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    Health

    #PTonICE Podcast

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

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    Latest Episodes:
    Episode 1623 - Obesity management: the 5 A's Dec 19, 2023
    Show notes

    Dr. Ellen Csepe // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses using the "Five A's" model in the clinic with patients to begin to address obesity management as part of a plan of care. Take a listen or check out the episode transcription below. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ELLEN CSEPE Hey, good morning, everybody. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'll be your host today. My name is Dr. Ellen Csepe. I'm with the MMOA Older Adult Division, whose life's mission is to give grandma gains this Christmas to fight off frailty and level up what it means to be a geriatric clinician. So before we get started today, let's talk about our upcoming courses. We have two courses online that are eight week long cohorts where we talk about discharging the ankle pump and dialing in our skills for dosing in the level one course, which starts on January 10th. January 11th, our L2, level two course, we take it to the next level to really dial in our skills for older adults with specific conditions like osteoporosis, osteoarthritis, and even we have a new segment recently added on cognitive changes in dementia. So we're really glad that you're here today. Our topic for today is gonna be on obesity in the five A's framework. So your job, as a clinician and managing obesity in the Five A's framework. So I don't need to tell you guys, obesity is a growing health concern. Obesity and pre-obesity affect nearly 70% of the American population. This is obviously a big concern for us as a community, as a country, and as clinicians. And believe it or not, most patients believe that this is our job to manage, Managing obesity is something that is within our scope, and talking about the health considerations and health behaviors that contribute to obesity are within our scope as providers. But we have to take on this responsibility with excellence. We do everything here with excellence. And it's unfair to give this patient population anything less than that. And I've been saying this for a while, friends, but Our profession is uniquely positioned not to just add our opinion on how we should manage obesity, but in my opinion, we should be the leaders in health care. for how to manage obesity. We squander so many different resources that puts our profession above others. Things like time. We have more time with patients than any other provider and we often waste that resource because we're not confident in managing this problem well. We spend so much time with our patients and we have the strongest therapeutic alliances with them. We know our patients and spend hours with them as they recover from injury where they're kind of uniquely positioned at a position for behavior change. They're really primed to make the most with their health because they're afraid, unfortunately, because of their injury, because of what happened to them. prime time for us to change behaviors and we really waste that opportunity for lots of different reasons. And friends, we can no longer pass the buck off to other health care providers and say that this is their job. You know what I'm talking about. We ask our patients, does your doctor ever talk to you about exercise? Does your PCP ever talk to you about nutrition? They're like, no, they've got five minutes with me and they didn't do that. And we raise our hands and say, this is the problem with our healthcare today. No, we have a job to play in managing obesity. We have a role in this and we have to do it well because Friends, if you wish to treat obesity, you're responsible for not just identifying it as a problem in your patient population, but knowing what's going to work. For example, if I have a car and my battery is dead and I know my battery is dead and I take it to a mechanic and that mechanic says, yeah, your battery's dead. Good luck. That didn't help me at all. I need a mechanic that can identify the problem and then take the next steps to helping me fix it. We can no longer merely identify that obesity is a disease that causes significant harm to our patients. We cannot just merely identify it, cross our arms, look down the end of our nose and blame our patients. We can't do that anymore. We cannot just watch our patients suffer with a chronic illness and do nothing pragmatically to help support them. With that in mind, that same analogy of a car battery, if you had a car that needed a new battery and you came to me and I was your mechanic, I have no idea how to change a car battery. No clue. But if you came to me and I said, oh yeah, I've got this handled. I can help you out. That's an even bigger problem. We cannot address this concern with merely confidence. We have to have the skills to help our patients manage obesity. We can't just have confidence that we're providers of choice and that we're excellent. We need to have real skill in treating this concern. And friends, patients know that their weight is contributing to their problem. That's not that telling them is not the skill. That's not the skill. We need to be able to create an environment that's free of stigma. free of bias and filled with empathy for our patients that are struggling. Because patients know their weight is contributing to their issue, but in this void, in this vacuum of clinically meaningful discussion around weight and around behavior change, things like fad diets, diet pills, failed attempts at managing weight, ignorance to what might actually work, poor access to health care, and really at the bottom line, addressing their health alone. That's what happens if we don't bring skill to this discussion. If we can't bring skill to this issue, to this massive health crisis, what happens is the flip side. Patients having to figure it out on their own. So what I mean to say is there's a big difference in shooting from the hip and saying, yeah, you know, you'd probably have less pain if you weren't overweight or obese. There's a difference in that versus, can you tell me more about your exercise habits? Can you tell me, have other health care workers talked about how your weight might be changing or your weight might be impacting your condition? There's a huge difference and what that skill, if I could really articulate what that skill is, this skill is the hardest job that we have. The skill that you need is really the soft skills of being a good clinician. That's the hardest job we have. It's way easier to needle somebody's trap than it is to develop therapeutic alliance with them and make sure that they know that you're on their team and that you're an empathetic listener. That is way more abstract of a skill than just being able to do one small part of our job tactically. And I would argue that it might be the most important skill that we have. Patients need empathy if they're facing a health concern. Patients need us to see them as a person and not just as a patient. We need to address our own biases to really be impactful for this patient population. We need to acknowledge that if it were easy to lose weight, everybody would do it, but it's hard. Obesity is a relapsing chronic health condition that's multifactorial and it has a lot of psychological impact or impact bi-directionally that we don't even really fully grasp yet. Obesity is not easy to change and we need to address that first. So the next part of our discussion today, we're going to be talking about the five A's in obesity management. Now, when we talk about workouts, we're often given ideas and options to scale a workout. And so friends, if treating your patients with empathy and understanding and listening and patient-centered language is too big of an ask, I'm going to give you an option to scale this discussion with them. If the 5 A's and treating your patients with dignity and empathy and listening and respect sounds too hard, here's your scaled option for this discussion. You can say, it sounds like you're concerned that your weight is a contributor to this issue. I can refer you to a colleague of mine that has more empathy than I do and can have this discussion with you better. Bottom line, if you don't have empathy for your patients, if you haven't done the work to check your bias and how you might look down the end of your nose towards people struggling with your weight, looking for your help, then please step to the side and let a clinician come in to intervene that can have empathy and listening. Because unfortunately, you're likely doing more harm than good. Patients know that you're biased against them. They don't need you to tell them. Your face says it. And unfortunately, negative interactions with health care providers with weight bias often leads to further binge eating episodes for patients with a binge eating disorder. So no, you're not just telling them what they need to hear. You're actually being supremely unhelpful and likely making their problem worse. So if you can't have empathy, please scale this discussion and relay them to a provider that can actually be helpful. THE FIVE A'S MODEL So what are the five A's? The five A's model originates from the U.S. Department of Health and Human Services where it was developed as a framework for encouraging smoking cessation because, believe it or not, sticking your nose up in the air and saying, you know, those things are going to kill you actually doesn't help anybody quit smoking, shockingly. The same is true for older or for people struggling with obesity. So this framework was really developed to help put the patient who needs to make decision making changes in the driver's seat for their behavior change. So the five A's. ASK The first A is ask. Ask, is it okay to discuss lifestyle factors today during our session? Is it okay to talk about how weight might be contributing to your condition? Is it okay for us to talk about contributing factors like sleep and stress and nutrition? Have other health care workers discussed your weight in a way that was helpful or meaningful? So the five A's first, we want to ask for permission and some patients might tell you, no, that's okay. If somebody says, no, you know what? This really stresses me out. I'm not interested in talking about this with you. I just met you. That is understandable. We don't need to have a wrestling match with our patients. And if you have these soft skills, it should not feel like a wrestling match. It should feel like a natural discussion because again, patients already likely assume that their weight is contributing to their problem. You can ask which factor of their health they want to address today. So whether we know that sleep, stress, weight, exercise, diet, all interweave in regards to behavior change. We know that those things are interwoven and impact each other. ASSESS So our next A is assess. Assess, so you can ask a patient, hey, what do you want to talk about today? There are a few different things about your lifestyle factors that might be contributing to your condition. Yeah, your weight might be part of it. Also, sleep has a bidirectional relationship with weight. Exercise habits, dietary habits, stress, which do you kind of want to dive into today? And then let that drive the next tool of assessment. So if your patient says, you know, I actually don't know how much I weigh, do you have a scale here? Of course, that's within our scope to weigh our patients, to calculate BMI, to look at waist circumference. An important note should be that we do that in a private area because discretion with privacy is super important with this patient population. So we can't make good decisions with bad data. That's from our CEO, Jeff Moore. We can't, give patients and shoot from the hip that they need to lose weight when we don't know anything about their body composition. So weighing patients, providing that information about their waist circumference or their BMI is our next A for assessment. ADVISE The next advise, so the third A is advise. advising patients that sleep, exercise, appropriate nutrition management can be helpful in reducing pain. Most patients come to see physical therapists because they're in pain and so understanding that those factors deeply influence our success with rehab, and those are things that we can modify, that is hugely important for our patients to know. Also, not setting the goal too high. We might say, here's what your BMI window would be if it were normal, but who cares? Our goal initially should be to manage weight for five to 10% because even small percentages of weight change can be hugely impactful on lifespan. There's a lot of discussion about whether or not weight cycling and trying to lose weight only to gain it can be bad for our metabolic health, and meta-analyses recently would show that, hey, even if you lose weight and regain it, that can be beneficial for your overall health long-term, and you can still have a decreased risk of experiencing diseases. Noting that, you know, advising the patients that, hey, if you've tried losing weight in the past and it was a real stressor for you, we can talk about just increasing your activity level. It doesn't have to be a goal to lose weight. That does not have to be our goal. We can advise patients to just increase their activity level or decrease their added sugar, irrespective of weight changes, and that alone can be helpful in managing pain and managing injury. Third A is advise. AGREE The fourth is agree. So this is super important for our patients. We have to agree. We have to come to an agreement as to what we're going to do next. This is a pro tip. Let your patient set the goal. set what they want to do. Being told, okay, we are going to agree for you to stop smoking. We are going to agree for you to cut back to two cigarettes a day. Nobody likes to be told what to do. So asking your patient, what would you like the goal to be for the next week before we see each other again? Let's agree to talk about this again in the future, but I want you to set the goal for what sounds realistic for your life. I'm not going to tell you what that is. ARRANGI…

    Full show notes at the publisher

    Episode 1622 - Discussing hormone replacement therapy Dec 18, 2023
    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 the role of estrogen in the body, the important role estrogen (or lack thereof) may play in rehab outcomes, assessing menopause in the clinic, and hormone replacement therapy. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. And y'all, the pelvic division has been just really busy over the last couple of weeks, couple of months, heck, the entire year. But if you did not see, we actually just sold out our first online cohort for 2024. And so that is sold out. So our next cohort for our online level one is March 5th. Our brand new inaugural cohort for level two, if you've taken level one, is April 30th. And in 2024, I am going to be in Raleigh, North Carolina with Rachel Moore, January 13th, 14th. And Alexis is going to be teaching in Hendersonville, 27th, 28th of January. And then we're heading over to Bellingham, Washington, February 3rd and 4th. Those are the first three courses of 2024 if you guys are interested in coming to our live course and doing some of our skills check for cert. ESTROGEN & REHAB Okay, so I kind of want to talk about estrogen and specifically estrogen in later life and lack of estrogen and how it influences rehab. So this has been something that I've been really kind of geeking out about over the last little while around, you know, not just as pelvic therapists, but as anybody working with a person going through menopause, if you are working with anybody over the age of 50, a female over the age of 50, you are interacting with a person who is going through estrogen depletion in their body. And As I've learned more about the influence of estrogen on our bodies, the more I am recognizing even outside or maybe even especially outside of the context of pelvic health when I'm seeing people who are postmenopausal, but in my orthopedic rehab, how much it is influencing our outcomes. and just a person, a person who is a female in an aging body, what the lack of estrogen may do for the way that we experience aging. And then I kind of want to cap this podcast off talking a bit about some of the myths and misconceptions around estrogen replacement therapy. or menopause replacement therapy. And we'll talk a little bit about the change in the labeling of these types of treatments and where some of the thoughts around risk for things like sex-related cancers has come up. So to start this off, I want to start with a story. So I was working with a woman who was coming in. She was in her early 60s and dealing with shoulder pain. She had a history about 10 years ago of frozen shoulder. So when it comes to adhesive capsulitis, we know that being a female and being kind of in middle age is a risk factor. And I never really thought about that risk factor being linked to estrogen status or like the beginning of perimenopause. Still wasn't really thinking about it. But she said, you know, that was a really long journey when her shoulder froze. And but it got better, got better over time. She realized that she was going through hormone replacement therapy or she was going through menopause. She got put on hormone replacement therapy. She was on it for 10 years. And then her doctor on a follow up where she was trying to get a renewal said, actually, you've been on it for too long. I'm going to take you off of it, which that That's a whole other ethical scenario, especially because we should be weaning off estrogen replacement therapies, not just going cold turkey. But however, took her off and within a couple of months of that weaning process, her other shoulder started to freeze. I've obviously been in the weeds of this research right now around the influence of estrogen on our body, but I was thinking about and reflecting on how many women I have worked with over my career. THE INFLUENCE OF ESTROGEN ON OUTCOMES I've been a PT for 10 years, so very still early on in my career, but how many have I not recognized the influence of a person's estrogen status on our outcomes? And so when we think about estrogen, we think about fertility, rightfully so. We think about pelvic floor physical therapists kind of specializing in the fertility space, granted, but estrogen, when we have a depletion in estrogen as women go through menopause, it affects every part of our body where there is an estrogen receptor. And I don't think that many orthopedic therapists or people who kind of aren't niching into this space, myself included until I got into this arena, recognize just how widespread that is. And in pelvic health, we've done an incredible job of advocating for individuals in the perinatal space. We still have, of course, ways to go. However, you know, there's this rise of individuals going through menopause who are starting to advocate that we need that same type of education. And too frequently now that I've been asking are my patients saying to me, oh, well, my doctor said it was just part of aging and I shouldn't be on hormone replacement for this long or like have just been dismissed about their symptoms and have not linked some of these other body systems and the experiences that they're having in these other body systems with their estrogen depletion. I have a client seeing me for ankle pain and she's kind of in that postmenopausal window and she said, I am trying to learn a new body that I do not understand. And I think that was such a profound statement because so many individuals are feeling this way and we have a huge role to play in rehab. And I'm not talking pelvic, I'm talking generally. THE ROLE OF ESTROGEN IN THE BODY And so when we think about estrogen, estrogen has receptors in our brain. It has receptors in our joints and muscles. It has receptors in our heart, and it influences our bone, right? Bone is probably the easiest one. We know that individuals who are postmenopausal are at increased risk for osteoporosis osteopenia, that there is an accelerated rate of decline in bone mineral density loss with estrogen as rates of, estrogen helps rates of bone build up. And with estrogen depletion, we see a switch in the slope of the line where bone breakdown exceeds rate of bone growth. And so rates of osteoporosis go up postmenopausally. We also see that individuals who are in an estrogen depleted state have higher rates of joint pain. So kind of an umbrella term of joint arthralgia. and we see links to risk factors around things like adhesive capsulitis in individuals going through perimenopause, but very little research has actually looked at individuals' experiences of musculoskeletal pain in the postmenopausal window. So we could have individuals who are not responding as quickly to rehab, even though we're throwing everything at them that is evidence-based and evidence-informed, because they are going through menopause and it's the influence of their hormones is changing the way that their body is responding to some of our rehab interventions and we don't know about it. Our body also has estrogen receptors in the heart. And so we see that men tend to have a higher rate of cardiovascular disease and heart disease than women, but that change in rate between men and women starts to change in that postmenopausal window. So rates of heart disease start to go up postmenopausally because of the protective effect of estrogen on the heart. What we also see from a metabolism perspective is that there is a change to the way that fat is laid down when individuals are postmenopausal. So where we have the protective subcutaneous fat that tends to be something that is kind of a net, potentially neutral way of laying down fat, the more dangerous fat is visceral fat lay down, and that tends to accelerate in a postmenopausal female because of estrogen deficiency. which then increases risk for a whole bunch of different metabolic diseases, including, you know, heart disease, stroke, Alzheimer's disease, like all these diabetes, all of these things that we know are linked to pro-inflammatory cascades. It accelerates for individuals as they go through menopause. And then finally, from a cognition perspective, we have systematic review evidence that Individuals who go through premature ovarian insufficiency. So individuals who go into menopause before the age of 40 are at an increased risk for cognitive decline. So rates of Alzheimer's are higher in individuals who go through early menopause. And we see that there may be a protective effect, preventative effect of the development of cognitive decline for these individuals who are going through menopause early if they are on hormonal contraception. Which gives a very strong argument for the link between estrogen status and cognition. And when we think about symptoms of menopause, we kind of put them into different buckets. We talk about, you know, vasomotor symptoms, which are night sweats, issues with sleep, sleep disturbances are very high around the postmenopausal or menopausal transition, and hot flashes. Right? And there's kind of like this immediate withdrawal effect of estrogen. Like you could almost think about it as like a drug withdrawal. Like when we get withdrawn from estrogen, those vasomotor symptoms kick up. And then eventually our body gets used to being in that state of estrogen deficiency and those withdrawal symptoms kind of go away. But genitourinary syndrome of menopause is really focused on the aging of the pelvis and its influences. And so when we're in pelvic health and we're talking about estrogen deficiency, we see, you know, adhesions in the labia minora to the labia majora. We see an increase in friability of tissues. We see an increase or a changes to the pH of the vaginal microbiome. And so these all have influences, but the genital urinary syndrome very much focuses on the pelvis. ASKING ABOUT MENOPAUSE And so if you are not in pelvic health, you may not be really considering it a reason to be asking about symptoms of menopause and when you went in through menopause. But if you are an individual who is working with anybody who is a female over the age of 50, you should be asking, are you in menopause? Have you gone through menopause? When did you go through menopause? And menopause is diagnosed as the 12 month mark of not having a period. So when you have not had a period for 12 months consecutively, that is considering being in menopause. Average age is 50 to 51 in the United States. asking around changes in symptoms around the menopausal transition. Did you notice a change to your mood? Did you see a change to your sleep? Did you see a change to your cognition? Did you see a change to all these other things? Because we know that if you're depressed and not sleeping and your joint pain is up, we're probably gonna have a lot of conversations that we need to have around recovery. It's gonna influence the way that our treatment is going to go. And then we can be an advocate for ways to manage. Too often, and there is nothing that makes me more mad. Like when I see individuals who have gone to their doctor and they say, I am suffering with vasomotor symptoms. I am suffering with all of these things. And they say, I have no libido. And they say, well, you are going through menopause. And that's kind of the way it is. Men will get Cialis or other types of hormone replacement for their sexual dysfunctions very readily. And it is met with hesitation when we are talking about female reproductive aging. And I was just at a course where it has some individuals who are part of the military and the military nurse practitioners were there, which is really cool. But they said, you know, we are so willing to prescribe Cialis but we are very hesitant as a division to give hormone replacement therapy. HORMONE REPLACEMENT THERAPY And so the next part of this conversation, one, estrogen affects everything. It's absolutely gonna influence our pelvic floor. It's absolutely gonna influence our pelvic health. But then the next thing that people are asking is around estrogen replacement therapy, sex hormone replacement therapy, and its safety and efficacy. So I wanna do a little bit of a history lesson here around where this risk is coming from. So there is a large longitudinal study called the Women's Health Initiative that has been collecting data on women for a very, very long time. And early, early on in about 2001, a study was released from the Women's Health Initiative that said that there was a 25% increased risk of sex-related cancers for individuals who are on hormone therapy than individuals who are not. This was, potent, like kind of true, but it missed the forest for the trees. And so when we kind of zoom out and we look at relative risk of sex-related cancers, that, well, that translated into, instead of it being three in 1,000, and these are not perfect numbers, I don't remember off the top of my head, it changed to a four in 1,000 rate or incidence of sex-related cancers. When if you think about it like that, that is not the biggest difference. However, that one study came out and it changed everything. It was largely disseminated, many media outlets put it up, and it made everybody very, very fearful of prescribing hormones. So there's a couple things nuanced to this. When we are taking any type of medication and our sex hormones are not anything different, there is always going to be potential risks. Those have to be balanced by the benefits. We see, for example, that individuals who are on replacement therapy have a lower risk of Alzheimer's, dementia, especially if individuals are going through a menopause early. We see sexual health, sexual, satisfaction increases on hormone replacement therapy. We see an increase or rather a decrease in rates of urinary tract infections. And if you are working in the geriatric space, move this into Wednesday. It makes a huge difference. A urinary tract infection can change a person's life. A person can die of a UTI because it can end up, they get in hospital, UTI becomes sepsi…

    Full show notes at the publisher

    Episode 1621 - Rowing 102: adapt & overcome Dec 15, 2023
    Show notes

    Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses how to adapt the @concept2inc rower for patients & athletes who cannot use both legs, both arms, or seated athletes. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALLAlright, good morning everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Fitness Athlete Friday. We talk all things CrossFit, Powerlifting, Olympic Weightlifting, Endurance Sports, Triathlons, Marathon Runners, Cyclists, figure skating, all that wonderful stuff. If you are working with a person who is recreationally active in the gym, on the road, whatever, Fitness Athlete Friday is for you. Today, we're going to build upon an episode from three weeks ago, introducing you all to the Concept2 Rowing Machine. We're going to build and show you how to adapt this machine for a lot of different folks who might show up in the gym or in the clinic, post-op, adaptive athletes, all that sort of thing. Before we get started, just a heads up about courses coming your way from the fitness athlete division. Your next chance to catch us online for our level one course, online course, eight weeks, entry level course previously called Essential Foundations will be January 29th. So our Clinical Management Fitness Athlete Certification, Level 1 online, prerequisite for Level 2 online, that class begins February 5th. And then our live seminar is its own standalone event. Those are all over the country this coming year, so check out PTENICE.com and look for Fitness Athlete Live for courses coming near you. And then check out our two online courses beginning in January and February. Just a reminder, all of our courses currently priced at $6.50 will jump to $6.95 on January 1st. And really, we don't want to pressure you, but most of our quarter one courses, live and online, are selling out. Our pelvic level one online course just sold out yesterday, about a month in advance. So we're seeing about a three to six month sell out window currently. So if you had an eye on a course, we'd recommend grabbing it sooner rather than later, especially if you can take advantage of saving some money on that price increase. So that's courses coming your way from the fitness athlete division. ROWING 102 So before we get started, I'm going to show a lot of stuff today. So if you are listening on the podcast, and you are a visual person, or you're not very familiar with the rower, I would recommend you stop the podcast, you jump over to our YouTube channel, and continue watching this episode here on YouTube so you can actually see what I am doing. So I'm going to reference two previous episodes as we talk about today's topic. So we're going to get into some advanced mechanics of the rower, how to adapt the rower with different equipment. Go back three weeks, episode 1606, where we talked about the very basics of the Concept 2 rower, how rowing works mechanically, how to put yourself in the best mechanics to row, how the rower itself too works as far as what are the different pieces of equipment, how to clean them to make this machine last you, 10, 15, 20 years, and then also how to use very basic things on the rower like drag factor to understand where you should place your damper on the flywheel, again, to optimize the very basics of rowing. I want you to go back two weeks to Guillermo's episode, episode 1611, to learn a little bit about how intervals, he specifically talked about research on assault bikes, but how intervals on earth machines in a very small time window, two to three times a week, for eight to 20 minutes of work can have a significant increase on VO2max. So never forget, when we're working with patients, working with athletes, especially those folks already active, at the very least, we can help them maintain their current level of fitness, being intelligent with how we use machines, how we adapt the machines, and that's the point of today's episode, of how to adapt these machines. So folks coming in, they can only use one arm, they can only use one leg, they're pregnant, they're postpartum, whatever, how can they get on this machine and at least maintain their fitness as we work through their rehab. 1-LEGGED ROWING So I want to talk about how to set up the rower to row with just one leg. I want to set up the rower and show you how to row with just one arm. And then I want to show you what many people don't know is that the rower actually breaks down in half. Yes, to make it easy to store, but also to get rid of the rail so that seated athletes in a wheelchair can roll up to the rower and row on a Concept2 rower. So the first thing I want to show is very simple, one-legged rowing. So what you're going to want is one of these little things. If you've ever changed your own oil on your car, you know what these are. These are little caddies that roll underneath your car. So they have wheels, six axis, they move in any direction, and they're mainly designed to hold tools and stuff if you're working underneath in your car. So you can get these at an auto parts store for 10 or 20 bucks. You just need one of them and they'll last forever. Alternatively, you can also use a skateboard or something like that. But what we want is we want something that we can place someone's foot inside of that moves, ideally moves what we call six axis, right? Forward, backwards, side to side, and then each diagonal, right? It can potentially move 360 degrees so that as a person rows, their foot can move alongside the rower. So let's set that up. So for example, let's say I can't use my left leg, maybe my left leg is locked in a knee brace, I'm locked in full extension, maybe after ACL reconstruction or something, I can still get on the rower and row with one leg. So I'm going to get on my rower, I'm going to strap in, grab the handle, Until my wife was on the rower last, she cinched the straps all the way down. And now, instead of putting two feet in, because I can't bend this knee, right, it's locked in extension, I'm going to kick it out to the side of the rower, and I'm just going to let it rest in this whale caddy. Now, I can still more or less perform all of my normal rowing mechanics. I can still drive with my right leg, I can still lean back, and I can still pull with my upper body. So this is fantastic, folks maybe working with an amputation, folks locked in a brace, maybe folks that just can't tolerate that loaded knee bend, knee extension with that leg for whatever reason, we can have them still row using something like an oil caddy or a skateboard. So that's one leg rowing. 1-ARM ROWING Now, one arm rowing is totally possible. You're going to want a device like this. This essentially just looks like a hook. You can get this from Adaptive Training Academy. So if you don't know Adaptive Training Academy, we highly recommend them. They have a wonderful course on basically adapting all things fitness for adaptive athletes. So it's a course that has its origins with CrossFit, but now has expanded into the rehab community as well. How rehab providers and fitness professionals can work with adaptive athletes to get them moving, keep them moving. They have a wonderful store full of all sorts of really, really, really cool things to help you work with adaptive athletes. And this is one of the tools they sell. So these hooks are going to latch on to the handle of the rower, and they're going to allow me to row with one hand. If you'll notice on the rower handle, in the middle, it has places technically to row with one hand, but they're not very comfortable. you need to essentially weave your fingers through and then you have the metal chain kind of bashing against your knuckles the whole time you're rowing with one arm. It's also very wide, so you'll sometimes see people row with a neutral grip and that's just not very mechanically advantageous. This is designed to improve that. To bring the handle in so that I can grab it with one hand, I can technically even hook grip this to really get the most out of my grip on my right arm or left arm and row to my chest and maintain my normal rowing mechanics. This is also fantastic for pregnant women who maybe don't tolerate the flexion on the rower anymore because of their stomach or the extension because of the stress it places when they lean back. What's great about these is you can build them on each other and you can essentially reduce the range of motion needed to reach towards that handle. So this can even be great for kids to get them on a rower at a younger age or maybe they literally don't have arms long enough to reach the handle, we can bring the handle to them. So I'll show you what that looks like with one arm rowing. So sitting in the rower, taking the hooks, latching it onto the handle, and now it's reduced the range of motion by about six inches towards me. And now with one arm or the other, I can pull and I can maintain all of the same mechanics of rowing. with one arm. I'm still able to drive with my legs, lean back, and pull the handle to my chest. Again, if needed, I can put another one of these on here and continuously bring that handle closer to me. So this hook is available again from the Adaptive Training Academy store if you want to pick that up for your rowing. DISASSEMBLING THE ROWER FOR SEATED ATHLETES/PATIENTS The final piece is breaking the rower in half. Again, a lot of folks don't know that the rower actually disassembles into two pieces. That's to make it easy to store. It's totally possible to break this rower in half, and if you have a larger car, an SUV, certainly a truck, you could take the rower with you, maybe if you're a home health clinician, and bring it into people's living rooms. it is made to break in half and all things considered once it's broken into half it's not very cumbersome and it's not very heavy. So let's talk about how to do that and then adapt that for the seated athlete. So right here at the base of the foot plates you're going to see a black piece and you're going to see a little handle to lift up. If I lift this handle up you'll see that the rail of the rower is just sitting on metal rod that's connected to the flywheel and the computer portion of the rower. So if I lift this up, I can now disassemble the rower into two pieces. So now the rails here, this weighs almost nothing. This weighs a couple of pounds. Again, this would be very easy to throw in the back of an SUV or a truck. The heavier part, of course, is going to have the damper and the flywheel, and all of the computer parts, but now I have the front part of the rower. Now I can have somebody in a wheelchair roll up to this. We can play with different variables. In the gym, we like to lift it up a little bit, and we like to put sandbags or plates to anchor it down, and we like to sit it on some sandbags or plates. So depending on the type of wheelchair that your patient or athlete has, you may need to bring the rower up a little bit so they can roll up, get into a good position and row. And then definitely, because it's no longer as heavy as it once was, you're going to want to make sure you weigh it down so that as they begin to pull the handle, this thing doesn't move around. But with a little bit of ingenuity, this is something you could even bring into someone's home, maybe wheelchair bound, where they're able to row, maybe do some intervals on the rower. So make sure you understand that the rower breaks down. This also makes it really easy to store rogue fitness. So you can see one over here in the corner, my bench is hanging on it. They make hangers that can be mounted to a wall that can hang either benches or it's designed to hang the front part of your rower off of. If you're thinking you're in the clinic and you don't have room on the ground for a rower, that's okay, you don't need it. You can break the rower in half at the end of the day and you can hang it on the wall. So make sure you understand that the rower breaks in half. That's made for storage, for travel, but also really important to make sure that we can get seated athletes using a rowing machine. So rowing, this is a very versatile piece of equipment. Make sure you understand how to use it. Make sure you understand that you know how to adapt it for different patients and athletes that present to you in the clinic in the gym and get more people rowing, get more people working on or maintaining their current level of fitness as you help them through the rehab process. I hope this was helpful. I hope you have a fantastic weekend. Our very last live course of the year is this weekend. It's happening right now in Salt Lake City. It's a dry needling course with Ellis and Melrose. So if you're there, I hope you have a fantastic time. Other than that, I hope you all have a wonderful Christmas, a very happy new year. Have a great Friday. Have a great weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

    Full show notes at the publisher

    Episode 1620 - Excellence solves everything Dec 14, 2023
    Show notes

    Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com

    In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses how the pursuit & achievement of clinical excellence solves many problems. Individuals who produce high-level outcomes in the clinic tend to be the ones who get paid more, work less, dictate their schedule, and overall feel a significant return on the time investment they spend in the clinic.

    Take a listen to the podcast episode or read the full transcription below.

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

    EPISODE TRANSCRIPTION

    INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.

    JEFF MOORE All right, team, what's up? Welcome back to the PT on ICE Daily Show. It is Thursday. I am Dr. Jeff Moore, currently serving as the CEO of Ice, and always thrilled to be here on Leadership Thursdays, which are always Gut Check Thursdays. Let's get it out of the way. Let's talk about the workout, and it's a banger. We've got three sets of the following rep schemes and movements. We've got 21 burpees to target, followed by 15 devil's press, Okay, it's gonna be with 35s or 20s. Okay, so going into that deficit push-up, pop into a squat, weights above the head, and then back down. 15 of those, nine burpee into a chest-to-bar pull-up. Then, however long that took you, you're gonna rest one-to-one. So if that took… Let's see, maybe three-ish minutes, right? You're now going to rest for that same amount of time, and then you're gonna fire back up set number two. The workout is three sets with that one-to-one work-rest ratio for time. That, I'm looking at that, I'm gonna need to settle into about 20 minutes or somewhere on that workout. That is going to be rough. Okay, as far as upcoming courses, one thing I wanna mention is that Pelvic Live, I'm sorry, Pelvic L1 Online only has four seats left. I also wanna say a lot of the courses in January are looking that way. Remember, our prices go up January 1st. It's only 45 bucks. It's from, all the 650 courses go to 695, but if you're gonna grab a Q1 course, they're already all on the schedule. Make sure to jump in and grab that course before January 1st, because right now you can buy them all for the $650 price. So if you have any courses you're looking at in 2024, you know you're going to take anyways, just jump on there and grab them before that price jumps up to $695. on January 1st. So you've got a couple weeks, that being said, a lot of them are selling out. So try and scoop up those tickets over at PTOnIce.com as early as you can to save yourself a few bucks going into the new year. So that is my course announcement. EXCELLENCE SOLVES EVERYTHING Let's talk about excellence. So the topic of today is excellence solves everything. And what I mean by that is, There is a threshold of excellence at which no barrier survives to your success. This is where the idea of becoming undeniable feeds in really well. Now, we're going to chat PT, but you can think about this anywhere. Think about that musician who doesn't have a major record label. Think about that busy restaurant in a horrible building or a terrible part of town or bad location, what have you. Think about the individual player with a mediocre teammate who still wins the championship. There is a level of excellence at which once achieved, nothing else matters. That being said, that's very, very high level from a success perspective. Now I want to drill down and talk about a specific thing that possessing that excellence gives you or benefits you or arms you with because it is so relevant to today's practicing professionals. EXCELLENCE DRIVES AUTONOMY Possessing excellence, certainly at a level like we discussed before, allows you to always be deciding. And as I look at why that's so important, it's because autonomy is, from my vantage point, the most modifiable and important burnout variable or job satisfaction variable. Autonomy is the most modifiable. Burnout or job satisfaction variable. I was talking with Adam Fritsch down at South College I work with Adam over at South and that he and his colleagues over at Bellin published a paper I think it was in March of this year titled feeling exhausted how outpatient physical therapists perceive and manage job stressors and in that paper All the things you would expect kind of fell out of solution, right? Like if the workload was unmanageable or perceived to be unmanageable, that was stressful. If cultural differences were present, that's stressful. But what pops out at me in that paper, because it's so directly modifiable, is the lack of control or this idea of not having autonomy. Namely that if people did not perceive themselves to have control, they felt more burned out. Everybody I talk to making their way up the professional ranks, that constantly jumps out at me. Now, let me talk about why excellence takes care of that problem. That is because it allows you to always be deciding and that's what autonomy is. When you achieve a certain level of excellence, You get to always be deciding. You get to always have control. And I think the data shakes out to say that will prevent burnout and maximize job satisfaction. Let me give you some really specific examples of where you get to always be deciding that other folks might not that are going to lead to you perceiving that feeling of control that avoids burnout increases satisfaction. Number one, which insurance is to take? When you hit a certain level of excellence, you're deciding that. You can say to the insurances, look, your customer's gonna come to me either way. They're just gonna be furious that you're not covering it. But they're not gonna make a decision to not come. They're gonna come and then be mad at you. At a certain level of quality of service delivery, you will hit that reality. Right alongside that, how much to charge. You're the one deciding. The solution to burnout is appropriate return on your time investment, another huge variable. You can't balance an equation with the wrong numbers. You need to be able to drive what you receive for your time delivering services. at a certain level of excellence, you get to decide that. You're not thinking about what might this market handle or what's the, you're thinking, this is what I'm gonna charge because this makes sense for my model. Now, you're gonna combine a few things when you do that. Number one is make sure the equation works, but number two is putting that price point in a spot where you actually get to serve all the folks that you want to serve, that you feel called to serve. So, it's multivariate that coming to that number. but you get to come to that number, right? That's the beautiful thing about it. Number three, when to work. There are few things that decrease stress like having complete control of your schedule. This is the one that hits me the most personal. I have no issue giving you massive volume of work days. I have no issue being up at four, 4.30, getting after it, putting out a lot of production. I have no issue with that as long as Right now I'm holding 4.30 to 5.30 because my kids might text this morning they wanna hit CrossFit. As long as I have the autonomy to hold these parts of my schedule that are non-negotiable, I have no issue with the work output on the other part of the day. It's being able to control when you work that I think is probably a bigger variable or a bigger factor than the amount of work and people just haven't put that together yet. But again, at a certain level of excellence, you control that. Because when you say to that patient, I can only see you at seven a.m., if you're good enough, if they perceive you as valuable enough, they're gonna say, well darn it, that isn't a perfect time for me, but there's no way I'm not taking the appointment. They're only saying that if you've achieved a certain threshold of excellence. So now you're deciding when to work. You're deciding how or even if you want to market. You may choose to not spend any time in that space. I wouldn't advocate that from kind of a business consulting perspective, right? All the best companies market when they're busy. That being said, you could decide that. at a certain level of word of mouth demand, right? But certainly when you do market, it doesn't have to be salesy. At a certain level of excellence, you're simply reminding people that they want to come see you. They've already heard from nine other people they should. They've already been thinking about coming in for a long time. Now your marketing simply becomes creative reminders, which is a much nicer way to go about engaging with your audience than always trying to sell them something. So you get to decide at that certain threshold of excellence how or even if you market. You decide whether you stay at your job. You no longer need to stay at your job because you have to. You stay at your job because you love it. Because the people that have created the environment have done a great job. And you can't get enough of the culture. And you're learning a ton. And you're serving people you care about. You're staying for all the right reasons, but none of the wrong reasons. Because you can walk any day. You think to yourself every morning, need this. The people want to come see me no matter what. I'm choosing to stay here because I love it. That's a lot different professional world. You don't feel stuck. You're driven by choice because you've achieved that level of excellence. Excellence is so unique. because it solves all of those problems. Those are all problems that every business guru is trying to sell you an individual solution for, right? How to navigate the insurance market, how to come up with your pricing, right? How to get more control of your schedule. You could find individual products that would try to solve only one of these, all of them. EXCELLENCE: THE CLEAN SWEEP Excellence is a clean sweep. Once you get good enough, every single one of those problems gets erased at the same time with one thing. But there's one other thing before I sign off that I want you to think about that is so unique about possessing excellence. And that is that it travels with you. I don't think enough people think about this. Excellence travels with you. Relationships, local marketing, et cetera, all of those things, if you change where you're working, if you move or relocate, all of the other business hacks, if you will, that you leverage have to be started back up. But your excellence travels with you. It's gonna meet you there, right? Right from patient one, they're going to perceive the asymmetry and the quality of what you deliver, and all of those problems are gonna vanish without you having to restart any of the other machines. Excellence travels with you wherever you go it meets you there. This is why it is hands down because it solves all the problems at once and wherever you go it meets you there, it travels with you. This is why it is the greatest and most urgent investment. I'm not telling you not to leverage all the business tools. I would totally encourage you to leverage a wide variety of business tools and strategies. I'm just saying for the greatest ROI, Get good first. Get good, then busy. Because excellence is the greatest decider to your overall success and certainly the greatest driver of your individual autonomy. And that's what I think results in incredible levels of job satisfaction and very, very low levels of burnout. Get good. You'll get busy, but you'll also solve every other problem in the process. Team, PTOnIce.com is where everything lives. Thank you all for being here this morning. Have a wonderful Thursday. We'll see you next week.

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


    Episode 1618 - Strength in stillness: debating isometric exercise in rehab Dec 12, 2023
    Show notes

    Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses isometric exercise, in particular, that isometrics are beneficial for more than pain reduction. Mark cites research from the tendinopathy space about the importance of not using isometrics as a quick fix for pain, but as the starting point to gradually reintroduce functional, full range of motion exercise including concentric, eccentric, and power movements in order to fully rehabiliate a tendinopathy. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MARK GALLANT What is up PT on ICE crew? Sorry for being a minute or two late here having some technical difficulties over on the YouTube side. So it looks like that is trying to get going as we speak. We will see if that that comes online here as we're talking. What I'm what I'm currently seeing for you YouTube folks is just a spinning wheel of death saying going live, going live, going live for the last three minutes. So hopefully that'll that'll pop up here over the next second or two for you all. So I'm Dr. Mark Gallant, lead faculty for the ice extremity management division coming at you here, clinical Tuesday. We are done with live courses for the year. I believe there's one more live course, dry needling course this weekend. And other than that, we've got a few weeks off. So we'll be sharpening the iron over the next few weeks, gearing up for for the next year of the ice season. And we can't wait to see you all out on the road. So all of our courses, all of our online courses will be kicking off in January. And all of our live courses will be kicking off the first and second week of January. So if you all haven't been on here the past couple weeks, checking in, there will be a price increase for all ice courses starting January 1. If you've been eyeing those courses and you know a course you want to take over the next few months, we would highly recommend popping in, purchasing that now, save yourself $50. ISOMETRICS: CLINICAL VALIDITY & CLINICAL APPLICATION So what I'd like to talk about today is isometrics and their clinical validity, what they're good for in clinic. And isometrics have come up a lot recently. If you've been a daily listener to the podcast, what you'll have seen is Jordan Berry came on here two weeks ago and he talked about using isometrics for specifically for low back pain and then Alan Fredendahl came on last week and he did a podcast talking about how using the rack pull can be a nice way to add isometrics into a more functional movement, getting your folks back towards the gym. So clearly as a company, we really enjoy using isometrics and we believe that isometrics are a key part of clinical practice. However, isometrics have been under fire recently on social media, in the research, because they got touted as being a silver bullet for pain relief a couple years ago. So where this all came from, Ebony Rio published an article in 2015 looking at six male volleyball players who had patellar tendinopathy. And what she found with these six male volleyball players, if they held an isometric contraction at 70% of their max volititional contraction, for five sets, 45 seconds, that we would see a dramatic decrease in pain. And that's what she found. So for these young, healthy male volleyball players who had about five to seven out of 10 anterior knee pain, their knee pain was fully resolved after doing those isometrics and 45 minutes later. And so, of course, as a profession, we got extremely excited, like, oh man, these isometrics are the key to relieving pain. for our tendinopathy patients. We've gotta use these for everyone, so we extrapolated that to not only patellar tendinopathy, but to rotator cuff tendinopathy, Achilles tendinopathy, lateral elbow tendinopathy. We really just ran the gamut as far as tendinopathy goes, looking at this research. Again, it was one study, six healthy males, With that extrapolation, what of course followed was a lot of repeat studies. So this has been looked at about 10 times over the last eight years. So we've had people look at it in the rotator cuff, in the Achilles tendon, in the lateral elbow. We've had a couple editorials written. We've had one systematic review. And what's shaken out is it's been very inconsistent over the last eight years. There were a couple studies that showed very similar to what Ebony Rio showed, that there was a dramatic pain reduction using isometric contractions. And other studies did not get the same magic bullet results when it comes to isometrics. PAIN RELIEF OVERSHADOWS TENDON HEALTH And we really believe that this study has overshadowed the bigger picture with isometrics. and why we really love isometrics. So of course we live in a society that wants that instant pain relief. That instant pain relief is such a central nervous system component and it is unlikely to actually benefit the person who's got a true mechanical musculoskeletal problem long-term because what we see is if you get that dramatic quick pain reduction, although it's great, everyone wants to be out of pain, Oftentimes, that leads to the person not continuing out with rehab over the long term. And we know from a lot of research that most quick changes within the first six weeks are mostly central nervous system changes when it comes to how tissues respond, certainly to pain. And then at that six-week mark, we start to see a lot of muscular changes. And then for tendons, it can really take six months and up to two years to get a dramatic change. And so if we get that instant pain relief, we may actually be doing a disservice to the long-term health of that overall tissue and rebuilding that capacity. I don't like reading directly off of things, especially while we're here on the podcast, and I don't think that I need to defend Ebony Rio. She's one of the premier researchers in the world. listening to a lot of lectures that Ebony Rio has done, listening to her on multiple podcasts, reading basically every article that she's ever published. I believe that her intent was not for these isometrics to, for this small, small case study article to create such a huge wave and ripples across the rehab professions that anytime you listen to her speak, what she really dives into over and over and over again, is that isometrics are a nice starting spot and that we really need to rehab these people fully out with isometrics, heavy concentrics, eccentrics, dynamic speed and power training over a long period of time. So I want to read a quote from Ebony Rio that came out two years after the article with the Patella tendinopathy that sent ripples through the profession. And what the quote says, simply taking away someone's pain with a medical intervention may not result in a positive medium to long-term outcome, it is possible that simply removing pain does not equate to a positive tissue adaptation. So there's Ebony Rio directly saying that that quick removal of pain is not directly correlated to positive tissue changes. If we look at Karin Silbernagel, who's another premier tendinopathy researcher, and her response to the fad of isometrics being a huge pain reducing intervention. She states, a change in focus from improving resilience to a focus on acute pain relief may likely misguide patients and clinicians into thinking there is a quick fix. So what both of these women are saying, who are premier researchers in the tendinopathy spaces, there is no quick fix, that we need that long-term loading regardless of whether we get quick pain relief or not. THE LONG-TERM FIX: TIME UNDER TENSION, INTENSITY, SYMPTOM MANAGEMENT So why, despite all that, are we at ICE still advocating for and sticking with isometric interventions, both with our tendinopathy patients, our low back patients, literally for every region of the body, isometrics can be a nice tool to get your patients moving along the way. So let's break down why we believe that. So when we're looking at tissue care, there are a few things that we know have to be true to move and adapt those tissues in the long term. Number one is time under tension. There has to be enough time under tension for the nervous system in that tissue to respond to adapt. If it's just one quick motion that never gets repeated and has no time under tension, the nervous system doesn't have, isn't easily as easy to adapt to that stimulus. So time under tension is number one. Number two is intensity. There has to be enough of a stimulus to that tissue to create mechanotransduction to have that tissue adapt. And then number three is that we have to manage our patient's symptoms while trying to maximize the other two. So that's what makes us unique as physical therapists is we're creating time under tension. We're creating intensity while we have those symptoms on board to manage. It's really like this seesaw that we're managing. So we have symptoms on this side, we have time under tension and intensity on this side. It may start out that we've got more symptoms at first and we're trying to balance that scale and eventually have less symptoms, more time under tension, more intensity to our interventions. What isometrics, what we've gotten into over the last eight years is Even if you have 7 out of 10 pain while you're doing this, go ahead and do it because it's going to eventually reduce your pain overall. And we just need to get that time and attention. Well, what that creates with someone who's got fear of exercise and apprehension is a lot of yellow flags. So that's when you get people saying things like, I hate going to physical therapy. Oh, it's so uncomfortable. I really don't want to do this. And they start avoiding their intervention. The first thing we want to make sure is whatever that stimulus we're giving to the person, that they feel psychologically ready to tolerate that. Are you cool with exercising into three out of ten pain? Oh, you're not? One out of ten pain would be more tolerable to you? Okay, let's find an intervention that we can do there. So those are the three big components. Getting their symptoms, getting a stimulus that puts them in a symptom range that they can tolerate, creating a lot of time under tension, and creating enough intensity. ISOMETRIC EXERCISE: CONTROLLING MULTIPLE VARIABLES The reason we love isometric so much early on is because it's a much easier intervention to control all the variables that will allow you to balance those scales. So we go back to a podcast I did a few months ago talking about the guitar amp and things that stress tissues out. What we really are looking at is our knobs that we want to play with is the overall work volume, how much work has been going into that tissue over the course of a few days or a week. How much load has been going into that tissue? What is the actual weight on the bar, the body weight, the resistance of the band that you're looking at? What is the compression and strain on the tissue? So is that tissue all the way compressed in like that or is it strained all the way stretched out? That's gonna be one another way that the tissue can be stressed out and then the speed of the the speed of the intervention so if i do a heel raise versus sprint that's going to put a definite a very different type of force through that achilles tendon so again we've got overall work volume we've got the actual load on the bar we've got compression or stretch or strain and then we've got speed as all ways that that are going to manipulate and change the stress of the tissue. The beautiful thing about isometrics early on and why we're recommending them is you can control all of those variables much easier. So the overall work volume, you're going to be able to very cleanly set that with your patients. I want you to do five sets of 45 seconds or five sets of 30 seconds. whatever the agreed-upon work volume can be, and then it's clear with that isometric. It's very well set. As far as the load, that's not going to change with the isometric. You're going to determine with your client or patient, okay, I want 5 pounds on the bar, I want 10 pounds on the bar, I want 15 pounds on the bar, and then that becomes static. For compression and strain, you're going to find the range of motion they can tolerate. Okay, it's in a mid-range, that angle does not change. So we are no longer getting a change in compression or strain or say we bend it to 90. Now that's the new angle. There is no change during the actual intervention in compression or strain. So we have now controlled that variable. And then for speed, the speed is literally zero. Once you get that weight and that load into the position you want it, it's not moving for the remainder of that intervention. you can really control all the variables quite easily with the isometrics so that you know when something gets challenged or something gets flared up, well, ooh, it's really only these one or two variables that we're manipulating, and so you can much easier control the progression of treatment. So if we're looking back at Alan's example from last week, it's like, okay, Julie, we're gonna hold five sets for 30 to 45 seconds of this rack pull. We know very clearly that you can tolerate 135 pounds of weight. We know the angle of the hinge that you do well with is at about your knees pulling up there. And then once you start pulling, you're immediately going to get the block of that rack. So those angles are not going to change. You're not going to get any change in compression, stress, or speed from that movement. And then as you move that person on, okay, we can progress. Let's change the angle a little bit. or maybe we're going to change the load a little bit, and you can very isolated change these variables until that person's symptoms reduce enough, where then you get into your concentrics, your eccentrics, then you can progress them to your dynamics. So we are not looking at isometrics as this silver bullet of dramatic pain relief early on in tendinopathy. We're looking at it as a nice entry point into giving enough time of retention, enough intensity to a tissue while managing symptoms, becaus…

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    Episode 1617 - Talking prolapse with your patients Dec 11, 2023
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    Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how to better educate patients on prolapse, including a three-step framework focusing on education, risk factors, healing timelines, and empowerment. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.RACHEL MOORE Good morning, PT on ICE Daily Show. My name is Dr. Rachel Moore. It is Monday morning, which means it is pelvic day on our podcast here. So, we are going to dive in today. Our topic is using words that heal to talk to our patients about prolapse. So we want to make sure that when we are talking about our patients that have prolapse or maybe have been given this diagnosis of prolapse, that we're using words that are going to empower them. So we're going to dive into that today. Before we do that, a couple of housekeeping things, just letting you guys know the courses that we have coming up within our pelvic division. So we are done for December, nothing left in 2023, but we are kicking off 2024 strong. We've got two courses on our live docket in January. So we've got one January 13th and 14th in North Carolina. We've got one January 27th and 28th in Hendersonville, Tennessee. And then February 3rd in Bellingham, Washington. So we've got three chances within the first like month-ish of 2024 to catch us on the road. um on the those live courses that's where you'll be taking your certification test if you're interested in having that pelvic certification which includes taking all three we now have three of our pelvic courses our next online level one cohort starts january 9th and the sign up for our level two is now officially open so if you want to hop into that cohort it starts april 30th and that will be the first cohort of our level two so Really excited to kick that off and just kind of get that rolling. TALKING PROLAPSE So without further ado, let's dive into our topic of the day. We talk a lot about ICE or talk a lot at ICE about using words that heal, not harm. We preach it a lot and sometimes it can be really tough to figure out how to explain like difficult diagnoses. Especially things that are maybe controversial when it comes to the postpartum space and we're gonna see that with things like diastasis or prolapse and a lot of times our patients are coming in and maybe they've been given this diagnosis by another provider and it's not really explained very well and so they go down this scary Google rabbit hole and they come in and with all of these preconceived notions um oftentimes mostly negative preconceived notions from all of this research that they've done and they feel like they're empowering themselves with knowledge but in reality there's a ton of negativity and fear-based messaging about these topics so today we're going to talk about prolapse later on in a future episode we're going to talk about diastasis and i really just wanted to talk about some actual quotes that i use with my patients or kind of an outline or a framework of how we can break these scary diagnoses down, especially if you're newer to the pelvic population, you haven't had a lot of reps practicing talking about this, so that we can make sure that all of our patients are leaving their sessions feeling very empowered and excited to be working with you. EDUCATE So the first step of our three-step framework is going to be educate. I can't tell you how many times I have people come into the office and they're sitting there and they're squeezing their legs together because they are so terrified that if they aren't constantly contracting their pelvic floor and squeezing their legs together that their bladder is going to fall out of their vagina because they've been told that they have a bladder prolapse. with no other explanation this happens so often people will go to a provider the provider maybe will be doing a well women's exam or a check for whatever reason postpartum follow-up whatever and they tell them you have a bladder prolapse or you have a rectal prolapse and then that's it and they don't really tell them anything else and maybe they don't even really prescribe them physical therapy and they just wander into your clinic um on their own but there's not a lot of follow-up in most cases. So the very first thing that I'm doing when I'm sitting down with patients is breaking down. Okay, you were told you have a prolapse. Did anybody explain to you what that is? And usually that's followed with no, I went on Google and I saw a bunch of scary things. I'm like, okay, great. Like we're going to undo all of that. And even sometimes if they were explained, it maybe was using a very medicalized definition that can be, again, terrifying if you don't really know what's going on. So I'll bust out a whiteboard and I will draw out the pelvic organ. So if you're watching on Instagram or YouTube, you can kind of see with my hands, but if you're not listening, just visualize. I'll draw out, like, here's our bladder, here's our uterus, here's our vaginal canal, and here's our rectum. All of these organs sit within our pelvic bowl. When we have pelvic organ prolapse, essentially what that means is there is a descent of one of these organs or a drop down that pushes onto the walls of the vagina. at this point usually i'll take a minute to explain to people that the vagina is not a hollow tube it does not look like this it actually looks more like sides of soft tissue coming together most people don't realize that because every picture we've ever seen of a vagina in a textbook in anatomy books anything Looks like a hollow rigid tube. So a lot of times even letting them know like hey your vagina is not like this It's like this you'll see a light bulb moment where they're like, oh Okay, so maybe that's not a prolapse that I'm seeing maybe that's actually just my vagina. So that alone can be really helpful We'll talk about the fact that the vagina is not a hollow tube and that it is soft tissue and with that it is influenced by other things around it and so then we'll kind of break down here's your bladder maybe you have a descent of your pelvic organs and we see this kind of drop down if vaginal canal is here and our bladder is dropping down slightly and pushing onto that vaginal wall what we may see is a slight drop down of that vaginal wall oftentimes we're doing this test on our backs Oftentimes gravity is pulling everything down a little bit more and so when we take this person who's upright like this and put her on her back, our bladder drops down and we can kind of see and maybe feel that drop down sensation. When we layer in gravity with standing, we're upright, we drop down, we can sometimes feel that heaviness sensation from the vaginal wall not necessarily supporting that drop down quite as well. It is really important to highlight and differentiate an organ falling physically out of the vagina which can happen if we have a uterine prolapse where the uterus is dropping down into the vaginal canal versus an anterior wall or a bladder or a posterior wall or rectal prolapse where it is not the physical organ dropping down, it is just the wall of the vaginal canal dropping inwards. That education is huge. You will see people have this like weight lifted off of their shoulders knowing that their organs are not actually falling out of their bodies. Education is important. DISCUSSING RISK FACTORS Talking about risk factors is also incredibly important. Letting them know what the top risk factors are. Genetics and connective tissue immobility, BMI, chronic constipation, which comes along with that straining, that consistent straining mechanism where we're bearing down repeatedly over time, pregnancy or parity, and vaginal delivery. A lot of those aren't things we can necessarily control for, but what's important to let them know is that exercise is not one of those factors. We want to make sure that our patients know that they didn't cause their prolapse by doing too much too early, especially if they're in the postpartum space or if they have this like shame associated with, I have a prolapse and I did it to myself. That's not the case. More often than not, if a prolapse or a pelvic organ position change is going to happen, it's going to happen in a vaginal delivery after a pregnancy. And it's not necessarily something that they're causing by doing activities later on. Letting them know that they didn't cause this thing to happen, again, can be huge for somebody's mental state. If they're feeling like, oh, I did too much and I caused this, that can kind of cause this negative spiral of fear for movement in the future. DISCUSSING TIMELINES Finally, we want to talk about, on the education standpoint, timelines. It doesn't make sense to have somebody at six weeks postpartum come in and say, yep, you got a grade three prolapse. Your bladder is dropped down and your anterior wall is coming out of your vagina. We expect there to be changes. we expect that after a vaginal delivery, those tissues aren't just going to pop back and get to their original position or even a new baseline for a longer timeline. So talking about the fact that early postpartum is not the time to be diagnosed, quote unquote, with a prolapse or to even really be concerned about where things are. Instead, we want to talk about ways to talk to them about um body mechanics and um their strategies for bracing we want to talk about bowel health and making sure that they're not continuously straining and bearing down and let them know that when we layer these two things in And then we allow time as a factor. Where they're at at six weeks postpartum is going to look different than where they're at at six months postpartum, even if that was the only things that they did. So education is huge. Educate them about what prolapse even is, educate them about what the risk factors are, and more importantly, are not, and talk to them about the timelines for healing. The next step in our little three-piece framework is going to be normalize. there is so much conversation happening in the pelvic floor PT world that a prolapse or a like a grade one prolapse which is just a slight descent of pelvic organs might be normal in the postpartum population. Just like we don't expect our breast tissue to look exactly the same after breastfeeding, we can't expect our pelvic organs to be in the exact same position after they've undergone nine to 10 months of low load, long duration stretch that creep has set into those tissues. And then we also potentially layer in a vaginal delivery. A grade one might not be a big deal at all. That might just be a typical postpartum change. On top of that a grade two might even be somewhat of a normal finding I have not yet seen a grade zero quote-unquote after a vaginal delivery I think it's a unicorn that actually doesn't really exist and we've had a lot of conversation about this within our pelvic crew of has anybody ever seen that The consensus so far is no. And so if you guys have, drop it in the comments. I'm curious. But we want to talk about normalizing this change. We expect physical changes in our body after pregnancy. We expect physical changes in our body after vaginal delivery. It's OK to look like you've had a baby. It's OK for your body to show those signs. this can be a big thing for people to wrap their heads around because there's a lot of talk within our culture about bouncing back to what your body was before and Switching up that conversation to we're not worried about what it was before We're getting to a new baseline and that might show changes that have happened and that's okay Normalizing the fact that our bodies are going to change during pregnancy after a delivery is important The other part that we want to normalize is that in the early postpartum timeline, those muscles are recovering, especially following a vaginal delivery where they've had a stretch injury, they've been stretched out, elongated, they're returning back to their resting state. We expect those muscles to have a lower threshold for activity than they did before. as pts this makes sense as patients it not it doesn't necessarily um come to the forefront of the mind so reminding them these are muscles think about any other muscle in your body maybe you've pulled a hamstring maybe you've pulled your quad maybe you've overstretched your shoulder those few days maybe weeks afterwards it took less activity for you to feel something in that area in this case specifically what I'm really kind of preaching to people is that if you get up and you're feeling good one day and you go for a walk with your kiddo around the block and that's the farthest you've walked and then later in the day you start feeling some heaviness you didn't cause a prolapse likely those muscles are just tired. They worked harder than they have all this timeline leading up to this. And so they're fatigued. And just like every other muscle that fatigues when it fatigues, it doesn't work quite as well. And so we feel that heaviness sensation. normalizing that heaviness sensation. I love to do this when people are pregnant, set that expectation. Hey, look, as you start moving more, you might notice that you feel a little bit of heaviness. It's not a big deal. That's kind of our buoy lets us know where we're at. You're not causing any damage. It's going to be okay. That heaviness will resolve and over time you're going to build up your capacity where that heaviness sensation comes on later and later and later normalizing what a prolapse is, normalizing what the grades are, normalizing the changes of our body that happened during pregnancy and postpartum and normalizing recovery of those muscles and potentially having an onset of symptoms. FINISH WITH EMPOWERMENT Finally, we want to empower our patients. This is where our bread…

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    Episode 1616 - Testosterone Replacement Therapy (TRT) for the PT Dec 08, 2023
    Show notes

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

    Full show notes at the publisher

    Episode 1615 - Master the rack pull Dec 07, 2023
    Show notes

    Alan Fredendall // #TechniqueThursday // www.ptonice.com

    In today's episode of the PT on ICE Daily Show, ICE COO & Fitness Athlete Division Leader Alan Fredendall discusses utilizing the rack pull as a way to begin to load the spine isometrically. Alan demonstrates the rack pull, how to set it up, how to modify & scale it, and how to prescribe & dose loading of the rack pull.

    Take a listen to the episode or read the episode transcription below.

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

    EPISODE TRANSCRIPTION

    INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.

    ALAN FREDENDALL PT on ICE Daily Show, happy Thursday morning, hope your day is off to a great start. My name's Alan, happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer and a faculty member in our Fitness Active Division. We're here on Technique Thursday, that means it's also Gut Check Thursday. This week's workout, we have a 15 minute AMRAP, so a little bit more chill than previous weeks. We have an ascending rep scheme of American or overhead kettlebell swings, 5, 10, 15, 20, so on and so forth. Recommended weight, 53 pounds for guys, 35 for ladies. And then you're going to pair that every round with 10 back squats. We're going to do that at 135, 95, and then 30 double unders after every round. So a good goal there is to get maybe four or five rounds deep into that AMRAP. accumulate a good volume of everything. You're going to end up at about 50 to 75 reps of the kettlebell swings, of the back squats, and of the double unders. So that's Gut Check Thursday. Courses coming your way. We are basically done with live courses for the year. We have live courses this weekend, but they're all sold out. And then our very last live course of the year is next weekend in Salt Lake City with Paul for dry needling. So if you're trying to make a course before the end of the year, that's the last one you can sign up for. All of our other courses starting up in 2024 are on our website, ptenice.com. Remember, price change going into effect January 1st. Our rates are going to go from $6.50 per course to $6.95. So if you already have an eye on a course, make sure you sign up before January 1st and save yourself 50 bucks. MASTER THE RACK PULL Today, Technique Thursday, what are we talking about? We're talking about the rack pull. So I want you to go back to last Tuesday's episode with Jordan Berry, episode 1608, Spine Isometrics, to talk about all the research and the clinical reasoning supporting something like a rack pull. I want to take a deep dive into this, because on the topic of spine isometrics, I think this is a very effective exercise to use in the clinic with patients with low back pain, folks who are having trouble deadlifting, to really build a strong, robust low back, so that bending over and picking up stuff from the floor is no longer bothersome. Today I want to talk about why we're doing this, I want to talk about keys to success, and most importantly I want to talk about how to load and dose this and prescribe this to patients. WHY THE ISOMETRIC RACK PULL? So, why do we do this? First of all, it's simple and effective. It's essentially a very small partial range of motion deadlift. It is very scalable based on your patient's presentation. Somebody who's very irritable has very severe low back pain, we can move the safeties and the J-hooks to maybe above the knee, maybe right below level of hip, so we have a very small range of motion that we're contracting through. And we can scale that back down though as somebody starts to feel better. We can take that all the way down to a rack pull from mid-shin as if somebody was lifting from the floor. We can meet our patients where they're at with the scalability of that. The nice thing, like Jordan said last week as well, the key to a lot of isometrics is that most people can do these at home. A lot of folks have a squat rack. or a barbell in plates in their garage or the gym. So they can set something up close to this at home and be able to do that for home exercise. Those individuals already active in the gym already have access to this equipment at the gym they go to, so they can also do this as part of their home exercise program at the gym. Now that's why we do it. KEYS TO SUCCESS What are some keys to success? The keys are The setup here is everything. So you'll see I have a pair of safety bars here and a pair of J-hooks. My preferred way to do this whenever possible is to set it up like this. Whether I have two pairs of J-hooks or cups in the rig, I have a pair of safety bars and a pair of J-hooks. I have basically two start and stop points that's gonna let me control that range of motion. So setting it up is really, really, really important. So set up your environment correctly. The J hooks should be upside down. So what we'd like to see is that they're actually upside down so we have more surface area to lift the barbell against. So I'm going to show you a rack pull right now. and show you what it should look like. So, in this example, I'm starting right at the top of the knee. The goal with the rack pull is not to finish the deadlift. If I'm standing at the top of my deadlift, there is no tension here, there is no work needed out of the low back. I need to somehow stop myself short of full range of motion, so my back has to work to keep myself in the position. So, from mid-shin, a nice hinged position, and now I'm gonna lift and pull up against the J hooks and now I can't reach full extension and here my low back is just working to keep this barbell in place and then when I'm done I don't have much room to go to set it back down. So again the issue with the J-hooks put into the rig like normal is that that barbell can actually roll off in a way and lifting a bunch of weight off like that, surprisingly, can upset some people's low back. So if you're going to use just J-hooks, again, take them, turn them, and then flip them upside down. Now we have more surface area. We also have kind of a framing here of the J-hook so that the barbell can no longer slip down, out, and around the J hook. So that's setting up the rack pull. Again, meet your patient where they're at. Adjust the range of motion as needed. If you don't have two pairs of J hooks, by a second pair or what you can use in place of two sets of J-hooks, you can place the barbell on some plates as the lower edge of your range of motion and use the J-hooks to stop the top motion. Again, the key here is that this is an isometric exercise, so we wanna be pulling up against something for 45 seconds. All the benefits that Jordan talked about last week, the stress relaxation response, strengthening, blood flow, pain relief, and then being able to reproduce this in the gym or at home. Now finally, why do we do this? How do we set it up? DOSING THE RACK PULL How do we actually dose this? Again, that's gonna depend, what is it gonna depend on? Your patient's current level of irritability. Somebody that is very flared up, maybe you're thinking about starting with something like a reverse Tabata, so you're gonna do eight rounds, 10 seconds on, 20 seconds off. progress them maybe to a full Tabata, where they're now doing eight rounds, 20 seconds of work, 10 seconds of rest. And then for me, my ultimate goal, following some of the tendinopathy literature, is to get to that 220 seconds time under tension. I like to see patients be able to progress to five sets of 45 seconds of work, and then really however much rest they need. 15 seconds is probably too short, so an EMOM timer is probably not appropriate. I like five seconds of 45 on, 45 off. 5 sets maybe of 45 on, a minute, a minute 15 off, so maybe you can set every 2 minutes for 5 sets on your timer. Something like that though, building to that 220 seconds time under tension, ideally showing the capacity to be able to hold that rack pull for at least 45 seconds. So meet your patient where they're at, progress them, progress them, progress them, time under tension. Now what about loading? This is a partial range of motion that you don't need to lift from the floor. What does that mean? That means this should be quite heavy. This should be near, at, or maybe even above that patient's deadlift max, if we know it. Again, we don't have to lift it from the floor. The hardest part of the deadlift is done for us. It's already sitting above our knee. All we need to do is just a little lift and then hold. So, that means that this should be quite heavy. How heavy? whatever weight they can feasibly hold for maybe that reverse Tabata, and then that full Tabata, and then that full 45 seconds on with the rest coming. The key human beings who come into your clinic are not gonna be challenged by an empty barbell rack pull, even if their low back pain is really irritable, so keep that in mind. SUMMARY So the rack pull, why? We like that it's scalable. We like that it is easy to set up. It basically requires no thought or mechanical skill to be able to get into that position, We'd like that we can transfer this to home. A lot of folks have access to a barbell and the setup needed to do this rack pull. We'd like that we are really easily able to make people successful with this by just modifying the environment, setting up with plates as blocks and J-hooks as the top limit, two pairs of J-hooks, squat safety bars or J-hooks, whatever. This is very easy to set up and be successful with it. And then we like that it is easy to dose. We can see patients make progress from maybe 10 seconds on, 10 seconds off for a couple sets, to a full reverse Tabata, through a Tabata, and then maybe into somebody who is probably now ready to start deadlifting from at least the knee through a partial range of motion, if not from the floor, is somebody that can come up here, lift and hold for sets of 45 seconds. Five sets of 45 seconds really seems to be the sweet spot for the back to start feeling good, for the back to start feeling strong, and to now reintroduce full range of motion deadlifting, things like kettlebell swings, back into a person's exercise routine if they're already doing, or now, maybe for the first time, instruct that patient in the deadlift. So, the rack pull, easy to set up, easy to mess up too if you don't have a lot of attention to detail, but relatively easy to set up, load, dose, and prescribe as homework for our patients. So try that out. Thanks everybody, have a great Thursday.

    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 1614 - Leave nothing on the table with sarcopenia Dec 06, 2023
    Show notes

    Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses the scary stats of sarcopenia: increased risk of falls, fractures, loss of independence and the list goes on and on. Dustin emphasizes that rehab providers have HUGE opportunity in this department but often leave so much on the table. Listen in as Dustin shares some new research about Sarcopenia and it's implications for our work. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. DUSTIN JONES Alright Instagram, good morning, good morning YouTube. This is the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division and today we are going to be talking about leaving nothing on the table when it comes to sarcopenia. Leaving nothing on the table when it comes to sarcopenia. We're going to be covering some new literature that looked at the variations of intensity of different exercises with and its impact on sarcopenia and what that means for us as clinicians or fitness providers. Before we get into the goods, I do want to mention CERT-MMOA is rocking. CERT-MMOA is for those that complete our three MMOA courses, our online level one and level two. then our live courses. We have shut things down for the rest of this year but I want to let you know as soon as 2024 kicks off in January we are hitting the road hard. Both of our online courses are gonna be starting that second week of January and then we've got a few courses I want to mention that are gonna be absolutely awesome in that month of January. We got Santa Rosa, California January 13th, 14th. On the 20th, 21st we're gonna be in Greenville, South Carolina the 27th and the 28th we are going to be in Missouri. So we'd love to see y'all on the road. SARCOPENIA So let's talk about this, sarcopenia. So sarcopenia, for those that are not familiar, is age-related loss of muscle mass and strength. Sometimes now you are going to see the word function or physical function be thrown into that definition, but by and large, most of the time when you see this, it is age-related loss of muscle mass and strength. This is very important for every single person listening to this podcast because the vast majority of y'all are treating older adults in some way shape or form. But what we're seeing is that the term sarcopenia is starting to apply to individuals that may not have that older adult tag on them. Maybe those folks that are south of 65, maybe those folks that are in their 50s, sometimes even their 40s that are gonna qualify based on the criteria of sarcopenia. So this is a big issue and it impacts a large, broad audience. Just some stats, just so you are aware of how this could impact the folks that you're serving. 10 to 40% that's a wide range, but estimates are saying that 10 to 40% of community dwelling older adults have sarcopenia. All right. So 10 to 40% of folks, independent older adults that are walking amongst this, out in the community walking into your outpatient clinic would be categorized as having sarcopenia. And we would argue that that number is largely artificially low, that there may be even more. If you are a clinician that is working in a more acute setting out of the community, right, like acute care, home health, skilled nursing facility, this number goes up exponentially. So for you all, the vast majority of individuals, particularly older adults, would fall into that category of having sarcopenia based on the diagnostic criteria. So all to say, a lot of folks across the whole healthcare spectrum would fall under this category. SARCOPENIA: WHAT'S THE BIG DEAL? Now why is this a big deal? This is a big deal because if you have that label sarcopenia, you are at 60% increased risk of falling, If you fall, you're at an 84% increased risk of having an injurious fall or with a fracture. Those are big statistics, and we know the negative implications of those health outcomes. It is a big deal. It is an absolutely big deal, and it's important for us to understand how big of a deal this is, but then also to know what to do with it, all right? And this is where this new research, this new literature that was just published comes into play. There's a recent systematic review and a network meta-analysis that was published in the European Review of Aging and Physical Activity that looked at randomized controlled trials that use exercise in different intensities of exercise and how that impacted different outcome measures with folks that have sarcopenia. So they found that there were about 50 randomized controlled trials that totaled of about 4,000 participants. And all of these studies looked at the following outcomes. They looked at muscle mass, which we're usually measuring with something like a DEXA scan, right? Muscle strength tested by hand grip strength, chest press, and then a leg press on a machine. And then physical function, functional outcome measures, five times sit to stand, 30 seconds sit to stand, timed up and go, short physical performance battery, which is, you'll commonly hear us refer to it as the SPPB, the six minute walk test, and gait speed. All right, so these studies were measuring a lot of things that have huge implications for a lot of physical therapy and even fitness outcomes. All right, so all these studies were looking at those things. and they performed exercise at different intensities. So they performed exercise potentially at light intensity. This is categorized as at zero to four out of 10 on that modified Borg score where we're looking at relative intensity or RPE, rating of perceived exertion. that could also equate to under 49% of someone's one rep max. So typically what you saw in this meta-analysis is that the randomized control trials that were using that light intensity, they were often using aerobic-based training. So we're going to throw that in, kind of that light intensity category. Then we had moderate intensity. So this was that five to six out of 10 on that RPE. kind of 50 to 69% of a one rep max was considered to be moderate, and then vigorous, six to eight out of 10, and kind of that 60 to 80% of that one rep max. All right, keep in mind the updated ACSM recommended guidelines are calling, particularly for sarcopenia, are calling for 60 to 80% of someone's 1RM. They're calling for vigorous exercise, in particular resistance training for these individuals, all right? So they had those different intensities and they saw, all right, what's going to happen here with these folks that have sarcopenia? And the interesting thing to think about this is there's a lot of individuals, particularly when someone has sarcopenia on board, that the main focus is that, hey, this person may be relatively sedentary. They have low physical activity levels. Let's just get this person moving, right? Let's get them started in some type of physical activity. Let's bump up their overall physical activity. That's going to be a huge win. I would agree with that. Anytime that we move someone from being relatively sedentary or low physical activity levels and we can bump that up, we are going to see some positive benefits. We cannot deny that there's good in getting people to move more. STOP STOPPING AT LIGHT INTENSITY But what we need to acknowledge, especially after these results, is we cannot stop there. That is the first part of the journey to pushing people to more activity, but more intense activity. So what they found with this meta-analysis is the individuals that only received that light intensity, the only improvements that they saw across all those different outcome measures that I mentioned before was they did see some improvements in their hand grip strength. Awesome, that's great. That's a great correlation to lots of health outcomes, right? It's not a bad thing to have an improvement in hand grip strength. Great, that's awesome. There's a point for light intensity exercise. Now, moderate intensity exercise saw improvements in hand grip strength and important outcome measures like a 30 second sit to stand, a timed up and go, and leg press. Awesome. That's a few points for moderate intensity. We should probably be giving more preference to that than light intensity. And then the vigorous intensity crew saw improvements in all of those things previously mentioned that the light and moderate intensity experience, but they also saw improvement in muscle mass. They saw improvement in gait speed along with 30 seconds at the stand, five times at the stand, timed up and go, hand grip strength, leg press, chest press as well. They saw significant improvements across that broad spectrum of outcome measures that I talked about before. They get 10 points for those types of benefits, right? So if we're to rank them, the vigorous benefited tremendously much more than the moderate and the moderate benefited more than the light. So what this is basically telling us is that these folks that had that sarcopenia tag, which is based on, you know, a DEXA scan, but then also, you know, SPPB under 8 out of 12 or hand grip strength under 26 kilograms for males and under 16 for females. That's what we would typically look at, right? SARCOPENIA NEEDS VIGOROUS INTENSITY Folks that have that diagnosis that we need to be giving them vigorous intensity activities, particularly resistance training. If we do not give them vigorous exercise, we are leaving a lot on the table. Yeah, they're going to get better. They're going to improve on some of these outcome measures, but we leave so much potential benefit on the table that we're ultimately doing a person a disservice. So based on this research, I wanna focus on three main takeaways that we should walk away with after coming across some literature like this, all right? The first one, particularly for the ICE crew, you have such a unique opportunity that you spend so much time with these individuals, comparatively more time than any other healthcare provider, that you need to be well-equipped to screen and identify when sarcopenia is on board. We cover this extensively in MMOA level one and in our MMOA live course, but you need to be able to run an SPPB. You need to be able to run a hand grip strength. You need to be able to interpret those results and let that influence your course of care, particularly for the outpatient clinicians, because why do people come to you, right? What is a primary driver for your services? People are typically coming to you for pain, which you need to focus on, but that may not be the biggest issue. All right. So one we're screening, we're identifying number two, we are leveraging intentional under dosage. You've heard us talk about this podcast before. We've done whole episodes on this. So I'd encourage you to search that if you had, if this is a new term for you, but we need to leverage intentional under dosage because that is typically we're lowering the barrier of entry for individuals. So they're going to partake in particularly a new activity, right? For so many of these folks, they have not exercised before, they've not performed any intensity of resistance training. This is completely new territory for these individuals that we need to make it approachable. And so we may typically underdose initially. SHORTEN YOUR UNDERDOSAGE But in light of this evidence, that intentional underdosage period needs to be as short as possible. We don't have a lot of time here with these individuals and we need to make the most of our time. The quicker we can get to that vigorous intensity level so we get all those benefits that this meta-analysis discusses, the better, right? So that intentional under-dosage period needs to be as short as possible. That's a very vague thing, right? For some individuals, you may have their first visit where it may be intentionally under-dosed for their capacity. and then the next visit based on their response, their trust in you, their willingness to perform maybe a more challenging activity, that intentional under dosage period may be the span of one visit, right? But I know for me, particularly in home health, I've had intentional under dosage periods that have been well into the months. based on the person that I'm working with. Whatever it is, make it as short as possible. So we screen and identify, we leverage that intention on your dosage. And then number three, and I think this is something that we really need to grasp, is the clinical urgency in this situation. that if you continue with your light, with your moderate intensity exercise with these individuals, you're leaving a lot on the table. And ultimately, you are harming that person. You are robbing them from the potential benefits that we've seen in this meta-analysis, that they see the big improvements in the functional outcome measures, in their strength, in their muscle mass. These people have the capability to get those kinds of results. And if we waste our time and spend too much time in that intentional underdosage period where we're doing that sedentary, doing light to even moderate intensity activities, you are doing that person a disservice. You are doing that person a disservice. It is a dangerous situation that you're playing with. We need to have a sense of urgency when we're talking about sarcopenia. All right. I'm going to drop the link to this meta-analysis at Open Access. Really good read. It gives you a good idea of kind of the big body of literature around sarcopenia, but what they found in terms of these outcome measures. I'll drop that in the comments. If you have a tough time getting that link, just shoot me, DustinJones.dpt or the ICE account a direct message and we'll get that over to you. But this is a big conversation for many of you. You all are seeing tons of folks that would have that sarcopenia label put on them if they were properly screened and identified and you have a huge opportunity to give them that vigorous intensity, that amazing dose that is going to give them huge benefits across such a broad spectrum of outcome measures that have a huge implication for their quality of life. Alright, y'all have a lovely r…

    Full show notes at the publisher

    Episode 1613 - Deck chairs on the Titanic Dec 05, 2023
    Show notes

    Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses recent research supporting the effectiveness of conservative care compared to invasive care, but in particular, the efficacy of chiropractic care compared to physical therapy care. Zac postulates that being hung up on the concept of spinal manipulation is often to blame for reduced PT outcomes when it comes to spine pain. He challenges listeners that the majority of patients are going to seek out & receive spinal manipulation for their pain, so the best course of action is to learn spinal manipulation, practice daily, and understand how to explain treatment to patients in a manner that does not facilitate dependence. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course, our Cervical Spine Management course, or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZAC MORGANAll right, good morning PT on Ice Daily Show. I'm Zach Morgan. I'm lead faculty here with the cervical and lumbar spine management courses and lead that spine division as well. Wanted to bring forward some content this morning. So the title of this episode is the deck chair on the Titanic or deck chairs on the Titanic. But before we jump into the actual content and kind of unpack what we're, what I'm talking about with that metaphor, I wanted to start out by kind of pointing you all in the direction of the next courses that you can jump into from the spine management side. So we're wrapped up for the year, but if you're looking for next year, two options in the middle of the country for cervical spine on the weekend of February 3rd and 4th, we've got Wichita, Kansas, as well as Hazlet, Texas. So if you're in the middle of the country looking for cervical spine, those will be good options. At the end of that month, we'll be in Simi Valley, California on February 24th and 25th. If Lumbar is the one that you're looking for, there's one in January. So Rome, Georgia, 27th and 28th of January. And then March 9th and 10th, Cincinnati, Ohio. And then March 23rd and 24th over in Brookfield, Wisconsin or right outside of Milwaukee. So several offerings there to start the new year for cervical and lumbar. If you haven't looked into the ice ortho cert, do so. So we've, we've revamped our website and you can go on there and kind of look at what all is included. Um, but that cert is kicking off. We're testing people out on the weekends already and it's been a really good kind of, uh, initial rollout here. So if you're looking for an orthopedic cert, um, check out the new ice cert and let us know if you have any questions. FIRST PROVIDER SEEN FOR ACUTE LOW BACK PAIN I just wanted to kick off today by actually unpacking an article. This article was published in the PT Journal back in September. It came out of the University of Pittsburgh, so that's probably the crew that does the most looking into back pain, at least in our profession. University of Pittsburgh is pretty famous for a lot of their back pain research. Essentially, this article was titled, First Provider Seen for an Episode of Acute Low Back Pain Influences Subsequent Healthcare Utilization. So definitely a bit of a wordy title, but essentially looking at who do people present to first and how does that influence downstream medical costs. And this was from Christopher Baez and his colleagues over there. Anthony Delito was on this paper as well. So if you're familiar with Anthony Delito, he's definitely done a ton in the low back space as well. So really good university, really well done study here, published in our journal here just very recently. So very recent data that we're looking at here. And let me just kind of talk briefly through what they did with this article with the method standpoint, and then we'll talk about the outcomes. And then we'll unpack the metaphor and end with some action items this morning. So really what was done for this article was a retrospective analysis. So they looked back at cases of acute low back pain, meaning that the person had not been to any sort of a medical provider within the last three months for back pain. So they looked at acute cases of low back pain and they looked at where they presented and then those downstream medical costs and how those things were affected based off of where they presented first. So they were looking at chiropractic care, physical therapy, primary care physician, emergency department, and so on, and basically comparing the outcomes downstream depending on where the person went from one of those professions. As far as outcomes, what were they looking into? They were looking into things like episode length, future CT MRI use, how often did those patients wind up getting that advanced medical imaging, how often did they opt for things like injections or opioid prescriptions, specialist referral downstream, getting to a spine surgeon, those types of referrals. Actual surgery was one of the outcomes they looked at, and then just unplanned care. So they looked at all these variables, retrospectively after these people had presented to the health care system one way or the other to see if there was any difference in the variables over the following year after they had that first episode of acute low back pain. And two things really jumped out to me as I was reading this article. So there's two very obvious things to me. CONSERVATIVE CARE OUTPERFORMS INVASIVE CARE First, conservative care definitely outperforms more invasive care when it comes to the reduction of those expenditures. So physical therapy and chiropractic would be the ones we would lump into conservative and physical therapy and chiropractic significantly outperformed basically the emergency department primary care physician any of the other places that patients would have presented, which makes a lot of sense to us as the conservative care crowd. We know that a lot of times getting that patho-anatomic diagnosis is not helpful at all and often drives a lot more care. So if a person ends up getting that type of a diagnosis early on, often they're going to end up in the health care system for longer. as physical therapists and then even often as chiropractic work, we're more targeting symptom behavior versus anatomical diagnosis, so it makes a bit of sense that conservative care outperformed non-conservative care. CHIROPRACTIC CARE OUTPERFORMS PHYSICAL THERAPY CARE But the second thing that jumped out to me as I was reading through this paper is that chiropractic care significantly outperformed physical therapy. Basically, at pretty much everything other than use of radiographs, which is not overly surprising. Chiropractors have the ability to prescribe radiographs. But if you look at things like episode length, they got us by a couple days. If you look at CT, MRI use, injections, opioids, surgical referrals, actual surgery and unplanned care, The chiropractic profession outperformed the physical therapy profession within that conservative care chump pretty significantly. I'm not really trying to pin our professions against one another. What I'm more trying to point out is they pulled their weight. Whenever we look at this data set and we see essentially how this course of care went through for the patients, it's clear the chiropractors pulled their weight. Yes, we helped from the physical therapy side as well, especially compared to non-conservative care, but within conservative care, I would say we left them stranded a bit and didn't do as good of a job as they did. And so I couldn't help but start to think about why wow, we've really got to step it up as our profession. Like if we want to be in this conservative care battle, it's not enough for us to not contribute to that side of the fight. We have to step it up. We have to pull our weight in this fight. So let's talk a little bit about maybe some of the ideas as to why PT didn't do quite as well as chiropractic care in this study. Because they didn't postulate too much on that in the actual article, but I have some thoughts surrounding it. And so I just want to talk through those things a little bit. WHY ARE WE SO AGAINST SPINAL MANIPULATION? Let me just start by saying, team, every year since I've been a PT, even from school till now, things like spinal manipulation have always been super challenged within our profession. So it's very clear when you look at medical practice guidelines, when you look at our clinical practice guidelines, when you look at most of the clinical practice guidelines, especially for the management of acute low back pain, they have suggestions for spinal manipulation. But within our profession, what I've always witnessed is anytime we, as I put out posts about spinal manipulation, we get a decent amount of kickback from our own profession. we get all sorts of commentary on those posts suggesting potentially that it's not as safe as it should be or maybe it's going to create dependence or things of this nature and I think in our profession we argue about that a lot and it winds up plaguing us when it comes to the execution of those techniques or even feeling okay about using those techniques on patients and team This is something we have to get rid of if we're going to contribute our share to the fight with conservative care for the management of acute low back pain. ARGUING AGAINST MANIPULATION IS LIKE ARGUING OVER DECK CHAIRS ON THE TITANIC I don't remember when I first heard the metaphor about arguing over the deck chairs on the Titanic, but it really fits in my mind to this current conversation. It doesn't make any sense to argue over the deck chairs on the Titanic, right? But imagine that. Imagine the ship is sinking, it's dropping underwater, it's hit the iceberg, And you're up at the nose of that ship that's going to sink last, arguing about where the deck chairs go, which table they go out, how you want to orient those. That makes no sense, right? The ship is sinking. So I think in our profession, we tend to do this. We tend to argue over the deck chairs on the Titanic. Let me unpack that a little bit. What's the Titanic in this metaphor? The Titanic is that people are going to have their spines manipulated when they have acute pain. You can like that or not like that, but the fact is true that patients or just our communities seek that intervention out in relatively high volume when they have acute pain. That's happening. What are the deck chairs that we're arguing about as a profession? That's where these things like Will it create dependence? Does it work? Is it safe? These types of questions are arguing over the deck chairs. We know it's safe, right? Like that has become very clear. If you look through the literature, when spinal manipulation is done well, it's a very safe and effective technique, especially relative to other techniques that people might would choose or even other medications that people might would choose for the management of their acute pain. So we know it's safe. We know it works well for acute pain. We've got enough data to show that it works well. Also, I mean, I would say even empirically, just looking at how many people are driven towards that intervention, I think empirically we know it works. And then, does it create dependence? I think that comes a lot more from the narrative for how it is presented to the patient than it does from the actual technique. So I don't think it has to create dependence. And we sit here and argue over these types of variables. Meanwhile, people are going to have their back manipulated regardless of whether we come to some sort of a conclusion or not. And that conclusion doesn't really influence the end result of those people seeking out that intervention because they think it'll be helpful to absolve some of their pain scenario. So it's very clear to me that we need to start pulling our weight here. We're too busy arguing over meaningless variables. START LENDING A HAND What we actually need to do is lend a hand in this fight to our chiropractic colleagues who are doing a very good job managing things conservatively. It's time that we take some action here. So team, I wanted to end this podcast by talking about what that action might would look like as a profession and hope that over the coming years we can start to shift to the profession in this direction. I do feel the wave of that currently and it's really exciting to see that more and more therapists are starting to utilize interventions that their patients want to meet that patient expectation and help create a narrative surrounding it. But I wanted to leave you with just a few action points. So first things first, I think you have to learn how to thrust manipulate. I understand there's a lot of argument in this space, but if you aren't able to do the intervention, the patients will never hear these arguments. So if we leave them stranded, or even leave them to just seek out all sorts of other health care, when what they want is spinal manipulation and if you could provide that to them, you could then help them understand the mechanisms, those underlying mechanisms that might make them feel more robust about their body versus feeling weaker or feeling fragile. We want to learn to do it so that that way when patients need it, we can provide it and we can also provide a supportive narrative that creates independence, not dependence. And this is possible. And so I think we have to learn to manipulate, otherwise we have no fight. Nobody's going to listen to the data. They're going to need to see it empirically. And so I think for us, we've got to get them in and actually do these interventions with them. To get good at that, I think you have to practice daily. So first, learn to manipulate, then practice daily. So whether that's on your spouse, on a family friend, or practicing on patients that are in front of you with no contraindications and perhaps even some indications for doing those techniques, I think we should practice these techniques daily so that you can get good at the psychomotor skills. Once you've mastered them, of course, focus on other things. But if it's still a skill set that you're refining, I would do those speed drills that you pick up in classes. I would practice on your colleagues and frie…

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