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    Health

    #PTonICE Podcast

    The faculty of the Institute of Clinical Excellence deliver their specialized content every weekday morning. Topic areas include: Population health, fitness athlete management, evidence based spine and extremity care, older adults, community outreach, self development, and much more! Learn more about our team at www.PTonICE.com

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    Latest Episodes:
    Episode 1775 - Pushing strategies during birth Jul 22, 2024
    Show notes

    Dr. Jessica Gingerich // #ICEPevic // www.ptonice.com

    In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jessica Gingerich discusses pushing strategy during labor.

    Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

    If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

    Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

    EPISODE TRANSCRIPTION

    JESSICA GINGERICH Good morning, PT on ICE podcast. My name is Dr. Jessica Gingerich and I am on faculty with the pelvic division. Today's Monday, so you know that we are kicking off our week with some pelvic content. So today I'm going to talk about a question that I got from a client. So I wrote this down because I didn't want to get it messed up. And so She asked me, she said, if my uterus contracts to push my baby out during birth, then why do we as women feel or need to push during that second phase of labor? And I love this question because she has, she's done her research, right? She read that the uterus contracts to help push her baby out. And sometimes there are some nuances to our patients that we want to make sure that we clear and explain, and especially around birth, because we can decrease that fear around birth. Or if she wasn't having fear, at least empower her. So the uterus plays a key role during labor. So it expands during pregnancy to accommodate the growth of the fetus. There's also a thick muscle called the myometrium that expands to hold the baby, but it also contracts during labor, um, in this wave like pattern, starting from the top of the uterus down towards the cervix. And it helps to open or dilate the cervix. And it helps to thin or efface the cervix to allow the baby to move towards the birth canal. The contractions become stronger, more regular and more frequent as labor continues. So that is the role of the uterus. The pelvic floor's role is to be in a relaxed position. I like to think holes open, and I even say that to my clients. So it gives this really nice kind of internal cue. Now, while the uterus has a lot of work to do during labor, the role of pushing just helps descend the baby towards the birth canal. So it's just something that helps. And that's all we can that's what we can explain to our patients if they have this question. Now, this is kind of outside of the scope of this podcast, but I want to mention this is Because we do push during labor, we can imagine that the stronger our cores are, and really from an endurance and aerobic capacity, this can be a huge advantage, right? The stronger we go into labor can be a huge advantage to help with this. And so we want to make sure we're encouraging exercise in specifically core work, and even programming that as accessory work for our clients. So let's get into pushing. And there's two specific ways to push, and I'm going to talk about those today. This happens during the second phase of labor. I want to also mention that when we talk about pushing, we've got an open glottis and a closed glottis. The closed glottis is very similar to what athletes do when they are lifting weights. And so we really want them to practice how to push, especially those athletes that when they hold their breath, down below there are holes closed. And so as we talk about these strategies, I want you to be thinking about your clients who would really, really benefit from this. So the first one we're going to talk about is the closed glottis push. This, you think about your canister, so you've got your diaphragm at the top, your abs at the bottom, or excuse me, in the front, you've got your pelvic floor at the bottom and your back muscles in the back. You've got holes in the top and you've got holes in the bottom. And so as we create that intra-abdominal pressure by either tensing our core and holding our breath or tensing our core and exhaling, these are different strategies that create a different amount of force with each. So the first one is closed glottis or closed glottis pushing. This is going to be where we close our mouth, we close our nose and we bear down or strain putting the base or putting the pelvic floor in the basement or in that descended position. This creates a lot of force. This is going to be very helpful if mom is right at the end of that finish line and she can feel maybe she reaches down and she can feel the baby's head. or she, um, someone's telling her that her baby's crowning. She can close her mouth, close her nose and push. The second one is going to be an open glottis push. And so you can imagine we are creating a force through our abdominal muscles as air is coming out of our mouth and our noses. This is typically going to be really noisy and really loud. Maybe mom's screaming, maybe she's, making some really loud mooing faces, maybe noises, or maybe she's cussing because it hurts and that's okay. So this is gonna be a little less powerful, but it can be a really wonderful technique to help control their heart rate and help mom hold on longer, especially if she's got that marathon birth going on. Both of these pushing strategies can be influenced whether mom has an epidural or not. There's going to be less likely them to feel what they're doing. And so they're going to need coached pushing. That's going to be a nurse telling mom when to push. This is important to talk about because they need to practice. Practicing these birthing these pushing strategies for birth prior to birth can help mom come back to that and remember, Oh, this is what I did. This is what I did to prepare for this. I had a client tell me that she was in her second phase of labor. So she was pushing, she was so confused because she could not figure it out. She also had had an epidural. And then she remembered, she was like, wait, I remember that we practiced this, that you, you had me every day practicing how to do this. And so she went back to what she had been doing and she ended up being really, really proud and really, um, happy with how her birth went. But it took her a minute to like, remember, Oh wait, I did this. I knew going into my birth, how to do this. So she came out of that. She was really empowered, felt really good. So that is what I've got for you today. Um, we have our last cohorts coming up. So if you head over to ptonice.com, our last L one is kicking off on September 9th and our last L two of this year is going to be kicking off on September 15th. So head over there, snag your spots. Um, we'd love to have you have a great Monday.

    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.


    Episode 1774 - Front or rear mount trainer: which one is right for me? Jul 19, 2024
    Show notes

    Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the differences between front and rear mount bike trainers, which is preferred for different bike types, as well as budget options. 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 MATT KOESTERWhat's up everybody? Good morning and welcome to another episode of the PT on ICE Daily Show. Today I'm going to be your host. I'm Dr. Matthew Koester. I'm one of the lead faculty in the endurance athlete division with a specialty in bike fitting. I am super stoked to hop on here today and talk about probably the most popular question that we get in every live course and one of the most important things when you're getting into fitting for the first time as far as equipment goes. But before we dive into those topics, I want to talk about the opportunities that y'all are going to have to come and find us on the road. with number one being in Denver next weekend. We've only got four seats available for that course, so if you're interested in popping in, it's gonna be in South Denver in the Denver Tech Center area. We are really, really stoked to be heading out there soon, but if that's not gonna work out for you, we have another option, which is gonna be in Bellingham, Washington again, because the last time we were out there, it was completely sold out, the wait list was filling up, and we decided we'd run it back and set up a second course in Bellingham, Washington later this fall. There's gonna be another opportunity as well to see Jason London, who's the original content creator for this course, which is an absolute opportunity in Park City. That's a really cool location. We're gonna be out there in October as well for that course. So if you're looking to get a jump on some of this education and use this stuff in the clinic, the live course is the best way to get through it. So by all means, come find us on the road and check out one of those course options. Now, I said I was gonna talk about probably the biggest question in the course. The biggest one is really the thing that gets you into this. And it's what type of trainer do I need? We have two options in most cases. So to my left and behind me here, we have a front mount trainer, which offers a whole lot of options as far as what bikes can go on. And then we have the tried and true rear mount trainer. And what I want to do today is talk about probably like the biggest pros and cons of each. I want to talk about which one is probably the most appropriate for you and your clinic, depending on what type of bikes you're typically seeing. And then the ones that kind of have, I'd say, more budgetary constraints and or are just limited in availability sometimes. So, to start off first, I want to talk about the rear mount trainer because that is the one that is tried and true. That is going to be, in most cases for us, this green guy here. This is the Curt Kinetic trainer. Now, if I slide that thing forward, You'll see we've got the rear roller, which is basically what compresses the tire and allows you to kind of go through resistance while you're pedaling. You've got this rear cup that basically compresses the back axle of the bike and allows you to keep the bike nice and steady. And then we typically put something underneath the front wheel. Sometimes it's a custom wheel block. Sometimes it's an adjustable wheel block that allows you to lift that thing up and down and change the positions. But with this trainer, one of the things that people really, really love about it is that it's been around forever. They're used to it. When somebody comes into your clinic for a bike fit and they see something like this, they're like, ah, I know what this is. This makes perfect sense to me. I even brought my training skewer, which is typically the axle that they have to replace in the back of the bike if they're going to get on this bike. Because these metal cups here that compress the rear axle when they're tightened up are gonna basically act to lock the bike in place only on the contact points they get to touch. So if those contact points are plastic, which is pretty common as a way to save weight, save money on a bike, you have to replace that either with a training skewer, which just has metal cups on the sides, or in many cases nowadays with how bikes have gotten, these new through axle skewers. So the through axle skewer is typically a lot thicker, it's a lot more robust. It's common on bikes that allows them to put disc brakes on the bikes, which is really more and more ubiquitous these days. So having these options for different through axle skewers allows you to put metal on metal and compress it in the rear end of the trainer. Now depending on what types of bikes or what brands of bikes you're seeing more in the clinic, the skewers that you're going to need are going to change. So they all have various thread types that go on them. Some are very fine, some are medium, some are coarse. Now the Other kicker to this is that even though you might have the thread type dialed in, the distance, so the width of the actual screw itself might change. Last time I checked on the Kirk Kinetic website, which is the name brand for these guys, they had somewhere between, I think, five different options. I think it was like five different ones, three that were the different thread types, and then two more that were XLs for different distances. And each one was running about 50 bucks. So there's a bit of a financial investment to have all the options so that folks can come to see you and have all the options available to them. If you don't have one of these available to you and their bike doesn't have that, you're going to be kind of stuck in a place where you don't have an option with this style of rear mount trainer to throw them on and do the fit appropriately. That could be a bummer. got to have all the pieces. I'll say there's one other option out there, or not one, but two other like styles of these that are completely adjustable. CycleOps makes one, and I'm forgetting the other brand right now, but they basically have plugs and things that you can change in and out to put on. In my experience, they can be a little challenging to work with. They don't always match up exactly the way that I want them to distance wise. I like the tried and true nature of these ones from Kure Kinetic, but if you're in a bind, and you can only afford to grab like one adjustable through axle, I think you can figure it out. You just have to spend more time with it and go through the trials and tribulations of working through it. So, to recap real quick. This guy, tried and true, everybody knows it, everybody's used to it. It's a trainer they spend their entire winter on. The adjustability in terms of having different through axles is definitely a key. You gotta have them, especially nowadays as bikes have gotten more and more modern, going to disc brakes. These through axles are just like almost a non-negotiable So you gotta have all the different types so you can match the different brands and the different bikes that they come in. So, tried and true. Now, we step into one thing that Jason and I have been seeing over probably the last few years that's really become more popular is this front mount trainer. It really started to make its way in probably like a couple years ago in staging areas or like warm up areas for cross country cycling and downhill cycling. Specifically in downhill cycling, you'll see these guys everywhere when it comes to just getting through warmups. What this guy has to offer is two pieces that basically slide together. These two pieces include the front end triangle here, which allows me to remove and add the front fork of the bike. So we take the front wheel off, slide the forks over top of this guy, and snug it up nice and tight. The next piece from there is the rear rollers, where we have to get the tires centered in the rollers so they can smoothly pass back and forth as it's rolling. Cool part about this, they only have one adjustable piece as far as the actual front axle goes. So, and they send it with them. So when you buy this piece, you have everything that you need in order to do the fit. You can put any bike on here, because the front mount options will work for a standard fork, so they'll work for through axles. You can often put their own through axle back into the same bike. When you're talking about the distances here, there's a little track here that allows you to work with different size bikes so that when you overcome that issue, you can even separate them or buy the extenders. It just has to get, you have to make sure they're nice and perfectly aligned. Otherwise the back wheel might want to roll off one side or the other as you get started. So the rear trainer here offers a whole lot of options for being able to just throw a bike on quick. Now, the challenge that comes with that, as you start to get into like, oh, this thing works for everything, is that it kind of has that jack of all trades where it's not quite really any good at one thing. The challenge behind this thing is that it's not near as stable. It kind of sacrifices the stability and the tried and true nature of the rear mount for something that can be a little bit tippy if your patient or client gets on it and you're not paying attention. If they just throw a leg over it, it can kind of pull the weight with it, I'll say I've never had anybody fall off one. I've never had an actual incident, but I can definitely tell you that when I am with a client in the clinic and we're setting up to do a bike fit, I talk to them about getting on and off the bike carefully. I talk to them about how, like, when they're going to transition on, I'm going to grab ahold of the bars just to create that element of stability. But then even once they're up and on, an experienced rider, so I would say a good example of this would be a triathlon athlete. So somebody who's in the Madison area for me, who's doing Ironman Wisconsin and is coming in for a fit, If I throw them on this guy, it will work, and it will be fast to throw it on, but it lacks some of the stability and control that they're used to having when they're on the rear mount trainer that they spend all their time on. So they might hop on this, and they might notice that they just don't feel as confident. They don't feel as great. So they're more thinking about the experience of being on the trainer than they actually are thinking about the fit as they're going through it, which can be a negative. Okay. So there's the negatives to it, and there's the positives to it. From a financial standpoint here, if you were in a clinic where you were going to have to buy things new, and I'm going to kind of make that a subject for a moment, you can't just go on Facebook Marketplace and buy new stuff and throw it in at your organization. This guy's going to run you somewhere between $400 to $500, but it's kind of that jack of all trades. You can put anything on it. There's no bike you need. There's no custom pieces that you have to go through. You can just get any bike on here. The rear mount trainer, gonna be a similar ballpark. In many cases, it'd be like 250 to 450, depending on how nice you go, you can certainly spend more. It's gonna be limited in some ways because you're gonna have to have all of the different through axles to accommodate any different bike that walks in the clinic, but you're gonna have that stability and just steadiness that people really rely on and like when they're riding a trainer at home. So it's familiar, so that's kind of a nice option. If we take a step away from the idea of having to buy new, and you're like, okay, I'm going to budget my way through this in my clinic. And I know that if I buy something used, I can just make sure that it's good quality and it's broken. We started to get changed the tone here a little bit. These are harder to find use, but they are definitely. Hmm. They're harder to find used, you can get a hold of them, but they definitely have deals all the time on new ones. So you can find the ballpark, if you go on Amazon or various websites, you can get anywhere between that $400 to $500 mark. And this is where I would spend the bulk of the money, because you're going to have almost no scenarios in which you can't get the person's bike on the trainer. That is going to get you through more fits, even if it's a little bit less ideal of a setup. On the flip side, if I've invested in this one right here and I've got the money spent, I'm probably going to start looking at Facebook Marketplace because these guys are a dime a dozen. There were so many folks during COVID that were buying up bike trainers and they were going to spend more time on them at home. We saw the same thing with Pelotons and indoor bikes. These things are on Facebook Marketplace, Craigslist if you still go down that rabbit hole. They're everywhere for sometimes like under 100 bucks, maybe 50 bucks sometimes. And then from there, most of your investment on this guy goes towards the actual, through actual skewers that allow you to get all the bikes on. So your investments kind of change a little bit as you go through this. This guy's going to be the most money up front. This guy's definitely going to be cheaper as you go through it. But you got to get more components, more pieces. If I only had one in the clinic, which is kind of the question that people boil it down to, if I only had one, it would be the front mount trainer. and that comes with one more layer to it. I love the ability for a private practice or a clinic to be able to get out in the community and showcase the things that we do on a high level. If I want to go out to our local high schools here and go talk with them about mountain bike fits and making sure they get the best performance, injury rate reduction, all of those things, I can pop out to the local high school on one of their opening practices, which is actually coming up in a few weeks. I can throw up the front mount trainer, and in a very short time, take out their front wheel, put that thing right over top of this guy, pull the back up, and go right through things like seat height, have a quick look at their reach. I can make adjustments to small things on the bike very fast and make quick transitions to the next bike and not have to fiddle around with various components and other changes. So the, not only in the clinic does this kind of become the absolute jack of all trades, getting it on, It also makes some of those like community events that much more approachable and that much easier to go through. So I am always going to lean on this guy, but I will tell you it's nice having both for that occasion when somebody comes in and I…

    Full show notes at the publisher

    Episode 1773- Low irritability = function first Jul 18, 2024
    Show notes

    Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com

    In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses reimaging the objective examination for patients presenting with low irritability, especially only in specific positions or under specific loads.

    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

    JORDAN BERRYWhat is up? PT on ICE Daily Show. This is Dr. Jordan Berry, Lead Faculty for Cervical Spine and Lumbar Spine Management. Today we're chatting about a topic called Low Irritability Equals Function First. Okay, so I hope you're having an awesome Thursday. We're about to break down just a concept that I think matters when you're thinking about the novice versus the expert clinician and how they're efficient during their initial evaluation. This key concept of when you're thinking about going into the objective exam and you know the irritability is low or at least moderately low, we're always gonna test the functional movements first. Okay, so a few concepts that we talk about during our live cervical and lumbar spine management courses, when we're thinking about the objective exam and what the expert clinician does different as opposed to the novice, one of those things is that they have a very long, detailed, subjective exam, and they have a short, clear, and crisp objective exam. and how as you gain more experience and more pattern recognition, typically that will sway even more lopsided towards being a longer subjective while having a shorter and more dialed objective exam. And then another concept we talk about is that when the patient irritability is low, you have to be really aggressive during the physical exam testing in order to recreate the symptoms, right? Because if you under test, then you might not actually recreate those familiar symptoms to know that the treatment that you're about to apply is going to work and that you're moving in the right direction. And so, one way that you can accomplish both of those things, right, with keeping a short, clear and crisp objective exam, and then making sure that you're going to be aggressive during the physical exam testing when the irritability is low, is always thinking about testing the functional movements first. Okay, so let me give you a clinical example with this, and then we'll break it down and talk about why it matters and why it's important. So, Imagine that you're in an initial evaluation and you've done your body chart and you know that the symptoms are somewhere around the area of the lumbar spine, like we'll say low lumbar into the right glute wrapping around towards the right hip, maybe even like anterior lateral right hip as well. But you know there's some vague diffuse symptoms that are somewhere in the lumbar spine and somewhere in the hip as well. And during this objective, you also gather that an aggravating factor is squatting anything over 95 pounds. And so day one, during the initial eval, you know you're gonna be trying to differentially diagnose if the symptoms are coming from the lumbar spine, or if they're coming from the hip, or maybe both. But primarily, again, the initial evaluation, day one, during the objective exam, we're trying to tease out What is the primary symptom generator? We have to nail that down day one. What a novice would do is as they're going into the objective exam, they would likely just hammer through a battery of tests for the lumbar spine and the hip. So they'd probably have that person hop up and you're going through all the basic stuff, right? You're going through active range of motion, your joint exam, your segmental exam, potentially neurodynamics, your test and hit PROM and strength testing and palpation. You're essentially just working down this battery of tests to try to see if anything recreates the familiar symptoms. And so let's say that you go through that 12, 15 minutes of objective exam testing and you figure out that hip passive range of motion, like internal rotation or fader recreates that familiar hip pain. And so now we have an asterisk sign, right? We've got our, um, let's, let's call it internal rotation is what we're going to retest and we've recreated the familiar symptoms. So you've done a good job, right? You haven't done anything wrong, but I would argue that that is not expert level because number one, it took us a fairly long time to get to that answer of what is recreating the symptoms. And honestly, the patient doesn't really care about any of the stuff that you just tested. So, an expert here is going to look at function first. So, we might do some of the same objective testing that we did just a minute ago with the novice, but the first thing that we're going to do if the irritability is low to moderate is look at function. So, if the subjective exam we found out that anything over a 95-pound squat recreates the familiar symptoms, well, I'm going to look at a 95-pound squat. So I get that person out in the gym, maybe we do a warm-up set, and then we load up to 95, and right when they drop down, right when the patient drops down into the bottom of the squat, they get that familiar hip pain. Now, right then, you have one of your asterisk signs, but we could also modify that movement or try to tease out in real time if we can change the symptoms or affect them in any way. So let's say that person drops down into the squat, bottom of the squat, they get their symptoms, and you grab a big mobility band. wrap it around the hip, and give a big lateral distraction, a lateral pull, while they go down into a second rep of the squat, and the symptoms are completely gone. So think about what you've now done. Number one, you have a better asterisk sign, I would argue, because it's something that the patient actually cares about. It's functional, it's very easy to retest, but you've also clued yourself in on your differential diagnosis. Because if I can do something to the hip, right, do a self-mob to the hip or do a lateral distraction for the hip and immediately change the symptoms that we got with squatting, then I know when I go back to the table and I do my more traditional objective exam testing, I'm going straight to the hip. So maybe on day one now, I can leave all of the lumbar spine testing and maybe hold it off until day two. because now I know that I can affect the hip. Now we go back to the table. We do some of the objective testing and I go right towards PROM and I jam that hip up into IR and fader and recreate those familiar symptoms. Boom. Now we've got our two objective asterisk signs. We've got one passive range of motion. We've got one that's functional, the squat. So now when I apply it to some sort of treatment, I've got two ways that I can retest. SUMMARY So number one, why this matters so much of testing function first when irritability is low is differential diagnosis. It's just a fast way to identify oftentimes where the symptoms are coming from or at least cluing you in as to what direction you need to go in instead of just testing all the lumbar spine stuff and all the hip stuff. Now I've clued myself in that I'm probably going to focus on hip day one. So the second thing why it's important is efficiency. We always say during objective exam testing, as little as possible, as much as necessary. So I only want to test the stuff that's absolutely necessary so I'm efficient, but also I don't risk flaring up the patient with doing a bunch of tests and measures that aren't necessary to begin with. And if I can eliminate a few things right off the bat from that functional testing, why not start there? And then lastly, it's way better buy-in. It's way better buy-in. So day one, you're always trying to have the patient walk out thinking, man, I'm finally in the right spot. This person totally gets my issue. And they're definitely going to be walking out saying that if you're first off testing the functional stuff, the stuff that they actually care about that you pick up in the subjective. No patient cares about hip IR, cares about lumbar AROM, cares about palpation. They don't care about that. They care about the thing that they want to get back to that they love. And if you're including that in the physical exam, the buy-in is going to skyrocket. So think about that over the next week or so. About maybe changing the order of your physical exam if this is not typically how you order things. When the irritability is low to moderate and you pick that up during the subjective exam, then when you go into the objective exam, you make sure that you're testing function first. It's gonna help with differential diagnosis, it's gonna help you be efficient, and you're gonna get way better buy-in. All right, so think about that this week. Next week in the clinic, I'd love to hear feedback on that as well. Just to leave you with a few upcoming courses that we have with cervical and lumbar, this coming weekend, we've got cervical management in Oviedo, Florida, few seats left for that. And then also this weekend, we've got lumbar spine management in San Luis Obispo in California. And then coming up August 3rd and 4th, we've got cervical in Cincinnati, Ohio. And then also August 3 through 4, we've got lumbar spine management in Aspinwall, Pennsylvania. All right. Thanks so much for listening. Have an awesome Thursday in the clinic. And if you're going to be a cervical or lumbar spine management course coming up soon, hopefully I will see you there. All right. Have a great day. Thank you.

    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.


    Episode 1772 - Heavy vs. light loads in geriatrics Jul 17, 2024
    Show notes

    Dr. Dustin Jones // #GeriOnICE // www.ptonice.com

    In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones as he compares & contrasts the different roles of heavy & light lifting in the scope of geriatric rehabilitation.

    Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

    If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

    EPISODE TRANSCRIPTION

    DUSTIN JONESWelcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dr. Dustin Jones with the Older Adult Division and today we're going to be talking about heavy versus light loads, particularly in geriatrics. Which one is better? Is there a certain time, place, person that we may want to use heavy versus light? I want to take a dive into the research and some of the themes that we're seeing in the literature and also just from experience in clinical practice and in fitness. of how we want to think about these different types of load because to be very honest we have a big bias here at at ICE I would say and then definitely in the MMOA division where you will hear us talking about the need to push for higher intensities right especially with our professional pandemic of under dosage where we have individuals that are not being challenged and have the ability to change right like this is a big big issue and something that we really need to speak to and it's very easy to mix that message with that higher amounts of load heavy load is the only way to go and that could not be further from the truth all right so let's kind of get into the pros and cons of you know heavy resistance versus lighter resistance and when we may want to use these because it's really important to be very thoughtful in your approach of applying load to individuals I wanna start with talking about some of the advantages of lighter resistance training. That's the one that we typically associate, oh, that's under dosage, or that's too easy, or that's not gonna be that effective, right? That's not necessarily the case. So when we think about light resistance training, lighter loads, you know, maybe 40, 50% of someone's estimated one rep max, if you're doing those types of calculations, Those loads are really, really great for introducing movement. I think we can all agree that if we have individuals that haven't exercised before, that are relatively new to a movement, have a lot of fear on board, maybe a lot of irritability, that a lighter load is going to be easier to get the party started, if you will, with those individuals. And for some, it may be first set where you're doing a lighter load, check the box, things are looking good, and then we're going to progress to a heavier load. But in some settings, and I'll speak for home health at least, that's where most of my experience is, is that takes weeks and sometimes even months with individuals where we are doing somewhat of a lighter load before we really have a green light to really progress to a relatively heavy load with certain individuals. So introducing movement, I think light resistance training is a great place, a great tool and time to use that. I also mentioned irritability. When we have folks that are highly irritable, A heavy load is not necessarily a great situation, right, for those individuals. They'll often increase irritability and the behavior of those symptoms. They want to be respectful of that irritability and often lighter loads can allow us to introduce movement and helpful movement and activities without causing a big increase in their symptoms or a change in the behavior of their symptoms. So introducing movement, high irritability, those are great places. Another great place to introduce or use lighter resistance training is when we're really focused on movement velocity, of really creating speed with a particular movement, which in geriatrics, oftentimes, it's very helpful when we're working on reaction timing, for example, or performing movements that require a lot of speed, like stepping strategies to regain balance, for example. the lighter loads are gonna allow them to move quicker than if they were bogged down with the super heavy loads. We can use that in our training. Light resistance training also improves strength and hypertrophy as well. There is a lot of kind of mixed literature of showing that, man, heavy resistance training is kind of the gold standard, right? If we're wanting to get people really strong, if we're wanting to improve muscle mass as well, like we gotta lift heavy loads. but particularly in older adults and deconditioned older adults that they can see improvements and significant improvements in strength and hypertrophy with relatively lighter loads, 40, 50, 60% of their 1RM. Now, oftentimes you have to adjust the other variables of dosage, right? Typically higher volume, but we can see an improvement in strength and hypertrophy in older adults, particularly deconditioned older adults with light resistance training. And that's really good news. I think it's really helpful, especially if you're in a more acute setting, you're in home health, acute care, SNF, Those types of settings, the lighter resistance is typically more accessible to these individuals and we can still get benefits from it. So I hope you can see some of the value of lighter resistance training. There are certain times and places and people where we are going to want to use light resistance training over heavy resistance training. Now let's talk about heavy resistance training. What's some of the evidence showing and theme showing of where that really stacks up? What are the benefits? The obvious one is strength and hypertrophy. Most of the literature It's going to be looking at improving strength, improving hypertrophy is with heavier loads, you know, usually that 80-85% of someone's one rep max, you're going to see really good results with a lot of the individuals if you can be able to apply that. One thing that is not often discussed and why you'll often see the MOA faculty use, give a little bit more preference to heavy resistance training is the stimulus it will give to bone mineral density. that heavier loads are going to be a greater stimulus to improve bone mineral density than lighter loads. Most of the research that's showing pretty significant changes or a reduction in decline in bone mineral density are usually doing resistance type activities in higher percentages of someone's one rep max in the 80s, 85% for example. So bone mineral density is a huge one and that's why we'll often use it somewhat preferentially with folks when we can apply it. Another big one, and this is purely anecdotal and from what I've observed working with lots of folks, is the confidence piece. Introducing light resistance training can help build confidence, right? It can get people moving. They can start to do things that they didn't think were possible or what they thought they'd be able to do. initially, but once we get past a certain point, heavy loads are going to be the only tool to really change people's perceptions of themselves. There is nothing like, and this is in my experience so purely anecdotal here, but there is nothing like lifting a relatively heavy barbell off the ground and doing a heavy barbell deadlift with someone that perceived that they are weak, that they're old, that they're fragile, that they're slow, that they can't improve, they can't change. That is such a powerful tool for these people to improve their confidence, but change the perceptions of what they're truly capable of doing. And this has so many ripple effects, right? If I am able to deadlift my body weight, for example, and I'm absolutely shocked and surprised, usually for a lot of members of Stronger Life, a gym for folks over 55 in Lexington, that's where I'm working, it's usually the 100-pound mark. If people can deadlift over 100 pounds, it just blows their mind, and many of us know, like, 100 pounds, that's okay, cool, awesome, but can you do your body weight? Can you do two times your body weight? But for 100 pounds, for some reason, for these individuals, it just, like, kind of, flips the switch, and then they start to think of other activities in a different light. They start to see, well, if I could do that, a hundred pound deadlift, man, going to Lowe's and getting my own bag of mulch is no problem. I don't need help. I can handle that myself. I don't need to go ask Bob across the street to do this for me at my house. I can handle that. Oh, that trip that I wanted to do, I may be strong enough to do that now. I may be able to do X, Y, and Z. Oh, I'm more confident in maybe being able to take care of my grandkids because I know I can pick up 100 pounds off the ground. It has a ripple effect of how they perceive all kinds of different situations. And what I've observed is that behavior often changes, hobbies often change, leisurely activities often change, and overall their life becomes better and more rich and more lively all from an exercise, right? I shouldn't say all, but it's a very profound moment. So heavy resistance training does a great job of achieving that. Another reason heavy resistance training is very, very beneficial, especially in the context of rehabilitation, is it minimizes a detraining effect. So if I'm performing light resistance training over a period of six weeks, eight weeks, for example, I will likely have more of a detraining effect. I will likely lose more of the gains that I've received over that eight week period. I will lose more of that after I'm done, as opposed to if I were lifting heavy weights the whole time. So if you are working with individuals where you're not sure what's going to happen upon discharge, What are they going to do? Are they going to start that exercise class down the road? Are they going to watch that YouTube channel, fitness channel that you recommended? You don't know, right? Are they going to do that home exercise program? It's all up in the air. You're not really sure. We can use heavier loads. to typically get more results, especially related to strength, especially related to functional capacity, related to transfers and independence, we can use heavy resist strain to get more progress over that period of time and they're going to have less of a detraining effect upon discharge and they will maintain their gains for a longer period of time. For me, in the context of home health, this was absolutely crucial, that if I was pretty sure that whenever I discharged Doris, and I was probably gonna see Doris within five, six months, I needed to account for that five to six month period. Doris, I need to get you as fit as possible in this eight week period before we're gonna discharge. So I'm gonna give preference to heavier resistance training as soon as I can apply it with her situation. It'll minimize that detraining effect, all right? So there's lots of different reasons, but I hope you can appreciate the benefits of light resistance training, of when you may want to use it, what situations is it really helpful, but then also for heavy resistance training. There's certain situations where, yeah, we definitely need to avoid light weights and stick with heavier weights. It's very nuanced. There's a right time, there's a right place, there's the right person. We're going to apply these different types of load or amounts of load. We can also appreciate that oftentimes it's overlapped, right? There's going to be times where I'm doing heavy load and lighter load in the same program. They can coexist. And this is why at any ICE course, you're often going to hear us talk about and not or. That we're not here to be dogmatic. We're not here to polarize. We're not here to say, you know, this is absolute garbage. You only need to stick with this particular intervention. That is very rare in our profession of rehabilitation and fitness that oftentimes it's an and not or approach. And that's definitely the case whenever we're talking about the amount of resistance that we're applying to our individuals.SU

    SUMMARY So let me know your thoughts. Any other scenarios, situations I didn't touch on? I didn't even talk about tendon health, soft tissue, related adaptations to resistance training. Drop some of your thoughts and some of your experiences while using light versus heavy resistance training and geriatrics in the comments. YouTube, hop on Instagram, we'll talk there. But we appreciate you all for watching, for listening. I want to mention a few MMOA or Modern Management of the Older Adult courses that are coming up. We have our certification that is for folks that have taken all three courses. Our Level 1, which is going to be starting August 14th, that's eight weeks online. Then our Level 2 that's starting October 17th, that's eight weeks online as well. And then our live course. So all three of those culminate in the ICE certification for older adults. Our live course is coming up too that I want to mention. This weekend, Victor, New York is going to be going down. Jeff Musgrave is going to be leading that one. It's going to be an awesome crew up there in upstate New York. And then the following weekend is our big MMOA Summit. This is where all the MMOA faculty descend. In Denver, Colorado, we do this one time a year where we all come together, have an absolute blast. We do a lot of activities, hikes, we'll have a big cookout pool party with all the students afterwards. So if you're in the Denver area looking for something to do next weekend, we'd love for you to join that course. All right, y'all have a good rest of your Wednesday and I'll talk to you soon.

    OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.


    Episode 1771 - Arthrogenic muscle inhibition: should we ice? Jul 16, 2024
    Show notes

    Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com

    In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses the benefits of icing prior to exercise for patients dealing with arthrogenic inhibition.

    Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

    If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

    EPISODE TRANSCRIPTION

    LINDSEY HUGHEYAll right. Good morning, PT on ICE Daily Show. How's it going? I am Dr. Lindsey Hughey, one of the division leads of our extremity management here at ICE. Welcome to Clinical Tuesday. It is awesome to be with you all here to share a little clinical tip. I'm going to try to keep it short and sweet this Tuesday. about arthrogenic muscle inhibition, and specifically after surgery like ACL or a total knee replacement, not things we get to usually talk about on our weekend extremity management. So really the big question I want to tackle today is should we ice for this? When you come to our class, we talk a lot about peace and love principles, and this came out of the British Journal of Sports Medicine in 2020 by Dubois and Escular. And they really highlighted that when we're managing soft tissue injuries, we actually don't want to ice or use NSAIDs anymore. And so the question comes up weekend after weekend. Well, what about after surgery? Should we be icing still? Well, because of arthrogenic muscle inhibition, it's kind of a completely different animal. And the evidence would tell us actually, yes, we should be icing for this. And so I'm going to discuss a little bit about that research briefly. But let's just briefly talk about before that, what is arthrogenic muscle inhibition? Well, what happens after surgery, what we see is that the normal activation of the sensory receptors within the joint and its surrounding structures, think ligament, tendon, joint capsule, and even muscle, And these are all responsible for detecting change in joint position, tension, compression. They send signals to the central nervous system. But in response to injury or controlled trauma like a surgery, these processes get disturbed and interrupted. So what happens is after a surgery like that, the central nervous system kind of goes into protective mechanism mode. And so a lot of inhibitory signals get sent to really protect. Big picture, if we step back, this inhibits our quadriceps activation. So after an ACL repair or a knee replacement, we see a lot of the quad swollen, it shuts down, and this leads to sequelae of functional deficits, big ones being like knee extension deficit, which means we miss our terminal knee extension, leads to quadricep atrophy. if we don't quickly regain that knee extension and proper activation, we'll tend to see persistent knee pain if this is not rehabbed appropriately and poor function in our stability as well. So what does ice do? Like what, why is icing potentially beneficial here? Because just to review one more time, that arthrogenics, inhibition that is happening, arthrogenic muscle inhibition, what is happening again is that we see that abnormal joint afferent input, which will decrease excitability of the spinal neurons controlling that quadriceps activity. And so that decreases motor unit recruitment and then even our firing rate. And we see this time and time again in our folks with ACL and it becomes persistent and people after total knee replacement. So what is icing doing? Like why is ice potentially helpful? And then I'll share two articles and point you in the direction to read to share how ice has been beneficial. What icing cryotherapy is thought to do is that it may prevent the activation of those inhibitory synapses that are happen in response to that arthrogenic muscle inhibition or AMI. And By disinhibiting, it actually increases the excitability of the anterior horn cells. We're getting a little nerdy this clinical Tuesday. And so what happens then is that there's less supraspinal control over the reflexive activity of like guarding. And so the icing serves as a strategy to just basically overcome and create disinhibition, right? Prevent that inhibition from happening. two articles specifically in the ACL literature that I want to share. And what's really, I want to give a shout out to Jonathan, because it was actually a course participant that asked this question. And, you know, I said, I actually need to do a lip search because I don't know the answer for sure. And he was so awesome. And he like sent me these two articles. So shout out to him for doing so. So what we see out of the British Journal of Sports Medicine in 2019, there was a scoping review by Sonnery Cotlett et al. And this included 20 RCTs that had moderate quality evidence where they looked at the efficacy of cryotherapy in combination, so let's consider not just alone, but in combination with exercises that activate the quad after ACL. And so what they saw is improvement in activation. These folks tended to do better when cryotherapy was a part of their care and those that had that AMI present. In addition, We see another article I want to point you to, and I'll tag these links for you. We see another article specific to ACL, but that timing might even matter. So there was a study done in the Journal of Orthopedic Surgery in 2019 where they actually compared putting ice on folks before they did quad activation, and they had a sham environment where they It was actually kitty litter that they put on the knee, and then they put ice on the knee. And they did this so that the person measuring output and torque was blinded to know whether they had ice or not. And what they found is the folks that actually had ice prior to had better firing in their quad because what happened is it had disinhibition effects, meaning it stopped that inhibition that usually happens and shuts the quad off. So consider, and that really surprised me, that the timing of our ice in combination with exercise or stim might be the thing we also need to consider doing it before we start a bout of exercise care after surgery. SUMMARY So as promised, keeping it short and sweet today, I wanted to give you all an update that we are, in fact, advocating for cryotherapy for our folks after surgery because it helps with long-term, down the road, better quad activation because of its disinhibitory effects. I'll put those links here for you today. I hope everyone has a wonderful Tuesday and that you'll consider cryotherapy still for your folks post-operatively, which is contrary to our peace and love principles. If you want to learn more just in how we manage knee pain, rehab in general, please join us at an extremity management course. What's coming up is July 20th and 21st. Cody will be in Hendersonville, Tennessee. That course is filling up, so join him there. And then I'll be in Bend, Oregon with Hannah, which is sure to be a blast. We're going to go visit Justin Dunway, our Total Spine Thrust faculty that weekend. It's going to be a blast. That is July 27th, 28th. And then we have two opportunities in August across the country, 24th and 25th. I'll be in Bismarck, North Dakota. Never been there, so join me there. And then Cody, again, will be putting on a course, but this time in Greenville, his home base, the same weekend. So opposite spectrums on August 24th and 25th. I hope you'll consider joining us as you end out your summer. Thanks for your time this morning, everyone. Take care.

    OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.


    Episode 1770 - Defining normal in pelvic health Jul 15, 2024
    Show notes

    Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett takes a pragmatic approach discussing variations we see in practice and physiology and acknowledges where we still have work to do. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION CHRISTINA PREVETT Hello everyone and welcome to the PT on ICE daily show. My name is Christina Prevett and I am one of our lead faculty in our pelvic health division and I'm coming to you from a cottage on my 35th birthday because I had a Wonderful husband who surprised me but that does not mean that I'm not gonna get excited talking about all things pelvic health so We had a really interesting conversation come up over the last several weeks, and it's funny because it's come up in a variety of different circles around defining normal. What is normal when it comes from a pelvic health perspective? Because when we are trying to make diagnoses of different conditions, urinary incontinence, pelvic organ prolapse, diastasis recti, we have to know what the realm of normal is so that we know when we deviate from it. And so we had a question come up in our app about, what is the amount of normal voiding, the number of normal voiding episodes that an individual should have during the day? Because some of our literature says 5 to 8, and some of it says 8 to 13. And then if you leak a little bit when you're really tired, does that actually consider you to have a condition? Do you have urinary incontinence? If you have a kind of a spasm in your shoulder, you wouldn't say that your shoulder was injured, but you would say that you have urinary incontinence. And it's such an interesting question, and I kinda wanna dive into it a little bit today. So last week, as many of you know, I'm a postdoctoral research fellow at the University of Alberta. And so what I am looking at in my research, I am an interventional researcher, specifically looking at resistance training and its impact on health. And what my studies are looking at specifically right now is on resistance training in pregnancy and its impact with pelvic floor dysfunction. What I was doing was I was learning from physiology researchers. I was looking at individuals who were looking at pelvic floor assessment and measurement. And up in Ottawa, I was at Linda McLean's lab, they are doing data taking on what is normal force production of the pelvic floor and what are things that we can expect to see as differences in the pelvic floor on ultrasound, on EMG force activation, and on dynamometry, which is force production. in a younger cohort of individuals and an older cohort of individuals. And this sparked a lot of conversations because we know that with age, for example, pelvic floor dysfunction goes up, but what are normal wrinkles on the inside of the pelvis? And what are things that we would consider abnormal or needing to seek some intervention for? So I'm gonna try and take you through a couple of different examples in the literature of what we know, what we don't know, and what we have to acknowledge is just areas of gray. So we're gonna talk about the bladder first. So some of our literature is saying, you know, five to eight Ps during the day is normal. Some individuals have pulled that up to eight to 13 as a top end of normal. And then some people will say that you shouldn't ever have to pee at night, or it should be rare, like you shouldn't be getting up consistently to pee at night. And others say that that is true if you're under the age of 65. But if you're over the age of 65, getting up once to pee is considered within the realm of normal. So let's talk about why there is that variability. When we are looking at data sets and we are trying to incur where that normal distribution is. So we think we have an average if it's normally distributed and 95% or 97.5% of our data is going to swing within plus or minus two standard deviations of the mean. And I'm getting kind of in the weeds of statistics here, but that's kind of our normal distribution. And our P of less than 0.05 on a two-tailed test are the ones that are below that two standard deviations on either side. And what that's saying is like when we have this big group of individuals who are kind of distributed across this arc, and we are seeing that this other group of individuals is well below that, then we can say that these are probably different populations or there is something different going on. When we are looking at trying to characterize normal, There is so much that comes into human behavior that creates differences in a person's lived experience. And when we're trying to capture that descriptive data, it depends on a lot of things, right? If we are looking at normative data and we're trying to describe it, it is going to be very specific. to the data set that we are capturing that information from. What do I mean by that? I mean, if we have an individual who's an athletic group of people who are very conscientious of hydration, their normative values for how often they're going to pee is probably in that higher end between eight and 13. If I am working with a sedentary population who doesn't take a lot of care in their hydration, or it's not something that they think about, five is probably on the top end of that. And so we know that this hydration status is largely going to dictate frequency of urination. Similar to things that we know cause liquid to filter through the kidneys a lot faster, things that we call bladder irritants. So if I am working with an individual who has a higher caffeine or alcohol intake, right, that's gonna make it flow through the urine. Caffeine is not a diuretic, it's a mild diuretic. It does make us have to pee, but in the morning, we're oftentimes drinking caffeine that's simulating that the kidneys and the bowels to start functioning. We are peeing more in combination with having caffeine. Alcohol is another one where it increases filtration rate because alcohol is a toxin, our body is trying to get rid of it, and so it can change our frequency of urination. timing of when we drink water can dictate are you a person who gets up every night to go to the bathroom or not. So all of that can be in the realm of normal variation and that makes it extremely difficult then to diagnose things like nocturia or frequency issues where urination is over a threshold where we consider this to be a quote-unquote pathology or a condition. And so what that has done in our bladder consensus statements is that we have added a second part to this. We have said that when you're thinking about healthy bowel and bladder habits, you should be able to defer going to the bathroom as needed. Your urge to go to the bathroom should increase as the amount of bladder filling hits a more critical threshold. We're getting to the top of our bladder fillage. and we should be able to empty our bladder when going to the bathroom and have complete emptying of our bladder. And frequency of urination, we have like, you know, multiple studies that have tried to characterize normal, but the big asterisk sign on this is that frequency should be at a level that feels okay for you. You should not be stressing about your bladder. You shouldn't have anxiety about bathrooms because that's showing that there is issues with being able to defer going to the bathroom, being able to hold going to the bathroom, or you're going to the bathroom so often. that it's disrupting the cadence of your day, right? But that's really difficult because we can't necessarily say there's this cutoff, right? Where if you're going to the bathroom less than five times, you're probably dehydrated. That's pretty consistent. But if you're going to the bathroom six times versus 10 times, It depends on you and on how you are feeling, and if that is okay for you, or if that's something that is all right for your day. And so we don't really have these normative values, and it's why there's inconsistency in the literature about it, and we can't really give you a hard and fast number, and we really don't want to, because you're a human being. It depends on your day. You're not doing the exact same thing every day. So these healthy bladder statements that we have that are in our research and that are in our course are trying to give an idea, right? So if you have a person who's really underneath that or really above that, then it can almost introduce the conversations around frequency and work on things like urge suppression to potentially bring that frequency down or modulate liquid intake to maybe help with some of those concerns. A second example where we're not really sure about normal is when it comes to diastasis recti and pelvic organ prolapse. And this I actually see as almost a bigger problem because it really bottlenecks our research. It actually makes a huge difference in terms of the way that we are educating on normal conditions and normal changes, and how we create a threat response oftentimes when potentially we don't need to. Let me kind of dive into what I mean. When we are looking at our frequency of pelvic organ prolapse, so pelvic organ prolapse is a movement of one or more of the vaginal walls towards the vaginal opening, and it is assessed on a Valsalva Beardown Maneuver, which is done on a relaxed pelvic floor. Okay, that is where we are doing our assessment. We know that our vagina is not a hollow tube, our bits touch, and we do not have our vaginal wall as a cartilaginous ring, right? It is smooth muscle. And therefore, it should be moving, right? We should see some movement, but it is the degree of movement that we have tried to create a cutoff score for in order for us to have clinical care pathways that give us some idea about what is the next step for individuals who are experiencing signs and symptoms of pelvic organ prolapse, right? We can have individuals who have high amounts. So where are some of the issues come up? We can have individuals with high amounts of movement and low symptom burden and vice versa, right? We can have individuals with high symptom burden with low movement. So here comes the first hole in our argument is that there's discordance between subjective complaints and objective symptoms of prolapse. The second concern that we have with using our grading system as it is currently is that depending on, again, the study population that we are pooling data from, and this is gonna be especially true with our individuals who are post-menopause, we can have over 50% of individuals studied in a normal data set where individuals may not even have signs or subjective complaints of prolapse experiencing grade two movement. So not at or past the level of the hymen. And so they can have that movement. And so if greater than 60% or greater than 50% rather of individuals are experiencing grade two movement, can we truly say that this is an abnormal finding? Because that would mean that 50% of our female population or 25% of our population in general is experiencing a condition. and in combination with the fact that they're lacking symptom burden is a concern. The third thing when it comes to prolapse literature, and this is something that I've been thinking about a lot lately, is that so many of my clients who have really high symptom burden are most concerned with their standing and resting position of their pelvic organs. So for some of my clients with higher grades of prolapse, thinking stage three, stage four, it's standing and feeling that bulge around the opening of their vagina in the introitus. And our assessment is on an active bear down, which really is something that other than birth, we should not be doing a max bear down. So the clinical, the jump to this is how we assess pelvic organ prolapse to this is where my symptoms are most prevalent is missing. We're missing a step. And that is why in our pelvic division, we are such huge advocates for the standing assessment, right? We're not doing a max bear down, but I'm seeing where are your tissues resting especially for some of my postmenopausal individuals or those who have a larger vaginal opening, it's very easy for me to appreciate and I get a much clearer picture of the posterior wall at rest in a standing evaluation. And so when we were doing some of our work up in Ottawa, it was really interesting because when we look at individuals who are parous, those who have given birth vaginally, what we see is that our perineum is going to have more up and down movement. We are going to see post-delivery, an increase in range of motion, and it's been most characterized in the anterior wall. And we are going to see a shift in some of our pelvic structures, right? This is normal physiology. And so when we haven't done a great job of characterizing normal variation and then add in individuals who have had multiple vaginal births who have now gone through menopause, some of that shift in structures are wrinkles on the inside that we maybe don't need to pathologize. And so because we have so much of this variation of normal, again, now our definitions for pelvic organ prolapse are an objective sign of descent in combination with subjective symptoms and subjective complaints. And that's wonderful because what it means is, is that people are gonna have different range of motion. Just like some of our individuals from a musculoskeletal perspective are more bendy and can bend over and their elbows can touch the ground. And some people, they can barely get their fingertips to touch because of hamstring length. We're gonna see variations of normal in vaginal wall length. And this is not something that we need to pathologize. It's the combination with subjective complaints that is going to be our important distinguishing factor to potentially modifying or working on the anatomy, whether that's conservatively with pelvic floor muscle training and pest reuse, or that's surgically with a vaginal mesh type of surgery going into prolapse repair. The third where we don't have a very good understanding of normal is with diastasis recti. So two years ago was the first time that we had taken a big representative sample who were not coming in for core complaints and giving them an idea of what is a normal interrectus distance, right? And over 50% of individuals coming in had greater than two centimeters, which is typically our cutoff score for diastasis recti. And what that shows is again, this bell curve of normality is centered around two centimeters. So if our average is two centimeters or 50% of individuals on this normal distribution are experiencing a two centimeter gap, then again, we've had a failure to recognize normal variation when slapping on layers of pathology or conditions. And again, this is alarming because what it does is it halts a lot of our progress. Bec…

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    Episode 1769 - Deadlifts for every body Jul 12, 2024
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    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 different deadlifts variations and who may best benefit from their 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. EPISODE TRANSCRIPTION INTRODUCTIONGood morning, everybody. Welcome to the PT on ICE daily show. It is the best day of the week, Fitness Athlete Friday. My name is Guillermo Contreras, here with you today from the Fitness Athlete crew, talking all things deadlift. So this is an exciting topic here. We just finished up our level one course last week and we just had our fitness athlete summit a couple of weekends ago. One thing that we know that throughout the one course as well as the live courses is that deadlift is typically going to be one of the most spicy topics. Should everyone be deadlifting? Why should we, why should we be deadlifting and why should we be deadlifting heavy? One of the questions we most commonly get both in the live course as well as the online course is the question of all the variations we see. The conventional deadlift versus the, you see back here, the trap bar deadlift versus the sumo deadlift. What is the best position? What is the setup? How do we coach it? How do we look at it? And if you want to dive into all that, that nitty gritty, that really deep detail stuff, highly recommend you jump into the L1 course or you join us on the road for a live course. But today, all I'm going to be talking about are the different types of deadlifts. And the topic title is a deadlift for everybody. Right? So not everybody, but everybody. Because there are instances where individuals will be using a different setup or a different variation of the deadlift to be able to move the greatest amount of load in the deadlift movement. So the ones we're going to specifically talk about today are the conventional deadlift, the one we see the most often and the one that we coach typically in the L1 course, you see in CrossFit gyms, you see done all over the place. The sumo deadlift, which we see a lot more in competitive powerlifting where they're trying to lift the heaviest amount of weight humanly possible off the ground. We trap our deadlift because we see it a lot in athletic sports and individuals using it in different ways and we'll talk about the differences there. That'll be more of like an end of the conversation discussion there. And then lastly, some variations known as kind of the hybrid deadlift. And that is just going to be a slightly different for individuals who maybe can't get into position for conventional but don't need to go sumo, we find something in the middle. So first things first, we're going to talk the conventional deadlift. we look at the conventional deadlift we want to ensure that we are set up in such a way where that bar is close to our bodies. So when I coach this out I'm telling athletes that they want to set up hip width apart so their feet are right underneath their hips for this conventional deadlift setup. From there the bar should be lined up closer to my shins. I typically will tell athletes when they look down, they should see that the bar is lined up over their shoelaces and not too far forward, because now that barbell is far away, which makes moving a heavy, heavy load a little bit harder, because it's going to pull you out of position. So we want that bar nice and close. From here, with the conventional setup, what we tend to see is my hips are going to go back. And when I'm set up in this double overhand grip, my hands are outside of my shins. And when I get all that tension on board, my knees are below my hips, my hips are below my shoulders, and I have this really nice stacked set of position in which, again, my shoulders are above my hips, my hips are above my knees, and that bar is nice and close to my body. That is going to be our conventional setup. That is the most common variation you're going to see in the CrossFit gym with any athlete that walks in, someone that's just a recreational weightlifter and is doing deadlifts on a day-to-day basis. The second most common variation we're gonna see is something called a sumo deadlift. With a sumo deadlift, that barbell, and I apologize, if you're listening on the podcast alone, some of this won't make any sense, so I'll try to talk as much as I can, but the video will give you a lot more detail on this. With a sumo deadlift, we set up with a much wider stance. So my feet, if this is hip width apart, This is shoulder width apart. This is just outside of shoulder width apart. With a sumo deadlift, we are going wider than that wide stance. The reason for this, the reason we see this in power lifting is because we are essentially just decreasing the amount of work being done. Meaning that the amount of distance the bar has to travel is less because now, rather than having to go from here to here, the motion turns into here to here. so it's a much shorter distance to travel or a much shorter distance to pull that barbell off the ground. The other big differences we see with that sumo deadlift outside of that much wider setup is gonna be that the torso angle is more vertical. So because I have this wide stance with a slightly more toed out position, or sometimes excessively toed out position, I can now set up with a much more vertical torso, and that bar can stay right underneath me. This means my erectors can be locked in a good position, I can stay nice and tall, and I'm driving through my thighs, boom, to lock that barbell out and overhead. Because I'm so wide with my legs, my grip is now just inside of my hands in this nice narrow position. Because again, I'm trying to decrease the amount of work being done by reducing the distance that bar has to travel. So that is our sumo deadlift. The points of performance still stand when I set up for a sumo deadlift here. my knees are still below my hips, right? It's just a slightly much less difference there, and my shoulders are still way above my hips, but I am much more vertical and I'm driving straight up off the ground. So it's a very different looking movement. The emphasis on load is going to be moved to different muscle groups, but it's a way to do essentially less work because you are moving a shorter distance and you can move much, much greater loads typically if you train it enough. So that is your sumo deadlift. The one here that most people don't know about, that most people don't do, is the hybrid. The hybrid is typically only given for athletes who might struggle to get into position with a conventional deadlift, but want to still be in a more narrow stance position because it's going to translate more into Olympic lifts or other type of lifts from the ground. And what that is, is if this is our conventional stance, this is our sumo stance, we break the difference and we are just slightly wider. So we're no longer just under our hips. We're now maybe just outside of our shoulders and our grip is just inside of our legs there. That setup mimics that conventional deadlift a lot. So I'm still in that hybrid deadlift. I'm sorry, I'm still in that hybrid deadlift stance here. The bar is still lined up nice and close to my shins. I'm sitting back, I'm getting over that bar, my hips are still above my knees, my shoulders are still above my hips, my hands are still nice and close to my body, and I'm pulling there, sitting back and tapping down. That one is most commonly given to athletes who just might not be able to handle that position of hip flexion in a conventional deadlift for one reason or another. or that just slightly wider position, allows them just enough room to sit comfortably into that setup for the deadlift. You'll see athletes, especially longer, taller athletes, when they go to set up in conventional deadlift, they set up here and they can only get there with this kind of nice, kind of rounded position because of how long their femurs might be, or their limbs might be, or if they have a shorter torso. So by just giving that little bit of clearance in that hip, they can sit there in that same deadlift stance, pull, and then get back down. So that would be your hybrid. So again, to recap, we have our conventional deadlift here, slightly wider for our hybrid deadlift, even wider and more upright for our sumo deadlift. That is how we pull heavyweight off the ground. Regardless of how you do your deadlifts, we know that the deadlift is one of the best ways to improve low back pain, to reduce low back pain, to reduce kinesiophobia, to build strength, resilience, and just overall good quality life and function because of the way that you're moving a heavy load off the ground, training every muscle group, strengthening your grip, strengthening your back, strengthening your hips, strengthening your posterior chain. So the deadlift should be something we should have in our arsenal. The one thing I want to give some love to is the trap bar, right? So this behemoth bar over here, we see this a lot. and it's shaped like a, what would that be, a hexagon, I think? Hexagon. We see this a lot in sports, a lot more in like, you'll see it in like football, basketball, because they just want to reduce risk. So they claim that the bar being out in front is just too unsafe. But in reality, what happens a lot of time when you have a lot of athletes, the time it takes for a strength and conditioning coach, if they don't have a large strength and conditioning staff to really coach, cue, and ensure good quality movement with a barbell deadlift, it's hard. So the trap bar takes away a lot of those things that you would normally coach by allowing an athlete to set up with the bar at their sides here and be in a more squatty position. You can get more hingey with it if you'd like, but most people are going to tend to falter back towards that more squatty movement pattern when it comes to a trap bar. There's nothing wrong with using the trap bar. The trap bar is a great way to load up that hinge pattern, that deadlift pattern, get comfortable pulling weights off the ground, even like jumping or heavy farmer scares. You can do a lot of different things with the trap bar, but it's not going to be the same thing as loading up that barbell, having good quality coaching, ensuring that that back is being nice and strong and holding that really stiff, strong position as you hinge forward. And that's where a lot of that magic happens with the barbell deadlift. So again, trap bar, a wonderful tool to use. It also, if you're dealing with crossfitters, it's not going to translate to literally anything else besides maybe some loaded carries, heavy carries, sandbag carries, jerry can carries, things like that. But it's not going to transfer over into strength for Olympic lifts such as the clean and the snatch. So we want to really try and work and improve on that deadlift. So again, one final recap. What do we see? Deadlift, one of the best things we can do for low back pain. Improved kinesiophobia, just get rid of it all together. Improved strength, resilience, quality of life, everything there. This is the health lift, what it was normally known as back in the 20s, I believe. We have a conventional deadlift in which our stance is around hip width. Bars close underneath our shoelaces, hips above our knees, knees, hips above our knees, shoulders above our hips, and that really nice pattern there. We have that hybrid, we'll be slightly wider stance, and now our grip, instead of being outside our knees, goes inside our knees. and we are still driving with that same shoulder above hip, hip above knee position of our body. And then lastly at that sumo deadlift, that really wide stance that again allows us to reduce the distance that bar has to travel so we can do more load typically. the hips are still above the knees, the shoulders are still above the hips, we have a much more vertical torso, and we are driving straight from the ground, standing tall with it. Sumo deadlift, hybrid deadlift, conventional deadlift, and special shout out to the trap bar deadlift as well. So there's a deadlift that anybody can do, we should be deadlifting in the clinic with our athletes, especially if you're dealing with fitness athletes and crossfitters, they're gonna deadlift, so be really good at coaching it, understanding these different variations that they can use to train in different ways. If that's just a little bit, and you're like, oh, I want to learn a little bit more, please, please, please join us on the road. We are not traveling a whole lot in August and July, but starting in September, we are on the road right away. 7th and 8th, we are in Austin, Texas with Fitness Athlete Live. Then the 14th and 15th of September, we are in Longmont, Colorado. And then the 28th and 29th, we are back in Texas, in Springs, Texas, which I believe is down on the coast near Houston, I could be completely wrong, so I apologize for anyone from Springs, Texas if I got that wrong, but please come check us out, we're on the road. If you want to see, learn a lot more, be able to dive into it a lot more, into the science of everything a lot more, the level one, the fitness athlete level one starts back up on July 29th, so that'll be in about three weeks. We're starting up our next cohort of the CMFA L1. And then the CMFA L2, if that's the one course you are waiting to finish up to get your CMFA certification, that starts up on September 3rd. That course is only twice a year. That course always sells out. So please, if you're thinking about getting your CMFA cert and you want to take that L2, dive into all things programming, movement modification, some business aspects, high-level skill, gymnastics, and Olympic weightlifting, Sign up for that one on the PT on ICE website. CMFA L2 starts up September 3rd, CMFA L1 July 29th, and we are on the road in Texas on the 28th and 29th and the 7th and 8th of September, and then out in Colorado on the 14th and 15th. Gang, thanks so much for tuning in this morning. Have a wonderful weekend, and we will catch you Monday on the PT on ICE Daily Show. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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    Episode 1768 - Pain now or pain later Jul 11, 2024
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    Dr. Jeff Musgrave // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Older Adult lead faculty member Jeff Musgrave discusses how choosing pain now can help you avoid pain of regret later in your career. 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 Welcome to the PT on ICE Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy, currently serving in the Institute of Clinical Excellence in the Older Adult Division. It is Thursday, so it is Leadership Thursday. Super excited to be bringing to you a message that I think a lot of people are going to relate to. Pain now or pain later? When thinking about this topic, it really came very organically out of a class that I was coaching. So I get to coach people 55 and up, we're all about pushing high intensity, we celebrate sweating, we celebrate heavy weights, and really pushing things in a business called Stronger Life. But we were finishing up class, it was a really tough workout, and I was talking to our members and I said, you know, the reality is, team, you can have a little bit of pain, a little bit at a time, or you can have some uncontrolled pain later in life, maybe years from now, maybe decades from now, but that pain, you're unlikely to get to choose. And we all know this, if you're listening to this podcast, you know that we're all about being fitness forward. We're all about choosing that little incremental consistent pain to avoid greater pain later, right? Whether we're talking about building reserve for not even just older adults, but all people, right? The stronger we are, the fitter we are, the less likely we're going to have those uncontrollable pains through health complications, whether we're thinking about heart attacks, type 2 diabetes and amputation, strokes, Those type of things, for the most part, are very avoidable by choosing a little bit of pain, a little bit at a time. So this really just resonated with me, and as I was reflecting on it, not that I have that many great quotes, but this one, I was like, this one kind of lands. It connects a little bit. And then it made me think about my career. It made me think about people that, in scenarios that I've been through, as a clinician, and my journey in my career. So I think this not only relates to us from a physical standpoint, but thinking about our career, where we're headed, having big dreams, like what do you want out of your life? Who do you want to serve? And how are you going to get there? And the reality is, I truly believe you've got to choose some discomfort. You've got to choose a little bit of pain if you want to reach your goals. Likely, if they're worthwhile at all, they're going to be hard to obtain. They're not going to be easy to get to, and you're going to have to push yourself. And you're going to have to seek some pain. If you're choosing comfort in your career, you're unlikely to reach any big, meaningful goals. That's just the reality of it. So I'm gonna give you some examples, thinking about the perspective if you're an employee and if you're a business owner, if you're an entrepreneur. So for these, really we're just gonna talk about two scenarios. So the first trap that can lead to you not choosing pain is really just seeking comfort, career comfort. And it can be a career comfort as an employee and as an entrepreneur. So the way I see this is if you're early in your career or maybe you're later in your career, it doesn't really matter. But if you were choosing comfort as an employee, it could look like choosing prioritizing a paycheck over growth. right? And I've been there too, right? Student loans, debt, paying the bills, that's a reality. We all have to pay the bills, right? And the more financial margin we have, the easier our life is from that perspective. But that's not always the path to a meaningful career. Those two things can coincide. You can make great money and you can be serving your life's passion, the mission, the thing that you are here as a clinician to do, you can get both. But oftentimes, there are so many more opportunities to choose a paycheck and comfort over growth, over meaningful growth. Some signs, because I've worked at these places before, I've been there, team. Some signs that you are in the wrong place and you're choosing career comfort over growth or that small incremental pain is you're working with a bunch of burned out clinicians. They've been there for a long time. Their interventions are ancient, right? They're not up on the research. They're the ones doing shake and bake with heat and e-stem. They're using the ultrasound machine, whether it's plugged in or not, right? We know it's going to work. Not to say we won't do that to meet a patient's expectations. If they believe that's what they need, we'll do that and then we'll get after it later, right? Another sign you're in a place of just comfort, seeking a paycheck, is all of your clinicians or maybe you have gotten into the habit of using handouts. There's like, here's my older adult knee program. Here's my shoulder program. Here's my hip program. Team, we know if it works for everyone, it works for nobody. Right? Care has got to be individualized. We've got to meet people where they are, do an individualized assessment, and then we can dive in and really bring them the goods. But there's a good chance if you're in a work environment where everyone's super burned out, they're there for the paycheck, it's probably a pretty good one. and the expectations are probably pretty low. No one cares what the quality of care is. All they typically care about is billing units. If billing units is more important than quality, if you're not getting your sword sharpened by the people you're working around, you may be choosing career comfort over growth. I think another area where people can fall into a trap, there are lots of different companies that are gonna offer mentorship. This happened to me. I was switching settings early in my career. I was promised mentorship. What I got? Super full schedule, no help, no supervision. I wasn't even treating during the time my mentor was supposed to be there. No conversations about mentorship happened until I told them I was ready to leave and put in my 30-day notice after I'd been there for five months. No mentoring, didn't execute on the schedule they said they would give me to slowly on-ramp and sharpen my skills. Look around. If your mentor is not available, if your mentor is not someone you want to emulate, that's at the cutting edge, that's constantly growing, that hasn't reached the peak of their career, if you've peaked and stopped, you're done. You're learning or you're growing. So that's another trap that I typically see. So if that is you and that is what your situation is like, you need to run. If you're interested in growth, you're interested in being the best, you can't hang around in a work environment for very long with people that are burned out, that aren't trying, that are doing the minimum, that are there for the paycheck, it will crush you eventually. You can swim upstream for a while, but you need people to go with you. And if you're in that scenario and you can't change your scenario right now, stay connected with us. Listen to the podcast, go to good content courses, and we can help you get through that period. But long-term, if you want solid growth, you've got to find a solid mentor. You need to be surrounded by like-minded clinicians that are going to push you You want people that are gonna point out the things that you're doing poorly. You need a mentor that's gonna say, you know what? I think you can do better. I know what your capacity is. You're smarter than this. You're better than this. Let's get better. Let me show you how. And that person better be someone you're ready to follow. Okay, so that's if you're an employee seeking career comfort. If you're an entrepreneur or a business owner, one of the traps that I see with seeking comfort is you probably busted your tail to get started. I hear Jeff Moore talk about this all the time and it's so true. Getting that boulder, pushing that boulder at the beginning to get some momentum is so hard. It's so challenging to do that. Once you get it going and get some momentum, it's easy to just be like, oh man, I did it, like this is good, I'm making money, I like this, and it's easy to get comfortable there. When really, there's so much more that you could do and I think Sometimes that is not bringing on someone else to help you. You're seeking comfort through just doing it all yourself. Not trusting someone else with things maybe you're not great at. relying completely on yourself. And basically you've turned yourself into an employee for yourself. You don't have time to work on the business. You don't have time to expand. You don't have time to bring on more business or new employees that are smarter than you or better than you in a certain area to really grow your business, to have a big impact. If you're really good, bring more good people with you. Serve your community well. Push yourself, push your business. If you are seeking comfort and you're an entrepreneur, this is my challenge to you, to grow your team. Find something that you suck at and find someone better than you at it. Offload some of those things, a little bit of time if you can. You don't have to go all in. I'm not saying cancel your schedule. What I'm saying is bring someone on that can help take on a little bit of the burden that's better than you in a certain area. That can help shake off the comfort. That'll make you feel a little uncomfortable. It'll be a little harder to teach someone else. It's gonna take some time investment, but it'll pay huge dividends. So that's one of the main ways that I see that happen. But you've got to free up enough time that you can work on the business, not just in the business. That quote I pulled from the EMF Great Book. If you're an entrepreneur, you've never read it. That's a trap that I fall into. I wanna do the work myself, but I've gotta get comfortable giving other people tasks that I'm just not that great at. We can't be good at everything. We can be good at a lot of things, but if we're gonna grow a business, we're gonna have a big impact. We've got to share the load. We've got to share that burden. The other, on that same note with hiring someone, another thing that we see, is if you get too disconnected. So the one extreme that I see with entrepreneurs that you can fall into this trap and I tend to fall into is I want to do too much work and not delegate or let other people do things I'm not good at. The other extreme that I tend to see is we have people that then continue to micromanage really talented people. You give them a job, you give them tasks, but you're upping their grill all the time. You're checking up on everything. You're not giving them the space to be creative. You're not giving them the space to spread their wings and do their thing, to let them fly out of the nest. You're hovering over them, micromanaging everything. You've got to find smart people. You've got to set some clear expectations. You've got to give them good support. Be clear. Just as a side note, when you think you're being clear, you're not being clear. I fall into this trap all the time with not having enough clarity. But the biggest key, once you get someone talented on board, is get out of the way. There's a reason you hired them. Give them the space to do their thing. Okay, so that's part one, career comfort. The second piece, risk little, gain little. If you risk little, you're likely to gain little over time. So if you're interested in growth, being the best in your area, being the go-to in anything, you gotta risk a little bit. You've gotta throw some money at your skills in an efficient way. You've gotta go through the discomfort of getting real feedback. If you're not getting real feedback on your skills, whether you're in the clinical or you're doing some type of mentorship or you're continuing education courses, people should tell you when you do something wrong. They should be bold enough to tell you, hey, that's not great. You can do that better. Here, let me show you and have a trusted source for that. But you're going to have to see some incremental pain and discomfort of being told that's not great. The other thing is if you are one of those people that were like me, you're in a career, you're ready to make a jump, you want to do your own thing, you're gonna have to suffer some pain. You're gonna be on the bubble for a while. You're gonna have to have some revenue streams to help support that jump as you're getting things going, and you gotta be prepared to not make money for a while. For most scenarios, there are very few scenarios where you can just hop straight over, go completely from being an employee into being an entrepreneur. So you need to have a period of time to build an on-ramp for yourself, and this is going to be uncomfortable. You're going to have to have revenue streams that are going to help support you through the period of time that you're working on building a business or building up your referrals so that you can make enough money to sustain things. That period of time will not last forever, but you need to have a solid plan. and you need to have a long runway. The longer the runway you can create financially, the more reserve financially you can create before you start doing a second thing or a third thing. Whatever it takes to be able to build your dream, build your business, you gotta do it. There's no path forward without some pain, without some discomfort, without some extra hours. I've just never seen that happen. If you've been able to do it, please share in the comments. I'd love to know how you pulled that off. So that is the second piece if you're an employee and you're trying to move forward. and you want to start your own thing. If you're an entrepreneur, I think another big mistake through being comfortable and not not risking enough is not risking to make yourself an expert in one area. I see this a lot too where clinicians are well-rounded. They can do a lot of things and that's great. You need to be able to treat all of the things that you want to treat, but eventually, after you become successful, you've got to niche down. You've got to find that specialty area. You want to be the go-to for this. When their friend says, oh, I've got someone that's got pelvic floor dysfunction…

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    Episode 1767 - Rethinking post-operative guidelines Jul 10, 2024
    Show notes

    Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses reframing the conversation around post-operative guidelines for physical therapy treatment. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in our geriatric division. I'm coming to you from the University of Ottawa, so if there's a little bit of background noise, that is exactly why. But today, what I wanted to talk to you about, and the reason why I'm on here a little bit early is because I feel like this is gonna take me a little bit of time to get through, is to start reconceptualizing our post-operative guidelines when we're thinking about not just musculoskeletal injury, but many of our post-operative protocols when we're thinking about early healing and early recovery. in the post-operative window. And so I just posted a reel on our ICE Instagram account that's talking about hip precautions and how we have research going back from as like synthesis of research systematic reviews of research going back as far as 2015 to show that these precautions that were intended to reduce risk of early hip dislocation actually don't do that and what they actually do is they exacerbate post-operative deconditioning and they increase fear of movement. And we see this all the time in clinical practice, right? Individuals go for surgery. They're given these restrictions. These restrictions are not evidence informed. They're never discharged. And what it does is it causes people to disengage with activities of daily living, with sports, with activities that they enjoy. They become more sedentary. And then downstream, we see that the amount of postoperative deconditioning is greater and their capacity to engage back into the things that they enjoy before surgery is less. You know, I've had clients that have said to me, I'm so much worse. Like, my pain is better, but I feel worse than when I went in for surgery. Like, why did I even get this done if I could have dealt with this surgery? And so over the last couple of months, I have really been thinking and noodling on this. I did a podcast on the pelvic section on our Mondays around how our pelvic restrictive guidelines around lifting are not evidence informed at all either. And that when we remove those guidelines, and we have now multiple RCTs that have said, you know, other than don't have penetrative intercourse for six weeks, when we say here are your buoys, and here's how you can progress based on how you feel. not only do you not see an increased risk of postoperative complications in those individuals with liberal restrictions, but they actually have a reduced pelvic floor burden in that postoperative window. And so that early recovery is actually enhanced. And so we have to kind of understand where some of these guidelines come from and how are we as a profession in allied health going to start pushing the narrative and where is our role in that because I think we have a really massive role. So the first thing that needs to be acknowledged that is really front of center when it comes to post-operative guidelines is that when we do research and we take surgeons and we have done cross-sectional surveys, not we other researchers, and asked, you know, where did these lifting restrictions come from? Like, where is your evidence? Or do you believe that your restrictions are evidence-informed? In our pelvic literature, we saw that 75% of urogyne surgeons recognized that the reason for their restrictions is because this is what they have always done. And only 23% of the surgeons surveyed believed that the restrictions that they were giving were evidence-informed. Now that is a massive problem, right? We so often in medicine come through the lens of let's avoid bad outcomes that we don't acknowledge that the lack of doing something by restricting a person's movement can actually lead to adverse outcomes down the road, right? Because yes, they're not saying we did X activity and caused X outcome, but the removal of activity, now what we know in all of our accumulated literature on the effect of deconditioning on trajectory of aging, clinical geriatric syndromes, and post-operative deconditioning that can lead to changes in independence, that deconditioning also needs to be acknowledged in our algorithm of what we are thinking when it comes to our post-operative guidelines. And so what we are acknowledging first is that one, we have evidence that does not support restrictive guidelines in many different examples, right, our arthritis literature, not sitting in bed post cardiac surgery, our lifting restrictions post pelvic surgery, we now have a variety of different areas across different organ systems, musculoskeletal surgery, cardiovascular surgery, urogyne surgeries where we are acknowledging that our restrictions are overly restrictive and that that restriction does not create better outcomes. The step forward that I want to make is that not only are they not leading to better outcomes, but that subsequent deconditioning by overly restricting a person is an adverse outcome in itself in the opposite direction. And what this is highlighting is that we have a big knowledge translation gap problem. We acknowledge in many areas of medicine that this exists, but this is front of center for our allied health clinicians around what we are allowing in our practice or what we are acknowledging in our practice. And so you're gonna say Christina, okay, where are these restrictions coming from and why as a clinician am I hesitant to push back on these guidelines despite the fact that I know that these are not evidence-informed, right? So because there's a hesitancy on the side of the clinician and We want to acknowledge those. Those are the elephants in the room, right? So the first thing is around the fear of an adverse outcome, right? When we don't do anything, we don't have that same feeling of responsibility if something was to go wrong, right? Because I didn't push them. So it wasn't me that caused that adverse outcome, right? And we can't always avoid adverse outcomes, but what we do a lot at MMOA is we try and flip the script of, you know, we think about the harm of loading people, but what's the harm if we don't load them? And that's a slower churn, a slower burn, but it's important to acknowledge that that's relevant too, right? So that fear. But the fear also comes from going against the surgeon and liability and referrals. And so I want to acknowledge that piece and I want to acknowledge it on a couple of different stances. Number one is that our messaging is never to, you know, speak negatively to the surgeon and speak about the person. We speak about the concept. And so the way that if I'm trying to remove restrictions that have been placed on somebody or deviate from a protocol, which I tend to do a lot, when the surgeon has outlined this, I will say where your surgeon was looking at was this is their scope. They're looking for lumps, bumps, infection, early complications. Where my lens is here. based on their assessment of you two weeks ago, they may have felt X from where I am assessing you today. Here's where I think our steps are going forward. So it is not bashing the surgeon. It is not going against the surgeon. It is using my scope as a doctorate level clinician to be able to make further recommendations going forward. And as a newbie clinician, the thought of going against the protocol set out by the surgeon used to terrify me, right? I'm a rule follower and our medical system has placed medicine at the top, which, you know, they have the brunt of the liability. I understand where that is coming from. But as I get into my research degree or when I get into my research career and I acknowledge the level of the evidence when I see the outcomes that are so much better when I ditch these protocols and load people more aggressively earlier and I recognize that a surgeon has never never actually rehabbed a person after their surgeries, it changes my mind, right? I would never go up to the surgeon and say, you know, you are going to go with that anterolateral approach for that hip replacement. I really think you should take a posterior approach. It would be better. Because that's not my scope of practice, right? That's not what I do. That is not where my skill set is. So why are we so shackled by a surgeon telling us what our job is, who has never, never rehabbed a person after their surgery, has not actually seen them for more than 15 minutes in an appointment after their surgery. And so I I would never take continuing education from a PT who has never treated the condition that they are teaching about, right? Like you would never go to see me and teach in geriatrics if I have never rehabbed a person who is over the age of 65. So why is our system created in a way where we are taking rehab advice from someone who has never done rehab, whose medical degree does not actually have an exercise prescription component in a lot of cases. And so that acknowledgement has really shifted my perspective on this is maybe foundational work that they are giving and they are catering also to the lowest common denominator, right? Like when I am working with a person and they are trying to give a blanket statement guideline that has exercises on it, they have to cater to the person with the most amount of deconditioning in order to believe that this protocol is safe for everyone. And we acknowledge as clinicians that that blanket statement never ever works, including blanket protocols, because our people come in with a variety of different chronic diseases, comorbidities, positions, supports, biopsychosocial considerations, motivations and drives, and musculoskeletal reserve around that postoperative joint. And so what we have to acknowledge is the flaws in the system, but I'm not saying that as a bad thing, I'm saying that as this is where I come in. High five me in, this is my job, and I need to advocate for my profession in making an opinion on this, right? And this is where we need to lock shields with medicine and surgery, not blast each other with swords and acknowledge where our scope is and where their scope is. The final thing is around liability, right? And I think the post-operative guidelines around joint replacement are a really good example of where the liability, we have to be acknowledging liability, but we also want to make sure that we are thinking on the other side of the equation, where when we are working with individuals post-operatively, we are worried about post-operative dislocations. And what we see is that those with low musculoskeletal reserve going into surgery and have a fall in the early postoperative window are the ones who are more likely to dislocate or those that have a size fit issue or get a deep infection in the early postoperative window. So what we are doing by deconditioning is we are impacting one of those risk factors in a positive way. If we are creating more deconditioning, if we are lacking reserve around that joint and we are not supervising them, potentially in the early post-operative window, that is where we can have liability on creating an adverse outcome. But we don't have any evidence around pushing individuals too far from an exercise perspective early on, creating adverse outcomes. Now, if that was to change, sure, we're gonna change our strategy, but we want to really be thinking about this from a clinical and critical lens, because it's really important that we acknowledge these things. So, What do I think we actually need to think about with our post-operative guidelines? Or what do I think we are missing with our post-operative guidelines? I feel like we are missing our confounding variables that are going to dictate how quickly we're going to be able to progress individuals. So what do I mean by that? We acknowledge as clinicians, because we do this all the time in our assessments, that there is going to be different things in a person's background that is going to allow us to be more aggressive in rehab or is going to cause us to take a slower approach. Those are not acknowledged in our postoperative guidelines right now. So what are some of those things? One is our level of frailty, burden of clinical geriatric syndromes or complex comorbidities. Secondary is musculoskeletal reserve going into surgery or the amount of deconditioning we are able to stave off with early postoperative mobility. And so what we are acknowledging or what we want to acknowledge is that some individuals, we obviously have that early protective phase around a graft. I'm not saying that we're just going to blast that out of the water, but we know that after two weeks, most of our collagen synthesis is there and now it's remodeling in order to get stronger. And that remodeling requires load. But then we create a brace around an individual for six weeks where we're actually not creating a lot of loading through that joint or we're not actually having pulsing forces from our muscles that are acting and contracting to start creating tensile forces in order for our collagen fibers that are coming down or our healing fibers that are needing that load in order to get stronger. And there's a huge amount of variability in our in vivo studies around the strength of collagen resynthesis and that range is probably related to musculoskeletal reserve. And so, one, we need to acknowledge that yes, we have that early protective phase, but their amount of reserve going into their surgery is going to be a predictive factor of how aggressive we can potentially be post-operatively. Their complexities with respect to comorbidity are going to incur a higher or lower inflammatory load that is going to dictate how fast we're gonna be able to progress exercises, right? When we really step back from all of our comorbidities, a lot of them are related to inflammatory cascades, depending on the organ system that is impacted by the disease. And so when we have individuals with a high comorbidity burden, they are gonna have a higher inflammatory load, and that higher inflammatory load is going to impact how fast we're gonna be able to get individuals working, but on the flip side of that, exercise is anti-inflammatory. but it's going to slow down our progressions. So all of this to say is that one, we need to be confident in our assessment skills that includes early postoperative management. We need to acknowledge that our role is one of critical thinking that allows us to take information medically from the surgeon and some of their early protective phase issues, and then be able to progress them as we see fit, because we're the ones who are seeing individuals that are progressing and we are responsible as well for their wellbeing and their capacity to return to activities of daily living. And that baseline musculoskelet…

    Full show notes at the publisher

    Episode 1766 - The hidden details of tendinopathy Jul 09, 2024
    Show notes

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

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