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Episode 1745 - The role of the deltoid in functional fitness Jun 07, 2024

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Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the anatomical & clinical considerations of the deltoid muscle in functional fitness, as well as the best ways to begin to train the deltoid in the gym. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app/switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. ALAN FREDENDALL Good morning, PTonICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan, happy to be your host today here on the PT on ICE Daily Show. It is Fitness Athlete Friday. We talk all things CrossFit, powerlifting, Olympic weightlifting, endurance athletes. For that patient, athlete or client of yours that is recreationally active, Fridays are all about topics for that person. We are finishing out deltoid week here at ICE, so we're talking all things shoulder, in particular the deltoid muscle, exercises for the deltoid, manual therapy for the deltoid, so go back if you haven't been listening the rest of this week to all the episodes from all the other faculty, Monday, Tuesday, Wednesday, Thursday, dry needling techniques, cupping techniques, exercises, modifications, importance of deltoid exercises for pregnant and postpartum moms, we've got it all. Plus, we have a whole bunch of great content on our Instagram page as well, related to the deltoid and all of those topics. Today on Fitness Athlete Friday, we're going to tackle the deltoid from its role in functional fitness. So in particular, we're going to be talking about vertical pressing. So we're going to talk about anatomical considerations of the deltoid as it relates to lifting weights overhead. We're going to talk about clinical considerations of why do we care about someone's deltoid when they come in for physical therapy treatment. And then we're going to finish talking about how we think you should actually train the deltoid with these patients and athletes in the clinic. THE DELTOID: ANATOMICAL CONSIDERATIONS So a brief anatomy overview to start. What are our considerations for the anatomy of the deltoid? We need to understand and recognize the deltoid muscle is large, it is designed, it is built for blunt force trauma. If we come away from social media and computers, and the past 2000 plus years of human progress, and we go back to ancient man and even before we became humans and we were walking around on all fours, understanding the role of deltoid, but as we're crawling around on all fours, we have hip extension from our hip, we have glutes and quads as our primary lower extremity muscles, and in the upper body, we are pulling ourselves along the ground. We are designed for vertical pulling in particular, We all understand the importance of the lat. There's probably not a single person, if you walked into a room and recommended that the average person could benefit from doing some strict pull-ups, there's probably nobody that would voice opposition or concerns. But yet, when we start to talk about vertical pressing, all of a sudden, the conversation changes. Whoa, don't lift your arm overhead. That's dangerous. We've heard things, and I've heard things, like even when I was in school, that the shoulder is so mobile, it's just really not optimal to lift your arm overhead. Which, if we go back to our history and our evolution, doesn't really seem practical. And I think it's a fundamental misunderstanding. of how the deltoid functions and its role in providing that stability to the shoulder joint. So being quadruped, now bipedal organisms, now standing up resisting gravity, great at vertical pulling, not great at vertical pressing, especially when we don't do it. Why? The shoulder is inherently mobile, it is inherently unstable. It does not have a lot of bony support. The deltoid is the primary muscle that gives us that stability. throughout the whole range of motion of the shoulder. The deltoid is primarily responsible for flexion and abduction. It is the prime mover of shoulder elevation. And in particular, as we begin to approach 90 degrees of flexion and abduction and move up towards 120 degrees and beyond, the deltoid really becomes the only mover. A lot of the other smaller muscles, upper traps, rotator cuff muscles, whatever, really fall off and the deltoid stands alone as moving things overhead. And so we see that that does not happen. That does not happen in a lot of people. We already know most people are sedentary. They're not lifting weight overhead, pushing or pulling. But for those folks that are, we need to get them doing probably more vertical pressing to train that deltoid to really understand and respect the anatomy that we need to have a really strong deltoid if we really want to have a strong and stable shoulder. Really great evidence on the importance of the deltoid as the prime mover of the shoulder. An article back from 2021, the Journal of Elbow and Shoulder Surgery, Hecker and colleagues, Really cool study. They took people, they gave them an axillary nerve block on one side, and then they gave them nothing on the other side. And they tested maximal isometric strength. And what they wanted to find out is how much strength comes from each of the shoulder muscles, at what degree of shoulder flexion, shoulder abduction, internal or external rotation, adduction and abduction. And what they found is when they blocked the axillary nerve, and they tested isometric strength, instantly with the arm still at rest, moving into flexion, the shoulder strength was reduced to 76%. In flexion and in abduction, it was reduced to 64%. And now again, as we elevate that shoulder further up towards 90 to 120 degrees, the strength fall off was even more significant. Flexion now at only 25% strength, and abduction at 30 strength. So the deltoid is involved in the entire range of motion of primarily flexion and abduction. But in particular, as we get up towards 90, and as we start to bring our arm all the way overhead, it is primarily deltoid, which means we need to be training the full range of motion, and we need to be training more pressing patterns, and not so much laying on our back or laying on our stomach and doing prone rotator cuff work, trap work, whatever. That stuff is great early on in therapy, but if we really want to get the deltoid strong, we need to move it through the range of motion that it controls, which is all of it, and in particular, all the way up and overhead. THE DELTOID: CLINICAL CONSIDERATIONS So discussing clinical considerations, who might we see with a deltoid problem? How could we pick up that somebody might need to get stronger deltoids? I would argue just like with glutes or quads, it's every human being, right? There's no one that is checking the box on strong enough muscles. I don't think you'll find a single elite athlete who thinks, I don't need to train anymore. I've made it. They're probably always aware of their weaknesses and things they need to train. and I would argue vertical pressing, training the deltoid is true for every single person. But we do see these presentations come in. where we start to think, hmm, what I'm seeing, I think I'm treating the symptom of a bigger problem. So when the deltoid isn't doing its job, that's when the other smaller muscles of the shoulder complex take over. That's when we have people with upper trap stiffness or upper trap pain or headaches or posterior cuff pain or issues up in their neck, trouble with rotation, side bending, whatever. those smaller muscles that can act to elevate the shoulder are taking over because the deltoid isn't pulling its weight. The long-term solution isn't to only train those muscles, it's to train those muscles if it makes the person feel better, but again, get back to training the deltoid. So when we see those patients come in the clinic, oh, my traps, my traps, my traps, my traps, my neck is stiff, I've got a headache, and we start to dig into the subjective, what have you been doing? Oh, we've been doing a handstand push-up cycle at my gym. Oh, we've been doing a split jerk cycle, a clean and jerk cycle, a snatch cycle, whatever. you start to hear that this person has increased their volume and overhead lifting and they're complaining of all of these secondary symptoms of upper trap, neck, headache, whatever. When I hear that, I'm thinking this person, this person, yes, needs my help. reducing pain, restoring range of motion, but I'm also thinking, I need to get this person on a vertical pressing program. Especially a functional fitness athlete, I need to be getting them doing strict press, I need to be getting them doing handstand pushups, strict handstand pushups, whatever they can tolerate, wherever they're at in their fitness journey, maybe it's handstand pushup, eccentrics, whatever, but I'm thinking, we need to start integrating some vertical pressing in this person's program, because yes, while we're treating their symptoms short term, the way they're presenting tells me they would benefit a lot from stronger shoulders. These symptoms are probably going to be less likely to show up in the future if we do that. And so as we're reducing the symptoms, resolving the symptoms in the local tissue, we then need to evaluate if the deltoid needs strengthening. A lot of folks ask, how strong should your shoulders be? We have a lot of really great evidence on bodyweight normalized exercise in the lower extremity. We know the stronger your squat gets relative to your bodyweight, the less likely you are to develop lower extremity injuries. So the stronger a 1x bodyweight back squat, a double bodyweight back squat, stronger, stronger, stronger, less, less, less injury. We don't have a lot of that research in the upper extremities, but I would say that a strong person should be able to press 50-100% of their bodyweight overhead. Now that's going to depend on a lot of things. Training age, right? Somebody that just started lifting overhead six months ago is probably a very long time, like years or decades away from achieving a bodyweight strict press. Somebody that has been training a lot and is close is obviously going to get there a lot closer. But we don't necessarily need to get there with a strict press. Somebody that can push press their body weight, somebody that can jerk their body weight, somebody that can show me a strict handstand push up, that person really tells me that they have really strong shoulders. Arm length plays a big role here. Those of you with longer arms, I know you're listening right now, nodding your head. I'm five foot seven. I have these little T-Rex arms. I don't have a lot of range of motion before my arms are locked out overhead. Someone built like me. isn't actually going to have a stronger press, a stronger handstand push up capacity than someone that is six foot six and their fingertips touch the middle of their fibula, right? So consider that as well. Don't hold people's feet to the fire on that too much. But no, we want to see people getting a strong press, we want to see them move towards a 50% bodyweight press, and then continue to train that as much as possible. We have a number of different tools we can use as well to look for asymmetries in the clinic. I love to just stick with a dumbbell strip press in the front rack. Hey, let's try a five to eight rep max. Let's see if we have an asymmetry. If somebody can't tolerate that due to pain, I love to go to a landmine press and try to find a five to eight rep max there, and then try to see if I can observe any asymmetry. And then we know if we talked here on the past on the Daily Show, to clear up asymmetries, we need to be training the weaker side three to four times the volume. So that person needs to be doing maybe four to five sets of pressing work for every set that the strong side does. So that's always a consideration as well. When we look at ratios in the upper body, we need to understand the upper body is or at least should be a little bit weaker compared to our lower body. Humans are primarily legs. We do have those people out there. You probably all have a friend that has a 400 pound bench press and a 200 pound back squat. They're just built. They're built different, right? They love upper body, skip leg day a lot. But in general, our legs should be stronger than our upper body. How strong? About 40-60, maybe 30-70 at the most. But when you start to get to a ratio of 80% of my strength is in my legs and 20% is in my upper body, we really get into an issue where now our lower body can generate more power than our upper body strength can handle. And so we have some really cool research, Matt Sura and colleagues, 2023 Journal of Science and Medicine and Sport followed swimmers and asked that question in their research. Hey, is there a ratio where lower body strength leads to upper body injury? And the answer seems to be yes, which is really interesting research. So this study followed 48 competitive swimmers across six months. At the start of the study, these swimmers had no pain. Across the six months of training, 20 swimmers developed pain and the researchers testing baselines and reassessments throughout the study wanted to pick up on how can we determine who's most likely to develop a shoulder injury across a season of competitive swimming. And so finding that folks who developed a stiffer shoulder across those six months, worse posterior deltoid range of motion, And those folks who had higher ratios of lower extremity strength to upper extremity strength went on to develop pain. Their legs were able to generate so much power in the water that their shoulders were too weak to keep up. And over time, we're assuming and carrying forward that that led to overtraining essentially of the upper body. We can see that in the gym, with movements like push…

Full show notes at the publisher

Episode 1744 - Myofascial decompression for the deltoid Jun 06, 2024

Show notes

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

In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses when, why, and how to perform cupping to the deltoid muscle.

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

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

EPISODE TRANSCRIPTION

INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How is it going? Welcome to Technique Thursday. My name is Dr. Lindsay Hughey. I am division lead of extremity management along with Dr. Mark Gallant, and I am here to talk to you about a deltoid myofascial decompression technique. So in honor of deltoid week, I want to share just a common technique we'll use. First, I will kind of give a little context of why we would use this technique, and then I'm literally going to show you how we'll do cup placement, and then how we'll follow that up with active movement. So we do passive, and then we actually do a little neuroreeducation to that area.

WHY CUP THE DELTOID? So why we might choose this technique is someone that literally has pain with palpation at that deltoid, baby with abduction, they have a painful arc, and or when you manually muscle test into abduction and or flexion, they have some pain symptoms. So this would lead us to want to do this treatment. In our extremity management course, we usually call this the weak shoulder bucket. A lot of these folks fall under that umbrella. So I actually have an assistant with me today. So Paul is going to come and sit, and I'm actually going to have him sit like this. I usually have the patient either lay in supine, side lying, or prone to do this technique. But for ease of you all to view the deltoid, I want to have him sit, and then we'll have him lay on his side. So we want so just to orient us to the deltoid and I'm going to move this camera just a little bit right so the deltoid actually gets its name because it looks like an upside down delta so if these points all the way down to that deltoid tuberosity by the way to dive deep into the anatomy of the deltoid check out Clinical Tuesday with Ellison Melrose because we are doing all things deltoid this week. And she did a fabulous episode on not only the anatomy, but the function. So take a look at that. But here we're going to target, we want to target the anterior, the medial, and that posterior region. So some people think of this as like clavicle, acromion, or spinal. So what we're going to do is attach our cups to each of those regions and then all the way to that deltoid tuberosity. So I'm going to grab my gadgets. So practical things we need are some kind of lubricant. I'm going to use Free Up today, but it doesn't really matter, kind of your favorite lotion oil that'll help this stick. So I'm going to put a little lotion anterior, medial, and then that posterior, right? Because we have three main parts here. And then we'll go down to this deltoid tuberosity area. So I'm going to use these nice curved cups. These are actually the newest cups from our colleague and friend, Cup Therapy. So Chris DiPrato just came out with these and his team, and they are awesome for suction. We really, by the way, love myofascial decompression because it's really the only thing we have that really offloads tissue versus like our dry needling, our exercise, our massage, our wonderful treatment adjuncts. but they're compressive in nature. So sometimes this decompressive technique is just a novel stimulus to help that muscle relax and move better and activate better.

CUPPING THE DELTOID So I'm going to start with that middle portion and I want For muscle, we usually want about 300 to 600 millimeters of mercury or pressure taken off. And there are gauges that pumps that actually show you that pressure. This is just a standard pump today, but just to keep that knowledge in your back pocket. And then we're going to go posteriorly. So again, I want to make sure lotion is there. I'm going to attach here. How are we doing, Paul? Such a good patient. Such a good model. And then we're going to go anterior. So I'll just kind of shift my body so that you all can see that. Again, we're pumping up. We try to get enough besides that 300 to 600 millimeters or mercury, but enough that they don't pop off. And if this do pop off during this demo, we'll just reattach. And then finally, down here, a little bit more lotion. And then we'll pump. We're getting a little slidey there, doing OK. Sometimes you're doing OK. Sometimes hair gets us, and we might. User error is always fun, too, when your hands are sliding. I'm just going to change this out. Here we go. That one, we needed to go, I think, a little bit smaller. That one was a little too big for the surface. That's why there's different size cups. OK. To visualize, we have anterior, medial, posterior, so we're hitting all parts of that deltoid. And then we're trying to sink into that deltoid tuberosity. For our treatment, I'm going to have Paul lay in sideline, so that shoulder is up. First part of this, and I'll just adjust the Instagram camera a little bit, is we're going to do some passive movement. So we're never just having the patient sit with the cups and doing nothing. It's very rare that we would just let this be a static treatment. So I'm going to take Paul's arm, and then I'm going to move him into all the motions that the deltoid produced. So that anterior is more flexion, internal rotation, abduction for that medial and then posterior contributes to extension and external rotation. So I'm gonna move in and out of all those positions. So I'll demo just a couple of those and then the next part is let's let the patient own this movement with some neural re-education. So then Paul will do those movements and I'll show you our favorite sideline trio for that. So I'm going to flex him and I'm moving my body with this. And then I might mess with a little bit of internal external rotation. And when you're up close to the cups, what you see is some pumping on off of that tissue. And I'll do just a couple more of these. And then I can even abduct. A little bit for Paul on off, and I would spend like a minute or so kind of going off on off and deflection, internal external rotation. I might even go into a little bit of extension. And then I want him to do some of these movements. So I'm going to go from behind to direct Paul and get out of your way. But one of our favorite things for the weak shoulder and to really light up that deltoid and even the cuff, because we know they work together in upward elevation, is we're going to do external rotation. Elbow straight, do flexion, come down, and then go to 90 and do horizontal abduction. So we're hitting all parts of that deltoid and the cuff with this movement. And we'll have Paul do a few of these reps unloaded, but then I'm going to give him a change plate, and I'm actually going to have him load this up. And probably the hardest part is just remembering all the movements. It doesn't quite matter what order you do it in, but what matters is kind of targeting all the different areas of that beautiful deltoid muscle. So go back to external rotation, and this is just like a real patient, right? There's going to be some error in each movement. Again, it doesn't matter necessarily the order. And then horizontal abduction. To make it a little harder, we're going to go ahead and give him a weight. So he's going to go ahead externally rotate. I'll just guide him through those first reps, elbow straight, go ahead and flex. Meanwhile, the pods are still attached, offloading that tissue. He'll come back to 90 and then horizontally AB duct, right? And then we'd give him a sweet spot. You can go ahead and relax. A sweet spot, what we call an extremity management, the rehab dose because we are targeting local tissue. So our rehab dose is anywhere from 8 to 20 reps, 3 to 4 sets, and we're taking a rest break of about 60 to 90 seconds. And our intensity varies from 30% to 80% depending on tissue irritability. But we've done this out.

SUMMARY So some key things, we apply the cups, right? But then we actually move the human passively. Then we have them actively do the thing, neuroreeducation. And then finally, we take the cups off. And what we would do is reassess one of those things that blipped an exam, whether it was palpation, whether it was that presence of a painful arc, and or our manual muscle testing to see, did NPRS change with our palpation? Did painful arc, was quality of movement improved, and or NPRS, less pain associated with that elevation? The other thing, one little other pearl I want to share with the cups. So we remove the cups and then we'll massage that area a little bit. But what's neat is you can even take some pressure off. I'm taking this last cup off, but I can reduce the pressure a tiny bit and I can end with like a sliding technique where there's a little bit of offloading still present, but we're sliding along that tissue. for overall treatment dur be more than like 3 to 5 technique. And what's neat asterix very quickly. And pain. The motor bands tha immediately are a little and then they're able to elevate their arm better. And so this quick and efficient technique is one that I would really encourage you to use with your folks that have any deltoid and or cuff issues. You've heard me throw out some terms today regarding weak shoulder, the rehab dose, and the sideline trio. These are all terms that are really common to our extremity management course. So if you haven't taken it yet, Mark and Cody and I and our team to see you on the road an offerings. If you check u dot com in the summer. So in Salt Lake City with Ja and 14th will be in Kent, Washington again. And then July 20th, 21st will be in Hendersonville. So Cody will be there. That is bound to be a blast with that Hendersonville crew. And then it keeps on coming. We have another course in July, Bend, Oregon. So a lot of West Coast opportunities. So my West Coasters join me. I will be doing all those West Coast courses. And then we have more offerings in August. So you can't miss us. Thank you for joining me on Technique Thursday to learn a little bit more about the deltoid. And thanks to Paul, my patient who always looks like he's sleeping, but he's actually awake and with it. I hope you all have a beautiful day. Take care.

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

Episode 1743 - Permission to succeed Jun 05, 2024

Show notes

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses three tips to give older adults permission to succeed in physical therapy: acknowledge their concerns, craft experiences that ensure success, and focus on belief change. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. JEFF MUSGRAVE Welcome to the PT on ICE daily show. I'm going to be your host, Dr. Jeff Musgrave. This podcast is brought to you by the Institute of Clinical Excellence. It is Wednesday, so it is all things older adults. So excited to be here with you today. So even if you're not treating primarily older adults, I think you're gonna find a lot of value in today's topic. So today's topic, we're gonna be discussing permission to succeed. So this is very common in the older adult space, but you're gonna see this in lots of different populations that you're gonna be treating. where because of the interactions that older adults or any of your patients on your caseload have had, they've got a very negative outlook on their ability to recover, their ability to return to the things that they love. I've seen this across acute care all the way into the fitness realm. and especially people when they first come to us in the fitness realm for training as older adults in stronger life, they will need some encouragement. They will need some reframing of what is possible and reframing of how they see themselves. So I believe that you will not get the person physically if you do not first get them mentally. You have got to build that confidence in between their ears. They've got to see and understand a path forward before you're going to get the body on board. So I would love to share with you today some tips to make that just a little bit easier. I think a quote that really sets the stage for this discussion is from Dr. Justin Dunaway. We love to quote him in the older adult division and one of our favorite quotes of his is, beliefs and expectations are the foundation upon which outcomes are built. Beliefs and expectations are the outcome are the foundation upon outcomes are built. So we really have to believe that it's possible. We've got to know our patient's beliefs and we've got to set the stage for them to be successful. So, because our older adults have heard, you've got the worst case of, insert diagnosis, bone on bone, you've got degenerative disc disease, they've heard all these nocebos or noxious language that strikes fear in the hearts of our patients. Whether they're older adults or not, you're going to see this in younger populations too, but we see it a ton in our older adult population. So I've got three tips for you today to try to help move patients towards a mindset that's going to allow you to be successful. ACKNOWLEDGE CONCERNS So the first one is acknowledge. You need to acknowledge their concerns. Our older adults come with some baggage typically. They've lived more years, more decades, they've had more injuries, and oftentimes they've been told more negative things than our younger patients. They've been told You can't get better, or you'll never do X, Y, or Z again. Jog, run, swim, lift heavy things, insert the favorite activity that they love that is part of the reason they're living their life. This happens all the time, unfortunately. So, we need to hear those concerns. If it looks like we're running into a barrier where they think they can't do what your job is to help them do, we've got to ask some clarifying questions. We need this information anyway. Why do you think it's not possible for you to fully recover from this back injury? Is it a bad experience with physical therapy? Is it negative expectations that have been set from another provider? Is it an experience a friend or loved one had? And then you get the opportunity to find out what was their bout of care like? What type of treatment intervention were they getting? Was it even appropriate? Was it the right movement? Was it at the right intensity? Was it across the right duration? Was there such a huge disconnect between what they actually wanted to do and what they were being asked to do? that they didn't see the connection, they never did their home exercise program. There is so much we need to know about why they have the negative outlook that they have. And then you get the opportunity after hearing everything, because if you cut them short in this phase, you will not get them. If you don't hear all their concerns and why, you can't give them the information they need to help them bridge that gap from I can't get better to oh, maybe I can get better. You don't have to completely change their mindset in one or two visits. Unlikely you'll be able to do that anyway. What you need to do is inspire some curiosity. You need them to be curious about the possibility of getting better. If you can get them from, I don't think it's possible, to now I'm curious, you've cracked the door open and created just a little bit of hope. you may be wildly successful with this patient. So, once you've heard everything, you get the opportunity to share some success stories. And you can say, man, I hear you. I know you've been told by this provider, and I can understand based on what you've seen, based on your imaging, based on your past experience, why you would be concerned that maybe you can't overcome this. but I've seen people in your condition with this diagnosis at your age, maybe even older, maybe even less healthy than you, get over this. It's gonna take time, it's gonna take hard work and consistency, but man, how would your life be different? If you could bridge the gap to a full recovery, what would you do differently? How much better would your life be? Let's just be curious. We've got time together. Let's do this thing. So I would call that step one. Acknowledge their concerns, ask clarifying questions, share success stories. have to do that first. Let them get it all out. You want to know every objection they have so that you can tell them why they don't need to be concerned about that. CRAFT EXPERIENCES THAT ENSURE SUCCESS The second piece, your job is to craft. Your job is to craft experiences that ensure success. There are two ways that we commonly do this with older adults that I assure you work with younger adults as well. The first one is make it laughably easy. In the older adult division, we call this intentional underdosage. This could be because someone is fearful, This could be because someone just has very low confidence. This could be because they're in unfamiliar setting or they've never done any weight training before. You're getting to set the stage for them. And you can do that by building successful reps. You want to make it so easy there's no way they can fail. Ramp it up a little bit. Let them be successful. Oh man, that's awesome. You're stronger than I thought you were. Ramp it up a little more. Ramp it up a little more. But what you don't want to do here is get greedy. If you get greedy as a clinician, I've done this several times, where you're like, man, I think they can actually deadlift 100 pounds, let's see if we can knock that off the list on day one deadlifting. And then they get scared, they get fatigued, or maybe you just misjudged it, and they can't lift that up, and now you've ended on an unsuccessful rep. You've shot yourself in the foot. So when you make it laughably easy, you intentionally underdose, make it easier than what you know they can do, you want to stop short of their maximal capacity. typically on that first visit, unless you're calculating an estimated one rep max, which is a whole nother topic. If you're already familiar with estimated one rep max testing, that is not the same as intentional underdosage. We're talking day one, building confidence, okay? So that's how we're going to, that's the first way we can craft an experience to ensure success is to intentionally underdose. The second thing that we're gonna do is test retest. We're going to show them that we can be successful. We're going to identify the asterisk sign, the comparable sign, whatever you want to call it. Doesn't matter. Especially when the primary concern is pain. Often with older adults it's function, but sometimes it's still pain. So I don't know, you know, the reason I'm here is because I can't get my arm up into the top cabinets anymore. I get shoulder pain. I get stuck. It hurts. Your job as a clinician, after you do your assessment, you figure out their range of motion, their strength, you've done a solid subjective, you ruled everything out, you've got a pretty good idea of what's going on, you're gonna give them some treatment, and then you're gonna retest, right? You need to make it very clear, you need very accurate measurements, and you need to tell the patient, here's where you got to. Man, that was about here, wasn't it? and make it really clear to them. You want them to remember that first measurement because what you're going to do is you're going to make them better. You're going to use your voodoo, right? You're going to throw your darts. You're going to do some manual therapy. You're going to do some exercise. You're going to put all those components of a solid treatment together and then at the end, you're going to knock their socks off, right? They thought that their shoulder could never get better. They've already been to PT several different times or it's been 10 years since this has been going on and you're going to show them. You're going to crack the door open on a successful recovery, just enough to at least make them curious. Test, retest. So when you craft that experience, you've got two solid options here. You can Intentionally underdose, if you're looking at a strength or a functional goal, or you're gonna use test, retest. Make it very clear, be very accurate on both measurements. Make it super clear, make sure it's your asterisk sign. You're gonna show them success. You're gonna give them the experience of being successful when they walked in the door and thought they could not be successful. FOCUS ON BELIEF CHANGE And then the third thing, once you've done that, you've still got work to do. You've got to focus them. You're going to have to focus them. You're going to have to refocus them throughout the entire bout of care. These beliefs go deep. They've been going on for a long time. You're going to have to chip away at those across the entire bout of care from the first interaction to the last one. Okay, especially if these beliefs have been long standing. So once you, the bedrock of changing their beliefs is giving them a successful rep and then reminding them of that success. You would think it would be obvious. There are so many client interactions where I did not do a good job of sharing. Remember, here's where we started. You can only slide your hands down to your knees when you came in and you had searing pain down your leg. And then they're at mid-shin, or maybe almost they're touching their ankles in the first visit. When that is their comparable sign, they're like, oh no, I moved that much. like you absolutely did not, but I did not make it clear enough what was going on at the beginning to show you how you progressed. So you need to make that painfully clear. After that, you need to remind them of their progress. Each visit, remember where you started. Remember where you started. The first day you walked in, you thought that it was going to be impossible to lift up this 10-pound weight from an elevated surface. You looked at that weight. You stared at it. You looked at me. You looked back at the weight. You were like, this is not happening. And then what happened? You walked up, you moved that thing. You got several reps. We even got up to 15 pounds that first time. You didn't think you could do 10. You thought that was out of reach. Now you're lifting 30 pounds. 30 pounds. You have had a 300% increase in your functional ability. Incredible. Now you're doing it off the floor. Think about how that opens up your life. How many things in your life weigh 20 to 30 pounds? Now you're doing it for reps. Think about all the things you can do now that you could not then. And the reality is, our patients aren't gonna have this nice, linear progression. So the third step on focus is going to be to share with them, these are a couple of my favorites I like to use, is progress is non-linear. We like to think it's just going to go up and up and up and every visit is going to be a smashing success. It's going to be the most you've ever done. It's going to be incredible. But that is not the case. We know that it's more like a good stock in the stock market. A really solid stock has got down days. and your patients are going to have down days. Medically, especially with older adults, they tend to be more medically complex. If you've got a progressive neurological condition, you've got someone with MS, and they're going through an exacerbation, there may be two weeks where there's flatline progress or reduction, but if it's still above where they started, you need to highlight that. Yeah, but we're not where we started, and we know this is going to end. And then we're going to start climbing again. And when we back up and look at this picture, it's going to be off the charts. When we back up, we've still got a solid line going up that day. So the other quote is, every day is not going to be your best day. Come in and give me what you got. That gives our patients permission to do what they can. And sometimes that is enough to crack the door open on a really solid recovery. I love this quote. Now, I…

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Episode 1742 - The deltoid: form, function, and clinical application Jun 04, 2024

Show notes

Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling faculty member Ellison Melrose discusses the form & function of the deltoid muscle, as well as clinical applications for dry needling to the deltoid for different patient populations. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling, Lower Body Dry Needling, and Advanced Dry Needling. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to Jane.app slash switch. And if you do decide to make the switch, don't forget to use our code IcePT1MO at sign up to receive a one month free grace period on your new Jane account. ELLISON MELROSE Good morning, PT on Ice daily show. We are live on YouTube and on Instagram. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of Ice. I'm super excited to be here for deltoid week. So I kind of compare this to like the sharp week from childhood, right? So this is the most exciting week of the year for us. Um, we are here to talk all things about the deltoids. So we came off of yesterday. Jess, um, started talking to us about the importance of deltoid strength during motherhood and how we can maybe implement some deltoid strengthening in some um, early postpartum period, right? Using more of like a hypertrophy style training versus, you know, diving right into things like CrossFit right away. So that was really awesome. Um, I'm here to tell you guys today about the form function and some clinical applications of deltoid strength. So let's dive right in. Um, if you have been to an upper quarter course with either myself or Paul, we spend a few minutes just on the deltoid side, just talking about how cool the deltoid is. THE DELTOID: FORM So let's start with form, right? So if we look at the deltoid, there is no other muscle in our body that is shaped like the deltoid. Some may compare it to the glute, the glute max of the lower quarter width, you know, how it kind of spans that, that joint and has multiple origins to the single point insertion, um, similar to the glute max. But if you actually look at the deltoid, the origin is almost a full circle, right? So it's about 300 degrees of, um, contact with our, lateral third of the spine of the scapula, the lateral border of the acromion, and the lateral third of the clavicle. So it's about 300 degrees to a single point insertion at the deltoid tubercle. Right? That's like really, really cool. There's no other muscle in our body that does this. This allows us to move in multiple planes of motion. And we'll talk about the function in a little bit more depth later. But just by looking at it. There's nothing else like that we have in our body. Next, we have its innervation, which is also fairly unique, right? So the axillary nerve, its number one job, let's see, its number one job is to provide a motor response to the deltoids. I'm having a little bit of issues on Instagram, We'll come back, we'll just keep it going here on YouTube. So, its main motor branch is to the deltoid. It does innervate teres minor, but I would argue that's probably the smallest muscle we have in our shoulder girdle. And likely the most important part of the axillary nerve is its motor contribution to the deltoid. So if we did not have an axillary nerve, what would that look like in the shoulder girdle, right? That would look like a significant sulcus. So we would not be able to use any of the other muscles in the shoulder girdle without the axillary nerve. Next, we have different regions of the deltoid. So we have the deltoid can be separated into three primary regions, right? We have anterior deltoid, we have middle deltoid, we have posterior deltoid. Well, in 2010, what they found, there was a study that looked at those compartments and what they found was there's actually a further fascially subdivided region in both the anterior and the posterior delt. So each of the anterior deltoid and the posterior delt, each of those have three separate fascially subdivided regions. Really cool. What they also, another study looked at was the EMG activation throughout the deltoid. And what they found was there's at least six differentiations with EMG activities. So we have those fascially subdivided regions can be turned on and turned off, maybe independent of each other, which allows us to maybe think about the function of the deltoid a little bit differently. Right? So our form, we have a very unique origin and insertion. We have a very unique innervation with only a single nerve. And that's main job of that nerve is to innervate the deltoid. Our brain perceives that muscle as really important when things, when we have one nerve and its main job is to just provide motor function to that muscle. So it's super important. We also have the form as the we can divide it further from those original three divisions that we kind of think about back in PT school to seven different subdivisions that we may be able to activate, turn on and turn off independent of each other. THE DELTOID: FUNCTION So let's dive into the function, right? There are four main functions of the deltoid. The first is it's a mover, right? And that's what we think about when we think about the deltoid. We think that it moves into flexion, abduction, extension, internal rotation, external rotation, right? It's a mover in our primary planes of motion. It can also fine tune movements, right? So now that we know that like the deltoid has all of those subdivisions and we can maybe recruit those independent of each other, we can fine tune specific movements. It acts as a synergist with other primary movers in different planes. For example, the posterior deltoid is a great synergist with infraspinatus. We're thinking about, you know, end range external rotation or external rotation in that abducted position. The deltoid may be able to help or maintain that movement pattern and act as a synergist with the infraspinatus. Really cool stuff. So it's a mover. It's also a stabilizer. So I mentioned earlier that if we had an axillary nerve lesion, that would look like a detrimental sulcus sign to the glenohumeral joint, right? So the deltoid, when we think back to PT school, we were like, I at least put a lot of emphasis on the bicep tendon, you know, maintaining its humeral head placement, the rotator cuff, fine-tuning those movements so that it stays in that ball, the humeral head stays in the glenoid fossa appropriately. But if you took away the bicep tendon, right? People do that all the time. We have biceps tenodesis. We still have a functioning shoulder, right? If you took away the rotator cuff, we see that a lot. People have full thickness tears of specific rotator cuff muscles, and they still have function of their shoulder. If you took away the deltoid, you would not, right? you would not have the ability to use the rotator cuff, to use the bicep tendon, to do their primary movements. So it is a stabilizer to the glenohumeral joint. It almost provides an accessory like suction to that labrum to help maintain that humerus in the glenoid fossa. It also provides stability to other joints in that area. So if we think about where it crosses, it spans the AC joint. There's only one other muscle in our body that spans the AC joint, and that's the upper trap. So when we think about if we have damage to the AC joint or our passive structures have maybe been or have been impaired, we have an active stabilizer in the deltoid and the upper trap that cross that AC joint. So again, deltoid strength may be able to help maintain that stability in the AC joint when some of those passive structures have been lost. So it's a mover, it's a stabilizer. Next, it's a cushion. So we don't really think about this often when we think about muscles, but muscles cushion the bones, right? So they cushion the bones, they protect some higher, more sensitized structures in the region. And in this region, in the axillary region, we have brachial plexus and all of its branches exiting the axilla. So we have some very important neurovascular structures close by. So what could be very detrimental to those tissues would be a proximal humeral head fracture. So what the deltoid can do is it can cushion or kind of dampen the blow to a blunt trauma to that bone, which may help reduce the impact, and reduce the likelihood of a proximal humeral head fracture. So really cool stuff. So we're thinking maybe patient populations, that would be beneficial for. And we'll talk about that in a second. So it's a mover. It's a stabilizer. It's a cushion. Last but not least, it's a pump. A lot of what we do in physical therapy, we're just pumping fluid. Our goal is to reduce chemical irritation in that tissue. if we have pain, for instance, right? So we need muscles that help facilitate hemodynamics. When we look at the upper quarter, one of the best muscles to do that is the deltoid, not only by its pure mass, but its capillary density. So it has a higher density of capillaries, which helps with it both, you know, the hemodynamics and the perfusion in that area, but also its proximity to the lymphatic axillary watershed. and just the venous structures, right? So if we think about our venous return coming up into the axilla, all of those things are very important. And when we look at research that was surrounding lymphedema and edema reduction in the upper quarter, what they found was that the deltoid plays a key role in edema evacuation from that upper quarter. So function, right? We have, it's a mover. Not only is it a gross mover, but it's a fine tuner. It's a stabilizer. We would have no upper quarter function without the deltoid. It is a cushion. So it can provide some cushioning for any trauma that occurs in that upper quarter, which is going to protect some of those more sensitized structures we have in this area. And it's a pump. We're pumping fluid, right? So it can help with edema reduction, any sort of acute injury in the distal extremity, not only thinking lymphedema, but also thinking like acute injury. Maybe we don't want to target those tissues. Speaking specifically from a needler, maybe we don't want to needle the tissue that's the issue because it's in an acute inflammatory stage. We want to think proximally. What can we do proximally? we can needle and stem the deltoid, which may help with that fluid dynamics. THE DELTOID: CLINICAL APPLICATION Lastly, I want to talk about three different patient populations that may be beneficial to think about improving the robustness of the deltoid. I'd argue that every single patient population could benefit from a more robust deltoid. But when you look at the research, First, let's talk about operations. So shoulder surgeries. When you look at the research, the deltoid, the strength and mass of the deltoid is one of the number one predictors of a positive outcome from both rotator cuff surgery and something like a reverse total shoulder. So no matter what the surgery, what they're finding is that if you have a stronger deltoid going into it, you have better outcomes coming out of it. Right. So say we had a patient who, you know, they've come, they've been seeing us for a few months, conservative methods of rotator cuff for rotator cuff tissue healing. Right. And they're like, you know what? I'm still in pain. I think I'm going to get the surgery. And you're like, great. Let's keep hammering that deltoid. Right. You have six weeks until surgery. Six weeks is a great time for some progressive overload, some hypertrophy and strength building to that deltoid. It's only going to set you up for more success post-op. So I believe Paul will be putting out some research for that or a post about post-operative implications with deltoid strength today. So look for that on Instagram. Next, we have our hypermobile shoulders. So when we think about shoulder instability, may have had some recurrent subluxations or have had trauma to this area where some of those passive structures have been stretched or maybe aren't doing the job that they were meant to do, right? When we think about the detrimental effect of not having a deltoid, not having the ability to maintain that humeral head in the glenoid fossa or at the glenoid fossa, like how detrimental that can be to upper quarter function. We know that strengthening the deltoid, or we should know, we should implicate that the strengthening of the deltoid would significantly improve their tolerance to loading that shoulder girdle, right? So we kind of, you know, you think about, we're always hammering people with rotator cuff exercises. And sometimes I think we forget about the big guy of the deltoid. because we don't necessarily contribute that to maintaining that glenohumeral joint support, right? So we're thinking pre and post-op, we're thinking shoulder instability, and last but not least, we're thinking our older adult population. So this is going to kind of follow into tomorrow, where we'll have the older adult division diving into the importance of deltoid strength in that older adult population. But let's speak a little bit to the research. So as we all age, we know that we have some sarcopenia that typically occurs, right? So we have a little bit of change in our muscle mass. And when we look at independence in the older adult population, one of the things that helps folks maintain their independence is being able to lift things overhead, right? Their overhead capacity. So deltoid not only does that movement, but as we age, what we find is we have a shift in fiber type or maybe mass. And we'll talk about that gender specifically. So males, as they age, they don't necessarily see significant atrophy in the number of fibers or the overall size of the deltoid. But what they do see is they see this shift from type 2 fibers to type 1 fibers. So we have atrophy of type 2 fibers and more preferential activation of type 1 fibers, which is going to limit their power producing ability in the upper quarter. Females, it's a little bit different. We don't see that shift in fiber type, but what we do see is we see general atrophy, right? So we see loss of muscle mass in the deltoid, which is significantly going to impair their independence with that overhead movement. Don't want to steal too much of that for tomorrow, but three main patient populations that may benefit from a more robust deltoid, pre and post-op, hypermobile or instability, and then the older adult population. SUMMARY So today we kind of dove into all things form, function, and clinical application of the deltoid. Hopefully we can get this p…

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Episode 1741 - Deltoid week: pelvic floor edition Jun 03, 2024

Show notes

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses the role of the deltoid and upper extremity strength in pregnant & postpartum moms.

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

INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

JESSICA GINGERICH Good morning, PT on ICE daily show. My name is Dr. Jessica Gingrich and I am here to kick off deltoid week. So if you are wondering what that is, the faculty have come together and we are going to take this week and we are going to talk about the deltoid. This is gonna be a really fun week. We are going to learn just how to assess it better, how to use better pain management strategies, and really ultimately how to load the deltoid better and just treat shoulder pain differently. Now, we are coming hot off of semifinals over in Knoxville. We had wonderful, also Monday, here's my dog again, if you can hear. Olive with the trash guy We are coming hot off of semifinals where we watched Tia Claire to me dominate That was really cool You know, there are other athletes out there Haley Adams. I'm wearing her shirt today I mean coming back and just in just doing such a phenomenal job, but Tia crushed it and that was really cool to see her coming back postpartum So we're going to take today and we're going to talk about the deltoid and the pelvic floor. I know you guys are probably like, I'm sorry, what? How are you going to put that together? And you know, I a little bit thought that as well because we're not going to palpate the deltoid and then bring on pelvic floor symptoms likely. So the deltoid, we know abducts the arm. It's going to flex and internally rotate with those anterior fibers and it's going to externally rotate and extend with the posterior fibers. We want to make sure that we can take this muscle and maximize it for motherhood. So we are going to further break down the pelvic space with the deltoid, and we are going to bring this into the pregnant and postpartum space. Motherhood is a journey. I'm not yet a mother, but I treat moms every single day, and I see the different pieces that they have to do, the challenges that come with it. We have new tasks, right? Like tasks that look different than when we were before a mom. Getting back to exercise, a lot of the times is a massive goal of a lot of people. We're starting to see pregnant and postpartum people just infiltrate exercise, like the exercise space. And that's so fun to watch. So we are gonna first break down and talk about pregnancy. PREGNANCY: A PERFECT TIME TO BUILD STRENGTH So pregnancy is a wonderful time to build strength. A lot of times we have moms who don't feel great all the time, especially further into their pregnancy, getting their heart rates up. In doing these metabolic conditioning pieces, going on long runs, they don't necessarily feel great all the time. Some moms do. But we can take that time and we can bodybuild. and we can hit a strength piece and then we can sit down and rest for three minutes and maybe that rest for three minutes is also the same time as giving our baby some attention. So things that we can do in the pregnant time is work on things like push-ups, bench, elevate the bench if you have to, go down to your knees for your push-up, elevate the push-up. overhead press, variations of overhead press, whether we're doing a push jerk, a strict press, a Z press, a bent over row, hitting those posterior delts, and then even doing things like a front rack hold or a front rack carry. These movements are going to mimic a lot of the movements that they're going to have to do postpartum or they may already be doing if they have another kiddo at home. So in pregnancy, focus on setting the foundation for upper extremity strength. Breastfeeding, bottle feeding takes up so much time. Sometimes that time is valued and sometimes it's not and that's okay. Sometimes that's very frustrating. Let's prepare mom so when she's breastfeeding or bottle feeding every two to three hours that she doesn't come in and she's like oh my neck and my back hurt because we're building that strength. So now we're going to switch and go into the postpartum space. The postpartum, we have this with a zero to two weeks is our healing timeframe, right? We aren't doing a push jerk at 70%. So maybe we're doing things like stretching the posterior delt with a sleeper stretch. loading the delts with banded I's T's and Y's, stretching the anterior delts and the pecs with a doorway stretch, and then doing some banded pull aparts. And maybe we can incorporate that after every feed, or maybe if that's too much, can we do it at least once a day to help utilize these muscles to decrease back pain and decrease neck pain? So, we're gonna dive further into this week with other divisions, so extremity, dry needling, where they're gonna talk about pain management strategies. So using dry needling techniques, soft tissue, cupping, joint manipulation, and other loading strategies to help load the deltoid, make the deltoid feel really good, and incorporate this into your moms, into your pregnant women. help them. You look at them as a whole body, not just pelvic floor because that's rarely what it is. So, if you are thinking about taking pelvic courses, head over to PTOnIce.com. We've got our live course, our L1 online course, and then we've actually recently added a third L2 at the end of the year due to high demand. So if that is something that you are or that is on your list, head on over and check it out and we will see you at 9am tomorrow.

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 1740 - The SAID Principle May 31, 2024

Show notes

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the principle of Specific Adaptations to Imposed Demands (SAID), the principle of Somewhat Humdrum Adaptations to Rehab Treatment (SHART), and how to help patients & athletes reach & meet specific goals. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. ALAN FREDENDALL Good morning, PT on ICE Daily Show. Happy Friday morning. I hope your day is off to a great start. Welcome to the PT on ICE Daily Show. It is Fitness Athlete Friday. I'm your host, Alan. I currently have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader in our Fitness Athlete Division. We're here on Friday, Fitness Athlete Fridays. We talk all things CrossFit, Functional Fitness, Endurance Athletes. If you have a patient or client who is active on a regular basis, Fridays are for you. We have an exciting announcement next week you'll see on our social media. An entire week, thanks to dry needling faculty member Paul Killoren, an entire week dedicated to the deltoid. So you'll see the podcast next week, all the episodes will be about the deltoid, and you'll see all of our social media posts next week focused on educating you, everything related to the deltoid muscle. If you've taken our upper body dry needling course with Paul, you know that he has quite the obsession with the deltoid muscle. So we're really excited to see just how much shoulder content we can give you all next week. So tune in beginning June 3rd for an entire week of deltoid themed content. Today, the topic for Fitness Athlete Friday, what are we talking about? The SAID principle, specific adaptations to impose demands. You may have heard of this principle at some point in your life. You probably heard a very generalized definition of this term that maybe did not really help you understand what it is or how it could possibly apply. to exercise or to clinical practice. WHAT IS THE SAID PRINCIPLE? So the SAID principle, really, again, very basic definition that training a particular movement pattern, training a particular skill, training a particular time domain or energy system will result in the most efficient adaptation to that imposed stimulus that imposed demand on the body. And when we uncover, when we unpack the definition of the said principle a little bit more, we talk about actually the two ways that we see changes from this. The first being structural, that we see muscle size and shape takes place, and the other being neuro or neuromuscular, that we get a more efficient recruitment of muscle fibers, that we're able to recruit more fibers, larger fibers, recruit them in a more efficient sequence, so on and so forth. So that's the said principle in a nutshell. Today we're gonna talk about why it matters, give you a practical example from the gym, give you a practical example from the clinic and kind of wrap up why maybe we need to reconsider this. Maybe if we did learn this back in high school or undergrad or grad school or maybe all of them, maybe why we need to consider this more often in our practice, whether we're working with patients in the clinic or athletes out in the gym or a more active setting. So when we interact with folks in the clinic, whether they're patients for physical therapy, whether they're athletes coming to us maybe even for performance help, they don't necessarily need help with a physical therapy related issue. They come in and they may complain about a plateau about not making progress with their physical therapy about not making progress with their performance in the gym in their running plan or whatever. And if we take the time to unpack, and if we take the time to assess a couple things, what we usually find with these folks is they seem to be at a plateau, but it's really because they're not doing things specific enough to create the adaptation that they're wanting from the stimulus that they're giving themselves. Their rehab exercises, their exercises in the gym, their strength training, their endurance training, whatever that might be. WHY DOES THE SAID PRINCIPLE MATTER? And so why does the said principle matter? Training similar things may result in some carryover, but people I think fail to understand that it won't result in the most efficient, time-wise, in the most efficient carryover to develop a specific skill, a specific movement pattern, a specific progress towards a goal. So we often say, hey, well, doing a bunch of strict pull-ups make you better at strict pull-ups. Yes, of course. Will doing a bunch of strict pull-ups make you better at free climbing El Capitan? Well, there's gonna be some carryover, right? But probably the best thing to do to get really better at free climbing is to do free climbing. And arguably, we would say and not or. The best thing to do would be to practice the thing you want to get better at and then do accessory stuff like strength training to further enhance your way onto goals. We see this a lot. In the gym and CrossFit, folks always complain about not being great at running. We do run in CrossFit, but often lower volume, shorter distances than someone who would consider themselves a runner would consider running. And so when folks want to improve their 5k time, or they want to run a 10k or a half marathon, or maybe even become a marathon runner, They often say, I'm not getting better at running. And when we ask, okay, how often are you running? And they say, oh, well, I hate running. Running bothers my shins. So every time there's running, I just row or bike. Again, is there going to be carryover from rowing or biking or doing some other cardiovascular modality to running? Yes, of course, but not as specific, not as great as if you did running training to improve your goal of getting better at running. There are certain things that happen when you run more, You get an improved running economy. You get more efficient in that movement pattern because you're spending time in that movement pattern. And yes. We can get cardiovascular adaptations from rowing or biking, but it's just not gonna translate 100% to that specific thing. So that is why the said principle matters. PRACTICAL EXAMPLE: "GRACE" When we look at our practical example in the gym, we just had a benchmark workout last week at our gym called Grace. You may have heard of this CrossFit benchmark workout. 30 clean and jerks for time at a standard barbell weight of 135.95. And talking to members that day, people asking, hey, like, what is the world record on this? Do you know? I do know it's it's 59 seconds, right? With some people completing it, CrossFit Games athletes under 90 seconds. And so the conversation began, okay, If this takes me eight minutes, and it takes them 90 seconds, what is the difference between them and me? And I think a really lazy answer when people want to improve their performance when they want to break through a plateau, whether that's in the clinic, whether that's in the gym is well, they're just in better shape than you, right? That's a very lazy answer. When we break down why is that person better at doing that workout than you, we can start to unpack some characteristics, some specific characteristics of why their performance is higher than yours. We look at somebody like Matt Frazier, five time CrossFit Games champion, a minute 18 clean and jerk, grace time 30 clean and jerks for time, which is faster than a clean and jerk every two seconds. So moving fast, moving unbroken for 30 clean and jerks, what do we know about that athlete? Again, the lazy answer would be, well, he's been doing CrossFit a long time and he's just in better shape than you. Yes, but why? And the why matters, the specifics matter because that can turn into a training program for a person who wants to maybe cut 15 or 30 seconds off their grace time. or cut time off their 5K, or get better at strict pull-ups, or rock climbing, or whatever, right? When we look at Matt Frazier, why is he better at that workout? A long history of Olympic weightlifting, very familiar with a movement like the clean and jerk, very efficient in the clean and jerk, very strong, not only in the clean and jerk, but the movements that support the clean and jerk, the front squat and the strict press, an athlete who can strict press above his body weight, an athlete who front squats several times his body weight, and an athlete who has a 425 pound clean and jerk, right? So when we look at 135 pound barbell compared to a 425 pound clean and jerk, a 500 pound front squat, a 250 pound strict press, we say, okay, this is a very strong individual and specifically related to things like the SAID principle, he is very well trained in this specific movement pattern. It makes sense that because this is an incredibly light barbell for him, but he can hang on to it for 30 reps, move it touch and go unbroken, and get that workout done in 90 seconds that might take you five minutes. Why? You don't have as strong of a clean and jerk. You don't have as strong of a strict press. You don't have as strong of a front squat. You aren't as efficient at cycling that barbell because you have not been doing CrossFit as well. And in specific, we also look at time domain, right? He is getting a workout done while he is still in the anaerobic glycolysis time domain. He still has a lot of high power output. versus when you transition, when it starts to take you more to two to three minutes, we know your power output goes down. We know you're transitioning into your aerobic energy system. He's getting it done because he's more efficient at it before he runs out of gas. And so, how do we take that and translate that to a training program for that athlete? Well, of course, we need to work on your front squat. We need to work on your strict press so that your clean and jerk gets stronger. We also need to train your clean and jerk so you get more efficient at clean and jerks. We need to train your clean and jerk where you do touch and go reps at a light to moderate weight so you get efficient in the endurance of the clean and jerk, not just the strength. And we need to train a very fast, explosive time domain for you, right? That is a great athlete where we might say, hey, every minute on the minute, I want you to do five clean and jerks, seven clean and jerks, 10 clean and jerks, progress it and make them work in the time domain in the movement they want to get better at, right? This is what endurance athletes do all day long. They progress their volume, they progress their time domain, and they get very specific in what they're doing, right running, biking, swimming, maybe all three of those, maybe just one of those, but spending a lot of time in the movement pattern you want to get better at spending a lot of time in the time domain you want to get better at. THE SAID PRINCIPLE IN THE CLINIC Switching gears, we see this happen in the clinic as well. Just like somebody is plateaued maybe on a workout like Grace, we have patients who are maybe plateaued in their plan of care. And if we're not careful, if we're not specific, if we're not assessing in the clinic, if we're not using our clinical reasoning, we can develop a very high quality loading program, a very high quality accessory program for the wrong area, for the wrong athlete, for the wrong time domain. I call this the specific humdrum adaptation to rehab treatment or the sharp principle, right? A very boring adaptation that serves no purpose, because that person in rehab was forced to do what we told them to do. And maybe we weren't giving them specific enough of a treatment. So without proper assessment, we may not know what people need to work on. And so we're often surprised and curious and maybe upset when Gladys comes in and she hasn't improved her 30 seconds sit to stand. She is still only getting four reps done in 30 seconds. She's been here for six weeks and we look back at her treatment plan and most of her treatments consist of coming into PT and riding the new step at zone one heart rate for 30 minutes or most of her session. We should not be surprised when we reflect back on the said principle that Gladys is making no meaningful improvement, right? She is struggling with a high power, short time domain demand, a 30 second sit to stand, and her treatment almost entirely consists of relatively low intensity, long duration endurance activity. Again, specifics matter. What we have our patients do, they will adapt to. If we give them the wrong stuff, or maybe just not as effective stuff to do, we should not be surprised when we do not see them make a lot of meaningful progress. We can see the same thing with patients who are symptomatic. Why are we surprised when Mark comes to the clinic, he's made no progress on his lateral elbow pain, and all we're giving him in PT is high volume, low load, banded, or lightly resisted exercises. We know that's a tendinopathy, we know it needs load, specifically it needs time under tension, and it needs progressive loading. Giving that person a high volume, low load dose is likely what caused that condition in the first place, so we should not be surprised that that person is not making any meaningful progress. So getting specific, adopting the said principle matters. Avoid the sharp principle. We can make people pretty averagely better at stuff they don't need to get better at or don't want to get better at if we're not careful with our rehab treatment. I truly believe we have a lot to offer patients and clients from both a rehab and performance perspective, but only if we take time to assess where is this person weak in their game? What is the most important thing or the maybe most important two or three things they need to work on? That's what our rehab plan, maybe that's what our accessory program…

Full show notes at the publisher

Episode 1739 - Loading the lateral shift May 30, 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 three different variations to load the lateral shift: side plank variations, RNT side bends, and unilateral carries.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

JORDAN BERRY All right, what is up PT on Ice Daily Show? This is Dr. Jordan Berry, Lead Faculty for Cervical Management and Lumbar Spine Management. And today we are continuing our theme of the lateral shift. So we've had a few episodes over the last few weeks. For the first episode, we were chatting about how do you actually recognize the lateral shift? Like from a subjective, from an objective standpoint, how do you pick up a lateral shift in the clinic so you're not gonna miss it? Second, we went over what are our lateral shift correction variations. Besides the standard one, then standing, what are some other ways that we could correct the lateral shift based on the patient irritability? Today, we're talking about loading the lateral shift. So this is something that comes up in courses quite often for our lumbar management courses when we're talking about the lateral shift and we have some different ways to reduce symptoms and to correct the shift or reduce the person's pain, decrease the irritability, but then what do you follow that with? Like in the session, right? We're not oftentimes just doing 40 or 45 minutes of a shift correction. We want to try to apply load to the person's system as well. And if we can start to load that person, the shift correction is going to quote-unquote stick more or be more effective during the session, between sessions. As long as the irritability allows for us to start to apply some load, we want to be able to. So we're going to go over three exercises that we commonly use in the clinic to start to load the lateral shift. So I've got Jenna again with me. Jenna is part of our fitness athlete division. She's going to be demoing some of the exercises while I'm talking through it. So let's get the camera set so we can see the ground a little bit better right here. Okay, perfect. SIDE PLANK VARIATIONS The first way that we're going to talk about that we load for the lateral shift is a side plank variation. So I want you to think about really just loading unilaterally. Whether it be the midline, core, whether it be the lateral hip, we're just trying to load that side to get the person to load that part of the spine. So for example, let's say Jenna had left-sided symptoms. Left-sided symptoms. So we said in a previous episode, almost always the lateral shift is going to be away from the side of symptoms. So, it might be slightly backwards depending on what platform that you're watching with the camera, but we are shifting away from the side of symptoms. So again, we're saying this side here, and if you're listening on the podcast on whatever platform that you're on, be sure to hop on either Instagram or YouTube and watch this episode as well so you can see the exercises in real time. Okay, so the first exercise. So we're going to say again that left side is painful and we are shifted towards the right. So we are going to do a side plank variation in order to load in to the painful side. So we're going to start with our standard side plank variation. The painful side is going to be down. So again, the side towards the floor would be the symptomatic side. And you can appreciate as Jenna comes up and squeezes the glute, squeezes the midline here, she is loading this bottom side that is towards the floor. Now, we could of course go through our same variations with the side plank that we would if we were loading the lateral hip to increase or decrease the difficulty, right? We could have the feet together, we could have knees together, we could also have that top leg floating that makes the bottom side work even harder. How would we regress that? if the person can't tolerate that full version. So Jenna, you can come up here. We would go to an elevated surface. So you could use a bench or you could use a box or you could use a table. But what Jenna is going to do is mimic the exact same position. only now she's at an angle, right? So she's not fully on the ground and we've taken out some of the load. So now it's likely only about half of her body weight that she's having to hold up. And again, the painful side is still down. You can appreciate if this is the painful side and we went here, that's basically the way that Jenna would be shifted. But when she contracts, that is the same thing as a shift correction. Only now we're applying load. instead of regressing it, how would we progress it? We could just add some resistance to the side plank. So we've got a band right here around the rig here. And what you would do, I'm gonna lift this up, Jenna would do the exact same side plank, only she's got this resistance band right around the hip. Much more challenging. When she comes up, she has to press into the resistance band and now she's getting way more load and working way harder to correct that shift or load that shift after we have done the lateral shift correction. You can come out of that, Jenna. So that's number one, a side plank variation. There's a million different ways. You just have to respect the irritability. RNT SIDE BENDS Number two is essentially an RNT side bend. So RNT meaning reactive neuromuscular training. So we're going to take a band and put it around Jenna's torso. And the band is just essentially pulling her in the direction that we don't want to go so that she has to fight against it and go in the opposite direction. So we're going to take this band, Jenna's going to wrap it around, and then bring your arm over top. Perfect. So we've got the band here, okay? So we are saying again that the left side, side here, is the symptomatic side. So if we had a lateral shift, she would be going this way. Well now, in order to stand in midline and keep herself centered, she now has to push in to that resistance band. So again, the band is pulling her more in the direction that we don't want her to go, right? There would be more in the direction of going away from the symptoms. So the more that resistance band or the more resistance the band has and the heavier, thicker that band is, the more she's going to have to fight against it to self-correct into that position. essentially a standing version of the side plank that we just demonstrated. Okay, so that's number two. UNILATERAL CARRY Number three is going to be a unilateral carry. Unilateral carry. So you could use dumbbell, you can use kettlebell. We typically will load it with a kettlebell. But again, just to stick with the same theme, saying the left side would be the symptomatic side. So Jenna would almost always be shifted away towards the right. we are going to put the weight on the right side. So we are putting the weight on the side opposite of symptoms so that she has to fight against the weight and correct back to midline. So again, the weight is pulling her in the direction that she's already going, avoiding the symptoms. And the heavier the weight is, she's going to have to work that much harder to pull herself back to midline. So you could start with just the static hold with the kettlebell. We could also add in a march to make it more challenging. And she's just lifting one foot at a time, going nice and slow and again, trying to just make sure that her midline is really engaged and active and holding her in this neutral position, fighting against the direction that she would typically be going to avoid the side of symptoms. SUMMARY So those are our three variations. We've got the side plank, very similar to how we would typically load the lateral hip. We've got progressions and regressions, just based on the patient irritability, find something that they can tolerate that does not increase symptoms. We also have that RNT, that banded side bend, where the band is pulling more in the direction that we don't want the person to go, so they have to fight against it. And the exact same thing with the unilateral carry. Whatever side the symptoms are on, the weight is on the opposite side, so they have to self-correct and pull themselves back towards midline. Three ways that you can start to load a lateral shift in the clinic. So again, we've got three parts now in this series that we're doing on the lateral shift. Part one, how to actually recognize it in the clinic. Part two, what are the lateral shifts? And three, how do we actually start to load the lateral shift? All right, that's all I've got. Have a great day in the clinic. And we have a few lumbar management courses coming up this month. We've got Anchorage, Alaska, and we've got Paoli, Pennsylvania. So check out PTOnIce.com for tickets. All the other dates coming up. Have a great day in the clinic.

Episode 1738 - Urinary incontinence in the older male May 29, 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 the management of urinary incontinence in the older male, implications for function, and quality of life. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. CHRISTINA PREVETT Hello everybody 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 and today I am hoping to talk a little bit about urinary incontinence in the older male. A lot of times we focus a lot of our conversations around pelvic health on the female side of the sex spectrum. But today I really want to talk about males. We talk a lot in MMOA, especially in our Level 2 course where we do an entire segment on pelvic health for the older adult. around how every clinician is a pelvic floor clinician. And the reason why we say that is because if you're interacting with hip and low back pain, then you're interacting with the pelvic floor as part of our core canister. And urinary incontinence is a leading cause of institutionalization and a very big reason why some people may not want to engage in the dosage of exercise that they need in order for them to gain the independence that they're hoping to gain. And so we really want to make sure that we are at least doing our due diligence in screening. When we are working with individuals, we wanna know if there's any urinary incontinence on board. And then we wanna talk about what is going on with respect to the male aging pelvis and how that interacts with signs and symptoms like urinary incontinence. So the biggest, biggest, getting bigger area of the male pelvis where there's a lot of conversations around its impact with age is the prostate. So we do know that there is an enlarging of the prostate that occurs with age. And the main roles of the prostate is to create seminal fluid and help with propulsion of ejaculation of that seminal fluid when mixed with the sperm when achieving orgasm. And what we recognize is that as individuals age, there is a growing of the prostate, an enlargement of the prostate that occurs. that is called benign prostatic hyperplasia. Now this is non-cancerous. This is not a malignancy. This is a part of aging physiology in the pelvis. And what we recognize is that there's also a lot of discrepancies of if this is something that we need to worry about or not. So enlargement of the prostate happens in almost every human with a penis. And it can be associated with lower urinary tract symptoms. In the literature, sometimes it's called BPE, benign prostatic enlargement. If it is associated with symptoms, that is not always consistently done, but there is screening that can happen. And then that enlargement, if it does have cancerous tissues in it, now we're thinking prostate cancer and individuals are going for screens for malignancy in the prostate, and then leading to potentially intervention, including radiation and, or radical prostatectomy. And I've done podcast episodes on radical prostatectomy before. When we're thinking about lower urinary tract symptoms, that can include stress urinary incontinence. And oftentimes in males, because of the length of the urethra, the level of incontinence is significantly less than in the female pelvis. So only about 5% of individuals over the age of 65 have incontinence. And usually it is as a consequence of conditions like radical prostatectomy. So it can be radical prostatectomy. Individuals can have pelvic fracture trauma. Some neurodegenerative conditions can also have a urinary condition associated with it. And so usually there's a precipitating event, not always, but most of the time there is some sort of precipitating event that has happened around the pelvis that has led to urinary incontinence. For example, when you have a radical prostatectomy, the prostate is removed. That includes the areas around the external anal sphincter. The urethra is then pulled up to reconnect to the bladder, which can disrupt the pelvic floor, the deep pelvic floor muscles that are responsible for kinking that hose of the urethra in order for a stress urinary incontinence not to occur. And so it makes sense why there's a disruption to that longer urethra can lead to things like stress urinary incontinence. When you have an older adult with stress urinary incontinence, I know it doesn't sound that, that surgery doesn't sound that great, but it is minimally invasive and people do respond pretty well to it, but we have podcast episodes on the, the surgical art of radical frost detective and what we can expect postoperatively. So when we're working with individuals, urinary incontinence is something that we may be managing and we have a big role to play in helping with post-operative or the new development of urinary incontinence. And so when we're thinking about management, we have kind of our conservative buckets, and then we have surgical management. If you are a person who's had a radical prostatectomy, the natural physiology is that many symptoms resolve within a year. So usually we are not doing any follow-up, or your urologist is not doing any follow-up surgical intervention around the pelvis until a year post-operatively with individuals post-radical prostatectomy. But we do have conservative methods that we can use in the shorter term, and hopefully to try and avoid a subsequent surgical management. And so those buckets are pelvic floor muscle training, penile clamps, and surgical intervention. And so the first and go-to knee-jerk reaction is always going to be conservative management, especially if initiated pre-operatively or pre-event, where individuals who are males get an awareness of the pelvic floor system. Because incontinence and pelvic floor issues in the male pelvis are not as common, many times education around the pelvic floor is not as widespread, individuals are not having these conversations as frequently, and then recognizing how to contract and relax the pelvic floor muscles can be something, especially if there is a training effect that we are doing with appropriate dosing, can help with mild to moderate urinary incontinence post pelvic event in the older male. When we are thinking about pelvic floor muscle training, we are trying to cue the pelvis either to stop the flow of urine, or to try and shorten the base of the penis. Those are the two cues that have been shown in research to have the highest EMG activation of the pelvic floor when trying to teach the pelvic floor contraction in an older male, and trying to get a strengthening effect with appropriate dosage. And there's some protocols in the post-radical prostatectomy world that tries to accumulate 20, 30, 40 reps. It's a bit variable, but we wanna make sure that we are getting a training effect based on where individual's baseline status is. initiating pelvic floor muscle training, seeking a pelvic floor physical therapist, or if you're okay with palpating externally, you can go kind of medial to the sits bones and see if there's a contraction of those pelvic floor muscles in the male. If you are a non-internal pelvic floor physical therapist, then you can work on some of that coordination and contraction in individuals who this is a barrier for them going out into the house. So that's kind of our first option. Our second option is a penile clamp. And so if you're aware, in the female pelvic space, we have a device called a pessary, which is inserted intravaginally, and basically what it does is it kinks off the urethra mechanically in order to help reduce symptoms of pelvic floor prolapse, or pelvic organ prolapse, rather, or urinary incontinence. We see this a lot as a conservative management in order to avoid pelvic surgery, We have a similar type of compression device for the male, but obviously there is not an intravaginal hole for our male anatomy and therefore it is placed externally. So what a pelvic clamp is, is It is attached to the mid shaft in a flaccid penis and it has a little bump on the bottom of the device. So there's a compression and on that bottom ridge, it essentially applies the same type of compression as the pessary to the bottom of the male penis in order to avoid incontinence issues. And what we see is that it can significantly reduce the number of pads or reduce the pad test, which is urine coming into a pad in a certain amount of time by weight. and the amount of subjective reports of incontinence. When we are thinking about penile clamps, comfort is going to be one of the biggest concerns where, you know, individuals, I think the last study that I was looking at was like about half of individuals reported that it wasn't really that comfy to be wearing the clamp on the shaft of their penis. It may be because of, you know, making sure that we have proper education or finding the right fit of the clamp, but something for us to be thinking about or, you know, having conversations about with the individual where we may be suggesting this conservative management strategy. And then the second thing that is a really important part for us to be considering is vascular health. We know that a lot of issues around the pelvis, including benign prostatic hyperplasia and erectile dysfunction, have a big vascular health component, aka we're screaming from the rooftops about health promotion, including around the penis. It's just super important for us to consider if individuals have poor perfusion, that even with a small amount of compression, we have to think about vascular health and skin integrity concerns. So trying to figure out who this might be the best individual to be using this type of thing with. Individuals who may really like this option are those who are very adamantly against having surgery or those who are not a candidate for surgery. So here's that double edged sword, right? Where a lot of individuals with high amounts of vascular concerns are going to be individuals who cannot undergo another surgery. They may be the ones that we are thinking about, you know, using this clamp, but we're going to make sure that we take a lot of breaks from wearing it. There was a study that was done out of Japan that was showing that individuals were able to wear it for two to three hours with a 15 minute break. and there was no adverse events to using it. Other studies have talked about doing an hour on, hour off, or using it when trying to do activities around the house. So you're kind of using it for a specific goal or task in standing to try and prevent some of that UI issue from happening. So that's bucket two. So we have our pelvic floor muscle training, We have our conservative penile clamp, and then we have our surgical interventions. And so for the two interventions for our males, we have a urethral sling, which is done through the trans or obturator foramen. And it is essentially a meshing tape that helps to apply resistance to the urethra with or without additional compression, depending on the technique that we are leveraging. in order to help keep the sphincters closed when we want them to be closed. These are indicated for mild to moderate types of urinary incontinence and not usually indicated for more severe cases. When we have individuals with more severe cases, individuals are using an artificial sphincter. So what this is, is it is a device that comes in and essentially creates a clamp with a balloon, or a cuff with a balloon rather, over the urethral opening, not the urethral opening, mid urethra, and your urine starts to accumulate in your bladder. Person's body is going to get the cue that they have to go to the bathroom, and when they go to the bathroom, they release a button in the scrotum that's placed in the scrotum, and it deflates the balloon, allowing the urethra to unkink and for urine to be able to pass through. And then the mechanism goes on a timer. So either it's between 90 seconds and three minutes, depending on the device, and that allows the urethra to be open for that amount of time. And then after that time has elapsed, the cuff closes. Yeah, it's really incredible. Like the technology is really intense. So when you're thinking about who might be indicated for using this artificial sphincter, dexterity and cognition are two big issues in an older male population where we may be thinking about, you know, are they gonna be able to get to the release mechanism on the scrotum? Are they cognitively gonna be able to do the procedure in order for the cuff to deflate? In more severe cases, this is indicated. And there is a fairly severe revision rate. So 20 to 30% will require some sort of mechanical revision, whether the device is kinked, whether there's clogs or hoses, like there is a higher chance of that happening because it's a more, it's a mechanical device, like there are moving parts. And so those parts can break down versus in a sling where you're essentially tacking up that resistance against the urethra. It's something that's a little bit more, doesn't have the same amount of moving parts. So there's a very high success rate for both of these surgeries. Infection rates and things like that tend to be fairly low and it can help to improve sexual function and be able to help individuals achieve better quality of life and physical function and is a good option for individuals who have exhausted their conservative management and have not seen the improvement that they wish to see. So if you are working with these individuals, usually the post-operative instructions are to avoid heavy lifting for six weeks. and then can start returning to moving around. It's not very smooth where individuals can get back to what? That is a conversation for another day. But overall, management can be quite good. So I hope you found that helpf…

Full show notes at the publisher

Episode 1737 - Building the perfect HEP May 28, 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 tips to build the perfect HEP: time availability, equipment availability, and dosage. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. CODY GINGERIC All right, good morning, PT on ICE Daily Show. My name is Cody Gingerich. I'm one of the lead faculty with the extremity management division, and I'm coming on here today to talk about building out the perfect HEP. Okay, so there's several factors revolving around building out what is considered the perfect HEP. Now, perfect means best ability for our patients to complete the HEP that we want them to, okay? And so what I'm going to go through is all the different factors that you need to consider, including what you are deciding you're doing, but also the patient's expectations and what they have the ability to accomplish when you are trying to say, all right, these are the HEPs. These are the exercises that I want you to do at home. What factors do you need to consider to build out the HEP that is going to give you the most compliance? Cause ultimately you can build out the perfect HEP as far as these are the exact exercises that I want them doing. These are going to be what I consider the perfect exercises for what I found. But if the patient doesn't do them, that HEP is no longer perfect because they can't get it done and they're not going to progress the way that you want them to. Okay. HOW MUCH TIME DOES YOUR PATIENT HAVE? So starting off the, the number one thing that you have to figure out is what time does your patient have? Okay. I know a lot of times when you know, you're going through your, if it's an initial examination, you're trying to figure out the first HEP, you're, you could have multiple different exercises available to you. Um, so let's say, you know, it's a shoulder issue and you're wanting to give them three, four, maybe five exercises that immediately you're like, Oh, okay. This would be good. That would be good. This also would be good. But if it takes 20 minutes for your patient to do and they have five, they're not going to say, oh, well, I'll just do a couple of them and get, they'll do none. Okay. So the first thing that you have to figure out with the patient is what time available do you have to, do you think to get these things done? Some people will say, whatever you tell me I'm going to do. And those people are great, right? You know, they're going to do it. Whatever you think is best. That's great. There are other people that said, you know, they've got kids, they've got to take care of family members. They've got jobs that are stressful. They've got all kinds of things. Maybe they're traveling a ton. And so they're like, you know, honestly, I may have five minutes at the end of the day to be able to get something done. Or they say, I can get to the gym five to 10 minutes early to get things done. Or, you know, I can get to the gym, I'm like running in like two minutes late every time, I'm barely, you know, either for class or it's like right at the end of the day. And they're like, well, yeah, but I could end class and stay 10 minutes extra. Um, and so that's where you then have to start figuring out, all right, well, if I choose two things in each and I give them a rep scheme that can get accomplished what I want and still get them in and out and under 10 minutes. Now, all of a sudden we have something that they feel confident that they can get done. Okay, what I would consider then 1A and 1B is like time is 1A, but 1B or maybe flip-flop those two things would be, you know, what are you trying to accomplish as far as your exercises in general? DOSING So in extremity management, we talk about dosing a lot, and that's one of the primary factors as far as when you're treating people out is dosage, and it matters. And there's a strength dose, and there's a rehab dose, and there's a power dose. And you need to make sure the HEP is equally as dialed into that as what you're doing with them in clinic. So up front, you need to think, am I trying to get this tissue legitimately stronger? in which case you are building them out their HEP for probably closer to that five by five right at about 80 percent of their one rep max or around that like three sets of six to eight somewhere like that where it is heavy load being lifted on whatever tissue you're trying to accomplish And in that moment, they may not need to do that multiple times a day, maybe not even every day. So if your brain is saying, well, this tissue needs to get stronger and I'm going to dose this out as a strength dose, then you could say, hey, you know, I might ask you to do this. It might take you more like 15 to 20 minutes, but can we do this three times a week? We want to really hit this hard. We want to make sure your tissues are going to significant fatigue. but then we're going to give you at least a full day of recovery in between. Those tissues also need to be able to recovery, repair, and then come back stronger. So then you have a day in between. Now I'm only asking you to do this three days a week. Could you do that for me? If you're thinking more of that rehab dose, you're wanting more blood perfusion to those tissues. Maybe now you give your one exercise that you think is going to be best, but they're highly irritable, and you need to get just as much blood pumping to that system as possible. Maybe you give them something that takes one minute, but you ask them to do that four, five, six times throughout the day. Because we need a lot of touch points on that tissue often throughout the day, as opposed to saying, I need you to do a lot X amount of time for this specific thing. But if you're saying I need blood pumping, they're sitting at a desk for eight hours a day, but they then have. 20 or 15 minutes where they do something to their shoulder, it's probably not going to bump them forward as fast as possible. But if you say, Hey, 30 seconds to a minute of this, I just, anytime you think about it, like set an hour timer, can you do one minute every hour or every two hours? A lot of times that becomes, um, more manageable for people to do. And then even if they, you know, you're like, Hey, could you do the six to eight times in a day? They say, yes, maybe though that gets accomplished three to four times and you're still doing okay. Okay. Those are kind of your one A, one B. What time do they have and really what are you trying to accomplish with their tasks that you're giving them? EQUIPMENT AVAILABILITY Okay. The third thing is what equipment do they have available to them and how willing are they to potentially go and get equipment? So that means before you start doing anything, you need to ask, do they have bands? Do they have weights? What kind of things do they have at their house? What access do they have to anything at a gym? Different gyms have different equipment, right? Do they have kettlebells? Do they have dumbbells? Do they have small looped bands? Do they have big pull-up type of bands? You can manufacture exercises from almost anything and your goal There is no one perfect exercise. There is the exercise that's going to get the person doing what you want them to, to the tissue that you think is most involved, and then you build that exercise for that person, right? So, let's say they have absolutely nothing at their house, but they go to the gym five or six days a week. That first visit is not the time where you say, you know what, I need you to go by XYZ. Nope. You say, great, your HEP is only going to be done at the gym. I need you to do this every time you step in the gym for five minutes, whether that's before or whether that's after you can make that choice, but you need to build out the HEP so that they can get that accomplished as simply and easily as possible when they go to the gym. That's the only way that they're going to get it done. Alternative, if they have nothing at their house, at our clinic a really good option is have either bands for sale or an Amazon link or something. The best one is bands for sale right there and then. Or if you can find them in bulk somewhere and can just hand those out, if they're like a dollar a piece, maybe eat that cost and give them out. But that's a really good way to say, okay, well I need you to do, you know, some band pull aparts or some 90 90 raises or something. And you have one of those like booty bands that you can hand them. And now all of a sudden they have something to accomplish at home. So that's where you need to get a little bit creative up front and maybe at home they've got like a two pound dumbbell or a five pound dumbbell or they've got one band, right? That is again where you start navigating that whole question of what exercise can I build based on the equipment that they have available to them. Potentially then after you have built a little bit of rapport or if that person in front of you is like, Hey, I'm going to do anything you want. You just tell me what to go and I'll go get it. That's when you can start shooting off Amazon links. Be like, Hey, go to play it again. I need you to get a 10 pound dumbbell. I need you to get a kettlebell. I need you to get this band. There are those people, but those questions have to be asked before you say, here's what I want you to do for your HEP. SUMMARY You first have to ask how much time do you think you have in a day? Your own brain has to be saying, what's my goal for these HEP exercises? Is it strength dose? Is it more rehab dose and blood perfusion? Then you say, okay, well, what do you have at your house? Do you have anything, any type of equipment that can be built on weights or whatever? Or is everything that you do at the gym cool? What is your gym routine look like? Do you get there super early in the morning? Do you get there in the evening? Do you have more time before? Do you have more time afterwards? Right? All of those questions have to be asked. Ideally, before you start thinking, I need them to do this exercise, this exercise, and this exercise. Now on that first visit, you might pitch optimal a little bit more heavily and say, Hey, this is really what I would like to do. And like for you to do, even based on those equations, Then they come in and say, Hey, you know, I don't think I was, I wasn't really able to get those things accomplished as much as you told me. After the first visit, if they're not able to do that, that first time is on you because then you have to say, okay, well what can I do to make your life easier? I have other options that we can do. There are more things, more different ways that we can make this HEP more accessible to you. If you don't answer that or ask that question, then the reason they're not doing their HEP still falls in your hands, not on theirs. If they say, you know, this is really easy. I should be able to get this done. And they take responsibility for it. Great. But until that happens, I would still say that you need to figure out how can you still make it easier? pitch optimal, then we negotiate acceptable. And you can still have that conversation and say, look, this isn't exactly how I would like it to be, but I think we can get the job done if this is really all you can commit to. Okay. So in that sense, now they know that like, Hey, this probably my, you know, my shoulder pain isn't going to go away quite as quickly as Cody probably hoped because I'm not able to do exactly what he was thinking. But if I still do something, it's still going to bump forward. And as long as they're okay with that, you have to set those clear expectations. But overall, that's how we are building out a really nice HEP that people are going to also be compliant with. Bring them into that. Use your creative mind as far as exercises are concerned, because really it's not the exercise that matters, it's the dosage. You need to know what tissue that you're hitting, and you need to know what dosage that you are trying to use to try to make those tissues happier. If they need to be stronger, we could potentially pull back the actual number of times per week that they do it. Give them an opportunity to recover. If it's more blood perfusion and a rehab dose, maybe make that incredibly short where they can do that one time for 30 seconds to a minute. You give them one exercise and say, hey, you're hammering this over the next week. You're pumping as much blood to that. When you come back in next week, then we're gonna adjust and do something different. But overall, you then need to know what equipment do they have, what do they have access to, what are they willing to go and get? Can you provide them with something that will help them get that accomplished? Whether that is selling something in store or in house, whether that's handing them something that costs a dollar to $2, something like that, that again, lets them be more compliant with what you're hoping for. Okay, so those are three things building out a perfect HEP. The perfect HEP, shocker, is not the exercise that is the best one. It is the exercise that they're gonna get done, that you have dosed out perfectly, that is going to be compliant, and you know what dosage and tissue that you're hitting. Okay. That's all I got for today's PT on ice. If you want to catch extremity on the road, we've got two courses happening this coming week, one down in Texas, one up in, um, Wisconsin. And then in a couple of weeks from that, we've got one happening out in Utah. So hit one of those up sometime in the next couple of weeks, we're all over the country and I will see you next time. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this c…

Full show notes at the publisher

Episode 1736 - Murph for the pregnant & postpartum athlete May 28, 2024

Show notes

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses the CrossFit hero workout "Murph", including modifications & considerations for pregnant & postpartum athletes.

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.

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

EPISODE TRANSCRIPTION

INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at signup to receive a one month free grace period on your new Jane account.

RACHEL MOORE My name is Dr. Rachel Moore. I am here this morning on Memorial Day to chat with you guys about the MRF workout and reflections for the MRF workout as a prenatal or maybe postpartum athlete. So whether you yourself have been that athlete and been prenatal or postpartum while doing MRF, or maybe the population of patients that you see is this prenatal space. I want to dive in to some reflections on that today. So first of all, we're going to kick it off. If you are not familiar with the CrossFit space, you're not in the CrossFit space. What is the Murph workout? So Murph is a workout. It's called a hero workout. it's done typically on or around a memorial day so whether memorial day weekend or memorial day itself it is a hero workout which is a named workout in the crossfit space for somebody that has given the ultimate sacrifice and paid their life for whatever the reason so michael murphy Um is who this workout is honoring he was a navy seal and he died in the line of duty So the workout itself is a one mile run 100 push-ups or sorry 100 pull-ups 200 push-ups 300 air squats and then you cap it all off with a mile run and the rx version of this workout is wearing a weight vest 20 pounds for guys 14 pounds for ladies If you have never done this workout, it's a long one. Most people kind of fluctuate like earlier times or fast times or sub one hour, but a lot of people tend to hover around that one hour a little bit more mark if they're doing a quote unquote full Murph. We also can do a half Murph, which is where we take that workout. and cut that volume in half. So the Murph itself is one of those workouts that is a really powerful symbol within the CrossFit community. Typically, most gyms are getting together, whether it's on that Saturday or on that Monday. It's a large community event. It's a really exciting thing to be a part of and a really exciting thing to come together. A lot of people really look forward to this workout every year. not only for the reason of what it represents and the fact that we're paying honor and tribute to people that have given that ultimate sacrifice of their lives so all of us have the freedoms that we have. but also because it is a pretty big test of fitness. And depending on what season of life we're in, sometimes those tests of fitness can be hard. Whether it is physically hard or emotionally hard, regardless, it can be tough. And in one of the largest seasons where we see that is in the perinatal space. So when somebody is pregnant or when somebody is maybe newly postpartum, and they're trying to figure out how to tackle Merv. it can be tough to set aside that athlete brain. It can be really hard to turn that off, especially if you're somebody that's done Murph maybe in the past, and you want to know where you shake out. Or if you're brand new to CrossFit, maybe you started doing CrossFit, found out you were pregnant shortly after, and you're seeing everybody in your gym get super excited about testing their fitness and seeing where they're at, seeing how they compare, maybe doing it for the first time, and knowing that you can't do it the way that you would quote unquote like to. So let's unpack that a little bit. For one, we at Ice really preach that we don't modify unless we need to modify. Just because we're pregnant, quote-unquote, is not a reason to modify MRF. If you're somebody that this workout is in your wheelhouse, maybe you are doing pull-ups and have been doing pull-ups in the gym. maybe push-ups are not bothersome to you, you're early enough on in pregnancy that your bum's not getting in the way, you feel good doing all those push-up volume, air squats feel great, running hasn't gotten to a point where it's bothersome at all, then there's no reason to modify the workout. We don't modify the workout because of pregnancy. We may be able to tweak it slightly, so maybe you partition instead of doing all of the reps in a row to save some of your core fatigue, So instead of doing 100, 200, 300, you do 5, 10, 15, and just give yourself some breaks in between. But if none of those movements are problematic for you and the volume isn't problematic for you, then it's okay to just do the workout, maybe a little bit slower than you otherwise would have, but it's okay to send it. If you're somebody who has issues with one of those movements, whether it is the pull-ups. You don't have that midline strength and stamina anymore and you're seeing a lot of that coning repeatedly over time and it's something that's bothersome to you or maybe the push-up volume is way too high for you or squatting below parallel triggers some pain. It's also okay to modify the workout. Modifying a Murph is not a sign of shame. Doing the Murph in and of itself is huge. modifying the MRF, whether that is because of pregnancy, whether that is in the postpartum season, or whether it's because of an injury, or you're a new CrossFitter, it's okay to modify when we have a reason to modify. It's still exciting to show up. It's still exciting to be a part of your community and do that workout. I have done this workout myself. This was my sixth MRF this year and I did it as a new postpartum. So it was three months postpartum and I was a newer crossfitter. I've done it as a, I think 18 week pregnant crossfitter. I've done it as a year-ish postpartum crossfitter, and then I've done it Rx twice. And in each of those seasons, the challenges were different. When I was a pregnant athlete, I wanted so badly to send it. I wanted to do a full MRF. I wanted to do the entire volume. But my body didn't feel great with that. And so that year, my husband and I ended up splitting the MRF. So we ran the mile together. It was a little bit slower than I otherwise would have ran. and we did you go, I go rounds and we took turns so that I had some built-in rest breaks because for me at that stage in my pregnancy, my heart rate was skyrocketing and I was having a really hard time managing that much volume with that high of a heart rate for that long a period of time. That was a challenging year for me. It has nothing to do with the physical side. Honestly, when we finished our MRF that we split, I was just like, okay, like that was fine, I guess. I'm excited I was here. But physically, it didn't feel like that much of a challenge. But that was the most mentally challenging year. On the flip side, the very first time I did MRF, I did a similar thing. I split a Murph, quote unquote, with a friend. We did you go, I go rounds. I was a newer CrossFitter and I was postpartum. So I scaled the pull-ups for ring rows. I did push-ups for my knees and I did air squats, but I did it all with a vest because I wanted to know if I could. So half a Murph shared with somebody, quote unquote, with a weight vest on, so reduced volume and scaled movements. And I have never felt so powerful than when I finished that workout at three months postpartum. It was awesome. So those are two very different seasons, two very different iterations of the workout from the standpoint of RX movements versus scaled movements, weight vest versus non-weight vest. And the outcome was different. One, I felt physically strong, mentally strong, felt super empowered. And one, honestly, was a really hard mental load for me because I wanted to do what all of my friends were doing in the gym and I wanted to be able to push myself. that athlete brain is tough to turn off. So if you are one of these patients, or one of these people that is doing MRF this year, or has done MRF by this point at 9.20 on a Monday Memorial Day morning, and you struggled with that, it's okay. If you have patients coming in in the future, and they're talking to you about, I wanna do MRF this year, but I just don't really know what to do, it's okay to tell them to modify. It's also okay if they wanna send it. At the end of the day, we're not modifying just for the sake of modifying. We had a gal in our gym last year who was in her 30th week of pregnancy. She's a former CrossFit Games athlete. She crushed it. She swapped out the pull-ups for ring rows, but otherwise did everything else RX and did fantastic and felt fantastic for her body. that challenge and that load was appropriate. We've also had people like myself who at 18 weeks pregnant decide that I need to modify. I'm not going to do a full Merv and I'm going to scale the movements. All of these options are okay. The beautiful thing about this workout is there are so many ways to modify it. There are so many ways to modify the movements themselves. There are so many ways to break up the volume. There are so many ways to cut the volume down. And at the end of the day, showing up and being a part of the community is what is really key this weekend. Being there, paying that tribute, showing that respect, and getting to be a part of your community is huge. If you're somebody that's been in this season and wants to chat more, shoot me a message. I would love to talk with you more. This is a topic that I'm super passionate about because I've been there. I've been in those shoes. And sometimes, you know, we just need to commiserate together about how hard something was. SUMMARY If you are looking to join any of our pelvic courses, we have got, we're about halfway through our L1 and our L2 cohorts. So we've got another L1 cohort kicking off. Our next L2 cohort is not until the fall. If you're interested in that, hop into it because it's going to fill out. Catch us on the road this summer. We've got a lot of opportunities to get to the live course where you can sit for that cert test and become ice pelvic certified. I hope you guys have a great rest of your day. If you did MRF today or at any point this weekend, make sure you take care of yourselves. Hydrate get your electrolytes in make sure you're getting protein in take care of your bodies And I know I'm feeling a little bit sore from my Saturday Murph So just know that in the next couple days you may be feeling some type of way, but it's temporary and it'll pass See you guys around

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