#PTonICE Podcast

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Episode 1684 - Gapping mobilization to improve knee flexion Mar 14, 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 demonstrates a manual therapy technique to mobilize the knee joint to improve knee flexion. She also discusses dosing the mobilization as well as demonstrating a home exercise follow-up for patients.

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

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

EPISODE TRANSCRIPTION

LINDSEY HUGHEYGood morning, PT on ICE Daily Show. How are you? I'm Dr. Lindsay Hughey from Extremity Management coming to you on a technique Thursday. This is my first technique Thursday, and I'm delighted to be with you today. I am going to show you a knee flexion gapping technique today. This is a technique that is really helpful for your folks with knee pain that are having any kind of mechanical knee sound. So maybe it's popping, maybe it's clicking, maybe it's even catching a little bit, or even just like crepitous sounds that maybe bother the patient. And they have some knee flexion deficits. So this gapping technique is one of our favorite in extremity management. So I'm going to show you on our demo model today is Paul. So first things first, we'll go over your position as the therapist, setting yourself up for good body mechanics. We'll chat a little bit about dosage. Then we'll actually talk about a follow-up mobilization to make this technique really effective. it happens what comes next. So this patient really needs to get after self-mobes to follow this up and for it to be its most efficacious in continuing to gain knee flexion and to reduce those mechanical knee sounds. POSITIONING & SET-UP So as the therapist, you are going to come alongside the patient. The table should be at about mid thigh height as the therapist. Your patient often will position themselves in the middle of the table. Tell them to scoot their hip to your hip. So go ahead and bring your hip to me, Paul, so that they're close, so that you get some really nice leverage here. The other thing is when you bend their knee into whatever flexion they have, their knee, the top of it, should sit about your chest height. If that's not the case, you might want to drop the table a little bit lower. So that will depend on therapist's torso side and then femur length of that patient. Next thing, you are going to come under that popliteal fossa with your elbow. And the patient's leg is just going to rest in your pubital fossa. So patient, you'll wait for them to just kind of relax. And then this hand is going to go somewhere along the tibia and fibula. in a cupped fashion, and then you're gonna sink in with your body. So it looks like so. So if I were to give you a little space here to see, my hand wraps around the tibia and fibula. And then I get back to that staggered PT stance, and I'm gonna lean in with my body and oscillate on off. I'm going to let Paul down for a second and do a little shadow mobilization body position. So I'm going to be staggered stance, midline is tight and active. That arm comes around, carries the limb, and we know we carry some big limbs here, right? If we're dealing with knee OA, meniscal injury, our big athlete legs, maybe they have some ACL stuff going on. Scoop here. Allow the leg to hang and then get that arm here and then it all becomes body. My body sinks so there's no break in the arms at all. This all stays tight and you'll oscillate. DOSING KNEE FLEXION MOBILIZATIONS Recommended dosage is 30 to 60-second oscillations, three to six reps, and then you'll retest that knee flexion. So we're looking for a change in either pain response, knee flexion, possibly even the mechanical sounds that they're having, but we try not to emphasize overall on the sound part. But we do want to do that test-retest. I'm going to show you one more time from the top, and then I'm going to show you the follow-up mobilization that we'll go to for this. So patient is close to you. I'm in staggered stance. I'm going to scoop that knee up, let it rest on my forearm so that I create a little gap in the knee joint. My hand is going to cup. I'm superior to medial and lateral malleolus. And then I'm just going to oscillate and sink for that 30 to 60 second oscillation. whatever the patient can tolerate, but really making sure I create that gap underneath the knee joint and sink in. And then you can get into progressive and more knee flexion. After that, we wanna follow up with a good mobilization. So right, we pretend we did those three to six reps, we've retested, he's feeling good. HOME EXERCISE FOLLOW-UP So now Paul needs the tools to own that autonomous access, right? To own the joint motion or range of motion that we just restored. So Paul, I'm gonna have you come sit on the floor and we're gonna actually use a band under his knee and a towel to create the gapping mechanism that my forearm created. So Paul's going to put that under, and then we're going to try to also get that band. So we'll put that in first. Beautiful. And then he's going to grab that lower tibia and fibula, lean back slightly. So lean on back, Paul, so that your foot's off the ground. And then he's going to oscillate his legs. So go ahead and lift your foot off the ground. And now he'll do that same, whatever oscillatory time, 30 to 60 seconds felt good. He can set a timer and he'll just kind of bounce on off. It should feel easy and feel very similar. And you can go ahead and relax to what we just did on the table. So again, try to match that dosage time. This technique is good for restoration of knee flexion, helping with pain, and kind of easing some of those mechanical joint sounds. It's one of our favorite go-tos for knee flexion restoration and extremity management. SUMMARY If you want to learn more from our team, from Mark and Cody, we would love to see you on the road. We are going to be in Spring, Texas this weekend, and then Aiken, South Carolina. Both of those locations have some spots left, so dive in. If you want to learn more about how we manage common knee conditions like knee OA, meniscal, patellofemoral pain syndrome, patellar tendinopathy, iliotibial band pain, we'd love to share what best practice looks like in that area. And we also cover the hip, ankle, foot, shoulder, elbow, wrist, hand, and best practices for dosage and tendinopathy. I will be on the road next weekend in Victor, New York. So if you'd love to join me, I would love to see you. And Alan will be there, our COO. So join us on the road. Check us out on ptonice.com. And if you're not on the app, we just launched our Ice Physio app. That is a wealth of connection. So join that as well. Have a happy rest of your Thursday. Thanks for joining me this morning.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 1683 - Why older adults NEED to lift heavy Mar 13, 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 4 important reasons for older adults to lift heavy: improving strength outcomes quickly, reducing fear, improving confidence, and translating heavy lifting to real-life function. 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 CHRISTINA PREVETTHello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our division leads in the modern management of the older adult division. Today I am going to talk about a question that I got from one of the physiotherapy students that I was working with last week. So last week I had the pleasure of going down to McMaster University to teach movement analysis. So basically to create the foundation of some of our big movements, including the squat, deadlift, press and pull. Talking to our students about all this normal movement variation and what that means for our foundational knowledge before before we kind of start building in these additional layers around aging and different diseases and all these types of things. And we started talking about exercise principles and we talked about you know that strength versus hypertrophy versus endurance And I made the argument, as you know, that we have within our older adult division, how we need to be less afraid to make our older adults lift heavy. And I love that this student was really like thinking through, and he said to me, well, does it really matter? Because we see that our people, if we use lightweights and high repetitions, they're going to get some hypertrophy as well, right? So then why do I need to do this if I can just get them doing three sets of 10 at the right intensity and they get better? And so I loved this question. You could tell that he was really thinking about the literature and trying to bring it into where he wants to go with his clinical practice. And I always love the challenge. I love having a meaningful conversation around our thought processes when it comes to certain principles that we are teaching. And this is no exception. So I thought that I would do a podcast episode on this around what we know in the literature, where we are going from a PT perspective and an OT perspective, rehab perspective in general, around this type of thought process. and then kind of take our four takeaways about why we do this within MMOA. So let's talk about the research first. So this student was not wrong in that if you take an individual who is not doing anything and you get them doing something, even low repetition work, at a moderate intensity, they will see initial improvements, right? They will. Stu Phillips group out of McMaster actually did a Bayesian network meta-analysis that was looking at the comparisons between high load and low load and high volume and low volume. And he showed that all groups did get a little bit better. especially with hypertrophy, which is building muscular bulk, that high load, low volume training is not necessary or sometimes maybe even ideal because of the amount of load that's required for muscles to get bigger if that is your goal. However, what we did see is that individuals got stronger faster when exposed to higher loads versus lower loads. NO TIME FOR A SLOW BURN And so this is our first principle that we really hold true to within MMA. We do not have time for the slow burn. When our older adults are one slip, trip, or stumble away from losing their independence, when it comes to their aging experience and where they want to be in the next five years, yes, they will get stronger a little bit with low load training, but they will get stronger faster by making them lift heavy. And so I have what I feel like an unbelievable amount of urgency when it comes to working with a lot of my older adults who are at this cusp of losing their independence. And I don't have a ton of visits with them. I want to get the biggest bang for my buck. But he was absolutely right in that what we used to consider really tangible buckets around like, you know, less than six is this and six to twelve is that and twelve to twenty is this. It's more blurry than that. And as rehab professionals, that's OK. We embrace the land of the gray. But where I'm going to prioritize the heavy lifting piece is because I know that they're going to get better faster. So that's number one. LIFTING HEAVY REDUCES FEAR OF LIFTING The second reason why we get individuals lifting heavy in rehab is because it reduces fear. So many of our older adults are afraid. They have been told by our medical system that they shouldn't lift more than 20 pounds, that they shouldn't do this, that they shouldn't do that. They're being told by their family members, oh mom, like let me get that for you. Like basically you are too old to lift this on your own, let me do it. And I'm not saying that this is coming across as something that is disrespectful. It's meant to be helpful, but over time and with reps, it creates a ton of fear. And so many of our older adults are afraid over a certain threshold and require graded exposure in order for individuals to feel okay and feel confident about going and approaching a load that was making them uncomfortable before. And what we know is that when individuals lack or have a high amount of fear or lack self-efficacy in a movement, they avoid that movement. And so if they are afraid to lift over a certain threshold, then that might mean that they have relinquished their independence with certain tasks around the home. And again, that can be a threat to their capacity to stay up to date with their activities of daily living, right? So number one is we get people to lift heavy because it gets them stronger faster. The number two is that it reduces fear. LIFTING HEAVY IMPROVES CONFIDENCE And two is very closely linked with number three, which is it increases confidence, right? I say to my older adults all the time, if you are lifting this 50 pound weight with me, you are never going to be afraid to lift something in your day-to-day life. And I hold true to that. I will say, you know, if you are able to lift a hundred pounds, then you know that that kitty litter that is 30 is something that you're going to be able to handle. And so exposing to supra physiological loads compared to what their activities of daily living are gives confidence. It reduces fear and subsequently increases confidence and self-efficacy. And that is a really important narrative for so many of our older adults where their interactions with our healthcare system make them afraid, make them feel fragile, and therefore make them lack confidence with their capacity to do activities of daily living. Now, I'm not saying that we are going to ignore risk, right? We're going to have individuals who have balance impairments or things like that that do make them have a risk for falls, slips, and trips. But a person with more physiological reserve with respect to musculoskeletal reserve kind of in the bank. is going to always do better with a fall than somebody who isn't, right? Because that sedentary behavior, that lack of musculoskeletal resiliency from the muscle, the tendon, and the bone is more likely to give you an injury as a consequence of a fall. So we want to take into account all of their other variables within their medical history, but we want to increase confidence when it comes to a lot of our tasks. So that's one, two, and three, right? So people get better faster if you get them to lift heavy weights versus low weights for high repetitions. It reduces fear. It increases confidence. PEOPLE LIFT HEAVIER IN REAL LIFE THAN THEY THINK THEY DO And my last one is that people lift heavier than we give them credit for in their day-to-day life, right? When we're handing them five-pound dumbbells or we're handing them pink three-pound dumbbells, they are lifting their 25-pound dog. They are bringing their 40 pound grandchild onto their lap. So they are doing a seated hip hinge with 40 pounds. They are making sure and doing a very forceful pull if their dog is pulling on their leash because they see a squirrel and their dog is 40 pounds. Like they are doing so much more in their activities of daily living. And if we are truly trying to do a rehab program that is work hardening and This is true not just for our outpatient community dwelling older adults, this is our home health older adults. This is our, you know, even the plate full of food that individuals are taking from their walker from their kitchen into their living room, that plate weighs two or three pounds. has a load to it. And so individuals lift so much more than they even think that they do. And I'm not like, when I think about my so many of my clients, like they forget how much load things are, or they like push a couch that's 50 pounds, and they don't think that they do a 50 pound, if I get them to a 50 pound sled push, they think that that's too much. I was like, you just told me you moved your couch. Like that is exactly what you did, right? So they lift so much more. And when they have more resiliency, the percentage of strain on their body with those tasks changes, right? So going back to that, can you lift a hundred pounds versus the 30 pounds of kitty litter, right? If they are working at 30%, that is a repeatable effort. If I got them to do a set of 10 at 30 pounds, yes, that would be a lower strain. But then if I gave them 35 or 40 pounds and they're afraid to lift it and they think that they can't lift that anymore, then they're topping out at 80% of what they believe their max capacity is to move that kitty litter. And that is a much harder reproducible task, even with some of the exposure and higher repetitions. than if they believed that they could lift 100 pounds and this was only a 30% effort. And it makes me really kind of think to even the state of our research and how much are we missing because of this inertia that we've created that this is the repetition range that we have always done so this is the repetition range that we are going to replicate and that is where we get into a lot of 3x10 repetitions right like we have always gone in that moderate intensity range and now we have this inertia in research as well where We have so much evidence that is accumulated in this area that our studies that are on the fringes in the 20 plus repetitions looking at muscular fatigue rates in our our rep ranges that are in the five minus or five or less ranges are so small that the bulk of our evidence is in the middle. And so then we think that this is where all of our exercise programs need to be. And I'm not against three by 10. I absolutely am not. But it is recognizing that there is a lot that can be done by exposing individuals to higher loads and then allowing their confidence to thrive. So where we go with this is not to say that our older adults don't gain anything from the three by ten repetitions. That's actually not true at all. And oftentimes what we will do is we will have individuals lifting heavier with us in a supervised setting where we can monitor irritability, especially when irritability is high. And then a lot of our at home repetitions are in that endurance hypertrophy range, because we bring the load down, we bring the intensity up to a moderate range with a less amount of load, load that tends to be more readily available in the home. And then we get this beautiful combination of getting that exposure to high loads, but also getting some of that hypertrophy resiliency in those higher repetition ranges. So where are we kind of going from here? One, we need so much more research that is comparing different types of exercise programs, right? When we are thinking about high load paradigms, so much, the bulk of the decisions that we make in rehab, and this is so true in our older adult divisions, and actually it's everywhere, but a lot of our health intervention research is comparing doing something to doing nothing. And they say that it's not doing nothing because they give a home exercise program, but then they don't tell us how often people actually did set a home exercise program that you gave them at the beginning of your 12 week intervention and then never checked in on them again until the end. And we are always going to see at least initial newbie gains when we compare doing something to doing nothing. It is a lot harder as a researcher to do doing moderate intensity to doing high intensity and making those comparisons, hence why we are using indirect Bayesia network meta-analyses to try and gain insights into some of those comparisons. Because it takes a lot longer for us to see differences between individuals who are doing nothing to doing something in both groups, but the intensity is slightly different, but still hitting thresholds for adaptation potentially. So we have so much work that we need to do in this space, but until then, I have the four reasons that our division uses and why we try and expose our individuals to intensity and know that the main biggest take home that you can see in your older adults, and that is important for driving physiological adaptation to resistance training at any rep range, is effort. Effort is the important part, and so often in MMOA Live, we see that people don't wait for effort to show up in our older adults. They don't wait for the grunts, they don't wait for the redness, they don't wait for the sweating across their brow. And that is always one of my markers of effort. And so when I have my people in the gym, and I would say that probably 70% of my time in rehab is spent in the gym, the rest of the 30% is education and manual therapy, they're sweating. they're working hard, their muscles are feeling tired. I always say I love the shakes. I get the shakes and some of the core work, you know, like those are the things that effortfulness across the lifespan that I am looking for. So how can you get some ideas around exercise prescription and effort? SUMMARY Well, I'm so glad that you asked. We start our next cohort of MMA level one this week, actually today. Today is the 13th. We have some big things coming at us. One is that our MMOA level one starts today. So if you were hoping to get in and dive into some of this research on exercise prescription, we have three weeks that focus on where our mindset is with respect to loading the older adult. And we also are seeing big changes around moving to an app. So if you guys have been seeing, jump into the iStudents group. We are going to be migrating over to Circle, so all of our courses are gonna be moving in that direction. So if you are interested in getting, thanks Taylor, we are going to be going in that direction. So if you guys are looking for where some of our slides and things from the courses are gonna live, they are going to be on the Circle app, which we are really excited for, that platform migration. All right, I hope you all are having a great week. We will see you all. If you are at our MMOA Digest, please get on there…

Full show notes at the publisher

Episode 1682 - Barbell isometrics for the powerlifter Mar 12, 2024

Show notes

Dr. Brian Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose makes his debut on the Daily Show to discuss how to come alongside powerlifters, the differences between raw & equipped powerlifting, the sport-specific demands of powerlifting, and how to keep powerlifters competing. 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 BRIAN MELROSEGood morning, PT on ICE Daily Show. My name is Brian Melrose. I'm one of the lead faculty in the spying division, teaching both cervical and lumbar courses. I'm stoked to be here on clinical Tuesday to talk about all things barbell isometric with a very particular population. That population that I want to talk about is with the power lifting athlete. And if you haven't had the chance to work with one of these guys before, then again, you don't know that when you lift 600 to 800 pounds of load, you tend to end up with some neck and some back pain. And so that's where this sport has crescendoed well with my clinical practice. And so I treat a lot of recreational, national, and even world-level powerlifters here in northern Colorado. And the story for me really begins about two years ago when Natalie Hanson walked into our clinic. And Natalie's a world-level powerlifter. She's won worlds multiple times and was in a new weight class and looking at returning to the sport. And so as I begin to work with her, as well as other powerlifting athletes, we can begin to understand, number one, why they have so much spine pain, but number two, how we can help them in the clinic to mitigate some of those symptoms, both leading up to competition and on competition day. COMMON SYMPTOMS OF THE POWERLIFTER And so the first thing I want to do is just provide a little bit of background as to why these folks end up running into some symptoms during competition. And so a typical powerlifting competition is going to consist of three different lifts. You get three attempts to get your highest lift total for the end cumulative sum. And so the powerlifting competition is always done in fleets or groups, and it begins with the squat. So everyone comes out going from the lowest weight to the highest weight, and they get three attempts to throw down the heaviest squat possible. After that, all of the athletes will transition to benching. Again, same style there. Three lifts to get the highest bench possible. And then they end the day with a deadlift. And to put this in context, right, in smaller events, like in Worlds, so last year I got the opportunity to go to Lithuania with Natalie and check out the World Competition. And there's only six other athletes that are throwing down similar weights. And so the entire competition takes about an hour and a half. So in 90 minutes, you are One rep max loads, again, either just below your one rep max or trying to hit the new PR. And so nine different lifts of, again, compound movements tends to really tax this system. And so both athletes are pretty gassed, usually by the time they get to the deadlift and then again at the end of the day. But when we begin to take a deeper look as a physical therapist at what's happening at the spine, we begin to see why things can kind of, again, become problematic. First, we have the squat, where again, there's a large compressive load through the spine. And then the athletes have to transition to benching. And if you've never watched powerlifting before, then you probably are unfamiliar with their unique benching position, which is extremely arched. And so the feet have to stay on the ground. The hips have to be in contact with the bench. all arch to end range, their end range in the lumbar spine. And what that allows them to do is typically decrease the distance the bar has to travel to their chest to complete the lift. It also helps pin the shoulder blades down. On the flip side, it makes it extremely difficult to maintain that arched position. The lumbar extensors are working incredibly hard to be able to maintain the hip contact down on the bench. And so they're in that lumbar extended position. The extensors are very shortened, but they have to be extremely active. All of the athletes, after benching, then have to switch gears and go out for the deadlift in an opposite position, where the lumbar spine is much more flexed, and those extensors have to then elongate. And so you can see why that can be challenging for a lot of those powerlifting athletes. But for someone like Natalie, it's even more challenging. And so Natalie, it's mostly because she has such a strong bench. So Natalie was just down in Austin, Texas a couple weeks ago and broke another world record. And because her bench is so high, she's typically one of the last people to go within that fleet. So she'll be the last person doing her third bench attempt. And then all the athletes switch gears, and they start doing the deadlifting. And so because of her geometry and history of back bend, she tends to be lower down in the pack when it comes to the deadlift. And so sometimes she has about 10 or 15 minutes to come off of the stage from the bench and then go ahead and switch gears and get ready for one of her first attempts warming up in the back with deadlifting and then coming out on stage and hitting a deadlift. And so for her in particular, that kind of, again, high bench, lower deadlift really decreases the time that her system can kind of switch. And so that's one of the reasons why we like using the barbell isometric. RAW VS. EQUIPPED POWERLIFTING But the other thing that I want to describe real quick is the difference between raw powerlifting, which I think a lot of us are imagining at this point, and what's called equipped powerlifting. And so raw powerlifting is a little bit more popular now, typically just done with a weight belt. Equipped powerlifting is what's done a little bit more historically. In equipped powerlifting, in the squat, you're allowed to use knee wraps as well as a squat suit. In the bench, you're allowed to use a benching shirt. And then in the deadlift, you can also rock a deadlift suit. And so these are single ply materials that are a little stretchy, but fairly rigid. And what they do is assist the athletes in some of the most difficult positions of the lift. And superficially, you might think, well, that probably makes things a lot easier for the athlete. And if they stayed at the same weights, that would be true. The thing is, though, is that these athletes tend to load the barbell way more aggressively and lift loads that physiologically they would not be able to do if they didn't have, again, the assistance of the equipment. And so the equipment becomes this other variable within competition or within the equation in the sense that they can They also have to almost fight the equipment to get into position. So with the bench, again, they're lowering down, have to balance the weight, and still have to touch their chest, but they're fighting the stretch of the shirt to get there. In the same way, when they end the day down in the deadlift, not only have they just taken those extensors from end range extension and activation of the bench, and now they're asking to kind of elongate for the deadlift, They have to fight the shirt to even get down and get into position. COMING ALONGSIDE POWERLIFTERS And so the answer to helping these athletes, either on competition day or in training, is really twofold. The first thing that we need to fix is, how can we get those tissues to be a little bit more pliable or extensible after benching in preparation for the deadlift? And so to do that, I'd like, again, referring to one of the things that we talk a lot about in our lumbar course, And we're talking about repeated motions, particularly folks that are recovering from a derangement and are reintroducing flexion. When we reintroduce flexion, we tend to start in non-weight bearing. And I do the same thing for my powerlifting athletes mid-competition. I like them to lay flat on the ground, on their back, and pretty much just rock their knees to their chest. postural tone, we already decreased some of the activation in those muscles. And then as the athlete brings their knees up, again, usually about 20 repetitions or about a minute, they flex the lumbar spine from the bottom up. So instead of reaching forward, they're kind of, again, coming at it a different way. And so usually that can help relax some of those muscles. Next, is what we typically like here. So again, looping a band behind the back, getting it down here, and then sticking in the first 50% of the range to begin to get a little bit more motion at the joint, as well as some muscular activation. Last, we end up going to the Jefferson Curl. So now in a weight-bearing position with a lighter load, but segmentally flexing that athlete all the way down to end range, and then coming back. And so what that can do is, again, take those tissues from a very guarded, shortened position, and gradually tease them in the right direction. In a powerlifting competition, especially for someone who's stacked like Natalie, that might be three or four minutes that we have. In the clinic, we can leverage things like manipulation, dry needling to mitigate those symptoms. But in the competition, it's going to be much more movement-based. BARBELL RACK PULLS TO PRIME THE DEADLIFT So now that we have the tissues relaxed, the next question becomes is how do we prepare them for the deadlift? And again, these athletes warm up a lot backstage, and they go out and pull something pretty heavy. And this is where the barbell isometric comes in. It's my favorite exercise to give as a primer in this situation, because we can control the environment and give them the work in the position where they feel most vulnerable, where the lift is the most difficult, and not have any movement of the bar. And so for most athletes, that is going to be right when it's coming off the ground. So they're fighting the suit to get down, but they're also trying to pull these extremely heavy loads from the floor. And so typically in the back, during a competition, we would bottom out the J-hooks or the arms and kind of standardize it at the height of where the Olympic plates would rest. And so what the athlete is able to do is get into their conventional or sumo position, get into the bar and then just hold and just maintain some good activation at the rig where they get maximal effort in terms of the extensors, but there's no change in the joints or the muscular position. And so our dosage on competition day is typically going to be something a little bit lower in reps and lower in terms of duration. And so if you've ever watched powerlifting, sometimes those folks are grinding a lift out for anywhere from 5 to 10 seconds. And so I tend to dose the isometric at 3 to 4 reps of around 10 seconds. And so that tends to, again, get some good primers on board during competition day. But you better believe that we've been leveraging these throughout the training leading up to the competition or event. And so the day I like to select for that, for a lot of these power lifting athletes, is on a day when they've done a lot of high volume or heavy benching in that arch position. Their back should be kind of locked up as much as it is. We run through that flexion progression, going from non-weight bearing to across gravity to standing. And then I have them end with some barbell isometrics at the rig. Now we can cook things a little bit longer. And so what we'll typically dose on a training day would be longer holds, anywhere from 10 to 25 seconds for four to five repetitions. And we really, again, want to tax those muscles all the way to work on the endurance and the positional tolerance where they have the most difficulty. And so that's how we really like to leverage the barbell isometric with powerlifting and athletes, both on competition day and in some of the training leading up to the event. It is helpful as this is for both powerlifting athletes. You may be able to transition this to other folks in the clinic. If they have some back spasms or issues at a particular part in the lift, you just match the isometric to where they need it. For a lot of folks, that's in the bottom. But if they were having trouble at mid-range, we would just move the J-hooks up and have them perform the isometric where they're having the most difficulty. And so this has been an incredible way to help these athletes train. Why are these folks having some pain and dysfunction in this area? We guys love the deadlift. The deadlift is king. If there's one exercise below the spine, you know that's what we're going to choose. But what do you do when you get an athlete that rolls into the clinic and they're already deadlifting? Or they're not only already deadlifting, they're doing it multiple times a week, and they're doing it We're going to be answering that question over the next couple of podcasts I'll be throwing down in the coming weeks. And I'm going to give you some seeds of things to kind of marinate on as we get there. But when it comes to loading the spine for folks that are already deadlifting, we need to consider things like planes of motion, as well as speed and fatigue. If we can get our athletes kind of oriented to some of those things, I think we help them create the most robust and resilient spine. So that'll be coming down in the future. SUMMARY Thank you for hanging out with us here on clinical Tuesday. I just want to plug a couple of courses we have coming up next. If you guys are looking to hop to any of our cervical courses, I'll be teaching down in Longmont, Colorado here in just two weeks. There's a couple of seats left, so go ahead and hop on that if you'd like a ticket. For lumbar, We're going to be kind of active April 6th and 7th. I will be out in Carson City, Nevada. Zach Morgan will be on his home turf in Hendersonville, Tennessee. And again, you can grab us on the road for both those surfable and lombar courses. Hope you guys have a great Tuesday. Thanks for hanging out and talking about barbell isometrics with the power lifters. 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.

Full show notes at the publisher

Episode 1681 - Menopausal women deserve better Mar 11, 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 a story of usual patient care when experiencing menopause in the American healthcare system.

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

RACHEL MOOREAlright up and running on Instagram and YouTube. What is up guys? My name is Dr. Rachel Moore I am on faculty with the pelvic division here at ice Pollen has been wild in my area of Houston and I have a sinus infection. So I Sorry about the congestion that you're likely going to hear throughout this episode. This morning we are here to talk about menopausal women and how they deserve better and how they have been kind of set aside and really isolated in the type of pelvic care that we are starting to see normalized. I really want to kick this off this morning with a story that inspired me to even pick this topic. So Last weekend I was teaching in California with Alexis for our pelvic live course and on the plane I ended up sitting next to this older couple. It was a husband and a wife and they were having a hard time like connecting to the Wi-Fi. I didn't really know how to get the United app up and running so I leaned over and I helped him kind of figure that out and I had my iPad with all my slides next to it because I was going to prep for my lectures on the plane. So I always like to work on the plane on the way there. And the lady leaned over and she was like, oh, like, thanks so much for your help. And just kind of started making small talk. Asked what I was traveling to California for. And I told her that I was actually going to work. I was going to go teach other physical therapists because I was a physical therapist. And so this kind of kick started a whole conversation where she was telling me she was flying out to California to run a marathon and she had been rehabbing a hamstring injury for like two years and she had gone to in-network PT and then she had gone to out-of-network PT and all along the way like her hamstring would get better and then it would come back and it would get better and it would come back and so we kind of chit-chatted about that a little bit talked about her running volume and things like that and then I kind of alluded or something I said I don't even remember exactly what it was but told her like I'm actually a pelvic floor PT and that's a big part of what I treat And she was like, oh my goodness, I can't believe this. Like I just had a pelvic floor evaluation and her husband leaned over and he was like, oh boy, you have no idea the can of worms you just opened. And we, she really just dove into her story. And so she had had surgery or not surgery. She'd had a bladder pacemaker put in because she was struggling with urgency and frequency of urination. So she had been at this point to a gynecologist, to a urogynecologist, to an orthopedic doctor for her hamstring, and on the MRI that was done for her hamstring, the report also said that she'd had some issues with her bladder, and she asked her ortho doctor about it, and he was like, I don't know, all I know is about the hamstring, I'm not here to treat your bladder. and she was really feeling hopeless about her pelvic floor and about whether or not she could get help for her pelvic floor. She'd gone to a pelvic floor evaluation and she said it was really helpful and she learned a lot but it was an out-of-network provider and she'd already spent a lot of money on out-of-network care for her hamstring and she didn't want to dive into this area at that point. And so in this conversation we really kind of got into the weeds a little bit. So through this conversation, it's like those conversations on the plane, you never know where they're gonna go. We ended up chatting about cycles and menopause, and she was menopausal at this point. And ever since she had been in menopause, that's when her hamstring symptoms started. That's when she started noticing issues with the pain in her hamstring, and we started talking about fueling especially with her running volume and we started talking about how there's estrogen receptors in other parts of your body aside from in your ovaries and all of the ways that being in menopause can potentially set you up for issues with your musculoskeletal system And in this conversation, she was shocked because nobody had ever really talked to her about what menopause consists of, all of the different ways that menopause can cause issues aside from just you don't have a period anymore, you may have hot flashes, and it was really upsetting to her. And we kind of continued talking over the course of the flight, it was a four, three and a half, four hour flight, and it kind of dawned on me in that in this moment in this conversation because she had a son and we were talking about how when she had her son pelvic floor pt was not done nobody talked about it nobody uh it was just normal that you pee on yourself and i know these days we like to feel like that is still a thing but if we think about perspective shifts like 20 30 years ago It was even less common than it is now, right? Like it was not a thing that was really prescribed at all. So many women were getting surgeries right out the gate after having had their kids. And so this group of women that are now going through menopause were really kind of, I don't want to say shafted, but shafted in their prenatal and postpartum pelvic floor care. And I think that that means that we as pelvic floor PTs need to put it out there that we can help them because they have lived their entire lives up until this point, believing that it's normal to pee when they sneeze, believing that it's normal to leak when they exercise, maybe not exercising at all because this has been something that they've dealt with since they delivered their kids 20 or 30 years ago. And now is the time that their symptoms are potentially flaring back up. We see an increase in pelvic symptoms as we transition into this stage of life. And so if we are not addressing these issues and we're not putting it out there that we can address these issues, women aren't getting the care that they deserve. And not only did they not get the care that they deserve initially, when they first got into this pelvic floor space after having had a baby, they're not getting it now. I think as pelvic floor PTs some of us may really lean into the prenatal and postpartum space and it makes sense because a lot of us are maybe in that time stage of life where either we are having kiddos or people that we know are having kiddos or maybe thinking about it in the future. And so it really feels like this easy transition as we're entering into the pelvic space to lean into the prenatal and postpartum space. And it is needed. I'm not saying we shouldn't do that, but I think as pelvic PTs, we really need to get comfortable with explaining menopause and explaining the changes that happen in menopause. And more importantly, talking to women and talking to providers like, gynecologists like urogynecologists getting together with these people and letting them know like we can help mitigate these symptoms. We can help be an adjunct to care on top of things like HRT or hormone replacement therapy which absolutely should be talked about especially now that we're seeing the shift away from like absolutely don't do HRT because it can increase your breast cancer risk We're seeing that language changing. And so it's exciting to see these women start getting the care that they need in the realm of HRT. But as pelvic PTs, we can step up to the plate and help layer on even more in terms of helping them manage their pelvic floor symptoms, the genitourinary syndromes that they're experiencing. We can really talk to them about building up strength and building up muscular support for their bones as everything changes with their bone mineral density. We can maybe teach them how to exercise for the first time if they're people that have been avoiding exercise for the majority of their life because of symptoms that they have been experiencing since they first had their babies. So really, my whole point of this episode this morning is if you are not in this menopausal space, If you're a pelvic PT and you're not comfortable talking to people about menopause, or you really don't feel like you know enough about menopause to really truly serve this population, I truly feel like it's time for us to step up to the plate and get comfortable with it. We have a lot of resources out there. A few resources, I'm just going to list a couple because otherwise it kind of sounds like a rambly list. The North American Menopause Society actually has like a provider list that you can go in and search for menopause-informed urogynecologists and providers. Letstalkmenopause.org is a website that you can take a peek at, you can also direct your patients to, has resources for patients, really kind of breaks things down into patient-friendly language. The Menopause Manifesto by Dr. Jen Gunter. And then in our live course, we actually dive into menopause in week five. And we talk in more depth about how, sorry, our online course, not live course. We talk in depth about how we can help as PTs serve this group of women. I really feel like it is time for us to do this y'all. I think that this group of women and maybe it's my heart going out because I'm thinking about like moms and grandmothers and all of all of these women in our lives that have just been told that this is something they have to deal with. And now they're being told this again. It's time for us to help change this. It's time for us to bring fitness forward PT to this group of women, especially this group of women. They deserve it. I don't want to say more than anybody else because absolutely we all deserve it, but they deserve to get this quality of care.

SUMMARY If you're interested in jumping into our online course to learn about menopause in that week five, our next cohort opens up April 29th. We have two live courses coming up, April 6th and 7th in Windsor, Colorado, April 13th and 14th in Spring, Texas. That's where you can catch us on the road in April. We've got some more courses coming up in May as well, so if you're looking into summer, hop on the website, sign up for a live course, and catch us on the road. Thanks for tuning in this morning. If you guys have any questions about menopause, reach out to all of us on the ice pelvic faculty and we'd be happy to answer. Thanks. Have a great Monday.

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

Episode 1680 - Return to running following ACLR Mar 08, 2024

Show notes

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Endurance Athlete Division Leader Jason Lunden discusses helping patients return to running following ACL reconstruction (ACLR). Jason describes healing & strength benchmarks to use to initiate running, strengthening needed to facilitate return to running, and biomechanical changes that need to be addressed to improve performance.

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

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

EPISODE TRANSCRIPTION

JASON LUNDENHey, good morning, everyone. Welcome to another edition of PT on ice daily show. My name is Jason London. I am the endurance or the endurance athlete division lead. And I am happy to be chatting with you all today. We'll be talking about return to run following ACL reconstruction. Sorry that I'm on a little late. I just wanted to avoid my dogs going crazy when my daughter was getting picked up. So for those of you who are patiently waiting since seven, thanks for your wait. So we're going to be talking about return to run following ACL reconstruction, covering, you know, why do we care? when that happens and why do we need to be thoughtful about that, what do we look for as our athletes are returning to run, and then how do we address it. So one, why do we care? Well, several different reasons. First and foremost, performance. We want to set our athletes up for success with when they're returning to run and being able to demonstrate good mechanics for performance, but also We do want to be thoughtful of that healing ACL graft and as it is going through the ligamentization phase, we want that to have basically been gone through that full phase before return to run just because of the stresses placed on the ACL with plyometrics, even though running itself in healthy adults should have very low stress on the ACL. And then third, probably the most important piece with really being cognizant of what's going on with their gait mechanics is a high rate of early onset osteoarthritis following ACL reconstruction. And with that, there's been studies looking that have shown that It really comes down to one of the risk factors is patients who under load the operative side seems to be one of the driving factors for early onset arthritis. So it's going to be something that you want to look for. CHANGES IN MECHANICS FOLLOWING ACLR So what do we look for in these patients who are returning to run following ACL reconstruction? Well, the main things that we see in the literature and then I would say I see in the clinic as well is, um, I'm jumping ahead here a little bit. But what we want to look for is those patients that are underloading the knee, so decreased knee flexion on the operative side in the sagittal plane at mid stance compared to the on operative side. So any difference greater than two degrees of knee flexion at mid stance is something that we need to address. That patient is underloading that knee. And then the second thing, particularly for patients following a hamstring autograft, semi-T, semi-membranosis autograft, is increased tibial external rotation during stance, which has been shown to be in the literature. Now, I jumped ahead there a little bit. WHEN CAN WE RETURN TO RUNNING? You know, when are we actually allowing these patients to return to run? Again, we want the graft to have gone through the ligamentization phase. So that is going to be at four months, anywhere between three and four months. But to be on the conservative side, you would want to wait till to the four month mark. And in addition to that, we don't want to just be timeline based because, you know, assuming that the graft has gone through the ligamentization phase is all done on you know, benchtop research. So we do want to have our objective criterion as well for when these patients are ready to return to run. And so we want, first and foremost, you know, full passive range of motion, minimal to no swelling, and normal walking gait. Those three things, in my mind, should almost always have been achieved by the six-week mark, so it gives you plenty of time before you're even thinking about returning to run. In addition to that, objectively we want them to have a certain level of strength. So we want 90% limb symmetry index, so 90% of what they can do on the non-operative side for hip strength, particularly hip abductor, adductor, and extension strength. And we want 80 to 85% LSI of knee strength, so quad and hamstring strength. Ideally testing all of these with, isometrically using a dynamometer. If not, you know, coming up with other ways with one rep maxes, planks, et cetera, to try to get a little bit of a better sense rather than just your hand doing that isometric hold and rating it a, you know, five out of five. In addition to 80-85% LSI with isometric strength testing for the knee, we want there to be some objective testing too. So we want the athletes to be able to perform single leg squat to 60 degrees with really good form without having to put their contralateral leg down and then do a two minute timed single leg squat max reps in two minutes and comparing that to the contralateral side and wanting that to be at 80 to 85% of what they can do on the non-operative limb. So this is, of course, going to take them some time to achieve. And so generally when that is going to happen is between the three and four month mark. So again, 90% hip strength, 80 to 85% knee strength, both isometrically and objectively. INITIATING RETURN TO RUNNING And then when they are returning to run, we're going to start with a walk jog program. where they're going to be jogging for a certain number of minutes and then having a walking interval with that. And gradually ramping up, depending on their experience, to where they are running continuously for 30 minutes. Once they've hit that, then you can have them do a threshold test. And basically, after they've had two successful bouts of running at 30 minutes without pain, having them on that third run of that week going to run as long as they can without pain during the run and for 24 hours after and that would set their threshold in terms of where they're going to be starting out at and then you're going to increase their running volume off of that. LOADING TO FACILITATE RETURN TO RUNNING I got a little bit ahead of myself earlier on but what we do want to look for is decreased knee flexion or underloading in mid stance on that operative side or excessive external rotation on that operative side as well of the tibia. And so how do we address that is mainly making sure that for the loading that one that they do have adequate quad strength to accept the load so really working on a lot of eccentric quad strengthening using the extension machine, leg press or or weighted wall sits, and then also doing focused loading patterns. So I really like having them do crouched carries with the knees flexed to approximately 60 degrees. I'm really teaching them to load through that knee that way, as well as doing some supported hopping with a monster band, a pull-up assist band, to really get them to load through that knee. ADDRESSING GAIT MECHANICSAnd as we know from a lot of the literature is, you know, strengthening alone is not going to carry over to the gait mechanics, unfortunately. And so we need to give them some cues while they're running to increase loading and knee flexion at mid stance. Probably the best cue to give them is to try to hit the ground hard when they're running. It's a nice external cue that seems to work better. Otherwise, other things you could try is telling them to try to sink into their stance more when they're running too. And, you know, having them do that in block training. So, you know, a lot of verbal feedback for them or auditory feedback based on how they're they're striking and titrating that over time. For the increased tibial external rotation that really again goes back to hamstring strength particularly medial hamstring strength since that's where the graft was taken for those hamstring autografts and in the study by absorted kick in 2017, they found that those athletes who had less than 85% hamstring strength compared to the contralateral side were more likely to have that tibial external rotation. So again, focusing back to that strengthening of the hamstring, but having to get that carry over for gait too. And what I found is I don't have really good external cue for them, but just having them thinking about when they're coming into flight phase is having them pick their foot up and internally rotating their foot to overcompensate initially, and then gradually that works itself out. So return to run for ACL reconstruction, you know, we're probably getting in the time right now where this has been happening for a lot of you for those athletes who tore their ACL in fall sports. Winter sports, we're probably not quite there yet unless they tore it in early season, but really be thoughtful about the timing of that. Again, thinking of wanting the graft to have gone through that ligamentization phase, so generally around four months, and generally they're not going to be ready until that point anyways if we look at our objective criteria, particularly of the 85% isometric strength of quadriceps and hamstring and being able to get 85% of what they can do on the control at all time with that two minute timed squat to 60 degrees. Again, this is important for performance. important for good outcomes following that ACL reconstruction and most importantly important for trying to decrease that rate of early onset arthritis at the knee following ACL reconstruction. So hope you gained a few pearls here. Working with ACL reconstruction patients is very rewarding and a lot of fun and don't just fall into the habit of When it's time to return a run, just sending them off with a walk jog program. Make sure you're looking at their gait mechanics and addressing that and thinking also about what is that athlete's history of running and what are their goals for running too. SUMMARY If you're looking to join us for any of the endurance athlete courses, we are just starting up the second cohort of online and unfortunately that is full for any of those that would want to join. So your next option there is May 7th, I believe. The first professional bike fit cert is coming up here in April, April 20th in Asheville. This is a little bit of a special one. as that the other lead faculty, Matt Keister, and myself will both be teaching that, so it should be a lot of fun. And we're really looking forward to hitting the trails around Asheville for some great biking. And then the first rehabilitation of the injured runner live course is going to be in June in Milwaukee. That one is filling fast, so if you're thinking or sitting on the fence on that, Make sure you sign up for that quickly. We do only have two live courses this year for Rehabilitation of the Injured Runner live, but we will be offering more next year as Megan Peach is moving back stateside and we'll be able to teach with that. I hope you all have a wonderful day. Get outside and do something fun with friends and family over the weekend, and we will catch you all later. Bye. Did you see him? I need to go get ready.

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 1679 - Don't miss the lateral shift Mar 07, 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 the concept of a lateral shift when addressing low back pain, as well as three objective & 1 subjective ways to assess the potential presentation of a shift.

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

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

EPISODE TRANSCRIPTION

JORDAN BERRYAll right, what is up PT on Ice daily show? This is Dr. Jordan Berry coming at you live on a technique Thursday or an assessment Thursday for today. So I'm lead faculty for cervical management, lumbar spine management. And today we're talking about the lateral shift and how in the clinic we can pick up on the lateral shift so that we're not going to miss it. So we're going to talk about just a few ways from an objective and a subjective standpoint that we can pick up on the shift so that we don't miss it. And so one thing that I commonly see in the clinic, whether it's a client who is not getting better, or it's a client who's not progressing like we think they should be, or if I'm doing a case review with another clinician or watching that clinician evaluate the lumbar spine, one thing that we commonly see is the lateral shift is not on that person's radar, or they don't know all of the different ways that a lateral shift can present. We're going to unpack that over the next few minutes here.

WHAT IS A LATERAL SHIFT? When we talk about a lateral shift, what we're really talking about is when someone has an acute episode of low back pain, oftentimes it's back and back related leg symptoms as well. they will oftentimes have what we call a lateral shift. And so that is when, quite literally, the body is shifted in a direction where the hips go one way and the shoulders go the other way. And there's a bunch of different theories on why this can happen, but really the person is going to inherently avoid this side of pain. So almost always the shift is going to be in the opposite direction of the side of symptoms. And so when we talk about a lateral shift, we name it based on the shoulder position, not the hip position. So for example, if I had pain on the left side and I was shifted this way, away from the side of symptoms, then we would name the shift based on where the shoulders are heading. So in this case, it would be a right lateral shift if I am going towards the right with my shoulders and towards the opposite side with my hips. And so again, there's a bunch of different theories on why this can happen, but one thing for sure that we see very consistently in the clinic is if someone presents with a lateral shift and it's not corrected or that treatment does not respect the lateral shift, you will typically not make very much progress. But it's not just a visible shift. There are other ways that we can sometimes pick that up. And so we're going to spend just a few minutes unpacking that. So I've got Jenna here to help me with a couple of demos. So if you're listening on the on the podcast right now, jump over to YouTube or Instagram if you want to see an actual visual of what we're talking about. So I've got four ways that you can pick up a lateral shift in the clinic.

FINDING A LATERAL SHIFT: USE YOUR EYES So starting with number one, number one is the most obvious. It's actually visible. So when someone has really significant back and or back related leg symptoms, you'll quite often see a visible, a literal shift when you're looking at them square on. And so if I have Jenna stand right here facing the camera. So let's say that Jenna had symptoms in the left part of her low back and then going down the left leg. almost always what you will see is the shift would be towards the opposite side of symptoms. So we would see Jenna's shoulders going towards the right away from the symptoms on the left. And the best spot to look when you're staring square on at the client would be at the forearms. And so we're looking at a difference in space between the forearms. So sometimes you might have to snug up the shirt a little bit or ask the client to relax the arms, but you will see a difference, more space on the side that the person would be shifting towards. It can be very obvious sometimes or it can be really subtle, but I'm always starting just getting a good visual of looking at the person square on. So number one is an actual visible shift. Okay.

FINDING A LATERAL SHIFT: LATERAL FLEXION RANGE OF MOTION OR SYMPTOM ASYMMETRIES Number two is an asymmetry in side bend or an asymmetry and lateral flexion. So when we're going through active range of motion, we will typically see that side bending towards the side that they're already shifted towards is gonna be much better than going towards the opposite side. So using this same example here, if Jenna is shifted towards the right, right, her shoulders are going towards the right side, what we will typically see is that she side bends towards that side, right, towards the right side, that it's pretty solid because that's the direction her body's already wanting to go to. And then when you go to the opposite side, it's gonna be, yep, very limited and oftentimes painful. And so anytime I see an asymmetry in lateral flexion or an asymmetry in side bend, I'm for sure gonna test out a lateral shift correction to see if it makes a difference. And when we say asymmetry in side bending, it's not always just an asymmetry in range of motion, can also be an asymmetry in symptoms. So even if the side bending is relatively similar from a range of motion standpoint with how far the person can side bend, if one side is dramatically different from a symptom, from a pain standpoint, that's also sometimes indicative of a lateral shift. Okay, so number two is an asymmetry in side bend.

FINDING A LATERAL SHIFT: HIP RANGE OF MOTON ASYMMETRIES Number three, an asymmetry in rotation of the hip. Specifically, internal rotation is usually the one where you're going to pick up on it. So if I have Jenna sit right here on the table and she just does internal rotation while she's sitting right here. So we're just assessing how much internal rotation we have. And then if I had Jenna fake a lateral shift, so let's go in the same direction, right? She's shifted towards that right side because she's off when her shoulders go to the right, she's offloading the left side. And so now it's going to present like she has much better internal rotation on the left versus the right. Now, it might not be true internal rotation that is different. It might just be of the position of the hips that it presents as if it's different. So picking up on internal rotation again, either because of symptoms or because of range of motion, can be a third way to differentiate between someone having a lateral shift. You can test it in sitting like what we're doing here. You could also test it in supine, but Very commonly it is the side opposite of the shift that actually might have a bit more internal rotation. Again, because of the position of the torso or the position of the trunk.

FINDING A LATERAL SHIFT: THE SUBJECTIVE HISTORY And then lastly, the fourth way that we can pick up on a lateral shift is in the subjective. So the first three are going to be more in the objective exam, right? The last one, the subjective, is going to be a preference for sleeping or lying on one side versus the other. So that could be, again, sleeping, that could be laying on the couch, it could be any time the person's non-weight bearing, they prefer to go in one side versus the other. And again, because they're offloading the painful side.

SUMMARY So if I hear any of those four things, whether it's in the subjective or the objective exam, I'm for sure going to test the lateral shift correction because I can't afford to miss it. So again, as you're going through this week and you're seeing someone that has acute low back pain, back-related leg symptoms, and you're trying to pick up on the lateral shift, what are those four things that might indicate that? Well, number one, the most obvious, it's visible. So you're gonna look at the person square on, and you're gonna look at the forearms to see if there's a difference in space side to side with their arms relaxed. Number two, an asymmetry in side bend. That asymmetry could be range of motion, being asymmetrical or symptoms being asymmetrical side to side. Number three is a difference in hip rotation, more specifically internal rotation. And then lastly, the subjective exam is a preference for sleeping and or lying on one side versus the other. All right, that's all that I got for you today. This is part one of two. So we're going to come back in a few weeks and jump on again and go over different ways that we can actually correct the lateral shift. The one that we know most commonly, right, when you're standing on the side and you're shearing the person or shifting the person in the opposite direction, that is by far the most common. But we've got a lot of other cool variations when the person might not tolerate that position. So as always, if you want to learn more about this, hit us up at one of our live lumbar management courses. And we've got a bunch coming up from the spine division over the next few months. I know we've got two coming up this weekend to next weekend as well. Cervical and lumbar spine management. Have an awesome day in the clinic. Thanks, team.

Episode 1678 - Prepare for adventure: SOC Mar 06, 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 the theory of selective optimization & customization, including how to help patients select goals, optimizing treatment around goals, and being OK with compensation as needed.

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

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

EPISODE TRANSCRIPTION

JEFF MUSGRAVEWelcome to the PT on Ice Daily Show. I'm going to be your host today, Dr. Jeff Musgrave, Doctor of Physical Therapy. It is Wednesday. That means it is all things geriatrics today. So excited to be sharing with you a topic fresh off a really exciting trip, Preparing for Adventure and the SOC Model. Now, don't get sick to your stomach if you're a home health clinician. We're not talking about start of care, okay? We're talking about a theory for successful aging.

THE STRONGER LIFE RETREAT So I'm gonna give you a little bit of background on how I got to this topic and why I'm excited to share it with you. just came off a trip out of the country with 20 members that are 55 and older. So we took an adventure retreat. Stronger Life members joined us out of the country to seek adventure and this was a really incredible experience. If I was preparing one of these members from a formal PT standpoint, what would I want to be thinking about? How would I select the goal? How would I optimize? When do we compensate for these patients? So if you're preparing someone for adventure, we need to be thinking about all these things. BALT's successful theory on aging has been a really helpful framework we use very frequently in our division, the older adult division. And what we want to do is, Adventure is relative, right? So we're taking 20 members from Stronger Life to the Dominican Republic where they're going to go snorkeling, where they're going to go horseback riding, where they're going to be walking or running on the beach, they're going to be swimming in the ocean, they're going to be kayaking in the ocean, all these exciting things. But adventure is relative. So maybe the patient in front of you, adventure for them is going to their grandson's baseball game. that may be a big overwhelming task that you need to break down. Or maybe it's just going for a walk outside. Maybe you've got a primarily homebound population and going outside feels like a big adventure. So I am going to use this higher level adventure example because it's fun, interesting, and fresh for me coming off this trip, which was so much fun. But for you, know that all of these things are scalable and this framework is going to be relative regardless. of the functional level of the client in front of you.

SELECTIVE OPTIMIZATION AND COMPENSATION So just a little bit more on this SOC model. So Selection Optimization and Compensation. So this has been a tenet of Lifespan Psychology and the process of development that entails Losses and gains of our patients over time. We know that in general, our patients who are not seeking fitness, who are going through this period of time where they're in a decline, if we can't interact with some fitness and get them active, we know it's gonna look like this. But for many of our clients that we're taking this fitness forward approach, there's gonna be gains and losses over time. And what we wanna do is we wanna learn how to partner with them in this aging process, knowing that there are some changes, despite our best efforts, things we can't change. We're really comfortable with things we know we can change, but we have a little more trouble when we bump into barriers and things we can't move forward. So this model, SOC, Selection, Optimization, Compensation, looking at the full lifespan and learning how to use these three tools.

SELECTION So the first tool is selection. So when we're talking about selection and we're thinking about older adults and their goals and successful aging for them, we're talking about goals that matter to them, not these BS goals like get better, get out of the hospital, feel better. Those things are things our patients may report to us, but it's our job to dig deeper and figure out why and why they feel that way and what specifically that means to them. So finding that meaningful goal and what they want to accomplish, we've got to break it down and get as specific as possible. The more effort we can put on the front end with selecting a meaningful goal and really understanding what that means, it makes the rest of our job so much easier. When it's time to select exercises, we're trying to figure out what tests and measures we need to be looking at. It becomes so much more clear. So a good start, I'll give you an example. We had lots of members who were planning to go horseback riding for the first time, or first time since they were in their teens. And if I had that client in the clinic, I'm seeing them in the fitness realm currently, but if I was seeing them in the clinic, the questions I would ask based on this framework of selection are, when is this gonna occur? When's our goal need to be accomplished? I would also want to know what's amounting, you know, excuse me. So when's this going to occur? How long are you going to ride? How big is the horse you're getting on? How frequently do you want to ride while you're gone? What gate is this horse going to going to experience? Is this member going to just be doing a slow walk? Are they going to be trotting where they're going to be oscillating up and down which may stimulate the vestibular system? Are they going to be cantering? How much dynamic balance do they need? How much strength do they need to be able to hold their position on the horse? So based on the frequency, the duration, the size of the horse, how often they want to do this, this is really going to help us break down what our patient needs specifically to reach this goal. And reminder, we're going to go through this same process if someone needs to carry their groceries in. We want to select a meaningful goal for them, then we need to break it down. We need to have all the specifics possible at our fingertips. So we want to know the strength, the range of motion requirements, the endurance requirements, the balance requirements, the vestibular requirements, which in this case are very relevant. When you think about the movement of someone on a horse, they're going to be going up and down. That's going to be stimulating the inner ear system, the utricle and the saccule as they accelerate, decelerate. There's going to be head turning. They're on a beautiful beach riding a horse. They're going to be turning their head, looking at stuff or trying to talk to their friends or get some selfies going. during that time. So we want to be as specific as possible to figure out what in the world they are going to need to be able to accomplish this goal. So selection is the first piece. We want to select a meaningful goal to them and we want to get as much information as possible.

OPTIMIZATION Once we have all the specifics nailed down, We're going to go on to the next step. And this is where most of us shine is optimization. So the first piece is selection. The second is optimization. Based on where this patient is starting, And the goal, we now have a start and a finish line. We've got to get accurate measurements at the beginning. Our CEO, Jeff Moore, is very famous for saying you can't make good decisions with bad data. We want to be specific of the conditions we're testing. We want to be accurate so we can actually see if we're making change in the future. Otherwise, we might as well not measure, by and large. So we want to be very specific with those measurements. But now we know This person wants to go horseback riding once. It's going to last about 45 minutes. They want to walk. They don't care if they canter or trot. They're going to be on the beach, so they're going to have to walk across the beach to be able to get there. So we now, we're going to say those are the specifics that the patient gave us. So now we're going to be looking at the range of motion of their hips. We're going to say, oh, these are going to be small island horses. There's not as much hip abduction required. We know that we don't have to get them stable in a seated position for a canter or a gallop. We just got to be steady in this seated position for 30, 45 minutes one time. And then we're going to, you know, hopefully the mounting situation we've asked about as well. Are they going to be able to go up steps unsupported to get on this horse? Or are they going to need, in the equestrian world, a leg up? Is someone going to come over and help boost them into position? So once we've got all that information, we've checked the range of motion, strength, balance, vestibular requirements, then we're going to go to work, right? We're going to challenge all of these different systems to reach this big, meaningful goal. range of motion that they need to really make this happen. We want to make sure that we're, you know, not laying on the table, kicking our legs, sitting, or outside of these positions that aren't relative to the goal. We want to make sure that these are big functional movements. We want to make sure that it mimics this movement and this activity as much as possible. Being in a seated position, can they go up and down, accelerate back and forth? There are lots of creative ways to do this on Swiss falls or if you're on, on a rolling chair going back and forth and adding some head turns. There's lots of ways we can replicate this. Even the mounting situation where we can use a high-low table and get really creative and maybe we're getting them onto a bolster or a Bosu ball, something like that. But during this optimization, we've got to make it as much like the actual goal as possible, as quickly as possible. That's going to help us with buy-in, And we know from motor learning, just in general, the more it replicates the actual activity and the conditions. I mean, heck, we can play some seagulls and some ocean music. We could do these things outside with distractions. There's lots of ways to layer in all the specifics that we gained from the first piece of selecting the goal. But once we know the optimization period, we've got to replicate that as much as possible.

COMPENSATION Once it's time for the third piece is compensation. This is the part that we get really uncomfortable. Most of us in the rehab world, we want to restore function as much as possible, and that's not a bad thing. We want to do that, but sometimes we don't have enough runway. The patient doesn't come to us in enough time. We can't help them change quickly enough to meet that goal on time. And if we want the goal to be accomplished, we're going to have to compensate. Oftentimes, our OT colleagues are much better at this. They're like, hey, just use the tool. Let's make this thing happen. Most of us that are physical therapists, fitness pros, we want to see people get stronger and we get really uncomfortable when it's time to compensate. but there are simple ways, little on-ramps, like getting a leg up, practicing having someone help them get on the horse, versus saying, you know what, you just can't mount on your own, so I don't think it's a good idea for you to do this, or you don't have quite enough range of motion to be able to throw your leg up behind the horse, for example, so this is really out of the question, versus saying, hey, can we have someone support you? Is someone else going on this trip? Can you bring someone into the office and we can replicate this mounting situation to give them a leg up, swing their leg around the horse, and help them be stable. Heck, even sometimes we can have someone walk alongside them to help keep them steady. If the goal is meaningful enough, we can accomplish it with some compensation. So whether it's an adventure retreat, whether it's a patient that needs to walk outside, get thrown groceries, go to a kid's baseball game for the first time, adventure is relative to the person in front of you. Regardless of that, a great framework, keeping in mind that compensation and changes in capacity happen over time, our BALT's theory of successful aging. So we wanna make sure that we're selecting meaningful goals to the patient, We're optimizing all the systems, getting good baseline data, and then if all else fails, we need to compensate to make those goals happen.

SUMMARY Team, I hope this was interesting. I hope this was helpful for you. If you're looking to catch us out on the road, We're gonna be in Newton, Kansas. I'll be there on the 16th and 17th, and then Madison, Wisconsin, we'll be there March 23rd and 24th. If you're trying to hop into one of our online courses, lucky for you, level one course is going to open up on March 13th, and then not long after that, we'll have level two. So I hope you enjoyed this. If you have any questions, comments, please drop them for me. I hope you have a wonderful day, and that's it for now, team.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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 1677 - Physiology/physics Mar 05, 2024

Show notes

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses the concept of viewing the human body as a vehicle or mechanical system versus recognizing the underlying physiological systems in place that make the human body adaptable & changeable. Zac encourages listeners to adopt loading a primary intervention as a way to cause physiological change in the body in a manner that could not be done with a vehicle. 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 ZAC MORGANGood morning, PT on Ice Daily Show. I'm Zac Morgan. I'm a lead faculty here at the Institute with Cervical and Lumbar Spine Management, bringing to you all this morning some concepts on physiology versus physics. And I would say physiology greater than physics is the title of this episode. Before we dive into the actual episode, I kind of wanted to talk through some of the definitions of these two sciences. Do you think it'd be helpful to frame our conversation this morning? And before we even do that, I want to start out by saying that really using physics to describe why someone develops symptoms or why someone gets hurt, I think it could be maybe one of the most unhelpful things we've ever done as a profession. So let's start out with definitions, and then I want to unpack that big statement that I just gave you. So from the physics perspective, let's start there. Physics is a natural science. Its studies matter. It's foundational constituents. and its motion and behavior through space and time. So that's the definition of physics. When you think about physiology, it has a different definition. Physiology's definition, it's a branch of biology. It deals with the normal functions of living organisms and their parts. It's the science of how the body and its parts work and function. Physiology covers a multitude of systems within the living organism, how cells, organs, and tissues work together and interact. The point here isn't that physics are completely irrelevant when it comes to why someone develops symptoms. There is certainly a part of the puzzle. But the unipolar commitment to physics from whether it's us as therapists actually understanding why someone develops symptoms or when we're actually describing to someone why they develop symptoms, that unipolar commitment to physics, it's devastating in the clinic. AN OVERCOMMITMENT TO PHYSICS So let's start with why I think as therapists we tend to overcommit to physics. Physics, while on the particle level, are very challenging to understand, when you think of physics on the big picture level, they're actually not all that challenging to understand. Humans, we tend to believe the things that we can actually lay our eyes on. When we can see something happen, when we can interact with it, we tend to believe those things as humans, and it makes sense because we can actually see them. And when things happen right there in front of us, it's just so much easier to believe them. We can observe the physical universe. We can test these things on ourselves. You think about things like gravity. Gravity is a physics concept. It's really easy to test gravity. You can take basically any object, drop it, and you can observe that object fall towards the center of the earth at a specific time or a specific speed. It doesn't really matter the object. They all move towards the center of the earth at that same speed. we can observe that, we can interact with it. So it's really easy to believe in gravity and it's really rare that you would interact with someone who doesn't believe in gravity. From a physics perspective that's easy to observe. Now let's extrapolate that more towards what we see clinically. I think a lot of times people will use these examples of things like vehicles. That's a very common example for the body. People will compare the body to a vehicle or tires to joints. And you think about like tires, that's a physical object and every mile that you drive on your tires, that tread wears out a little bit more over time. You can watch that happen. You look at the tread on your tires and you can see that it's wearing out with each mile that you drive. Really the only way to avoid your tires wearing out is to not drive as much. So we know that that stuff happens because we can watch it happen, and so we tend to believe in that. So it's so tempting clinically when you look at something like an imaging study that one of our clients comes to us with, and you can look at whether it's an x-ray, CT, MRI, ultrasound, you name it, really any type of imaging, and we can observe those tissue shapes on that image. And when we look at those shapes, we can attribute pathology to the shape of those tissues. It's really easy for us to observe that and say, hey, I bet if that gnarly looking intervertebral frame and that gnarly looking joint were to move through space, it would be painful because it looks really, you know, disrupted. It's not smooth. There's a lot of pressure or a lot of compression in that area. We can observe these things on imaging and then kind of extrapolate that out to the symptom presentation in front of us. And this is what's so devastating in the clinic. While it is a piece of the pie in a lot of our clinical cases, it's certainly not the whole pie. It's only one small slice. PHYSIOLOGY IS THE TICKET When you think about what the rest of that pie is, it's physiology. What environment that those tissues are living in. That's really where the ticket is. I think because it is so easy to wrap our heads around this concept of physics, it's so easy for us to observe it. We have tools that make it easy to observe. It's easy to make a lot of attribution of symptoms to those concepts. And so this is really challenging to our patients. Like you think about what that does to a patient's psychology, like it's devastating. for those people. People don't understand much about their bodies and so when we give them these descriptions they often catastrophize the symptoms or they catastrophize the physics. They worry that it's going to be like what they've seen in their tires where every mile they run their knee ends up with a little bit more osteoarthritis but yet we know that recreational runners have less prevalence of knee osteoarthritis than sedentary folks. So it's clearly not the same as our tires. That's not a physical object, it's a physiological object. It's much, much different. So again, physiology deals more with the ecosystem that these tissues live in and that's where we want to put our attention moving forward as a profession if we really want to have a chance at helping people conceptualize their body and and helping people feel stronger within their body and helping people understand the benefits of exercise. OUR BODY IS AN ECOSYSTEM So let's talk a little bit about that. When you think of those examples like a tire or a vehicle, the big thing that those things lack that our body has are things like a vascular system. Like your vehicle doesn't have a vascular system. It's simply just built by engineers. And like I said, each mile that you drive is one less mile that you can drive in that vehicle. Sure, you can maintain the vehicle. You can rotate your tires, and that will make them last longer. You can change your oil, and that will make your engine last longer. But at the end of the day, shy of not doing anything in that vehicle, it's going to break down over time. Our body is completely different. It has a vascular system. It has intra and extracellular fluid that are full of nutrients that are built to help your body adapt to the stimulus in front of it. It has an immune system that creates specific responses to stimuli that create a more robust underlying system. That can't be said for a vehicle. So when we compare our body to a vehicle, our clients often don't have that understanding that our body is actually full of a lot of adaptations that we've developed over a long period of time that are inherently built within us that help us continue to move forward. They help us build a more robust vehicle. That would be awesome if when you bought a car and you used it and you maintained it well, if it actually It actually lasted longer for every mile that you drove. That would be great. We would all want that car. But over time, cars break down. Over time, if our body has the right ecosystem underlying it, it builds more resilience. You think about like our MMOA crew, so Modern Management of the Older Adult, and you see some of these stories that they share where older adults start to put on so much capacity, so much strength, so much cardiovascular endurance over time. It doesn't make sense. If our vehicle was an actual vehicle made of physical objects that we could interact with, it should break down over time, but we know the physiology drives function. And so when we put it in the right ecosystem, and when we allow it to adapt over time, we get way more out of it. I mean, think about it. Your tire, it doesn't get nutrients from the fenders. The rims don't provide it nutrients. The air within those tires don't allow it to build more tread over time. Again, I would love it if that was the case, because we wouldn't have to replace these things, But our bodies, they do have those things. The vascular system is built for that. The immune system is built for that. Our bodies are so much different than vehicles and when our clients leave our interactions and they have in their head that they're going to break down over time, they end up opting out of activity and that's exactly what we want to avoid. Like you think about if someone feels the that every mile that they run is one less mile that they can run on their knees, or every deadlift that they do is one less time they could pick their grandkid up, think about what that does to them psychologically. It makes them avoid those activities, and so they wind up missing out on all these physiological adaptations that would extend their quality of life and lifespan. That's a huge mistake as a profession, and we need to move dramatically away from that over time. It's easy to observe problems in people's bodies. We can make attributions of the way someone moves with pain. You can look at those imaging studies and say, well, if that nerve root's that compressed, then this person's probably gonna be in a tough spot. But team, it's not like that in the body. The body is so well built to adapt over time. I'll never forget the first time I heard Jeff Moore say, back pain is not a tissue shape issue, it's a tissue health issue. And it just hit so hard in my head when I heard him say that for the first time, because it is that. I mean, you can look at the Brzezinski study, you can look at the Nakashima study, that's lumbar and neck kind of respectively, and you can see that people with no symptoms whatsoever have all sorts of physical deformities in their spines and yet they have no symptoms whatsoever. Over time, we're seeing the same concept throughout the rest of the body. Like I said, the extremity crew does a great job of pointing out the inadequacies often of imaging studies throughout the rest of the body. And team, seeing that over time, it is becoming more and more clear that these physics examples, while they're easy to understand both for us as clinicians, but also for our clients that we're teaching these concepts to, while they're easy to understand, they're such a small piece of the pie, but they have catastrophic responses within people's psychology. People tend to catastrophize those things. So we have to focus on physiology. LOADING CHANGES THE UNDERLYING PHYSIOLOGY And team, I think our treatments, what we choose to do with clients reflect this. When you think about, if you haven't taken the extremity course, you have to because they do such a wonderful job of framing things like tendinopathy. From a physics perspective, sure, you could look at a painful tendon, you could look at a histological study, you could look at an ultrasound sometimes, and you can see that those collagen fibers are disrupted from a physics perspective. But going in and physically stimulating those things isn't what creates adaptation. It's not cross friction massage, it's not those things, it's load. And why does load work? You take a relatively poor vascular supply, but still a vascular supply, and you force angiogenesis to that region, you get that tendon to adapt over time. You change that underlying physics. Vehicles don't do that. So we have to get our heads wrapped around how these things are different so that we can start to push our patients forward and help them work through a little bit of discomfort, which is a big part of tendinopathy management. People need to know that they're going to be okay and that their body is built for these stimuli and it responds in a way that is tremendously different from a lot of the other things that we can observe in the universe. It's so cool that our body is built for that. You think about spine management. We talk a lot about this on the weekend. Often a nerve root is in a really unhelpful environment. There's a lot of concentrated inflammation in the region and the person's reporting a lot of distal symptoms when that's going on. We do things like repeated motions or spinal manipulation or some sort of treatment to intervene on that region and we draw a lot of fluid in there and drop that concentration. Team, that is so amazing that our body can do that and that the person can leave feeling centralized and feeling so much better. But we didn't push the jelly back in the donut. It wasn't a physics issue. It was a chemical soup bathing that region. And when we draw fluid into that region, it feels better. The person feels dramatically better. ENGINEERING VS. BIOLOGY Team, We have to change our perspective. We can't keep comparing our body to a vehicle. Vehicles are built by engineers, and they're really well built, and they're built out of physical materials that we can all observe in the universe put together, and they all have specific wear rates. There are things you can do that might slow that wear rate down, but at the end of the day, they do wear out over time. Our bodies are biological. They're physiological vehicles, and within those, they are well built. They've been built over thousands of years. to heal, to move forward. They've been built for the one specific purpose of survival. It's what makes us so different from everything else in the universe and it's why a huge part of what we do is address this underlying physiology. It's about the ecosystem that the tissues live in. We have to move forward as a profession and this is why things like fitness forward care make so much sense. Because it goes so much far beyond that local tissue, like you think of the environment and you think of when y…

Full show notes at the publisher

Episode 1676 - What is the PT role in female fertility? Mar 04, 2024

Show notes

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses female fertility, including what physical therapy interventions are not currently supported by research for use in assisting with conception but also offers some key ideas to come alongside this vulnerable population to assist them within the limits of our scope of practice. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION CHRISTINA PREVETTHello everyone and welcome to the PT on Ice daily show. I'm trying to get YouTube up and running. I don't know why it's telling me that this isn't available, but I am gonna give it another go. If you don't know me, my name is Christina Prevett. I am one of our division leads for our pelvic division as well as our geriatric division. And today I wanted to talk to you all a little bit about our role in fertility. So we are working on our level two, finishing up our level two course content. And one of the areas, our level two course is talking about how to create a fitness forward approach to pelvic health in a variety of different conditions. And so one of those conditions is around fertility, infertility, birth control, that type of space. And I have thought, an astronomical amount about where our role is in fertility, fertility management, and infertility. And so to kind of give context to this, like it really has been in the last five or ten years where we have started to advocate for ourselves as a member of the obstetrical team, right? So we really advocate in pelvic health, especially with rates of pelvic floor dysfunction and pelvic injury that happen around the pregnancy and postpartum period, that we have a role to play from a rehab perspective when it comes to female health and male health in the fertility space potentially. And so we have kind of made this jump where we are now very well known for being in the obstetrical space, helping with birth prep, helping with reducing perennial trauma, rehabbing from perennial or abdominal trauma as a consequence of a C-section or a vaginal delivery. And so we really have etched our role in a wonderful way in the obstetrical space. And so it doesn't really seem like that big of a leap for us to think about coming into the fertility space, right? Because it's all kind of centered around the pelvis. It's an area where there is a lot of misunderstanding. There's a lot of grief. There's a lot of trauma that happens. And so we are seeing more and more of our physical therapists and other allied health providers start advertising services in fertility. FERTILITY GONE WRONG And so Before I go into some of the research in this space and where we at ICE stand in this space, I want to tell you all a story about where this can go terribly wrong. So I owned a physiotherapy clinic and a gym up in Kingston, Ontario for five years. And I had a woman come in to see me and she was looking for a consult for the gym. Her husband was in the military. He had done multiple tours and they were having trouble conceiving. So they had done multiple rounds of IVF, neither of which had been successful. I think they had done two rounds and he was currently deployed and he was struggling with mental health stuff. He was struggling with PTSD. She was, as a consequence of the healing process, was also struggling with a lot of mental health and anxiety, trying to be that person for him. So it was a really complicated situation, their fertility journey. And so they were, she was coming in saying, you know, well, if I can get in better shape, then maybe it's going to help this next round of IVF. And so I was talking about her history with exercise, and then I was talking about her history with rehab, just trying to get to see if, you know, she would want to come into one of our programs and what that program may be. And she told me that she was seeing another provider and was getting adjusted three times a week for fertility. And so I kind of asked her the situations and circumstances around that. And she said that, you know, I am willing to try anything to get pregnant. It's what I want more than anything else. And so she's like, I went to this provider and they did a x-ray of my entire back. And I was starting to have low back pain, which like infertility, trauma, mental health, baby that they want that they cannot have. Like her pain was focusing around her pelvis and her low back. And provider x-rayed the entire spine and said, oh, here it is. Here's your infertility. It is at your neck and you have a issue at C5, C6, and there's an innervation right there, right to the uterus. You're going to get adjusted by me three times a week for six months. And I guarantee you the next time you have IVF, it's going to be successful. And I have never raged internally in a conversation so much in my entire life. It was a really tough spot for me to be because I was a person that she had never met before. Then she was asking about gym-based services, did not even know that I was a physical therapist because that was not the role that I was playing in this interaction. And she was in such a vulnerable space that if I came in super hot and was like, that is not true, then I would have potentially severed a line of hope for her that she had developed, but oh my goodness, how unethical is it for you to make promises that you cannot keep? And so I tell this story to give the frame of reference that I think about when I make statements about where we lie with respect to our role in rehab. FERTILITY: A VULNERABLE POPULATION So the first thing that we always have to think with this, and this is in any space where we are trying to kind of go into new markets, and I am not against being in new markets, but this population in particular is a very vulnerable population. This is a population where individuals are feeling like their body is failing, The emotional and mental load of fertility is high. The shame and guilt and spiraling and social context and people asking you if you're gonna be having babies soon even though it is something you want more than anything else in the world and it is not happening. The feeling of your body failing you at something that you quote unquote should be able to do. These are all things that make us need to think very clearly about the statements and promises that we make as we consider niching into this space. The second filter of this is from a manual therapy perspective. We have no evidence that our manual therapy increases chances of conceiving. So we cannot say that we are changing the orientation of the uterus to make for a more hospitable environment. We cannot say that. It is not ethical for us to say that. One, because we have no evidence that there's going to be any movement of really strong really anchored organs in our body where we are placing hands on people right like our evidence is that we are horrible at landmarking exactly what what muscle we are on we are not doing a hip flexor release and and changing trigger points in our muscles We are not able to really localize our manifs and we're really interacting with the nervous system. So if we can't even do that at the superficial musculoskeletal system, why do we think that our manual therapy is going to impact our organs? So we need to be very mindful about what we are doing. And so the first thing we have to filter is the ethics. THERE IS NO EVIDENCE FOR THE USE OF MANUAL THERAPY TO IMPROVE FERTILITY The second thing we have to recognize is that we are currently going into a space that does not have evidence for our manual therapy techniques to change our fertility. That is number two. That is not to say that this evidence will not develop. It is a new area, but we cannot say, if you come to see me, you're more likely to get pregnant. We cannot say that. We can say that we are exploring different modalities and we can have lots of conversations about fertility. We are educated providers in the fertility space, but we need to be very clear with our communication about what we can promise to individuals because it is unethical for us to say that this is gonna happen. Three, there is a placebo effect of somebody taking care of you when you are in such a vulnerable space, right? There is one of the biggest and best things that we can do as rehab providers is that we are able to have space, have time to listen to our people and cater to and speak toward the emotional side of what they are going through. A lot of the interactions with our medical space when it comes to fertility are very much focused on the physiology of it, right? Because that is what they are trying to remove barriers for from a physiological perspective, whether it's on the male or female side, and allow fertilization to occur in successful implantation. But we need to be very, very mindful. So to finish off this episode, what can we do? Where do we have evidence around a potential role in rehab. Okay, so in order for conception to happen, right, we need to have, on the female side, we have to have an egg that is released on a monthly basis, right, so we have to be ovulating. That egg has to travel into the fallopian tube. Sex needs to occur with ejaculation so that the sperm is meeting the egg in the fallopian tube. And then the fertilized egg needs to travel through the fallopian tube and embed into the uterus and have the hormonal environment, have the enrichment of the uterine walls in order for that implantation to be successful and maintained. Okay. So the first piece in our fertility is the ovulation space. And if you've been following our pelvic crew for a long period of time, you know that one of the areas around ovulation, and we are not medical providers, so we are not looking at their hormone levels. We are not seeing if luteinizing hormone is creating a estrogen surge that allows ovulation to take place. But we are one of those providers that oftentimes can catch relative energy deficiency in sport. So We can have conversations that individuals are amenorrheic to be a resource dealer and a primary care provider to refer on if we think that something is going on with their menstrual cycle that has to do with their nutrition or that they are not ovulating as a consequence of low energy availability. So from that perspective, if they're not getting their period, like we may be that resource dealer to a registered dietitian or nutritionist that has a scope of practice that works with potential disordered eating, potential issues with fertility, and that has a more broad scope of practice to be able to speak to those levels, right? We could be referring to our obstetrician if individuals are thinking of conceiving in the next six months and they don't have their period, let's get them to get their doc to do blood work or let's like get earlier on that process and then send that letter and say, you know, I've been treating this person for musculoskeletal issues. Like I am a little bit worried about relative energy deficiency in sport and we can make that connection. We can also educate on the menstrual cycle and what is required for fertility to take place, right? We can be talking about when our fertility windows are, right? We are not reproductively positive or we're not able to have a fertilized egg at all parts of our cycle, right? Ovulation occurs between day 12 and day 14. So that window, usually between 11 and 15 days of your cycle is like your chance window of getting pregnant. So we can be educating on that. We have evidence for that. Medically, in our scope of practice, we can absolutely be talking about that physiology. We have a role in that space and we have the time to sit down with our people and talk about tracking your menstrual cycle and recognizing some of the signs that you might be ovulating, like changes in cervical mucus and body temperature and those types of things. The second piece where we have a role is that sex needs to be successful in that women are able to have penetrative intercourse and ejaculation needs to occur. And so I'm going to do an entire second episode on male fertility and male fertility factors and our role in male fertility, because fun fact, 30 to 50% of infertility cases are male factors. And yet all of our information is on female related fertility factors. And so in order for sex to be able to happen, individuals have to not have pain. and they need to be able to have penetrative intercourse. So here's another area where our role can be quite massive, right? In really extreme cases of pelvic pain or vaginismus or vulvodynia, there are circumstances where the pain is so severe that individuals do artificial insemination or other assisted reproductive technologies because they are unable, without significant severe pain, to be able to have penetrative intercourse in order for ovulation or fertilization rather to occur. So we have a role in that space as well. And this is where our evidence is, right? So if individuals are having pain with intercourse or on that guarded high nervous system response, right? Parasympathetic tone is a very important part of our arousal response. then we can be interacting with that nervous system and we can be working on pain-centered modalities in order to try and allow individuals to be able to participate in intercourse in order for individuals to be able to successfully, hopefully conceive. Where some individuals, and this is gonna be long, so I'm gonna try not to rant too much, where we're taking a bit too much of a stretch for where we are at in our opinion, is around the hypertonicity and what the hypertonicity of the pelvic floor is doing from a hospitable environment for fertility and saying, well, your body might not be ready. Let's talk about our vagina and our pelvic floor muscles and our cervix. Our pelvic floor muscles are here. Our cervix is here at the top. So once sperm has passed your cervix or has gotten through that, and you, I'm not saying that your penis goes past your cervix, but what I'm saying is when you are having that ejaculation, that the sperm is going to go up towards the cervix. Once you have passed that pelvic floor layer, the pelvic floor has nothing to do with our fertility, right? So that hypertonicity piece, likely has no impact outside of pain responses on successful fertilization of an egg, right? Because that sperm is gonna go up towards the cervix and sneak through to try and be able to ovulate that egg or to be able to fertilize that egg like really quickly and the muscles of the pelvic floor are not impeding sperm from getting there. So again, kind of coming full circle, like our role is in education and pain management from where our evidence stands right now. And if we are going into these areas of gray, we need to be mindful of our language. And then we need to really think critically about what do we truly think is going on? And is some of my manual therapy interacting with that nervous system, bringing that stress response down, getting u…

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Episode 1675 - Increasing training volume: why, when, how, and who? Mar 01, 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 strategy behind helping athletes & patients consider adding extra training volume on top of their normal exercise routine. Why should we add it, when should we add it, how should we integrate it into our normal training, and who is appropriate for extra volume? Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLWelcome in, folks. Good morning. Welcome to the P-Town Ice Daily Show. Happy Friday morning. I hope your day is off to a great start. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader here in our Fitness Athlete Division. It is Fitness Athlete Friday. It's the best darn day of the week, we would argue here, from the Fitness Athlete Division. Those of you working with crossfitters, Olympic weightlifters, powerlifters, endurance athletes, anybody who is recreationally active, part of that 10% minority of the human race that exercises on a regular basis enough to produce a meaningful health and fitness effect. We're here to help you help those folks. INCREASING TRAINING VOLUME So here on Fitness Athlete Friday, today we're gonna be talking about increasing training volume. A hot topic, especially this time of the year, the CrossFit Open has begun as of yesterday. This is often the time of year as people go through the Open, maybe they did not perform as they thought they would, and they begin to ask questions about how can I make my performance look more like someone else's, right? So 24.1 was released, a couplet of dumbbell snatches and burpees over the dumbbell. I just finished it this morning, just finished judging a few hours as well. First workout, usually very approachable. People maybe have questions of how can I get faster as we get into the later weeks of the Open. Heavy barbell comes out, high skill gymnastics comes out, people begin to have more questions. What else could I be doing besides coming to CrossFit class? This relates to other athletes as well. Endurance athletes who maybe want to get faster in their mile time, faster in their race times, stronger to have less injuries. All of those questions tend to come up of what else could I be doing? So today we want to focus on asking in the concept, in answering the question of increasing our training volume. Why should we do that? When should we do it? Who is the person that's appropriate for it? And then how should we actually begin to introduce increasing training volume? WHY SHOULD WE INCREASE VOLUME? So let's start from the top. Why should we increase training volume? I think this is really important and that's why I have it as the first point today. often folks are maybe disappointed with their performance in the open or a recent road race or competition or something like that and they want to do more training and just adding in more training without understanding why we're doing that training or having a goal for that training can be a very rocky foundation to build upon and can really ultimately maybe set us up for an unsuccessful addition of volume that doesn't meaningfully improve our performance and maybe leads to an increased risk of injury for no reason. because we don't really know why we're training for more volume, right? Just doing more CrossFit metabolic conditioning workouts or just doing more accessory weightlifting or just running or biking more miles without a goal is really just adding meaningless volume to the equation. We need to understand why should we do this. So when folks come to you with that question of What should I be doing extra outside of my running or outside of CrossFit class? We should be asking back, why do you feel the need to add more training volume in? What specific deficit are you understanding or do you feel has been recently exposed that we need to add more training volume in? To just improve general fitness, with those folks we would say, Be patient, right? Continue going to CrossFit class. Continue if you've only been running for a year or two, continue your normal running training, right? Understand that high level performance often comes with most folks. When you look at them, they have a large training age, which means they have been doing whatever they're doing for a long period of time. And so expecting to close that fitness gap in just a couple of years by just adding in more volume is not really an intelligent way to approach that. But if we have identified some specific deficits, then that can be an argument to maybe add in some extra volume. So, folks who are maybe long endurance athletes who are noticing the longer my runs, the slower I become. I perceive that I maybe need to add in some speed work. Folks may be doing CrossFit that say, you know what, I'm great when the weight is body weight or when it's a low to moderate weight, dumbbell, kettlebell, barbell, whatever, I'm okay. But as we get heavier, I perceive that my strength, my upper limits of strength is limiting me from moving the weights around. In CrossFit class, where I'm perceiving that if I added in some more resistance training to whatever I'm doing, Maybe my tissues would be healthier or I don't have some of the skills and I would like to begin to practice them, right? I would like to practice double unders outside of class. I would like to practice pull-ups or muscle-ups or handstand push-ups outside of class or maybe add in an extra day of running if I'm a CrossFit athlete. So understanding why we're adding volume in is very, very, very, very important and it should be to address a specific perceived deficit and all the better if we can actually objectively test that so that we know if we're starting to make up ground on that deficit or not with the extra volume that we're being asked to add into our programming. So starting with why is very important. WHEN SHOULD WE INCREASE VOLUME? The next question is, when should we do this? I would argue that we should really only add in extra training on top of what we're already doing when we feel like our current training has plateaued. Of that person who says, I have been going to CrossFit six days a week for 10 years, and I feel like my ring muscle ups are not getting any better. I feel like I have literally not added a pound to my max, clean and jerk, whatever. When a perceived plateau is there, That can be a good argument to begin to add in some extra volume, especially those folks, uh, endurance athletes as well. Like, Hey man, I have been running for a decade and my marathon pace got faster, faster, faster the first couple of years, but it's been pretty much the same pace for the past two or three years of races. I feel like something needs to change. Or, again, those folks who do not have a skill. So that's when we begin to action that extra volume. For me, over the past year, my extra volume looked like adding in some more running. Doing pretty well, pretty happy with my CrossFit performance, but when runs showed up, especially in workouts where the runs were longer, 800s, miles, workouts like Murph Hero workouts with a lot of running, really, really, really impacted my performance despite doing pretty well on the other stuff that wasn't running. So beginning to add in extra running outside of CrossFit class. HOW DO WE INCREASE TRAINING VOLUME? Now, how do we do this? This is as important as why. How do we add in volume in a very intelligent manner? The key is with anything else, just like when somebody first began an exercise program, we need to start low. We need to go slow. We need to stair step this volume. A lot of folks perceive a deficit or otherwise feel like they want to add in more volume and they just do more of what they're already doing. And sometimes they do it every day, right? The person who leaves CrossFit and goes to Planet Fitness and does an hour on the stair stepper. or does an hour of machine weights, whatever. Adding in a big chunk of volume, again, if we don't have the foundation of why and when we should be doing this, can be a really unintelligent decision. So we should do this carefully. For me, this looked like one extra day of running for a couple of weeks, two extra days of running for a couple of weeks, so on and so forth. Using a running coach to very carefully and controlled add running volume in on top of working with a nutrition coach to make sure that I was fueling appropriately. So making sure that if we do come to the decision that we could benefit from extra training aside from what we're already doing, that we do it very, very, very, very carefully. What we're trying to do adding in extra exercise pieces is we are trying to push ourselves maybe into a short period of what we would call overreaching, functional overreaching. We're pushing the margins just a little bit, but we also need to be mindful of all the other training that we're doing, and we have to be careful that this functional overreach does not become overtraining, right? We need to make sure that if we're adding an extra stuff, we respect this new volume. We do it carefully. This extra volume should come with a progression in a deload. So for example, my running coach always had me on four week cycles. where every fourth week was a deload, added a little bit of miles every week for three weeks, and then a deload, add, deload. That deload week is a chance to give my body a break, go back to essentially my pre-running amount of volume, but it's also a great week to assess how did my body respond to the previous three weeks of training. Should we continue with the next block of extra volume? Or should we stay where I was at? Or should we maybe even regress a little bit because it was a little bit too much of an overtraining feeling rather than that functional overreach? And again, being objective with why are we doing this can really help us know did that little burst of extra volume create a change? Did mile split times go down? Did a race time go down? Did strength go up maybe two pounds or five pounds or whatever? Can I do two muscle-ups now instead of one muscle-up? So on and so forth. Having those objective indicators lets us know, okay, we're making the progress we want to see, and as long as everything is feeling good, we're good to continue going to that next step on the staircase of increasing volume. And when we think about how we add in this training, most importantly, we have to ensure that this extra training does not impact the normal training, right? The worst thing you can do is have your extra volume, make it so that when you show up to your normal training, so in my example, I never wanted to get to a point where my running made it so that I could not come to CrossFit, right? That's a dangerous spiral to get into, where now my normal baseline strength and conditioning program can't be performed, and now I'm adding extra volume even though I can't handle the current level of volume I was already doing before I added in my extra training. So being sure that whatever we're training at baseline, CrossFit, weightlifting, running, whatever, that does not become impacted by whatever extra stuff we're doing. Now that being said, if we're feeling good, we feel like we're making progress, we are objectively making progress, and our normal training is not impacted Okay, continue to either maintain that extra thing, whatever you're doing, or maybe even progress it a little bit. WHO IS APPROPRIATE FOR EXTRA VOLUME? Now the final part of the equation is who should do this? I would argue the answer is very few people should do this. Who is the type of person that is appropriate for extra volume? that person should be incredibly consistent with whatever they're already doing, right? Which by default erases most of the people who want to do extra volume. A lot of people perceive a gap in fitness between maybe themselves and their friends in CrossFit class or themselves and their friends and their run club or whatever. They want to close that gap even though What they don't want to hear is that maybe the gap there is because they're already not consistent with what they're doing, right? They hit the snooze alarm a couple days a week on CrossFit class or going for their run, right? I want that individual who is already incredibly consistent with their normal training. They are training four to six days a week, every week. They understand the importance of active recovery and rest days. They are prioritizing their sleep and their nutrition. The volume means nothing if we can't match that volume with an appropriate dedication to recovery. Again, we're trying to create bouts of small windows of functional overreaching. We're trying not to throw somebody into a downward spiral, a death loop of overtraining where they're going to be at increased risk for injury, where their fatigue, their soreness, whatever is going to impact all of their training, not just the extra volume that they're now doing. Most people are not consistent enough with what they're already doing to consider taking on extra volume. And I think that's tough to hear, but it's the right decision. for you as the coach, the clinician, whatever your role is, to have in a conversation with that athlete. If you are only coming to CrossFit on Monday, Wednesday, Thursday, you sleep in on Tuesday because Monday wrecked you, you sleep in on Friday because you're sore, you don't come to the gym on the weekend, let's see what your fitness looks like when you're consistent with your current fitness routine, and then maybe later on we can revisit talking about extra volume. I have found in my coaching career that the folks who come up to me and tell me, hey coach, I'm ready for butterfly pull-ups, happen to also be, coincidentally, the people who maybe can't even do strict pull-ups, right? The folks who are able to tolerate extra volume, extra skill progression, are the folks who are already very consistent and it's very clear that they, because they are consistent with their normal level of training, recovery, attention to their sleep and diet, They are aware, and I am also aware, that they can probably handle extra stuff, and that the people who want it really, really, really, really bad are almost always likely the people that should probably not do it because they are so inconsistent already. CASE EXAMPLE: RYAN A really good example I have is our friend here at the gym. His name is Ryan Battishill. You may know him. He develops a lot of your websites. He's a website developer by trade. He's a member here at our gym. I love how calculated and intelligent he is with just a little bit of extra training every day after class. So I want to tell you a little bit about him and then tell you the volume that he's added in in the results. So Ryan's been doing CrossFit for five or six years now. He has a history of running as well. He has a good morning fault squat. So a very kind of hingy squat.…

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