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Episode 1581 - Does form matter? Oct 20, 2023

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Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com https://journals.lww.com/nsca-jscr/fulltext/2019/12000/validity_and_reliability_of_the_rear_foot_elevated.9.aspx https://journals.lww.com/nsca-jscr/pages/articleviewer.aspx?year=9900&issue=00000&article=00300&type=Fulltext In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad". Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ALAN FREDENDALL Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today here on Fitness Athlete Friday, the best darn day of the week. I currently have the pleasure of serving as our Chief Operating Officer at Ice and a lead faculty member here in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things CrossFit, power limping, Olympic weight lifting. recreational bodybuilding, running, rowing, biking, swimming, triathletes, marathoners, anybody who's out there getting after it on a regular basis, we address all things relevant to that population. Some courses coming your way really quick from the Fitness Athlete Division. Your last chance to catch us online for our eight-week online entry-level course, Clinical Management Fitness Athlete Level 1 Online will begin November 6th. So that's just two weeks away. That'll be our last cohort of the year. That class will take us right through the holidays. and then we'll take a little break. The next cohort after that will be available sometime in the spring. So if you've been hoping to join us for that class, November 6th is your last chance for the next couple months. Live courses coming your way between now and the end of the year as we get into the back half here of quarter four. You can catch Zach Long down in Birmingham, Alabama. That'll be the weekend of November 4th and 5th. That same weekend, Mitch Babcock will be in San Antonio, Texas. The weekend of November 18th and 19th, Mitch will be in Holmes Beach, Florida. Beautiful place, just actually took a vacation there a couple weeks ago. Wonderful place to get to, especially in mid-November if you're from the Northeast or the Midwest, Florida's a great spot that time of year. That class just has one seat left, so if you've been looking to get baby both to Florida and to fitness athlete, that is your chance. And then our very last live course of the year from the fitness athlete division will be December 9th and 10th. That will be out in Colorado Springs, Colorado. That course will also be with Mitch Babcock. So check us out online, check us out live. We'd love to have you here at the end of the year before we get into the holidays. 02:16 - DOES FORM MATTER? Today's topic, we're going to take a deep dive into form and mechanics. Does form matter? How much does it matter? We hear this question a lot in our courses as we're introducing movements, instructing the basics of how to perform some of the most basic movements, your squats, your deadlifts, your presses. This may be a question that you get from athletes or patients in the clinic and for a long time and even right now this is kind of a very dogmatic campy approach to this topic of yes form is the most important thing or no form has no application at all we've even heard things like Sheer force is an artificial construct created by physical therapists to scare people away from moving. Physics doesn't matter as much as we thought it did. That movement, however it happens, is normal, natural, and that's how the human chooses to move, and there is no right or wrong way to move. So, where's the magic lie? Where's the evidence lie? What actually works in practice in the gym with real human beings? And what are some pearls to take away from the discussion on form? So often we get questions of does it really matter if the low back rounds during a squat or a deadlift? Does it really matter if the back hyper extends with overhead lifting? Who cares if someone catches a snatch with a bent elbow or they never reach full extension of the elbow at the bottom of maybe a pull-up? If someone presses their jerks or snatches out, is it really that big of a deal? So today I want to approach this topic from a couple different directions. I want you to go back and watch last Thursday's episode or listen to it on evidence-based medicine about making sure we're addressing all of the facets of evidence-based medicine when we approach a really hot topic like this that also has a room for a lot of interpretation one way or the other. We need to look at what does the evidence say, we need to look at what does our friend physics say, what does our clinical experience say as far as What is our anecdotal experience with clinical pattern recognition with actual patients and athletes? And then what does the patient say? What matters to the patient? Patient expectation and input matters. So let's start from the top. 04:42 - WHAT DOES THE EVIDENCE SAY? What does the evidence say? As much as we don't want to hear this, we don't have a lot of strong evidence either way in this discussion about form. When we talk about what does the evidence say, we have nothing concrete or strong for or against poor mechanics and lifting. We have a ton of research out of the functional movement screen space that looks at movement quality and its association to injury. And time and time again, I have to declare my bias. I hate that test. I think that test is total garbage. I think the research supports that that test is total garbage. And when we look at does particularly unweighted movement transfer to predicting injury, we have stacks and stacks and stacks of research across a wide variety of populations, recreational athletes, tactical athletes, first responders, professional athletes, that shows the association between quality and injury prediction or injury risk reduction is simply not there. We do have some research that looks at the effects of lifting, and I'll put lifting in air quotes here for those of you listening on the podcast, that lifting with a rounded back does not seem to cause low back pain or make current low back pain worse with the caveat of when we look at that systematic review and meta-analysis from O'Sullivan and colleagues a couple years ago, that the papers they included did not have any patient lifting more than 25 reps across the span of a day at a weight heavier than 25 pounds. It's really hard to take research like that and extrapolate it to our population who might be deadlifting two or three times their body weight, cleaning or snatching their body weight, doing dozens or hundreds of things like pull-ups and handstand push-ups and double-unders, really getting a lot of load through their body, running, crossfit, lifting, whatever. That research really has no application. It's really hard to even call that lifting, right? Those are just kind of activities of daily living. We can't take research like that and extrapolate it to somebody dead lifting with a low back and say these are the same. They are just simply not. We also need to be mindful of the research that we do have. When you look at papers on deadlifts with low back pain, on the effects of lumbar reversal with lifting, what you'll find in those studies is that one of the variables that the research authors always control for is the lifting mechanics themselves. You'll often see, if you actually read the full paper, not to harp on that, but when you read the full paper, when you read the methodology, what you will find is that very often those folks are instructed how we would instruct a movement in the gym, which is to try to maintain a brace-neutral spine, modifying the load or modifying the range of motion to maintain that, to therefore reduce that as a variable in the research study. That if we cannot control mechanics, that's one more variable that maybe takes a little bit away from our conclusion when we look at the data. Of trying to standardize the mechanics as much as possible is how we can narrow down the focus of that research study on whatever the intervention is and whatever the outcome and feel really confident that the association there is direct and that other variables aren't at play. If we can't say deadlifts are safe, deadlifts increase low back strength, deadlifts improve low back pain, if we look at a study and there was no control on how the deadlift was performed or how the mechanics were performed through those deadlifts. One study does sumo deadlifts, another does conventional, one does trap bar, one allows back rounding, one does not. You'll see when you read those studies that controlling for those variables, controlling for those mechanics, is one of the ways that variables are reduced. And so it's hard to look at those studies as well and extrapolate to altered mechanics, what we might call a movement fault, and translate that to the population that we're working with. It's hard to take research and say, you know what? I'm gonna do everything this study did except change everything about it, right? That doesn't mean you're implementing that research and practice. You're taking the general idea and you're kind of going your own way with it. You no longer have that evidence base to stand on. From the research, we do know that symmetry can be objectively quantified, we can assess it, and we can intervene on it. Very often, physical therapists are very comfortable at calling out and identifying qualitative faults without really understanding what might be going on, how to assess it, how to measure it, how to track it, or how to change it. But if we look at some really nice research papers, a great one came out this year, I'm gonna butcher this name, I'm so sorry, Yuja Kovic and Sarah Bond came out this year, looking specifically at asymmetries and change of direction in basketball athletes and finding that there are ways that we can objectively quantify things like asymmetries, strength, speed, motion, quality, asymmetries, that we can also intervene on them. This study in particular sought to reduce the change of direction asymmetry by overloading the slower slash weaker limb with three times as much training volume compared to the stronger or faster side. That looking at an 11% or so difference in change of direction speed, able to reduce that down to just 4% simply by overloading the volume on the weaker, slower, basically problem area. In this case, it was the lower extremity. A very simple study, just using some lower extremity strengthening, three times as much volume as the contralateral limb. We know we don't need a biodex or some other form of fancy isokinetic testing or force plates in our clinic to have ways to objectively identify and assess maybe quality that is associated with asymmetry that is maybe the cause of pain, aggravating current pain, aggravating past pain and or limiting performance. Great study by Helm and colleagues 2019. wanted to validate the five rep max rear foot elevated split squat. Maybe you have heard of this as the Bulgarian split squat, but essentially kicking up that back leg, doing a five rep max on each leg. In this study, they used a barbell. In the clinic, you can use dumbbells as well, trying to find a five rep max per side, and then quantifying and objectifying the asymmetry side to side. Finding it's a very reliable, very valid way as compared to things like Biodex, and force plates to develop an idea of asymmetry from side to side. I would argue a paper like that we can extrapolate to the upper extremity, we can do something like a landmine press, we can do something with our lats or back with something like a bent over row and really start to think if we're seeing movement faults that we think are the cause of symptoms or some sort of performance issue to start getting more objective in how we assess, reassess, and intervene on these things. So that's what the evidence says. It doesn't say a lot. Besides that, we need to help people get stronger and we need to quantify where their strength is at as they're starting their rehab program and then reassess it as they're finishing in order to be sure that person actually got stronger and actually closed the gap on any sort of perceived or actual asymmetries that we found. 11:38 - WHAT DOES PHYSICS SAY? What does physics say? This is something that we tend to ignore a lot, that we exist as human beings on a planet with things like gravity, and that we are subject to certain physical characteristics that we can't avoid. Physics would say that the shortest route between two points is a straight line, and anything else, any other extraneous movement is a force leak. Any amount of force leak doesn't matter what your sport is. If you're an Olympic weightlifter, a powerlifter, a crossfitter, a gymnast, a swimmer, a runner, The more inefficient your mechanics, the more extraneous movement, the more your leg kicks out into circumduction in your run, the more your lower back rounds and extends back and forth as you go through deadlift reps, the more you bend your knees or bend your elbow in your pull-ups, it doesn't matter. The more extraneous movement you have, the more you're leaking force out of your system, the more you're limiting your top end performance. I have yet to this day see anybody break the deadlift world record by doing a Jefferson Curl. Yes, under extreme loads we might see a little bit of low back rounding, but we don't see people intentionally initiating a 1500-pound deadlift with a Jefferson curl mechanic. They tend to approach the barbell over and over again in a similar fashion, either setting up in a conventional or sumo deadlift and really doing everything they can, again, to minimize extraneous movement, put the maximum amount of weight through the ground to lift the highest load up in the air. That is performance, that is physics. We have to remember, unless we can invent some sort of technology or better understand physics, we can't get around that. So that's the evidence, that's the math. What does our personal experience say? Our clinical experience, maybe some of you would say this is anecdotal, but remember, part of evidence-based medicine is our clinical experience. 13:59 - WHAT DOES CLINICAL EXPERIENCE SAY? Our clinical experience would say that those folks in the gym that we see performing pull-ups, overhead movements with things like a constantly bent elbow, tend to be the people that we most often see over in the PT clinic for stuff like elbow pain. That the folks who rock up on their toes, catching their cleans, their snatches, because they lack ankle dorsiflexion, are the folks that we tend to see coming into the clinic with things like knee pain. That those folks who always quarter squats, no matter how much we try to help them get to a deeper range of motion, a greater range of motion, whether it's wo…

Full show notes at the publisher

Episode 1580 - Alternate approaches for dry needling lumbar multifidus Oct 19, 2023

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Dr. Ellison Melrose // #TechniqueThursday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses an alternate technique to dry needle the lumbar multifidus.

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

If you're looking to learn more about dry needling, especially dry needling with e-stim using the ITO ES-160 stim unit, take a look at our Upper Body Dry Needling course, our Lower Body Dry Needling course, or check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 - ELLISON MELROSE Good morning YouTube and good morning Instagram. This is PT on ice daily show. I am Dr. Ellison Melrose and I am currently lead faculty with the dry needling division of ICE. So we are going to go over a alternative approach for dry needling the lumbar multifidus today. Um, before we get into that, I want to go over our upcoming courses. So this, the remainder of 2023, we have, um, a handful of courses. This weekend, Paul's going to be out in Anchorage, Alaska, and I believe that is capped. After that, he will be down in Seattle, Washington on November 3rd through the 5th for the upper quarter. I will be out in Rochester, Minnesota for upper quarter dry needling on November 18th through the 19th. We will both be teaching the first weekend in December. So December 1st through the 3rd, Paul will be in Bellingham, Washington, and he will be hitting upper quarter then, and I will be out in Clearwater, Florida, so opposite sides of the states, doing lower quarter. So if you guys have a chance to find us out on the road, or want to join us for the remainder of 2023, those are the courses. We have one other one also in Fayetteville, Arkansas, the second weekend in December, where we'll be doing lower quarter. out there. So if you guys have any questions about those courses coming up, feel free to message us here or yeah, stay tuned for those courses. And then 2024 we'll be starting out pretty hot with some more courses and our advanced course as well. It will be, will be coming, um, in 2024. 02:10 - COMMON APPROACH TO DRY NEEDLING THE LUMBAR MULTIFIDUS So what I wanted to do today was to go over an alternative approach for, uh, dry needling the lumbar multifidus. So there, We are not gonna go over clinical reasons for needling the lumbar multifidus, but for those who have been taught how to needle the multifidus, there is one technique that is used fairly widespread across all educators, and that is the wrap-over technique. For demonstration purposes, I am going to be using my knuckle as the spinous process, and then we will be demonstrating it on a human body as well. For that wrap-over technique, so we have our spinous process here, Wrap over technique, we use two fingers to compress within a one centimeter gutter, just lateral to the spinous process. And we create a target window with our fingers and treating within that zone. In order to treat bilaterally, so both sides, you have to walk around the table to treat the contralateral side, which is fine, But when we're talking about clinical efficiency, it may be conducive to be able to treat or to needle staying on the same side of the patient. So we have an alternative approach for needling the multifidus where you are able to stay on the same side of the patient, and that will be your dominant side. So I am right-handed, so I'm going to be treating from the right side of the table treating the lumbar multifidus. I'll demonstrate first the wrap over technique and the alternative technique. 04:02 - ALTERNATIVE APPROACH TO DRY NEEDLING THE LUMBAR MULTIFIDUS For that alternative technique, so instead of using that spinous process, our palpation hand, two finger, stepping over that spinous process and compressing into the gutter, what we are going to be doing is we are going to be using our palpation hand, index and middle finger to orient us to where that lateral border of the spinous process is. In the lumbar spine, we have about a one centimeter gutter where we can feel fairly confident that we're going to be directing our needle towards the lamina with a directly posterior to anterior approach. From there, if we go outside that one centimeter gutter, we need to angle the needle medially to ensure that we have contact with the lamina as we need that laminal contact to ensure that we are at the depth of the multifidus. We are going to stay within that one centimeter gutter for today's demonstration, but we will start with that wrap over technique and then the alternative approach. The alternative approach, instead of using that two finger digital compression, we are going to be using the spinous process and either our middle or index finger to find that lateral border. So, first we want to find the spinous process and take the mid pad of our palpation finger and palpate that lateral border of the spinous process. From there, we're going to take our middle finger or our index finger, depending on which side we are treating, and compress tissue down within that one centimeter guide. From there, we're going to create a treatment window between our two fingers and treating directly posterior to anterior. towards laminal contact. 07:19 - ALTERNATIVE TECHNIQUE DEMONSTRATED So it'll make more sense when we're demonstrating it on the patient. So let's go ahead and do that. I'm just going to angle this camera down towards my patient. So here we have an exposed lumbar spine. I'm going to just orient myself to where we are. I am standing on my dominant hand side. From there, We'll just go over palpation. So spine is processed, we can palpate the lateral borders with our thumbs here. For that wrap over technique, we're going to take our pads of our palpation hand, stepping off, compressing tissue down, treating within that one centimeter gutter, okay? So let's start with that technique and then I'll show you the alternative approach after. So, palpating that lateral border of the spinous process, two fingers stepping off, compressing down into that gutter, keeping that needle angle directly posterior to anterior, so vertically, tapping, advancing the needle towards laminal contact. So in order to treat the ipsilateral side now, I would have to walk around the table and straddle that needle to do the same compression and same technique that we did on this side. So what I will demonstrate is the alternative approach and then we'll do another segment down below of the alternative approach just to show you how efficient this tool can be. So, instead of using those two fingers to hug the lateral border, I'm going to be using my middle finger on my palpation hand to palpate the posterior aspect of that spinous process. From there, I'm going to take the middle aspect of my pad and hug that lateral border of the spinous process. My index finger is then compressing into that gutter creating a nice treatment window. Again, we want to be aware of where that one centimeter gutter is and treating within that zone, directly posterior to anterior. So vertical, vertical needle approach here. So compressing down towards laminal contact. So there we have the alternative approach on that ipsilateral side. From there, thinking clinical efficiency, if we were going to set up multiple different segments in the lumbar spine, if we started proximally or superiorly and worked inferiorly, kind of like you're reading a book, that is going to be the easiest way to avoid some awkward hand positions with the needles. So we will needle the segment just distal to the ones that have needles in. So from there, Instead of using my middle finger to contact that lateral border, I'm gonna be using my index finger. We are treating the contralateral side from where I am standing. So again, we can appreciate the lateral borders of the spinous process. Take the pad of our index finger and hug that lateral border of the spinous process. Compress my middle finger now and create a treatment zone between my two fingers. Again, appreciate that we have a one centimeter gutter. Now we want to be treating directly posterior anterior to contact lamina. From there, I'm going to do a firm guide to compression, firm tap, advance the needle to laminal contact. And then we can do the same thing on the ipsilateral side. so middle finger palpating the posterior aspect of the spinous process wrapping to that lateral kind of hugging that lateral where it starts to curve creating a one centimeter gutter with my index and middle finger treating within that zone directly posterior to anterior towards laminal contact. So there we have, we went over the wrap-over technique and the alternative approach and just looking at the clinical efficiency that being able to stay on that ipsilateral side of the patient can do. I have a very small treatment room, so it allows me to not have to kind of wiggle my treatment table back and forth, and allows us to get a handful of segments within a couple minutes, which I think when we're thinking about using dry needling in the clinic, we want to save as much time as we have for using our electrical stimulation, as the new research is showing how beneficial that can be for treating pain, neuromuscular priming, also, um, recovery or hemodynamics, improving hemodynamics. So we want to get the needles in as efficient as possible as to allow for some optimal treatment time with the Eastern. So we, again, just to review with this technique, we are going to be using our index and middle finger. And instead of hugging the lateral border of that spinous process, we are going to be treating, um, with those fingers just off the lateral border, creating a one centimeter gutter between those two fingers, treating directly posterior to anterior and maintaining laminal contact to ensure we are at the depth of the multifidus. Thank you guys so much for joining me this morning, going over the alternative approach for dry needling the multifidus. And I hope to see you out on the road sometime this year or next year.

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 1579 - Cluster approach to dementia care Oct 18, 2023

Show notes

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the significant issue regarding the lack of individualization and care for older adults with cognitive impairments. Jeff points out that many older adults on their caseloads are at different stages of cognitive impairment, but this often goes unnoticed until it progresses to advanced dementia. The problem lies in the one-size-fits-all approach to treating cognitive impairments, where individuals with mild impairments are grouped together with those with severe impairments, or they are treated the same as the general population without screening for cognitive impairments. This lack of individualization and care for older adults with cognitive impairments is also evident in nursing homes. Jeff mentions a study from Germany that examined a population of nursing home residents. The residents were grouped based on their cognitive and physical impairments. However, the study found that there was a lack of personalized care, as a more diverse group was randomly assembled with varying levels of cognitive and physical function, and they all received the same basic intervention. Jeff emphasizes the need to tailor care to the individual's cognitive capacity, just as their physical capacity is considered. He uses the analogy of coaching a peewee football league, where practice would not be taken to the local NFL team if the capacity is not appropriate. Similarly, individuals with cognitive impairments should not receive interventions that are beyond their cognitive abilities. However, in the current state of rehabilitation for those with cognitive impairments, interventions are often not matched to their cognitive abilities. This lack of individualization and care for older adults with cognitive impairments is a significant problem that needs to be addressed. 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 00:00 - JEFF MUSGRAVEWelcome to the PT on Ice Daily Show. Good morning, my name is Dr. Jeff Musgrave. Super excited to be with you this morning, talking about a topic that's really important to me, but also reviewing a research article eight days off the press, a new technique called clustering to give better care to those with dementia on our caseloads. But before we get into that, if you're looking to up your Geri game, we are available. We've got some extra seats in our New Jersey course in Matawan, New Jersey this weekend. If you want to hop on that train, we'd love to have you. We've got space for just a few more. Next weekend, if you want to join us for live, we'll be in Annapolis, Maryland or in Central South Carolina. Last cohort of Essential Foundations just kicked off. We've got our first live meetup, so sorry if you missed it. We will be up in full force in January 2024. There is still time to catch advanced concepts if you want to sign up for that. The last cohort is about to begin, so grab those seats. 02:42 - JEFF MUSGRAVE So team, man, I'm so excited to get to talk to you about this topic. There are so many older adults on our caseloads in various stages of cognitive impairment. And this oftentimes goes unrecognized until it becomes advanced dementia. when things are a bit harder to turn the tide, but also there's a severe lack of individualization and care for those that have cognitive impairments. A big problem in general practice is this one size fits all. In geriatrics in general, whether we're talking about physical impairments, but unfortunately we see the same problem when it comes to cognitive impairments. We see those with cognitive impairments get treated the same regardless of how advanced those symptoms are. So we see one of two big problems here. We either see those with very mild cognitive impairments grouped with those with very severe impairments, Or we just see them treated the same because no one's screened or picked up on the fact that there's a cognitive impairment on board and they're treated just like the general population which is also not appropriate. So neither of those are a good look. So this study out of Germany was looking at a population of residents in nursing homes and what they did is they clustered them based on their cognitive as well as their physical impairment. So they used a clustering approach to try to get homogeneous groups of people based on not only their physical function but their cognitive function. So all these residents were 65 and up. They had mild to moderate dementia and were living in a skilled nursing facility. The physical measures that they used were the six minute walk test, the timed up and go, 30 seconds sit to stand. But the biggest place where they saw variation that dictated their function was on their mini mental state exam. So their cognitive impairment did a lot to dictate their function. So what they found at the end of this was that those that had more advanced cognitive impairments were not able, even if they had the physical function, to participate in as high level balance training as those that had more severe cognitive impairments. So those with more mild cognitive impairment were not able to participate at the same level, in particular when it came to balance challenges. 04:56 - COGNITIVE IMPAIRMENTS & TRAINING The interventions for this study unfortunately the link did not go through that I could see all the details but what they what they were doing was some form of strength training either seated if there was lower physical function versus standing or dynamic movement in standing if they had higher physical function. So lower to higher physical function and then they gave also a cognitive layer to their interventions while they were doing balance or strength training. So that allowed them to scale the intervention to those who, to make it more appropriate. So they had a higher and lower physical function, higher and lower cognitive function group, and they scaled the cognitive load as well as the instructions So one big thing that's missing is the environment and the type of cues that we give typically in clinical practice for those with cognitive impairments also need to be scaled. They can't be as complex of cues with multiple sentences in the same duration of time. We've got to really scale that to the person in front of us and individualize that care based on their cognitive capacity, just like we would their physical capacity. The way I kind of think about this is if you were coaching a peewee football league and practice is going really well, you would not march them over to the local NFL team for practice. Their capacity is not appropriate. But we do the same thing with cognitive impairments where we've got someone who has more advanced cognitive impairments, getting a much higher level of training than what they should be and it's no surprise when the results aren't as good and that's also what was found in this study was the experimental group had the matched physical and cognitive and then there was a more heterogeneous group that was just kind of randomly put together with higher and lower cognitive and physical function, and they all got this lowest common denominator intervention, which we commonly see, especially because this was looking at group training in skilled nursing facilities. What typically happens is we've got this big group of people, and we find the person with the lowest cognitive and physical function, and we give everyone that. So the person that has the lowest physical and cognitive function gets an appropriate challenge. Everyone else has lots more ability that is not tapped into and is not being challenged. So it's no surprise once you hear that's what's happening, which unfortunately is the state of rehab for those that have cognitive impairments in general, is it's not being matched to their cognitive ability. So those that were not matched based on their cognitive and physical function showed decline in their mental function by the time the study was complete. So those with matched physical and cognitive challenge to their actual, their functional level, They did great. They were able to maintain their cognitive level in this skilled setting. And those that were not matched showed cognitive decline in even a short period of time. This is pretty wild. 08:09 - SCREENING FOR COGNITIVE IMPAIRMENTS So some big takeaways here. Are we screening? Are we screening cognition in our older adults? The research says that the sooner we can screen people, the better chance we have to change their life and help them maintain their cognitive function and sometimes actually improve their cognitive function. There is a mountain of research that shows exercise is beneficial for cognition, especially if we're pushing into the fitness realm. and we're pushing people at high intensity and we're asking them to lift heavy things, we're asking them to learn new novel tasks. So we want to make sure we're doing that with older adults, not only for their physical function, but for their cognitive function. But we need to get a baseline of where they are to make sure that we're scaling these things appropriately. The tool that was used in this study was a mini mental state exam, which unfortunately is not great at screening for mild cognitive impairment, which is kind of that first phase before there is problems with activities of daily living, like once we get into more advanced forms of dementia. Tools like the MOCA, the Montreal Cognitive assessment may be more appropriate for catching signs of mild cognitive impairment. Also the SLUMS, the St. Louis University Mental State Exam. However, with that one, it's good to be aware that that can trigger automatically a local referral once it is complete. So you want to make sure that your patient, if there's any family members involved with care, that they're all aware that that will happen. And if this is like, man, I am not comfortable with this cognition stuff, this feels like way out of my depth, that's fine. You don't have to be the expert on everything, but you do need to be accountable to having resources in your area. Who is the SLPs, maybe outpatient, Or on your team if you are in a skilled environment that you can send for a cog referral. Or OTs, we have lots of OTs that are great at screening and intervening cognition and giving you an idea how many step commands, what type of environment, what type of cues are appropriate for this patient. but we have got to meet them where they are for cognition, just like we do for our physical interventions. So if you're not screening, start there. We've got to do more than alert and oriented times three. We've got to be getting these screening tools in use, or we've got to start making those referrals to people that are able to help get a baseline and make sure that our interventions are appropriate. So if you are screening, awesome, you are ahead of the curve. So now your job is to make sure that these interventions are appropriate, just like we're outlined in this study. 14:09 - SCALING UP OR DOWN BASED ON COGNITIVE PROCESSING DELAYS So what we want to make sure that we're doing is we want to know that there are things like cognitive processing delays, where it may take someone with more advanced dementia symptoms two minutes to process our commands. That was just five seconds of silence from me. If you can imagine two minutes of silence after your cues made this mistake so many times with this population. In two minutes, we've said a thousand things. and they're still processing the first thing that we said. So want to be mindful as we pick up on these symptoms. Cognitive processing delays can be up to two minutes. More mild forms, it could be five, 10, 15 seconds. It may feel a little more natural. Likely your skin's going to crawl, but it may be a very appropriate communication. It's going to look way different in this population. We want to make sure that the more advanced the cognitive impairment is, the more familiar the tools and the exercise interventions that we're using. We can't give a 40 point intervention and biomechanical explanation on a beautiful trap bar deadlift with an older adult. who has advanced dementia, we may be better off to use their purse and add some stuff to it, or add just grocery bags with food in it, and just ask them, pick this up. Once they do that, let's walk, walk 20 feet, or walk over to this area of the gym. No more cues, no more instruction, set it down. That may be a very skilled, very appropriate set of cues for an older adult with advanced dementia. So we want to keep in mind the tools. We also want to keep in mind the scenario. Can we control the environment? That is a skilled scaling tool. How loud is it? How busy is the environment? Is there lots of interaction? Are we at prime time in the clinic, out in a busy clinic where there's people throwing balls on a rebounder or the music's blaring? There's lots of laughter and fun. That may be a completely overstimulating environment for someone who has more advanced dementia. So the complexity… of the environment, the amount of noise, background noise, all those things are scaling options. So if we start in that quiet environment, we may eventually scale in to more advanced and complex environments where there are more distractions, where it is more like real life. But that's gotta be an intentional choice. That doesn't need to be an accident. We need to be very skilled with our interventions and that is part of it. How we choose to practice is also very important. Are we going to do random practice where we're jumping between tasks to task? That's going to be way less on the ability for someone with more advanced cognitive impairments. We may need to do block practice where we spend a big chunk of time, maybe 15 minutes, working just on a sit to stand. We may never get to a squat with a bar. That's fine. But if we can make it practical, we can meet people where we are, that may be where we need to stay. 15 minutes here, 15 minutes on the next thing, that may be our whole session. Or maybe it's something like a simple obstacle course. Pick this up, carry this, and follow me. That could be it. So I wanna keep these things in mind. If we are screening, we are getting a sense of what the cognitive ability level is of our clients, then our job is to scale it appropriately, and then you guessed it, then progress it as we're able. So we wanna use all those leveraging tools. So my advice to you, we're gonna switch gears, so that should be relevant to everyone. Now, if you are training in a group setting, kind of like this study outlines, where you're in a skilled facility, and you're doing group training, you can start with this lowest common denominator approach, but what you have to add in are easy scaling options. You've got to think about, we've kept everyone safe, but then for those that have the cognitive ability to do more advanced balance, or they're safe to do more advanced strength training, What can we do to…

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Episode 1578 - Catastrophize rest Oct 17, 2023

Show notes

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses the importance of working with patients to dispel negatives beliefs & fear concerning movement aggravating symptoms. Zac describes different strategies to discuss with patients how not moving after surgery or while in pain is probably the riskiest decision. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar 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 00:00 - ZAC MORGAN Good morning PT on Ice Daily Show crew. I'm Zac Morgan, so I'm lead faculty with the spine division. I teach lumbar and cervical spine management, so you can find me on the road doing those things. Shout out to that crew in Hartford, Connecticut or Waterford, Connecticut this last week. We had a good time learning about cervical spine over there in Waterford. Few more courses on that note coming up this year that if you're trying to jump into either cervical or lumbar, just wanted to point you in the direction of. So November 11th and 12th, we'll be back in that Northeast region up in Bridgewater, Massachusetts for cervical spine. December 2nd and 3rd, Hendersonville, Tennessee for cervical spine. And then if neither one of those work for you, the next chance will be at the turn of the year on February 3rd and 4th over in Wichita, Kansas. If you're looking for lumbar spine management, we've got three different courses this year that are all still have tickets available. Frederick, Maryland, that's next week or this upcoming weekend, October 21st and 22nd. Then we've got November 4th and 5th. That'll be over in Fort Worth, Texas. And then lastly, Charlotte, North Carolina on December 2nd and 3rd. So still several Good offerings if you're looking for cervical or lumbar spine management. We've already got quite a few booked for next year as well, so if this year the calendar doesn't work out or if the Con Ed budget resets at the beginning of the year, Take a look at the 2024 course offerings as well and more to book there. 01:36 - CATASTROPHIZING REST So team, this morning I wanted to talk to you all a little bit about rest and why I think we need to catastrophize rest. I think we need to make a bigger deal out of it when our clients come in and we find out that they've been resting. So let me talk a little bit about this. I've been chewing on this idea for a while and I think it's important for us to sort of understand that when someone's in pain, their risk meter is broken. Like they don't have the ability to conceptualize what's actually risky for them often when they're in pain. And so let me unpack what I mean with maybe a clinical scenario that we're all really familiar with. Let's think about something like a knee replacement. I think most of us in our career will interact with patients who have had a knee replacement. Usually we have interacted with those people on the days right after they have had a knee replacement or maybe you're the one that's getting them out of the bed in the hospital and you're the first person that's getting that person moving. I think we understand the risks to this person pretty well, and as a profession, we respond to them pretty well. We understand what this person's actual risk is when it comes to the knee replacement, and their risk would be being too sedentary or resting too much. And what would come alongside of that risk would be a lot of problems that we'll cover in a bit. You think about what that person's concerned about when you talk to that person in the subjective exam on day one, or maybe you just went into their hospital room and you're talking to them. That person's usually concerned about things that are unwarranted. They're worried that their knee is gonna pop out when you start to flex it. The first time you have that person do active range of motion, that person's like, oh my gosh, is my knee gonna fly out? Is the implement actually gonna pop out? They're worried about things like that, but we as PTs, we know that's not very common. We tend to mobilize knees really early and get them moving really, really rapidly and get as much range of motion as possible as quickly as possible in something like a knee replacement because we know that it's crucial that that happens at short term. So a large part of our job early on in managing this person who has just had a knee replacement is convincing them that their risk meter is off. Again, they're afraid to move. They walked through the door that day with a lot of blood in their amygdala. They were very concerned. They were worried, what if something's going wrong? I didn't know it was going to hurt this bad. I didn't think it was going to be quite like this. And they have typically not been moving as a response to all that pain. 03:22 - CONVINCING PATIENTS TO MOVE And our job is to help them understand that, hey, if you don't move, that's where the risk lives. The risk lives in being sedentary after a knee replacement. Like what's actually risky is if we don't move, the blood will pool, right? And we will wind up with things like a blood clot. Very risky. If a blood clot ends up dislodging and we end up with a pulmonary embolism, that's life-threatening. So that's real risk. That's something that we have to help those people understand is like, hey, if you're too still, we could wind up with something like a blood clot. And maybe we don't fear-monger that to patients, but we do help them understand that risk. You think about some of the other risks that that person has if they don't get moving. What about long-term mobility? If a knee replacement patient does not get their knee moving, you think about what that person's long-term mobility is gonna look like, and it's gonna be quite poor. That first 12 weeks after knee replacement is the most important time for us to restore full extension and get as close to full flexion as we can. We're really trying hard to push range of motion early because we know that person's long-term risk is having a stiff knee. and then not being able to participate in some of their ADLs because of the immobility in their knee. We get the risk so we help unfold that to the people in front of us. I mean the last big ones that happen if someone rests are things like atrophy or loss of cardiovascular endurance and we know this happens very very rapidly. when someone's on bed rest, when someone's immobilized, when somebody's truly sedentary or even sedated, things like that. We know the body responds and we see wasting of all those systems. The same thing's happening if someone doesn't move when they've had knee replacement. maybe not as rapidly as true rest, but we know that they're losing muscle mass, we know their muscle girth is going down, we know their endurance is getting worse. All of these things are truly risky for that person. And for that reason, I think we as PTs do a really good job of helping that person understand, hey, I know it hurts, but the risk of you moving through pain is much less than the risk of you not moving through pain. So I need you to move. And I think we do a really good job with patients like knee replacement patients or patients with a knee replacement. I think we do a really good job with those folks, getting them moving, even though it hurts, getting them back to their ADLs, getting them progressively loaded back to where they're out of sort of disability. I want to shift gears now. And I want to talk a little bit more about my expertise area, which is cervical spine and lumbar spine. So patients with neck pain and patients with back pain. That's typically who I'm seeing the most of in the clinic these days. And I think our response to these folks is a bit different than it is with the knee replacement patients, which is sort of understandable, because with a knee replacement, you understand exactly what happened to that person, where with back pain and neck pain, we never know what the tissue driving their symptom is. 06:57 - FEAR & OUTCOMES WITH BACK PAIN But I think we often respond with fear, and I think that influences the person's outcome. So let me unpack what I mean. So when someone acutely strains their back, they do something, they were lifting their kid and something happens and now their back is really strained and they're in high, high levels of pain and usually high levels of disability as well. Like a lot of patients will tell me, Zach, I can't even tie my shoes. I have to have my wife help me tie my shoes. I can't get my pants on. I can't get on and off the toilet. The activities of daily living are really influenced by these high pain levels. And a lot of these people, when you start to talk to them, they're terrified to move. Especially a forward bending, but really just to A lot of people in general with acute back pain, they're so scared to move their back around. And they're afraid that what will happen if they move their back around, is that they'll worsen their scenario. They're concerned that if they move too much, and maybe some of this is valid, but if they move too much, they'll worsen whatever's wrong with their back, and then they'll have long-term problems. But team, as you're hearing that unfold, you and I both know that's not the case, right? Like it's actually the people who choose not to move who usually wind up with worse recurrence of their back pain. It's why, I mean, you look at the Olivera study in 2018, where they compared all the lumbar clinical practice guidelines around the globe that they could get their hands on. And there's really only two things, all CPGs, not profession specific, um, not region specific, just all the CPGs that they looked at in that study, they agreed on two things. One of them, don't image. The second one, get moving, right? Don't rest, some sort of exercise. We know people with back pain need to get moving. It is clear, no one argues about that anymore. There's no studies, no big studies that have looked into, hey, rest is actually the successful recipe for back pain. It's not that. We gotta get them moving. But I think sometimes we let our fear of allowing that person to move hold them back. But we need to conceptualize those risk factors. Like you think about what it was like for your knee replacement patient. Maybe we don't have the same concern of like a blood clot or an infection, but think about this person's other risks. 06:57 - THE IMPORTANCE OF MOVEMENT Like, what about long-term mobility? If someone doesn't restore their ability to forward bend, they often end up with a loss of long-term lumbar flexion. And how does that usually wind up? Maybe sometimes they're fine and they're asymptomatic throughout the rest of their life, but often when I see recurrent back pain patients, They have had episodes throughout life and they've chosen to avoid a certain range of motion and part of our job is to do some graded exposure back to that to help them conceptualize the risk. To help them realize actually being still is where the risk is. We've got to get moving. You think about atrophy. You think about what happens to that person's muscular system. If they have severe back pain and they're not doing the things that they normally do, perhaps they're laying in bed a little bit more, sometimes they're laying on the couch a bit more, a lot of times their spouse is helping them out, their partner is helping them out with a lot of their ADLs. Team, when people have acute back pain, they often get very still because their fear level is really high, and part of our job is to help them understand that where their head is at, what they're concerned about, is actually much less risky than being still right now. Being still is where the risk lies. If we don't get back to movement, you're going to lose that long-term mobility. You're going to lose a lot of your muscular system. You're going to end up losing quite a bit of your cardiovascular endurance. That's where the risk lies. Because what do we all know about people who tend to lose muscle mass, who tend to lose cardiovascular endurance? Most of those people will struggle to get that back. And I think the longer they live, the more challenging that climb back to fitness is going to be. So our older adult clients are definitely in this boat. We've got to keep these people moving. We've got to get them afraid of resting. That's where the fear should be because what happens when you rest is the long-term stuff. That's what causes recurrent back pain. If a person hurts their back and they're now afraid to move in that range of motion and they don't restore capacity, whether that's cardiovascular capacity or the actual strength of the tissues because of fear, now that area is more fragile. It's more susceptible to injury. They're usually careful with that area and being careful with that area often is not a solution for getting rid of a recurrent back pain. As a matter of fact, we want to move more towards things like graded exposure, graded exercise, building that engine, building the tissues, how robust that underlying tissue is. That comes with movement. It doesn't come with rest. So team, I think just putting this whole thing into perspective, what I want to get across this morning is that when someone comes in to see you in pain, their brain is not in the right decision making area to understand risk. Their amygdala has all the blood in it. They're really concerned. they don't know if they're going to be okay. It is our job to use our prefrontal cortex because we can use that in that state because we're not anxious because we see this all the time. We use our prefrontal cortex to say, you know what, actually we need to develop a plan that gets you back to X, Y, and Z. And that's what we do with rehab. And that's how we try to bring down that recurrence, is we avoid all these catastrophes that happen when people sort of follow their natural instinct, which is to rest. So that's all I've got for you this morning. I want us all catastrophizing rest a lot more on our patients, helping them understand that that is not necessarily the safe choice. A lot of times people's risk meter is broken there and it's actually the unsafe choice. So let's catastrophize rest, get out there this Tuesday team, meet us on the road if you're looking for anything. Please feel free if you want to have a big conversation here, jot it into the thread and I'll be on here all day answering any questions. Thanks team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. Whil…

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Episode 1577 - Valsalva: what does it even mean? Oct 16, 2023

Show notes

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore takes a deep dive into the Valsalva Maneuver from 3 different lenses: the scholarly research, the pregnancy & postpartum patient, and the strength & conditioning world.

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 TRANSCRIPTION00:00 - RACHEL MOORE Good morning PT on ice daily show. My name is dr. Rachel Moore. I am here with Representing the ice pelvic division. I'm on faculty with ice pelvic division. Whoo. Sorry. I need to drink my coffee um i just got back in last night super late night flying from a course this weekend our pelvic live course in um wisconsin it was so much fun we got to see some leaves change which is exciting for me because in houston we don't really have that happen um so really awesome super great weekend awesome and engaged group that we had. If you are looking to join us on the road to catch our live course, our live pelvic course, there are still so many opportunities this year. In that course, we are doing so many things. We are talking about pelvic floor considerations. We're talking about the internal assessment and actually going over and practicing it on your back and in standing. We're talking about pelvic girdle pain which is such a huge topic in the pregnancy and postpartum and just pelvic world in general and then day two we're diving into the actual fitness side of things where we're doing squats and we're learning how to brace and we're using weightlifting belts and we're getting up on the rig and doing gymnastics moves it is a blast every time I come home from a course I'm hyped and there are four more chances of in 2023 to catch this course on the road. So October 21st, we've got a course in Corvallis, Oregon. November 4th, we've got one coming up in Bozeman, Montana. November 18th, we've got one coming up in Bear, Delaware. And then December 2nd, we've got one in Nova Scotia, Canada. So tons of opportunities to catch this course live on the road. Our online course will pick up again in January. So if you're interested in joining us in the ice pelvic division, that's what we got coming up. 02:08 - THE HISTORY OF VALSALVA This morning we are here to talk about Valsalva. So the word Valsalva is kind of a term that nobody really knows what it means or everybody thinks they know what it means and they all have their own separate camps of what it could mean because it's described so many different ways in the literature. So what we're going to do this morning is clarify what the different definitions of this one word are, talk about the history of it a little bit more, where this term really even came from in the first place. So this topic is really near and dear to my heart. Recently, Christina Prevett and I recently just wrote a clinical commentary on Valsalva and on the nuances of Valsalva. and how as clinicians we can take this term and how we need to take this term and understand the lens, especially when we're looking at research, but when we're talking to patients about what this term even means and what we're actually looking for in our strength training fitness world when we say the word Valsalva. So let's kick it off with the history of Valsalva. The term Valsalva is actually named after a physician from the 18th century. So he was an otolaryngologist. Anyway, he worked in ears and throat, ear, nose and throat doctor. And he created this maneuver essentially as a way to push infection out of the ears. So, the maneuver that Dr. Valsalva described actually doesn't even look like the Valsalva that a lot of people talk about today. His maneuver was plugging your nose and blowing out, but not against a closed glottis. And when he created this maneuver, the purpose of it was to flush infection out of the ear by having that tympanic membrane push outwards to, in theory, push pus out of the ear. That is where this term was created. So when we look at Valsalva in the research lens, when we talk about diving into the specifics of research on this topic, if we're looking in the ENT world, autolaryngological world, we're thinking about this maneuver as a plugged nose, closed glottis, now push out in order to push that tympanic membrane out. When we're looking at this word in the urogynecologic world, it has a very different emphasis or purpose. So when we think about pelvic organ prolapse and the diagnosis of pelvic organ prolapse, that's where we see the Valsalva, quote unquote, being useful, I would say. So the Valsalva in a urogynecologic world is an intentional bear down and strain with a closed glottis. in order to measure the descent of the pelvic organs, particularly during that POPQ or that assessment for pelvic organ prolapse. So on the ENT side, we have the focus of plugging nose, blowing out, pushing tympanic membranes out. In the urogynecologic world, we've got this strain down through the pelvic floor in order to descend the pelvic organs and measure what that descent is. 06:04 - VALSALVA IN STRENGTH TRAINING In the strength and conditioning world, the term Valsalva means something completely different. In the strength and conditioning world, the Valsalva is a maneuver that is advantageous, particularly if you're a competing athlete in the strength training world, where we need a little bit extra spinal stiffness in order to hit a lift to PR. so in the strength training world this is an inhale into the belly and then a brace of those core muscles that anterior abdominal wall and all of those muscles within the core in general in order to increase that intra-abdominal pressure and spinal stiffness to be able to lift heavier. So when we do the Valsalva, we have a 10% increase in that spinal stiffness and that carries over or translates into pounds on the barbell. So when we're again thinking about our competitive athletes who are maybe trying to like edge somebody out, the Valsalva is an incredibly useful and productive maneuver. Even if we're not a competing athlete, if we're talking about just getting stronger and we're pushing ourselves to the capacity that we want to push ourselves to in order to make those strength gains, the Valsalva is likely utilized in order to increase that capacity to lift heavier. The confusion here comes from that one word having many different definitions. And when we look at the urogynecologic world versus the strength training world, they really are truly opposite. When we're thinking about straining and bearing down, we're pushing down with our abdominal wall muscles, we're pushing down with our pelvic floor, and we expect to see that descent. I 100% agree that we shouldn't put a heavy barbell on our back and then strain and push down through our pelvic floor. That is not beneficial and it is going to put a lot of strain through the pelvic floor. Absolutely. However, when we talk about Valsalva in a strength training capacity, that's not what the Valsalva is. The Valsalva in a strength and conditioning world is that intentional inhale into the belly and brace of that anterior abdominal wall muscles. When we do that brace of those anterior abdominal wall muscles, we don't want to see a descent of the pelvic floor. That would be an improper brace that would need training to improve that coordination. What we expect to see with a valsalva in the pelvic floor world is a matched degree of contraction for the demand that's placed on that system. So if we're thinking about somebody who's lifting a heavy lift, a one rep max, We expect that pelvic floor to kick on, but we're not necessarily volitionally thinking about lifting pelvic floor and doing that pelvic floor contraction. As that core canister is engaged and we engage that proper brace, the entire core canister should kick on to a relatively equal degree. So in the strength and conditioning world, that Valsalva is advantageous. In the urogynecologic world, if we're taking that concept and applying it to lifting, it is the opposite of advantageous. So when we're looking at recommendations for our strength training athletes and our patients, we need to understand the language that is being used and what the definition of that language is. So from the standpoint of our OBs who are telling our patients, don't ever do a Valsalva, in their mind, they're saying, don't ever strain and push your pelvic floor down when you're lifting. Totally. We agree. 100%. Don't do that. It's not going to be great. But the disconnect is that this one word has so many different definitions. So we really have to dive in and break down what was that recommendation specifically. So when we're with our patients, that looks like breaking down the definition for them. 09:01 - VALSALVA MANUVEUR IN THE LITERATURE But if we're looking in the research world and we're trying to read literature, read the newest evidence about what recommendations are for our pregnant and postpartum athletes, we need to go into the article itself and look at how they define Valsalva. Because we can easily read the abstract and the conclusion of an article that says Valsalva is not recommended, but if we're, looking at this article and it's actually meaning the bearing down, then we're not getting, we're not able to extrapolate that to the strength and conditioning side. So really with this term, it's one word named after a man who the original maneuver isn't even what we're talking about anymore anyway. Across the board, we have to either figure out different words or different ways to describe this, or it really falls on us as providers to break down what it is we're talking about. So rather than just telling your patients, do a Valsalva, maybe we don't use that language at all, and we just talk about bracing. When we do a brace, we can manipulate breath. If we're gonna take that intentional inhale and then brace, that is a Valsalva, But in order to eliminate the confusion across the board, we can just call it a brace. This makes a lot more sense to patients than being told by one person to never valsalva and then by another person to valsalva. And when we lay it all out and explain what all of these differences are and how it's all one term, but it has different meanings, and none of these meanings necessarily are the same. And in fact, in the urogynecologic world, in the strength and conditioning world, they're literally the opposite. It starts to click with patients, why it's okay that my physician told me not to do this Valsalva, but you're telling me that I can, because I understand that these are two very different physiologic mechanisms. Our clinical commentary over this that dives into all of this and so much more comes out in the spring. So keep an eye out. We'll be sending it out in the ice pelvic newsletter. So if you are not signed up for that newsletter, head to PT on ice.com, go to the resources tab, sign up for that newsletter, not only for our clinical commentary in the spring, but for all kinds of resources. in the pelvic floor world. Stay up to date on the newest evidence and also just check out some cool stuff that we find along the way. I hope you guys have an awesome Monday and I hope we see you on the road soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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 1576 - Hip shifting in the squat Oct 13, 2023

Show notes

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses hip shifting in the squat. Zach emphasizes the need to ensure first and foremost, pain is in the hip or elsewhere in the body is not the cause of the shift. Second, Zach urges listeners to determine if the shift occurs under increasing loads or not. Finally, Zach discusses that if the squat is pain-free and that the movement pattern does not change under load, hip or ankle mobility is the final culprit.

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

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

EPISODE TRANSCRIPTION

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

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

Episode 1575 - Evidence-based medicine: are you doing it right? Oct 12, 2023

Show notes

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the three pillars of evidence-based medicine: clinical expertise, current best peer-reviewed evidence, and patient input. He gives suggestions on how clinicians can better incorporate all 3 pillars to improve practice. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 – ALAN FREDENDALL Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete Division. We're here on YouTube, Instagram, the podcast on Thursday. It's Leadership Thursday, that also means it is Gut Check Thursday. Gut Check Thursday this week, four rounds for time, some interval work. Four rounds, 10 handstand pushups. Those can be strict or kipping. Read the caption on Instagram for some help with modifications if you're still working on those. 10 handstand pushups right into a 50 foot double kettlebell front rack walking lunge. Kettlebells in front of the body, working the thoracic spine, working the legs, 50 feet of a front rack lunge, and then out the door for a 200 meter run on the treadmill, whatever. The goal there is one to one work to rest. That means we're looking to finish that round in about two minutes. Work two minutes, rest two minutes, complete for four rounds. you'll be done in ideally about 16 minutes. So read the caption, check for modifications, scaling is needed to try to get your round time as close to two minutes as possible, modify the handstand pushups as needed, reduce the load on the lunge as needed, and then sub out the run for a row or bike as needed. So hope you have fun with that one. That's a great one that really facilitates intensity. You've got some upper body with the handstand pushups, some lower body with the running and some monostructural, with the lunging, sorry, and then some monostructural with the running. So a great workout to really drop the hammer, rest, repeat a couple times, really working on that anaerobic glycolysis system. Before we get started, just some quick courses coming your way. Today I want to highlight our cervical and lumbar spine courses. A couple chances left towards the end of the year as we get near the holidays to catch cervical spine management. This weekend you can join Zach Morgan up in Waterford, Connecticut. The weekend of November 11th and 12th, you can join Jordan Berry up in Bridgewater, Massachusetts. That's kind of the greater Boston area. And then December 2nd and 3rd, you can join Zach Morgan at his home base at Onward Tennessee in Hendersonville, Tennessee. Lumbar management, also a couple chances left before the end of the year. Next weekend, October 21st and 22nd, Jordan will be in Frederick, Maryland. That's kind of west of the Baltimore area. He will also be in Fort Worth, Texas the weekend of November 4th and 5th. And then you have two chances the weekend of December 2nd and 3rd. You can catch our newest spine faculty member, Brian Melrose. He'll be up in Helena, Montana. And then you can catch Jordan Berry at his home base in Onward, Charlotte, also the weekend of December 2nd and 3rd. 02:55 – EVIDENCE-BASED MEDICINE Today's topic, evidence-based medicine. A couple different ways to frame this. Are you doing it right? Are you doing it wrong? Or it takes a village of really drilling down and better understanding what comprises evidence-based practice. For many folks, they think it's the research. For others, they think it's many, many, many years of clinical expertise, pattern recognition, and others believe none of that matters. What matters the most is actually what the patient believes is happening, what they believe will help them, and matching our treatments, our interventions, our education as best as possible to essentially the patient input side of the equation. And if you're on the podcast, I'm gonna show a Venn diagram. You're not missing much, if I'm being honest. I've got it right here on the whiteboard. What we know with evidence-based medicine is that it's actually all of that stuff, right? It is three different spheres, three stools, whatever analogy or metaphor you've heard to refer to these before is correct. When we look at evidence-based medicine, is it an overlapping of, yes, scholarly evidence, peer-reviewed research, Yes, clinician experience, practice and pattern recognition. And yes, also patient expectations and beliefs, and that the point at which these three areas overlap is the middle where we have evidence-based medicine, evidence-based practice. But what you'll find is because of this overlap, none of these areas can be evidence-based on their own. So our goal today is not to show you this Venn diagram, but to show you when evidence-based medicine goes wrong, how it goes wrong, and how we can all get a little bit sharper at evidence-based practice in our clinic with our patients. So, let's tackle these points one by one. The first, the one we're all most comfortable with as clinicians is our own clinical expertise. Probably more important than anything else with expertise and experience is the pattern recognition, the dose response relationship that begins to form in our brain The more patience we see, the longer we've been seeing patience. This is, you could call this the 10,000 hour rule, whatever you want to call it, but the belief that the more work, the more time you put in, the more you will maybe, theoretically, begin to master your craft. And there's some truth to that and there's some non-truth to that as well. 05:06 – AVOIDING DOGMA IN PRACTICE The biggest issue, as I have it written out here on the whiteboard, is that just focusing on this area in your practice, the bias here is that you become really prone to dogmas, becoming a dogmatic person, becoming almost a guru. We see this, of course, and we're going to mention it a lot on social media, of the approach on one side of the continuum or other. It doesn't really matter if manual therapy sucks. physical therapy doesn't do anything to the far end of that same continuum of, I believe that I'm putting people's bones back into place with things like spinal mobilization manipulation. So it doesn't really matter where people fall in the continuum, they fall somewhere on some sort of dogmatic continuum line, which is not great because it tends to the further they get into their own dogma and guru like behavior, the less they tend to incorporate research evidence from peer-reviewed sources and also the patient input. These people over time you may have heard phrases of I use what works with most people and the key there is that it works with most people not all people of the true person practicing evidence-based medicine the true clinical expert is the person that gets all almost every single person better. It's not enough to get 50% of your patients better, or 60, or 70. You should, or we hope you would be pursuing excellence in such a manner that you're thinking, how can I help 99.99% of people? And again, just focusing so much on one of the three aspects of evidence-based medicine with your clinical expertise is not gonna cut it. I often think of how much pattern recognition informs practice, but that doesn't mean that that's what we do with every person. I often think of when people come into the clinic, they present with anterior shoulder pain, what we might call instability, the feeling of looseness in the joint or otherwise just pain or maybe even stiffness on the front of the shoulder. I look at it as something wrong with the relationship between the deltoid and the lat. I understand the need to treat the rotator cuff, load the rotator cuff, but I also understand that the rotator cuff is ultimately paying the price for what the deltoid and the lat are not doing for the shoulder complex itself. That when these folks present with limited range of motion overhead, that getting in and treating, particularly the internal rotators, subscapularis can have a lot of value in restoring that range of motion and increasing tolerance to load long-term. However, that pattern recognition in my head is yes, where I'm going to go to first, but again, I can't get caught up too much in thinking this is what works with most people, this is what I'm gonna do no matter what. I have to be aware, I have to be humble that if it's not working for that patient in front of me, I need to go back and say what does the evidence say, what other treatments could I pursue, and also what input does the patient have into the equation of Are we maybe, yes, identifying the right cause, using the right treatment, but the patient expectation is that they can continue to do three to five hours a day of elite level CrossFit training on top of trying to move through the rehab of their shoulder. Those two things are always going to be at odds, and until I can start to incorporate more of the other arms of evidence-based medicine, I'm going to have a limited effect of how many people I can potentially help rather than most, I'm thinking again, how can I help that 99% of people? 10:40 – CURRENT BEST EVIDENCE That moves really nice into making sure that we understand that yes, evidence-based medicine does include evidence. It includes what we would call and what's labeled as current best evidence. That's the second aspect of evidence-based medicine. I think we can be really hard on ourselves and social media here can make you feel like you're not doing a good job at keeping up with the research. Because the truth here, if we're being really intellectually honest, is no one can keep up with the research. There are 1.8 million scientific journal articles published every year. There are 35,000 articles being published every single week. It is impossible for any individual practitioner to read all of those. Ever. It doesn't matter if that was your full-time job. You would not be able to keep up with it. So what we tend to see is that we tend to focus on specialty areas in practice. And I think that's okay. I think that helps narrow our lens. And as long as we are finding a source bias here is I think we do a good job with hump day hustling. There are other great sources as well that do a good job of taking a bunch of research and condensing it in a way that can be absorbed, especially that is then kind of classified by specialty area. But understanding, it's really impossible here to always be up to date on the current best evidence. And just being up to date and reading new articles doesn't mean that that evidence necessarily has any value. We need to be mindful of that fact as well, that just because something new has been published doesn't mean it has value. This is a great example. This is an article. You may have seen this make the rounds on social media. The title is, One and Done, The Effectiveness of a Single Session of Physiotherapy Compared to Multiple Sessions to Reduce Pain and Improve Function in Patients with Musculoskeletal Disorders, a Systematic Review and Med Analysis. This paper was published just a couple days ago, so brand new off the press, right? We tend to associate newer with better in research, which is not always the case. And we tend to try to immediately incorporate articles like this into practice and make giant conclusions that often the paper does not support. Already there are people on social media posting this article and saying, look, physical therapy doesn't work. You should not go to physical therapy. There are folks posting this and saying, see, I told you manual therapy does suck. In some of these studies, in a systematic review, they did manual therapy. I told you it was worthless. Dry dealing does nothing. Spinal manipulation does nothing. Cupping does nothing. People who practice that are committing malpractice. They should be fined or lose their license or be in prison for doing dry needling. And all of those giant conclusions are being made from just this one article. They're being made in such a manner too that tells a lot of us who read a lot of research that they probably haven't actually read the full paper, right? They probably have just read the abstract. Because if we read the full paper, what this paper is really saying is that more physical therapy doesn't seem to help as long as all we care about measuring is pain. No information was given about any other outcome measure, strength, changes in vital signs, did people's blood pressure get better, did stuff like depression, anxiety get better, kinesiophobia, all these other different things that we can measure about a patient that we would expect to change with physical therapy intervention were not measured in any of these studies. And probably the most important thing that's missing from this study all the studies that it analyzes and pretty much every piece of physical therapy research is there's absolutely no information on what was actually done to these people in a way not only that the study could be replicated in the future and possibly validated, or that we have any idea of what was done. It's entirely possible that folks in some of these studies only got manual therapy, that some folks maybe, yes, got exercise, but how was it dosed? Did they test the sub-max lift? Did they train at or above 60% of that sub-max number to ensure that strength was actually happening? And the answer to all those questions usually is no. So it's really important we don't get deep down the evidence-based hole, knowing that for the most part, a lot of the research that comes out, even though there's a high volume of it, it's all quite weak and doesn't necessarily get incorporated into practice because it doesn't really help change and inform practice pretty significantly. Also from this study, Most of these patients had a spinal fracture, they had diagnosed osteoarthritis of the knee, or they had some sort of whiplash disorder of the neck. So kind of specialty populations that can't just really be extrapolated to the general population to say that physical therapy doesn't work. Nonetheless, people grab this article and they cite it. That kind of shows us an overlap between the sphere of clinical expertise and pattern recognition and evidence. I've written it right here on the whiteboard. That person, we would call that person a cherry picker. That person has a very shallow knowledge of the research and they're basically using the research to better inform their own dogma, right? That is not evidence-based medicine. That is just cherry picking research that supports your bias and ignoring the rest and not really taking a deep dive in the research. We have to remember as well that it is evidence based not evidence only that we have to act in the absence of evidence we actually have to do something with people and that we don't always have the best research to inform…

Full show notes at the publisher

Episode 1573 - Shoulder instability: the plan Oct 10, 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 delves into the various phases of rehabilitation for shoulder instability, providing valuable insights and recommendations. One key phase highlighted is centered around core stability, with Mark emphasizing the significance of incorporating core-related exercises into the rehabilitation program. Specifically, exercises like plank and plank rotations are mentioned as effective ways to engage the core muscles. Furthermore, Mark discusses the importance of tailoring functional exercises to the individual's capabilities. He explains that if certain exercises, such as overhead press or full bench press, are too challenging, alternative exercises can be introduced. Examples provided include the landmine press, bottoms-up press, and push-up variations. The goal is to find a level of functional activity that the person can comfortably perform and then scale it accordingly. This approach not only helps to keep the individual motivated, but also allows them to track their progress towards their goals. In addition to core stability, Mark discusses the significance of incorporating speed work into the rehabilitation program. As the patient progresses through the program, Mark suggests gradually introducing speed training. This involves training the tissues to tolerate different velocities of force through a full range of motion. Specific speed work exercises, such as concentric-eccentrics at different beats per minute (30, 50, 70, 90, 120), are mentioned. Additionally, activities like Turkish Get-Ups are highlighted for their ability to improve core resilience while working on shoulder stability. Overall, Mark underscores the importance of integrating core stability exercises and speed work into the rehabilitation program for shoulder instability. These phases of rehabilitation play a crucial role in enhancing overall function and resilience of the shoulder joint. 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 00:00 - MARK GALLANT Alright, what is up PT on ICE crew? Dr. Mark Gallant here, lead faculty for the Ice Extremity Management Division. alongside Eric Chaconas and Lindsey Hughey. Coming at you, sorry, Lindsey, messing up that last name. Happened to me for years, now it's happening to you. Lindsey Huey, the other extremity management lead faculty. Coming at you here on Clinical Tuesday, wanna talk about atraumatic shoulder instability and traumatic shoulder instability, and what a good plan is if we're gonna treat these folks non-operatively. Before we get into that, I want to update on a few courses coming up. So I'll be in Woodstock, Georgia, November 11th. Cody Gingrich will be in Newark, California, December 2nd. And Lindsey Huey will be in Windsor, Colorado on December 9th. So a lot of opportunities, different regions of the country to check out ice extremity management. over the next couple months if you need to get in those CEUs for the year. So again, that's November 11th, Woodstock, Georgia. December 2nd will be in Newark, California, and December 9th will be in Windsor, Colorado. So definitely come meet us out on the road. 02:58 - CONSERVATIVE CARE FOR SHOULDER INSTABILITY So when we're looking at shoulder instability, it used to be that if someone had a traumatic shoulder instability, it was an automatic do not pass go, you're required to have surgery. And then the folks that had atraumatic shoulder instability, the people who were either born loose or worn loose, those folks, it was a maybe depending on how many dislocations, what was going on. But oftentimes a lot of these folks were getting filtered into surgical procedures. What we've now seen over the last couple of years, now that we're getting better with our rehab programs, is that conservative care and physical therapy can do quite well with both the traumatic shoulder instability and the atraumatic shoulder instability. So Anju Jaggi, who's been researching shoulder instability for years, came out with a trial this past year that recently released that showed in folks who had atraumatic shoulder instability, if they had conservative care versus if they had an inferior capsular shift, if they had an inferior capsular shift or an inferior capsular shift placebo procedure where they actually did nothing, that the folks who had the placebo treatment did just as well with physical therapy. So placebo surgery versus actual surgery, the placebo surgery with physical therapy did wonderful. We also have Ellen Shanley in 2019 who looked at what happens if people do have a traumatic shoulder instability event and they go through a full course of physical therapy and found that a majority of those folks were able to return to their sport the next year. So 85% of the individuals who had an instability event had good physical therapy and they were able to return to their sport. We do want to have some humility as physical therapists and allied health professionals that These folks were all individuals who did not have bony damage, so no bony bank hearts and no Hill Sachs lesions in these studies. If those things are not present, we can do quite well. So what is this actually going to look like? Margie Olds, who's another researcher who does a lot with shoulder instability, recently came out with a clinical commentary of how do we best do how do we best work with these folks? And we've been using it in clinic and seeing some really nice results. What the overall theme is, is we really want to get some of the local rotator cuff muscles really functioning well so that the lats, the pecs, the big movers don't have to take over. 04:13 - MUSCLE FIRING PATTERNS & PRIME MOVERS What we used to see is everyone would try to disinhibit the prime movers, the pecs, the lats. We saw this a lot in FAI treatment where we would try to disinhibit the TFL. What we realize now is this is very challenging, and what we actually wanna do is get the muscles that aren't firing as well to be more robust, more resilient, and fire well, and that will calm down the prime movers. So what we see is if we get the posterior cuff functioning well, if we get the subscapularis functioning well, that we will see the tone of the pecs and the lats calm down. The issue traditionally in physical therapy has been once we get to that stage, we don't move them on to more functional fitness, to more global resilience, to more general preparedness of the system. So what is this gonna look like in clinic? It's actually gonna look quite a bit like our tendinopathy progressions for rehabbing folks. So we're gonna start folks out with more isometric contractions, really getting the cortex and those muscles firing, progressing them more into a rehab dose with concentric eccentrics, then we're gonna focus on speed training, getting those tissues to tolerate speed and different velocities of force through a full range of motion, and then getting them back to their overall functional fitness. So what we specifically like to do in clinic is early on, first phase, they're first coming in to see you, they may or may not have been in a sling for a few weeks, Recommendation for slings and these folks now, if it's first time instability event, or if they've had that atraumatic shoulder instability and they had an instability event, is you can put them in a sling short term. There's no research that says it benefits them. There's no research that says it harms them. Put them in the sling. We don't want them in a sling for more than three weeks. If they feel like they need that to calm down, it is okay for a short period of time. We're going to get them in clinic and we're going to start with our isometrics. Two things that we specifically want to hit with our isometrics, if they can get into a 90-90 external rotation position, we want to hold that three sets, 30 seconds. If that person's willing to perform more, five sets of 45 seconds is even better. Whatever range of that external rotation they can get in, without pain going over a mild and whatever range they have access to, that's where we're going to perform that exercise. The other exercise we're going to perform to go after that subscapularis is a prone liftoff. So they're going to be on their stomach, they're going to put their hand behind their back as far as they can, and they're going to rotate into internal rotation to lift the wrist and hand off the back. If they can only get to the glute day one or just barely to their side, that's totally fine. When you're looking at this one, we want to be really careful that that person is actually internally rotating the shoulder. So this is not the time to turn around and type your notes. We want to be focused that they're getting true shoulder internal rotation. what a lot of people are going to do is they're going to wind up trying to extend their shoulder more or really dump through that scapula. So making sure that when they're doing that isometric, they're getting a pure shoulder internal rotation. We also want to start working on co-contraction of the shoulder. So where the delts, all the muscles are going. Oftentimes these people, although weight-bearing, closed-chain exercise is beneficial, early on it may be too much for the system. We're gonna start them out with a side-lying arm bar. So our big three exercises that we've found to be very beneficial are 90-90 ER, three sets to 30 seconds, if they can tolerate five for 45, that's even better, that prone lift-off isometric, and then a side-lying arm bar for that same period of time. Once they're able to demonstrate that they can do these exercises well, then we're going to, that they can do them well with pain less than a, than a three out of 10 or keeping it in that mild symptoms, they can tolerate the entire timeline. Then we're going to move them into a more of our rehab dose program where we're going to start getting some, some resistance through the system and getting, getting into some actual concentric eccentric repetitions. we really like to do the same motions. So we're going to stand them up, have a, have either a meter band, or if you have a cable pulley system, their hand is going to be behind their back. The cable will be to the opposite side, and they're going to have to do that lift off with resistance. We want them to hit somewhere in the 15 to 20 rep, keeping those symptoms mild for three sets. that will get their subscap, their internal rotation, again, making sure they're not solely substituting extension in that motion. Then we're gonna get them back, either on the table or in quadruped, hitting their 90-90 ER. This time we're gonna hit a light weight, two and a half to five pounds, and then we're gonna do, again, 15 to 20 reps. Can they tolerate that high volume, 15 to 20 reps? keeping their symptoms mild, that would be good for that motion. Then we're going to progress them now instead of doing their open chain arm bar, we're going to see how they can tolerate planks. So getting them into that plank position and having them do plank taps. We can modify this depending on the person by either widening their feet to get a better base of support or putting them onto a box. So for phase two, again, we want to hit that lift off, this time with either a band or a cable resistance, 15 to 20 reps, three sets. We're going to hit our 90-90 ER, two and a half to five pounds, if they can tolerate that, keeping symptoms mild. Again, higher on those repetitions. And then we're going to start working towards our plank taps. As they progress through this phase, then we're gonna start working on speed. 10:30 - SPEED & METRONOME TRAINING What we wanna look at with the speed is how much can that person tolerate velocity? The metronome is one of the best tools we can use to get this going. We've seen this a lot in the tendinopathy research. Margie Old is the first person that we're aware of that really laid out in a peer-edited journal article, clinical commentary, how exactly they're doing this with shoulder instability patients in clinic and what they're doing is they're starting them out 30 beats per minute on the metronome and they're going to do neutral internal rotation with a band or a cable column at that 30 beats per minute then as they can tolerate that well they're going to progress to 50 beats per minute then to 70 beats per minute, 90 into 120, which is moving pretty fast. If they're doing internal rotation at 120 beats per minute, it's pretty rapid. As they can tolerate that better, they're going to go out, put a towel under their arm, 45 degree angle of abduction, hitting those same 30, 50, 70, 90, 120 beats per minute, and then progressing to a 90-90 position, hitting that 30, 50, 70, 90, 120 beats per minute. Same with external rotation for that posterior cuff, 30 beats per minute in the neutral, progressing to 50, to 70, to 90, to 120. Then looking at can they do it at 90 degrees of external rotation or 90 degrees of front plane external rotation, 30, 50, 70, 90, 120. and then progressing up to 135 similar to that face pull type of motion. Again, 30, 50, 70, 90, 120. So really systematically progressing the speed training the same way you would with your loaded resistance exercise. Now, the other thing that we're gonna do during that phase three, we're gonna start progressing the plank taps. Can they now do a plank with a rotation going on to their side. So they've got to get a little bit movement through that closed chain exercise. And we love to add Turkish get up variations. So one thing that we see with a lot of, especially atraumatic shoulder instability folks, is that they're going to have a, their core is not going to be as resilient as it could be. So we often see a lot of that anterior and posterior trunk dysfunction leading to maybe the lats and the pecs having more myofascial tone and if we can work on that while we're getting the shoulder more resilient that can be a nice beneficial step. So what we'd like to do is do the first part of the Turkish get up or doing a whole Turkish get up so that we're getting some shoulder stability and we're getting a big massive core engagement. And then the final phase, phase four, where historically A lot of PTs have stopped. Oftentimes these folks are out of pain now, so compliance becomes more challenging. Really encouraging these folks that we want to get them fully back to everything that we're doing and build as much resilience to their shoulder. This is where you're going to really work on your vertical pulls, your horizontal pulls, so your pull-ups, your rows, your vertical presses, your overhead press, your horizontal press, your bench press, and then really getting into dynamic speed work or sports training. So snatches, push jerks, push press, burpees, things that are going to be more functional and have some velocity to them are really good here. Your kipping pull-ups. What we want to encourage is we're not going to only start the functional phase after they've gone through phase one,…

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Episode 1572 - Postpartum depression, part 2: screening & what to say to a client Oct 09, 2023

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Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick continues with part 2 of her series on postpartum depression. In this episode, she discusses how rehab providers can screen for postpartum depression. She also offers tips for communicating with clients who we suspect have postpartum depression with scripted suggestions and responses to support a client in the moment. 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 00:00 - APRIL DOMINICK What's up PT on Ice Daily Show fam? My name is Dr. April Dominick, and today I'll discuss how to screen for postpartum depression and share tips and scripted phrases that you can practice saying to get comfortable supporting someone you suspect has postpartum depression. In the ice pelvic division, updates and course offerings are going to be that we are on the road October 13th and 14th in Milwaukee, Wisconsin. And your next opportunity after that will be with myself and Dr. Christina Previtt. We will be tackling all things pelvic health in the Pacific Northwest in Corvallis, Oregon, and that's gonna be October 21st and 22nd. So head over to PTOnIce.com and grab your seat. Our final courses for the fall are still listed, and you still have a few chances to catch us live. So in episode 1553, that was the last episode I did of this postpartum series, depression series, we talked about prevalence rates, we defined postpartum depression, and we talked about risk factors for postpartum depression. Since then, I ran across another systematic review from 2017 that cited worldwide greater than 10% of pregnant and immediate postpartum women are having depressive episodes, greater than 10%. That number is still astounding to me. While screening for PPD or postpartum depression is one thing, if someone is sharing that they're struggling and you sense they have some signs and symptoms of postpartum depression, we as providers may feel empathy for the person in front of us, but we may be at a loss of words for how to communicate that with another individual. So in the second half of today's episode, I'll go through a few key phrases that you can build off of in response to someone you suspect having postpartum depression, with the ultimate goal, of course, being referring them to the appropriate mental health provider and or medical provider. 00:00 - SCREENING FOR POSTPARTUM DEPRESSION But first, let's chat about how we can screen for postpartum depression. Just a quick definition of postpartum depression, it is going to be someone with moderate to severe depressive symptoms. That can arise around post childbirth whenever that occurs, all the way up to four weeks post childbirth. And then that can also last for up to a year or more postpartum. Postpartum depression, it affects daily functions. So someone has some struggles with chores or daily childcare tasks compared to the baby blues, which is a more mild form of depression. Postpartum depression does require medical intervention as well. So pregnancy and postpartum, as we all know, is a time of psychological vulnerability, especially in those first few weeks when there's so much transition happening after delivery, which is why early identification and screening for treatment is key. So we want to ask the questions, whether that's verbally or in a paper or outcome measure form. So ACOG recommends that patients be screened for postpartum depression at a few certain timeframes. At the first OB visit, at 24 to 28 weeks gestation, and there was a study in 2013 by Wisner et al that suggested for a majority, depression begins prior to delivery. So this is why we have those checkpoints during pregnancy. And then the other times that they suggest that we screen for postpartum depression is at the comprehensive postpartum visit, whether that's at six weeks, four weeks, eight weeks. And then also I loved this at pediatric visits well into the first postpartum year, because pretty much after that six week visit, um, most women are not seen by their OB until the next year for their annual. So those are some timeframes that we as PTs are likely seeing these individuals maybe during pregnancy, postpartum, so we can also help with this screening process. In terms of outcome measures, there are a number of outcome measures out there that are used to screen for postpartum depression. We are going to go over two of the most common evidence-based tools. The first is the Edinburgh Postpartum or Postnatal Depression Scale, and then the Patient Health Questionnaire. They're both two scales that are recommended by ACOG and by the Postpartum Support International Group, which is a really cool resource, and we'll talk about it more in my next episode, but it's going to be a resource available for those in that perinatal mental health space period kind of combines those two things. So the two outcome measures, the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire, we love them because they are available in many languages and they are quick to administer and they're free. Who doesn't love free stuff? They are validated also for the perinatal population. which I think is something important that while we can give someone a major outcome measure that's for general depression, it's even really more helpful to have someone go through an outcome measure that is specific to the time and space that they're in. And then scoring, the lower the score for both of the outcome measures is going to indicate lower or more mild depressive symptoms. The cutoff value of 11 or higher out of 30 for the Edinburgh scale is going to maximize the combined sensitivity and specificity. 07:21 - THE EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS) Let's go through a couple of differences, though, between what we'll call the EPDS for the Edinburgh Postnatal Depression Scale. So for the EPDS, it's got 10 questions. And not only does it address the depressive symptoms and suicidal thoughts, but it also has an anxiety component of perinatal mood disorders. And that anxiety piece is likely what contributes to it being the most widely used screening tool. The other interesting thing I came across is that the EPDS is actually reliable and a valid measure of mood in the supporting partner, whether it is a male or a female, which I think is great. Example of items from the EPDS. are as follows. The person is going to be answering whether or not they have been so unhappy that they have been crying, the thought of harming myself has occurred to me, or I have felt scared or panicky for no good reason. Moving to the patient health questionnaire, that's going to be nine questions that assess for the depression component. It does include an item about suicidal ideation, but it doesn't have an anxiety component that the EPDS does. Instead, it includes some of the somatic symptoms of major depressive disorders, such as fatigue, sleep disturbance, changes in weight, and these reflect what is also on the DSM categories. Here's an aside for all these outcome measures. So in my research, I ran across a study from 2017 by Ukatu et al, reviewing about 36 articles that used PPD screening tools, and they investigated the outcome measures and their ability to detect maternal depression. So two of the conclusions from this review that looked at a bunch of articles that use PPD were, one, is that they found no recommendation could be made about the most effective tool for detecting PPD, which is, I guess the good side of that is you can use, there are a lot of tools out there and they will likely be capturing the depression component. 10:28 - WHEN IS THE ONSET OF POSTPARTUM DEPRESSION? The other thing that they mentioned was there's no recommended time duration in which to screen patients, again, from all of those reviews that they studied. So one of the reasons they suggest that the timing can be difficult to recommend is that For certain outcome measures that are administered at the two-week mark, the outcome measure may not be able to differentiate symptoms of baby blues, which commonly ends after about two weeks post-birth, versus postpartum depression that can have a much later onset. And that can be anywhere from post-birth up to three to four weeks for onset. So I just thought that was an interesting find from the screening side of things. But the two that we talked about are the EPDS and the patient health questionnaire. So outside of administering those two outcome measures, when it comes to screening, you'll want to also use the power of your ears and your voice to catch anything that may have been missed in those outcome measures. Remember, some people won't necessarily be honest on the outcome measures. They may be less likely to share that they're struggling due to the feelings of shame, abandonment, maybe they have a lot of guilt about not being enough for their baby, or they may not even realize their current emotional state, even when asked right on the outcome measure. So be an active listener. Ask the person How are you doing? But don't stop there. If you get a general response that's like, I'm good or I'm okay, I think you should ask it again. Say, I'm going to ask you again, how are you doing? Then you should also be on the lookout for words or phrases that the person may use in their conversation, like dark, heavy, blue. And then we certainly also want to have screening out postpartum psychosis in the back of our minds. So hearing voices that tell me to drop my baby, if you hear that, that is very serious. It is a medical emergency. This postpartum psychosis is going to affect about one to 3% of moms. So that's how to screen postpartum depression. How do we have the difficult conversation? How do we navigate the intricacies? when we suspect the person in front of us may be suffering from some postpartum depression. A few general tips. You'll want to listen with compassion and empathy, particularly to the non-physical symptoms. As neuroscientist, Dr. Andrew Huberman said, says, use your body to shift the mind. An individual that's not functioning at their usual physical capacity, or is in pain, or I don't know, recovering from a human body coming out of their body, or they're lacking sleep, right? This does not only affect the physical body, but it's also going to affect the brain and the soul. So it is within our scope to chat about this as their mental status is linked to their physical healing and recovery and management of their condition. As a provider, ignoring their mental status is not an option. You'll also want to avoid being dismissive. So someone may have been very vulnerable with you and they shared that, you know, they're just struggling. They're struggling to find the energy. They're struggling to feed themselves. And then you as a provider, like, okay, moving on to range of motion of your leg, like absolutely not. That is not acceptable. So avoid being dismissive, hear them out. Then remind them that addressing their mental health now will be so much more beneficial than months or a year down the line. And then mentioning that you'd like to take an integrative approach and refer them to a medication provider or their OB or a PCP or a psychiatrist, right? We'll talk in the upcoming podcast, but medications like antidepressants are also a good treatment option for them. So what are some specific responses that you can practice or just have in the back of your head when you suspect someone may be experiencing postpartum depression? I don't know about you, but especially in the public health space, I tend to get, you know, we talk about intimate subjects and there are some times that someone will share something with me. And I mean, I am feeling so much for them, but I have a hard time putting into words the quote right thing to say. And I'm not saying that these things, these scripting phrases that I'm going to give you are the right thing, but it's something to go off of if you're just struggling in that way. 16:43 - HIGHLIGHT & CELEBRATE So the first phrase, and I think it's probably one of the most impactful, your feelings are validated. I'm in a group text with a few moms and one of them, they've all been recently pregnant and recently postpartum. Some of them have been going through some tough times when it comes to emotions. And one of them said, my OB put her hand on my arm and told me how brave I am for asking for help and really realizing that I need to be my best self for my family. And she told me I could call her office anytime to talk to her. And that meant so much. So just letting the person in front of you know your feelings are validated. Number two, early identification. So if you've got someone who is pregnant and you suspect that they're going through some tough times from an emotional standpoint, you can say, you don't have to feel this way for the next eight months of your pregnancy. There are resources available. Number three, highlight and celebrate the person's abilities. Say, look at what you're doing. All of this is very impressive given the circumstances and all the stress that you've been under. Bring it back to a potential or current bond with the baby. And you know, if the baby's in the room with you, even better, have a little side conversation before the appointment starts with the baby. When I point to you, look at your mother with loving eyes. I'm just kidding. But definitely show the person or show the mother, look at how you're learning what your baby needs, right? For comfort, for snuggles, for food, for diaper changes. So remind her of the role she's playing. And then number four, remind her your health is a priority just as much as the baby's is. So often, as soon as labor and delivery is over, maybe we have that six week, postpartum visit, the rest of the visits are not for the mother, they're for the child. So just reminding her that her health is definitely linked and just as important to her baby's health. And then number five, say this happens. There's a fine line though between normalizing that this happens a lot, but also it's not so normal that you don't need to address, that we can't have you not address it. So there was a resource that is, was in the deep dive realms of the ACOG website and the title, the title just gives me chills. It says, how do you talk about mental health conditions in a strength-based way? Love that. Here were their suggestions. Say mental health conditions are common. Mental health conditions are like medical conditions or like diabetes. They need to be treated. Medical conditions are, or mental health conditions are treatable. And that reminding the client that the aim is that every woman who is pregnant or postpartum or every person who's pregnant and postpartum is screened for mood disorders. They also recommended that their clinical support office staff needs to be skilled in talking to patients in a stren…

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Episode 1571 - The needle is in, now what? Oct 05, 2023

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Dr. Paul Killoren // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren emphasizes the importance of using e-stim in conjunction with dry needling. This combination provides validation and helps the practitioner determine if the needle is in the muscle. Furthermore, using e-stim with needles can reduce post-treatment soreness, making it more approachable for patients. Paul also highlights research supporting the use of e-stim in various treatment goals, such as pain modulation, neuromuscular changes, tissue nourishment, nervous system accommodation, and somatosensory reorganization. Paul always recommends using e-stim after inserting the needle, as it offers multiple benefits for both the practitioner and the patient. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 PAUL KILLOREN Good morning. PT on Ice daily show streaming worldwide on Instagram and YouTube. I'm your host for the day, Paul Killoren, of the dry needling division for ice, and I'm hijacking the mic. Normally on Thursday for the PT on ICE Daily Show, we have practice management, we have leadership stuff, really inspiring messages from Jeff Moore, from Alan himself. I'm hijacking the mic and calling this Technique Thursday. We're talking needles on a Thursday. dry needling division. Before I dive in, some pretty exciting updates. Our very first advanced dry needling course is going down January 12th to 14th. And we actually have a registration page up and live that has a little work to do. But the course is going to be ready and the very first advanced dry needling course for ice will be in Washington in Bellingham in January. And then having the upper, lower, and advanced course that will form the ICE dry needling certification. So again, our division's not even a year old. We have had our upper and lower dry needling courses running across the country for almost 12 months. And this will be that final piece. So really exciting stuff coming out of the dry needling division. But I'm going to dive in, dive right in today. 01:58 - THE NEEDLE IS IN, NOW WHAT? And the title of today's episode is my needle is in, now what? And honestly, when I framed this topic, when I started to prep and form this discussion, in my mind, I pictured that novice clinician, I mean, you're on your first dry needling course, you're doing vastus medialis, vastus lateralis, glute medius multifidus, you learn the technique, the palpation, the anatomy, you're looking for a bony contact, you get super excited, just like, oh, sweet. There's the bone. That's what I was looking for. Now what? So really, this is a question I've answered consistently on level one or kind of first dry needling courses for the last decade. But again, when I started to prep for this episode, there's layers to this. And really, whether you're a novice, an intermediate, or even an experienced dry needler, Sometimes it's worth having this discussion of, our needle is in. Like first we learn how to do it safely, how to do it specifically, but our needle is in, now what? And to fully acknowledge, depending on who you listen to, how you were trained, the answer of, now what, will be very different. Because first of all, there's that technical spectrum of, well, now we piston the needle, or now we twist the needle. Now we use e-stim. But even there, let's say there's a dosage spectrum of, okay, if I piston how many times? If I twist it for how long? If I just leave it there, what duration? If I use e-stim, what parameters? So again, I thought this would be a pretty easy, a pretty short, quick-hitting topic, but there's layers to it. And first of all, let's say that there is significant value to my needle is in a very specific target. Again, safety always comes first when you learn dry needling, but I think we also can acknowledge one of the benefits, one of the advantages of the needle as a clinical tool is we can be sniper precise. We can put a needle in semi-membranosis, in multifidus. You know, this is not necessarily a technique of broad stroking manual therapy of like, we're doing the lateral hip, we're doing the low back, we're doing the SI region. To some degree, even a manipulation, we're saying, you know, we're not joint specific necessarily. We're kind of giving input neurophysiologically to joint receptors and there's more of a regional and global response to that. With a needle, I think we can just say, first of all, I have a needle in semimembranosus. 04:46 - THE BLESSING & THE CURSE OF NEEDLING I mean, The blessing and the curse of needling is it keeps us honest, especially if we use e-stim. When you get that motor response, the needle's telling you, it's like, you know what, Paul? You're not in semi-membranosis. You missed. You're either like, you drifted subcutaneously or you missed superficially in tendinosis, you missed deep in adductor magnus. So first of all, I don't wanna just like completely glaze over the fact that your needle is in a very specific target is a big part of the equation. I mean, for ice, for our dry needling, we teach safety for sure, but you as like highly educated, skilled clinicians, teaching you all how to be safe with a needle happens pretty quick. So our, our goals, our mantra with dry needling are be safe, be specific. Again, that's, that's a big part of using this needle as a tool and then be strategic. And that's what I want to go to today, because again, the topic here is, my needle is in, now what? And again, let's acknowledge that it depends, not just on how you're trained, it depends on that patient on the table, on what is your goal for that session, what is the acuteness or the chronicity of the condition. So by no means do I want to make this sound easy, but I am going to give a very specific answer to this question. And again, I have previous training, I know the narratives out there of the needle is in, now we twist it for two minutes. Or the needle is in, now we just let it sit there. Or we pissed in it. And again, there are narratives, there is research, and there is benefit to each of those approaches. But I'm telling you that those aren't the answers. Again, I have a pretty specific answer that I'm going to get to But I think I'll torture you just a little bit longer by setting the stage. And really, I'm going to flashback, not even talking needling, I'm going to flashback to my DPT education. I went to Regis University, graduated in 2010. So what attracted me to Regist was Dr. Tim Flynn, Julie Whitman, Jim Elliott. I mean, big manual therapy specialists, but researchers of our day. So we finally, you know, you're year one, year two, you finally get to that musculoskeletal management, you finally get to learn some manipulations from Tim Flynn and Julie Whitman. And you know, if you don't remember how you started with manipulations, it wasn't good. The hands were not skilled, like it wasn't crispy right out of the gate. So you spend a half day, you practice on your classmates at home, and finally you're like, man, I'm starting to feel like my hands have some skill. So imagine you are there, you're learning manipulations, your hands are feeling more skilled. Imagine how disheartening it was for me, and I remember this day, when Dr. Tim Flynn stands up and says, you know what, you can teach a monkey how to manip. And I mean, He's overgeneralizing, but the point is still true. He's like, you can teach a monkey how to manipulate. It's really how, like when to manipulate. Um, I guess how to apply it. There is skill there. We'll acknowledge that. But then it's what you do afterwards. So, I mean, that, that hit for me. And first of all, it's like, Oh man, there are manipulating chimps out there that are doing this better than I am. And again, that wasn't his point, but. But the point remains knowing when to use it, how to use it to some degree, but then the dosage and the follow through, the aftermath is really the true magic. That applies for dry needling as well. Again, can we teach a monkey how to put a needle randomly into tissue? For sure. Like there is not much needle skill to getting a needle interstitially, into muscle tissue. There is a skill to being more specific, and there is a skill to answering the dosage question, now what? And I'll tell you now, without further ado, we have our needle or needles in. The answer to now what is e-stim. And you know, I don't, you know, I kind of do the, you know, I was trained previously, I know the research, the narrative and the benefit to all the other approaches, but the answer today is eSTEM. And honestly, what makes me so confident in that is first of all, I have my own empirical anecdotal, like I was not using eSTEM, now I am. I have that sample size to make me confident. But what makes me more confident And it's not even just the research, I'll touch on that in a minute. But what makes me more confident is knowing or hearing that some of the other dry needling educators or other dry needling institutions in the US and worldwide that previously were saying there's no additional value to e-stim with dry needling, or we're essentially just doing tens through a needle, they're now starting to use e-stim. And whether they use it the same way we do with ice, whether they explain it the same way, what they're saying is there's value to e-stim. And here's what the research says, is our needles are in, now what? E-stim is the answer for almost any treatment intent. First of all, I mean, if you haven't taken one of our upper or lower courses, we teach e-stim right out of the gate. I mean, day one, we learn how to use the unit, we get muscles to pump, Again, there's high value when you first learn dry needling to using e-stim because it keeps you honest. Are you in that muscle? Are you not? But that immediately gives you some, I guess some validation, like I'm saying, but some grace. Because first of all, what we know is that if we use e-stim with our needles versus not, any sort of post-treatment, post-needle soreness will be much less. So there's a very, um, a very real like patient approachability aspect to using e-stim. And there's research to support that. 12:33 - E-STIM DOES IT BETTER But beyond that, what if our treatment goal is not pain modulation? What if it's neuromuscular changes? E-stim does it better. What if our goal is, tissue nourishment, blood flow, maybe venous return, lymphatic activation, edema evacuation. What if our goal is that? ESTIM does it better. What if our goal is nervous system accommodation? Or what if it's getting the biggest, baddest neuropeptide or enkephalin, endorphin, but our pain modulating up top cortical response. What if that's our goal? eSTIM does it better. What if we're talking pain science and there's some somatosensory reorganization, there's some homuncular smudging that we would like to remap. We'd like to give a very profound and precise input to that homunculus, to that somatosensory cortex. eSTIM does it better. So again, these are, these are research based answers. Very real research that says group A just got needles, whether that was pistoning or placing or what have you, and then group B got e-stim. What was the difference? At this point, e-stim does it better. And really, that is the long and short of this episode. And again, I think to not minimize the impact of you have to learn how to put a needle in safely, There is significant value, especially with the needle, to say, my needle is in, very precisely, fill in the blank. My needle is in peroneus brevis. My needle is in extensor hallucis longus. My needle's in glute minimus. There is significant value to the precision of that tool. But that's only half the battle. My needle is in, excellent. That took some training, that took some some skill honestly that took some three years of doctorate level like anatomical training and education and awareness that took a lot to say my needle just contacted I guess the external ileum like we are at the depth and the location of glute minimus that's awesome that you checked the box that is step one but if we don't fill in the then what you're leaving a lot on the table clinically And if you just logged on, the answer is eSTEM. So again, I know I see some of the names jumping on. Thanks for joining. I'm preaching to the choir, to some of you, because you've taken our upper or lower courses. We immediately talk about how to use eSTEM, the research behind eSTEM, and then we use it all weekend on the course. And it's a different experience. I think eSTEM makes dry needling a little bit classier. We can be a little bit more classy with our needles when we use E-Stim. We can also be a little bit more dialed, a little more tactical with our treatment intent. Again, is your goal pain modulation? Is it neuromuscular changes? Is it blood flow? Is it just fluid dynamics of moving fluid? Excuse me. So that's the answer for today. Again, jumping on on a Thursday for a Technique Thursday. We're talking dry needling. And the question was, needle is in, now what? And the answer was Easton. Excuse me. So if that prompts any questions, again, this is a big piece of our curriculum. Drop some comments in the thread. Hit us up on Instagram. This is on YouTube as well, so you can throw some comments there. Again, my name is Paul Killoren of the dry kneeling division for ice. If you hopped on late, We are launching our advanced dry needling course in January. That'll be the final piece of our upper dry needling, lower dry needling, and then advanced for the certification. If you're in Washington State, that'll be the third course of the series to allow us to dry needle as far as getting 75 hours. But if there's anyone out there who is trained in needling, who is uncertain about using eStim or the benefit of eStim, first of all, I'll just encourage you to try it. Like, there's value there to hearing your patients explain the difference of using eStim or not. Otherwise, we have an online course if you already have the needle skills, you know how to put your needle in, but then what? If you don't know how to use the eStim, there is an online course through ICE as well, eStim plus needles. That's all I've got for today. Thanks for logging on. I'm incredibly proud of myself. This is my most concise, my most brief podcast topic, but it's an easy one for me. So if you're out there saying, what do we do after we put the needle in? I'm not saying there's not value in twisting or pistoning or just static needling. There's blood flow changes. There's neuromuscular changes. There's tissue disruptive like inflammatory cascade responses to all of that but the answer is e-stim and With that I'm logging off folks. Thanks for joining PT on ice daily show. See you next time OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoye…

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