North Carolina at Chapel Hill, where he majored in exercise and sport science, and East Carolina University, where he earned his doctorate in physical therapy in 2013. He specializes in improving athletic performance and injury rehab of athletes from Olympians to weekend warriors. He is also a Sports Certified Specialist, certified in Dry needling, a performance enhancement specialist, and a Y-Balance test administrator. Additionally, He has published 8 publications.  He is the creator of  TheBarbellPhysio.com which is a website which provides great content . He also teaches the Online Course: Advanced Concepts in the Clinical Management of the Fitness Athlete  through The Institute of Clinical Excellence.    The Barbell Physio Website: https://thebarbellphysio.com/  Zach's Twitter Page: https://twitter.com/zlongdpt  Zach's Facebook Page: https://www.facebook.com/lczachar  Zach's Instagram Page: https://www.instagram.com/thebarbellphysio/  Fitness Athlete:  Advanced Concepts online course taught by Zach                       http://ptonice.com/fitness-athlete-level-two  Zach's Interview on the Doc and Jock Podcast: https://itunes.apple.com/us/podcast/e188-zach-long-talks-mobility-for-weightlifting/id982004635?i=1000386167402&mt=2  Zach's Interview on the Rdella Podcast: https://itunes.apple.com/us/podcast/dr-zach-long-strength-performance-meets-physical-therapy/id399483129?i=1000368035356&mt=2  Zach's Interview on Strength Chat: https://itunes.apple.com/us/podcast/strength-chat-39-dr-zach-long-barbell-physio/id1157215043?i=1000392166232&mt=2  Zach's Interview on The Movement Fix Podcast: https://itunes.apple.com/us/podcast/15-why-you-should-roll-out-for-max-5-minutes-getting/id915914866?i=1000371620439&mt=2  Zach's Interview on Therapy Insider's Podcast: https://itunes.apple.com/us/podcast/do-you-even-lift-physio-bro-w-dr-zach-long/id609009250?i=1000377083064&mt=2  Zach's Interview on The Duck Leg's Podcast: https://itunes.apple.com/us/podcast/014-becoming-the-barbell-physio-with-dr-zach-long/id1176312012?i=1000384753135&mt=2 

This week's Strength Chat guest is Dr. Zach Long, well known as the "Barbell Physio".    Dr. Zach Long is a physical therapist and CrossFit coach located in Charlotte, NC. He attended the University of North Carolina at Chapel Hill, where he majored in exercise and sport science, and East Carolina University, where he earned his doctorate in physical therapy. He specializes in improving athletic performance and injury rehab of athletes from Olympians to weekend warriors.

On Episode 188 of the Doc and Jock Podcast Coach Joe catches up with Zach Long (The Barbell Physio) to talk about his new Mobility & Technique for Olympic Weightlifting program that he created with Olympic Weightlifter Jared Fleming. If you aren't familiar with Zach he's one of the best Physical Therapist in the United States. At his practice in North Carolina he works with everyone from Carolina Panther's to kids soccer teams. Post Comments about this episode, potential topics, suggestions for interviews and questions to the Doc and Jock Website, facebook page, and twitter account. Also be sure to reach out to Dr. Danny and Coach Joe at their personal social media accounts listed below in the show sponsor section. Webpage http://docandjock.com/ Facebook https://www.facebook.com/pages/Doc-and-Jock/413659638795840?fref=ts Twitter @docandjock Instagram @DOCandJOCKpodcast Also, please check out these links to the articles and content creators mentioned during our conversation. Zach’s Web Site: http://thebarbellphhysio.com Instagram: @thebarbellphysio Twitter: @zlongdpt Facebook: https://www.facebook.com/thebarbellphysio/?fref=ts YouTube: https://www.youtube.com/channel/UCDkrIRlPUAe4aRSMJk4epPA More on the Show Sponsors Mobility WOD – The ultimate guide to resolving pain, preventing injury, and optimizing athletic performance. www.mobilitywod.com Doc and Jock would like to thank official Show Sponsor Mobility WOD for their support. Please gang head over to www.mobilitywod.com for all you mobility needs where you will find the latest MWOD products, episodes, upcoming seminars, daily MWODS, help finding a provider and the subscription services Mobility WOD Pro. Mobility WOD PRO is a perfect resource for any coach looking to up their positional knowledge base and infect their community with true suppleness! Facebook – https://www.facebook.com/Mobility-Wod-155425314471727/?fref=ts Twitter and Instagram – @mobilitywod Performa Sleep – Better Performance through Better Sleep. www.performasleep.com Performa Sleep has developed what they believe to be the perfect mattress for athletes. Their athlete – specific sleep technology is a three layer mattress designed to ease muscle tension, boost recovery, and sooth hard working bodies. Head over to their webpage to read learn more about their CopperCool technology and to read testimonials from our very own Dr. Danny, and CrossFit Games Athletes Scott Panchik (@ScottPanchik), Emily Bridgers (EmilyBridgers), and Lauren Fisher (LaurenFisher). Exclusive to the Doc and Jock audience, Performa Sleep is providing a discount code to receive $75.00 of the purchase of any size mattress. Simply head over to www.performasleep and enter the code JOCK75 at check out. Along with $75.00 off Performa Sleep already offers a 90 day money back guarantee and free shipping. Facebook – https://www.facebook.com/PerformaSleep/?fref=nf Twitter and Instagram – @PerformaSleep Athletes’ Potential – Where Movement is Medicine! http://www.athletespotential.com/ Dr. Danny offers an assortment of services. If you are in the Atlanta area be sure to look him up. If you are not in Atlanta please be sure to shoot him an email or follow him on the social sites listed below. facebook page https://www.facebook.com/athletespotential?fref=ts Youtube https://www.youtube.com/channel/UCzbIpnafDLDvqCztuFkdsdQ Twitter @AthPotential Instagram @dannyMattaPT Joe’s Barbell – where lifting at JOE’S is just a click away. http://joesbarbell.com/ Coach Joe offers a variety of live and online training options including a private facebook group titled #HeelsOff where you can get his honest and FREE opinion on your movement and unfiltered take on Weightlifing. Join the conversation at any of the links below. Webpage Facebook https://www.facebook.com/groups/905586666194729/ #HeelsOff facebook forum https://www.facebook.com/joesbarbell?fref=ts YouTube https://www.youtube.com/user/BarbellsandBabies Twitter @JoeShu2326 Instagram @JoesBarbell Thanks for listening and remember, If you have a BODY you’re an ATHLETE

We sit down with Zach Long to talk about the insane results that come from blood flow restriction training for rehabilitation and for other purposes.

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It is always fun learning about new techniques and Zach certainly did that when teaching me about blood flow restriction for healing, strength and hypertrophy training. He is very knowledgeable and great at making complex topics simple for people to … Continued The post Thunder Shirts, Craft Beer and Blood Flow Restriction with Dr. Zach Long appeared first on Bare Naked Health Podcast.

How long does patellar tedinopathy take to heal?  Dr. Zach Long of  The Barbell Physio shares a story of when a patient's expectations of time to heal and the actual time collide. Check out Zach's products on EDGE Moblity System!   Please subscribe and rate us on iTunes! Subscribe on Google Play Music Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.

How long does patellar tedinopathy take to heal?  Dr. Zach Long of   shares a story of when a patient’s expectations of time to heal and the actual time collide. Check out Zach’s products on   Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at  .  Be sure to also connect with Dr. Erson Religioso at  and Jason Shane at 

E107 of the Doc and Jock Podcast features Zach Long (The Barbell Physio). During this Friday short Doc Danny and Zach spend get deep like a Navy SEAL on the application of occlusion training (i.e. Blood Flow Restriction). If you are into lifting more while recovering faster without being a roided out douche than you gotta check this one out.

We sit down with the Barbell Physio, Zach Long, to talk about mobility, rehab from injury, some new methods of therapy, and more!

(#172) Dr. Zach Long, Founder of The Barbell Physio, is this week’s guest on the podcast. He joins the show to talk about strength and performance as it relates to his approach as a physical therapist. Zach is a Doctor of physical therapy, strength and...

In Episode 74 of The Doc & Jock Podcast Doc Danny and Coach Joe sit down with physio coach Zach Long to talk about training, recovery, coaching and PT life.

In Episode 74 of The Doc & Jock Podcast Doc Danny and Coach Joe sit down with physio coach Zach Long to talk about training, recovery, coaching and PT life.

Are physical therapist's good at prescribing and breaking down lifting heavy weights? How about exercise overall? Those are a few questions we ask our guest Dr. Zach Long aka The Barbell Physio, on this episode of Therapy Insiders podcast.

Zach Long, DPT, aka The Barbell Physio, discusses how to warm up properly and why you shouldn't roll out for more than 5 minutes