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    Health

    #PTonICE Podcast

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

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    Latest Episodes:
    Episode 1570 - Dynamic gait training: obstacle course 2.0 Oct 04, 2023
    Show notes

    Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult faculty member Julie Brauer emphasizes the importance of executing obstacle courses in a specific, dynamic, objective, and progressive manner. The purpose of these obstacle courses is to prepare patients for the chaos of their daily lives and help them confidently overcome these challenges. To make obstacle courses specific, Julie suggests replicating the functional demands of the patient's specific goals. This means creating exercises and challenges that directly mimic the movements and tasks the patient needs to perform in their daily life. By doing so, the patient can develop the skills and confidence necessary to navigate these challenges effectively. In addition to being specific, obstacle courses should also be dynamic. This involves incorporating a combination of exercises and layering dynamic challenges. By introducing variability and unpredictability into the obstacle course, patients can improve their ability to adapt and respond to different situations. This dynamic nature of the obstacle course helps simulate real-life scenarios and prepares patients for the unexpected. Objectivity is another crucial aspect of executing obstacle courses effectively. Julie suggests leveraging subjective and objective outcome measures to make the obstacle course objective. This means using measurable criteria to assess the patient's progress and performance. By having clear and measurable goals, both the therapist and the patient can track improvement and make necessary adjustments to the obstacle course. Lastly, obstacle courses should be progressive. This involves gradually increasing the difficulty and complexity of the challenges as the patient improves. Progression ensures that patients are continually challenged and can continue to develop their skills and abilities. It also helps to keep the obstacle course engaging and motivating for the patient. Overall, executing obstacle courses in a specific, dynamic, objective, and progressive way is essential for helping patients develop the confidence and competence to effectively navigate the challenges in their daily lives. 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 - JULIE BRAUER Welcome to the Geri on Ice segment of the PT on Ice daily show. My name is Julie Brauer. I am a member of the Older Adult Division, and we are going to be talking this morning about obstacle courses and leveling up our dynamic gait training. So I've been really passionate about creating meaningful obstacle courses for a really long time, and I've become even more excited about this topic since our live course has gotten this massive revamp where we spend an entire lab focusing on dynamic gait challenges and how to layer. So I'm so excited to dive into this today because obstacle courses can be a really challenging, fun, creative way to implement dynamic gait training into our plans of care. With the purpose of preparing our patients for the chaos that is their daily lives, right? We want them to be able to move confidently through the chaos of their lives. And if we really think about it, What better exercise could we give our patients than a combination of exercises, a combination and layering of dynamic challenges that exactly replicate the functional demands of their specific goal, right? However, I think we many times really missed the mark here on executing this in an effective way. And when I say executing in an effective way, I mean in a way that is specific and dynamic, objective and progressive. So when I reflect back on the past eight years of my practice, 02:37 OBSTACLE COURSE LIMITATIONS When I think about all the obstacle courses that I have seen throughout various settings, most of them are variations of stepping over cones, or stepping over hurdles, or many times it's stepping over canes. Many times it's one rep, the patient goes through that obstacle course forwards, and then the next time they go through it sideways. Many times it's weaving around cones as well as stepping over them or maybe stepping in and out of an agility ladder. And when we think about that, we have to realize it's pretty unidimensional, right? It doesn't exactly look like real life. Most of these patients are not on a clock. We aren't often capturing our PE while the patient is going through the obstacle course, right? Like I could go on and on about a list of things that are wrong with our typical obstacle courses that we see in our clinics, in our profession. And while stepping over cones and navigating around them is a really solid place to start, we really have to start thinking about moving beyond that, right? I consider stepping over cones and navigating around cones very similarly to our other underdosed exercise. I will go as far as to say that I think that cone stepping is the ankle pump of dynamic gait training. Stepping over cones is the ankle pump of dynamic gait training. And so why? So let's unpack that. Because many of you would probably say, like, what do you mean stepping over cones is challenging for my patients? And I'm going to respond with, well, yeah, I mean, tandem standing is challenging for a lot of my patients, but I'm sure as hell not going to waste multiple weeks of a plan of care with my patient in tandem stance, right? The question becomes, is it the right challenge? Is it the right challenge? Similarly to tandem stance, Do the demands of stepping over cones match the entirety of the chaos and the dynamic demands that comprise our patients' lives? We have to realize that stepping over cones only hits one aspect of dynamic gait and balance, right? It only hits on anticipatory balance. And we know that balance can break down in multiple different areas. And there's so many other components of balance and dynamic gait that we want to pay attention to. we have to realize that stepping over cones is not super specific, right? It doesn't look like real life. Our older adults are not moving around in an environment where these very bright orange cones are sticking out to alert them they need to step over that thing, right? And then also, you know, just thinking about If I am able to get my patient really competent and confident in stepping over cones or weaving around cones, does that actually translate to our patients feeling incredibly confident to take on the adventures in their world? 06:08 ROOM TO GROW WITH OBSTACLE COURSES So we have to first reflect on why there's just a lot of room to grow when it comes to our typical obstacle courses, all right? So now that we've set that framework, let's talk about how to level up our dynamic gait training from assessment to implementation and creating in dialed in workouts, focusing on how to make these obstacle courses specific, objective, dynamic, and progressive. All right. And we're going to put this in the framework of focusing on two different types of goals. And these were goals and dynamic eight challenges that students who were part of our MMOA live course a couple weeks ago in Oklahoma came up with. absolutely stellar students who came up with really awesome dynamic challenges. So I'm going to share some of these with you. So these two goals that we'll be talking about back and forth, um, that many of you can relate to with your patients are the goals of one, being able to independently navigate through the airport and board an airplane independently to be able to go on vacation. And then two, to be able to independently tend to a garden. All right. So two goals that are very common among older adults. And we'll talk about how to make it specific, dynamic, objective and progressive. All right. 10:21 SPECIFIC OUTCOME MEASURES So starting out with making our obstacle courses really specific. This is where we need to dig deep. So if you're part of our MMA crew, you hear us talk about our formula, make it meaningful, load it, dose it all the time. So this is that make it meaningful part, right? So we need to dig deep into what that goal actually looks like. I want to peel back all the onion layers. So if my patient is telling me, well, I want to be able to go on vacation. I am having my patient take me through from start to finish. I want to know exactly what that looks like for her or for him to go from getting out of that car into the airport through the airport onto the plane into into their seats right so I am asking question after question after question because I want to visualize what that goal looks like, right? If it's gardening, I want to know exactly what the functional movements are that comprise that goal because there is where I'm starting to create my obstacle course. I am in my head taking mental notes about what are all the pieces and parts that are going to comprise this obstacle course to make it very specific for the patient. Now, sometimes going seven layers deep with our patients is really, really difficult, right? They just, they have a hard time answering these questions or having that conversation with us. This is where we can leverage our outcome measures such as the PSFS or the FES and the ABC, right? Those are going to give us some insight into some components of their daily lives that are really scary or they feel like they're going to lose their balance or fall or components that they're actually really confident in. So you can use those outcome measures when perhaps the conversational part and you're asking a million questions and digging deep, is a little bit difficult for your patient. And then we want to really leverage our objective outcome measures, right? So our mini-best and our DGI, because that's going to give us very, very, very specific information. If our patient is telling us that, yeah, I'm having a difficult time because I'm afraid people are going to knock into me at the airport, well, I'm sure as heck gonna want to look at their reactive balance with their mini best, right? So we wanna use both digging deep, asking the questions, using those subjective outcome measures, and then definitely using those specific objective outcome measures to see where perhaps the balance is breaking down, right? So to give a couple of specific examples, If our patient, maybe in their PSFS, are saying that lifting that suitcase over their head is really the part that is limiting them from feeling confident and being able to go on that trip, maybe it's a strength component that we really want to focus on. So maybe I'm going to look at a press or a push press and see what that looks like in isolation and maybe coach that up, right? But then I know that I'm going to add a push press or a press into my obstacle course, because maybe it's not that the strength component of that push press is the big issue, but more that they are so fatigued after going through the entire airport that they just don't have the energy to get that suitcase up into that overhead bin, right? And so, again, to bring it back to the balance component, if they're telling us, I am so scared of getting bumped by someone at the airport, because I'm afraid it might fall, I want to know, hmm, what does their reactive balance look like? I want to look at forward. I want to look at backwards. I want to look at lateral. And then to put that into the obstacle course, maybe I can do something like our stellar students did a couple of weeks ago, where they use TRX straps. And as the patient's walking, they swing those TRX straps at spontaneous times, to see how the patient reacts to that, right? Or you could do something like as your patient is walking, you offer an external perturbation and see what their stepping strategy is. All right, so that's how to make your obstacle course as you're figuring out what the pieces and parts are very, very specific to what they're telling you and what you're finding throughout your assessments. Next, we have to talk about how to make it dynamic. And what I mean by dynamic is not just the patient is moving, right? Like, you know, I can see a lot of you being like, well, yeah, well, you know, stepping over cones or hurdles like that is dynamic. But we have to think more about just the patient moving, right? Yes, that is dynamic, but we have to remember that we need to mimic a dynamic environment, not just our patient being dynamic and our patient moving, right? And in addition to that, what I mean by dynamic is layering. 14:21 MIMICKING REAL LIFE CHALLENGES We want to combine anticipatory balance, reactive balance, vestibular fitness, strength, power. We want to combine all of those things together in our obstacle course, because that's real life. And that's when balance breaks down, when we were trying to navigate through all these different components. Remember that older adults are not waking up in the morning. And for the first two hours of their day, they're only doing a single task. And then the next two hours of their day, they're doing a dual task in reactive balance, right? Like they are constantly moving in and out of forward gate, sideways gate, making 360 degree turns, reactive balance, anticipatory balance, cognitive tasks, motor dual tasking. All that stuff is happening constantly. So we want to mimic that type of chaotic environment. We want to layer all of those challenges on. So what would that look like? Let's think about our gardening example. So if we're thinking, and our patient is telling us, okay, so I have to pull the hose, right? And I have to pull the hose and walk along the grass. And so you're thinking about this, hmm, how can I mimic that? Could I have my patient pull a rope? Could I also then have them do head turns where they're looking behind their shoulder to make sure that their hose isn't totally annihilating all of their flowers, right? You're making it that specific, but you're layering on challenges. What about for the individual who wants to go on vacation, they're really scared about stepping onto the escalator with their suitcase, right? So how do I replicate that? Can I step onto a variable terrain, like stepping onto a BOSU ball, while I'm lifting a weight or doing a suitcase deadlift, right? So now we have that sensory orientation, we're adding in that vestibular fitness, we're adding in the strength to step on and get stability on a moving object while also having the strength to lift an object. If we think about our gardening example, think about the act of pulling weeds. Maybe we're getting our patient down into a half kneel and we're doing a rowing exercise for strength. Or maybe it's more of the balance component our patient is worried about when they go to pull those weeds. So we do something like utilize squigs or we get a really heavy dumbbell and we tie a TheraBand around it and we have them pull the TheraBand and release. or we put a resistance band around them in half kneeling, and we go ahead and give them perturbations. So we layer on all different types of challenges, anticipatory, reactive, vestibular fitness, strength, power. That is how we layer. And we want to lay…

    Full show notes at the publisher

    Episode 1569 - Frozen shoulder: helping your patients navigate no (hu)man's land Oct 03, 2023
    Show notes

    Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey explains that patients with frozen shoulder often struggle to manage their condition and experience fear of the unknown, which can significantly impact their cognitive and emotional well-being. Lindsey emphasizes the importance of understanding the patient perspective and their emotional stories. She highlights that patients may fear the future and the unfamiliar territory of living with a frozen shoulder, which can have a profound effect on their psychological well-being. Lindsey also emphasizes the need for healthcare professionals to appreciate the expectations and experiences of patients with frozen shoulder, acknowledging that their pain is not an exaggeration. She suggests providing controllable solutions and empowering patients to advocate for themselves in order to receive timely care and diagnosis. Lindsey underscores the challenges faced by patients with frozen shoulder in managing their condition and the significance of addressing their emotional and cognitive well-being. Lindsey reinforces the importance of healthcare professionals assisting patients with frozen shoulder in finding ways to continue engaging in activities they love. This involves helping them adapt their activities or modify their movements so that they can still experience joy and maintain a sense of autonomy and independence. 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 LINDSEY HUGHEY Good morning PT on Ice Daily Show. How's it going? I am Dr. Lindsay Hughey. I will be your host today on Clinical Tuesday. It's so good to be with you all. It's been a little while. Today I am going to chat with you about frozen shoulder and helping your patients navigate no man's land. But before I unpack this episode, I'd love to tell you a little bit about courses that Mark, Cody, and I have coming up. Cody actually was just promoted to lead faculty. We are so excited. And he will be teaching his first class this weekend solo in Minnesota so Rochester and there are still tickets left if you want to join him he would love that and you're sure to have a blast with him this weekend so October 7th and 8th can you believe we're already in October so wild other courses coming up in November on November 11th 12th we'll be in Woodstock Georgia and then our final courses of the year are in December. So you have two opportunities on December 2nd, 3rd. Cody will be in California, Newark, California. And then December 9th, 10th, I will be at CrossFit Endure again. That's always a blast of a spot. So Fort Collins, Windsor, Colorado area would love you to join. Those are our last of 2023. And then we'll be in 2024, which is super wild. So please join us. Thanks for letting me share courses coming up. 03:37 LIVING WITH FROZEN SHOULDER So last week, if you tuned in to clinical Tuesday, Mark hopped on here and he chatted about frozen shoulder, just the challenges associated with treating folks with frozen shoulder. And he really highlighted not only best treatment as we know it, but the importance of coming alongside the patient. And we need to do that better because this is an area, and if you think about any patient you've ever seen with frozen shoulder, it's always challenging, right? Because they are suffering and there are just so many unknowns. But we do have more knowns in regards to the patient perspective that just came out this past May. William King and Claire Hebron out of the Physiotherapy Theory and Practice Journal published a qualitative review of frozen shoulder. So specifically giving us the vantage point from the patient. So this study involves six folks, two were females, four were males. Their age range between 35 and 66. So a varied mix of sexes and then age ranges. They all were British and there was a mix of right and left and even bilateral frozen shoulders. So these interviews were done with these six folks and the question that was asked of them was can you describe in as much detail as possible what was important and meaningful to you in your experience of living with frozen shoulder? They used hermeneutic feminology methodology for those research nerds that want to know and they found the following five themes And so today I'm going to tell you what those themes are, and then I want to unpack some of the participant details from each theme. And I'm sure you'll be able to relate with some of your patient care experiences. And then kind of end the show with suggesting a rewrite of the title, plus some key takeaways for us going forward in caring for these folks with frozen shoulder. So the five themes illuminated from this article, and again, that's title, and I'll drop the link, is Frozen Shoulder, Living with Uncertainty and Being in No Man's Land. The five themes that were found were, number one, patients felt an incredible pain experience that they described as dropping me to my knees. Two, a struggle for normality in life. Three, an emotional change of self four the challenges of traversing the health care journey and then five coping and adapting and learning how to do that. So I want to unpack each one of these just a couple examples to help you appreciate that patient perspective. So dropping me to my knees that incredible pain experience All of the patients that were interviewed described multiple experiences where if they move their shoulder quickly or hit up against an object unexpectedly or involuntarily kind of reached and forgot about their shoulder for a second, that this pain would literally drop them to their knees. That when they would go to like stretch in the morning, they would scream and writhe out of pain. And this not only affected their body and their discomfort but like their family. Some of the participants described kind of scaring their partner because of like sudden outbursts or yelled. So an experience that's not just personal but affecting those around them. 07:28 EMOTIONAL CHANGE OF SELF Number two, the struggle for normality. So a lot of the folks describe multiple daily activities just being very limited and I'm sure your patients have had the same right just getting dressed, just rolling over in bed, unable to sleep, just that constant ache that's with them always kind of being in their mind and then challenging just normal daily activities. Not just ADLs and IADLs, but starting to lose work function, missing work and or recreational function. So one participant actually had to sell their fishing boat or chose to because they said just transporting the boat became so cumbersome and a reminder of their shoulder limitation. One of the participants described being unable to throw the ball. They're at a family gathering and their kid is watching other people throw the ball with their parent and the parent that has frozen shoulders just sitting there thinking, oh I can't even like throw the ball with my kid so this normalcy doesn't only impact them personally again in their daily life but it's impacting their family relations around them their work right their ability to actually provide for their family and then the recreation like enjoyment in life people that love to fish that was my dad's like favorite pastime if there's an emotional psychological peace here that is huge then that is challenged when someone has frozen shoulder that they can't do that one activity that brings them peace or joy and they can't um help provide for their family because they're suffering Which leads us to that third theme found, an emotional change of self. So all of the participants described overall just low mood from being in constant pain, having low self-esteem and starting to feel less worth in their family unit. Just kind of feelings of uselessness because not being able to reach overhead or being limited in the ability to just help out with daily chores. this was a really challenging thing to read, but one of the patients described that emotional change as if you were an animal, you would be put down because you're miserable. So basically like lack of thriving and like that was heartbreaking to read, but like this is how low emotions get when you're in, when patients have that frozen shoulder state. And a lot of them said not just the emotional drain is challenging, but like you're physically drained because of that emotional taxation. So multiple participants reported poor sleep, which I already mentioned earlier from a normalcy perspective, but they linked that to how this led to fluctuating mood because you never know when you're gonna get a good night's sleep. And so overall mood was very cantankerous and unpredictable. which patients even again mention that they're not able to even sleep in the same bed as their partner because they're so disturbed and uncomfortable in their sleep. And so they're sleeping in a separate room, again, that's that intertwining like emotional change of self being affected. and when this happens right you start seeing sleep being affected it makes you want to prompt for health care help right and so this leads to that fourth theme where patients are traversing the challenge of the health care journey going to a health care professional hoping they can help them sleep better helping they can take away the pain. 09:28 IMPACT OF DELAYED DIAGNOSIS ON TREATMENT But what most of the participants really highlighted is that this delayed diagnosis happened consistently where they saw multiple healthcare professionals prior to actually getting a solid diagnosis that this is in fact frozen shoulder. And so there was this, there's this period of not knowing and switching back and forth, like what's wrong with my shoulder? And then you finally know. And, um, even the treatments they were getting were challenging because patients said they didn't actually see solid results. So they would ask for a pain medication and then some of the healthcare professionals would be afraid of addiction. So they wouldn't give them stronger medications to help. And so there was this balance of figuring out what's that pain medication that's right for the patient. A lot of the patients, said that injections were life-changing. So getting a corticosteroid injection was helpful, but it didn't always happen right away. And some of them had to really advocate for that to occur. And that some, even the patients that were finally recommended to get the injection mentioned they were afraid of the needle. So we have to understand it might be a delay to get to the treatment that's effective, And then they might even have a fear of actually using that treatment that's recommended from the healthcare provider. So they're dealing with a lot of challenges in the healthcare journal. And disappointingly enough, as for most of our audience that are PTs, a lot of the folks said that PT wasn't the greatest. They didn't have initial great experiences because the PT would give them stretches that were super painful and not working. And the patient would have to wait a whole week to tell the therapist that, and then the therapist would give them something new, and then the stretches would hurt and not really work, and they'd come back again. We can do better here, right? If you test, retest in that session, you'll know whether that's working. So some kind of disappointing healthcare journeys for most of these folks. But there was some hope along the journey. So the fifth theme found was coping and adapting. Once patients did finally get to the healthcare provider or the PT that started providing effective care, they did have hope. Once they saw it start working or when they got that injection and the pain started going away, they could move their shoulder a little bit more. So when pain's down and range is better, they were super jazzed about it and finally had some hope. Various participants did say that it requires that coping and adapting, it requires you to shift your mindset, that press on attitude in the face of adversity. So helping our patients get there quicker, I think is something that we have an opportunity for. Another part of that, some coping strategies was people just learning, some of the participants mentioning that learning to work around the disability, right? If they were right-handed, starting to use their left arm, to keep functioning in kind of a pushing through mentality. The final binding theme of all of these, so we've unpacked examples of dropping me to my knees, an incredible pain experience, the struggle for normality, three, an emotional change of self, four, the challenges of the healthcare journey, and then five, coping and adapting. That theme that they found binding them all together was uncertainty. Or as the authors of the study titled No Man's Land. One thing I said that I was going to unpack was a suggestion for a rewrite. So we are dealing with humans, not just men. So I'd love to suggest that we call this No Human's Land. But this does come from a phrase, right, that was used to describe unowned land or unoccupied land or land that's not officially owned or inhabited by someone. but we are dealing with multiple humans, right? Not just males. So that rewrite I think is important here. 13:58 FROZEN SHOULDER & THE FEAR OF THE UNKNOWN But ultimately the main thing I want you to appreciate is with the unknown of how this disease may progress or regress, we have to do better for our patients here. They will not be able to manage their present living with frozen shoulder if they're fearful of the future. They don't read it. Oh, hopefully you're all still there. Give me a wave or like a thumbs up. If you are a little alarm went off. Sorry about that. Um, but patients will not be able, um, to manage living with their frozen shoulder. If they don't know how to manage it in the present, if they're fearful of the future, sorry for the folks that had to hear this twice on YouTube, but That fear of the unknown, right, or no humans land territory, this affects cognitive and emotional well-being. So what can we do with these themes, knowing patient perspective a little bit more deeply here? And I know it was only from six folks, but I'm sure you can relate and think back and reflect on patients you've seen, and they've had similar tough experiences. There are powerful takeaways here. appreciate that expectations from your patient they're always tied to a real human with an emotional story and we have to know that and appreciate that. We have to know that this pain is not an exaggeration. We need to give stabilization to that human story. with some of the facts of the do's and don'ts about frozen shoulders. See Mark's podcast last clinical Tuesday because he dove into best treatment and about what we know, what we thought we knew, and where we are presently. We have to provide controllable solutions. Some solutions. Help your patients advocate for themselves early. and with tenacity with their specialist, right? Help them get to that corticosteroid injection. You don't usually hear us saying that, right? That medicalization, we try to av…

    Full show notes at the publisher

    Episode 1568 - Breath manipulation & the pelvic floor Oct 02, 2023
    Show notes

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

    In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich challenges the notion of associating the word "safe" with breath and movement, particularly during pregnancy. She questions why breath suddenly becomes a determining factor for safety in this context. While she acknowledges that the pelvic floor experiences increased demand as the fetus grows, she also affirms that it is a muscle that can strengthen with appropriate exercise.

    Jess encourages weightlifting as a means to strengthen the pelvic floor during pregnancy. She explains that stronger muscle fibers are more resilient, sharing this information with her clients in the clinic. She also highlights the fact that individuals are not instructed on how to manipulate their breath when coughing or sneezing, which exerts similar force on the pelvic floor as lifting 35 pounds. Since this natural phenomenon is beyond our control, it is unreasonable to expect individuals to exhale on exertion for every activity.

    Jess also address the misconception that breath holding is detrimental to the pelvic floor. She explains that breath holding actually increases spinal stiffness, enabling individuals to lift more weight and become stronger. However, She clarifies that breath holding with a bear down to the pelvic floor is not recommended. She differentiates between different positions of the pelvic floor, referring to the basement (during bathroom use or childbirth) and the first floor or attic for other tasks.

    Overall, the episode aims to alleviate fear and promote understanding of the pelvic floor. Jess emphasizes the importance of educating individuals about their pelvic floor and its functions, highlighting its potential for strength and dispelling myths and misconceptions surrounding breath and pelvic floor function.

    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 JESSICA GINGERICH Good morning and welcome to PT on Ice daily show. My name is Dr. Jessica Gingerich. And I am on faculty here with the pelvic division here at ICE, which means it's the beginning of the week. So happy Monday. We are going to talk about breathing in the pelvic floor. This is a hot topic in the pelvic space. often referred to specific breathing strategies that are like safe or protective to the pelvic floor. And in reality, it's just not that simple. So let's start with a few housekeeping items. We are currently in our last cohort of the year for the online course. So if this is something that you've been wanting to get on, we're about to put the pedal down starting January 9th. So head over to the website to sign up for that online course. In the month of October, we will be in Brookfield, Wisconsin on the 14th and 15th in Corvallis, Oregon, October 21st and 22nd. So again, those courses are all on the website, so head over there and snag your spot. They are filling up fast. 01:50 BREATHING DURING EXERCISE Okay, let's talk about breathing during exercise and how it stresses the pelvic floor. How many of you, as moms, clinicians, or just someone with a pelvic floor, hint, all of you, have been told to exhale on a lift or exhale on exertion? My bet is behind your phone, you are silently raising your hand because you've heard that. Whether it's for yourself or for your clients, wherever you are in the exercise space, you've probably heard that. When we think about this, so there's a lot of information from fitness professionals or medical professionals in the exercise space saying a lot of different things and boy is it confusing. This is especially true in the pregnant and the postpartum population. These clients typically come in having some kind of, have done some kind of research around breathing and lifting, and they're worried about their pelvic floor. So how do we help them understand how to manipulate their breath with exercise? So firstly, let's take the word safe out of it. If I am a non-pregnant female versus I get pregnant, Why is my breath all of a sudden making something safe or unsafe with a particular movement? There is more demand placed on the pelvic floor, especially as the fetus grows. Sure, yeah, that happens. Is the pelvic floor a muscle? Yes, it is. Do muscles get stronger as we place appropriate demand on them? Also, yes. We need to encourage weightlifting to some capacity during pregnancy so the muscle gets stronger. Stronger muscle fibers are harder to break. I love telling clients this in the clinic. We don't ask someone to manipulate their breath when they cough or they sneeze. which by the way is the equivalent of lifting 35 pounds or putting 35 pounds of force through the pelvic floor because it is a natural phenomenon that we cannot control. We don't tell them how to manipulate their breath there. So having someone exhale on exertion for everything is unreasonable. There are times where that can be helpful, especially early postpartum or if there are symptoms. But have you tried to exhale an exertion with double unders or box jumps or lifting 80% of a one rep max? You can't control your breath, like during movements where your heart rate's up. It's virtually impossible because your heart rate's up, your respiration rate's up. And as for the 80%, your body is just going to do what it's going to do, which is probably gonna include a brief breath hold or maybe even one that's longer so you can get through that movement well. Secondly, breath manipulation should be initiated one of two ways. Are they symptomatic? No. Continue what you're doing. Are they symptomatic? Yes. Let's change a bracing strategy or breath manipulation to see if we can continue that volume and that weight without symptoms. From there, we continue to scale as needed. And lastly, Breath holding during exercise. And what I mean by this is someone is lifting a heavy barbell or let's say both of their wiggly children at once from the ground. And Oh, by the way, one is screaming their head off. They're going to brace their core, hold their breath and lift the weight or their babies. Have they just ruined their pelvic floor or has their body just done what it's going to do naturally? My answer is the latter. We cannot always manipulate the breath, especially in life, especially life as a mom. We need to stop scaring moms and over-medicalizing breathing when in reality, our bodies are going to just do what it needs to do to get through a task. We believe in this so heavily that we teach bracing mechanics in detail, in depth, in our live course. So I mentioned those live courses at the beginning. Get on that. Like you, whether you're treating this population or not, you're going to see it. So to recap, there are no safe and unsafe exercises. It's simply, are we ready for that particular demand, whether that's weight or volume. We modify due to symptoms. We aren't ruining the pelvic floor by holding our breath. Breath holding increases spinal stiffness, which allows us to lift more weight, which also allows us to get stronger. And that's huge. Now, I do wanna be clear. Breath holding with a bear down to the pelvic floor is not what we want to do. When our pelvic floor goes down, and what we like to refer to that as in the basement, that's when we're going to the bathroom, right? That's when we are actually having a baby. any other time our pelvic floor is likely going to be on that first floor or in the attic and somewhere in between depending on the task at hand. So let's start taking the fear out of this. Let's start encouraging moms, really anybody, to do what their body's meant to do, and let's help teach them. It's something that we can do, we can teach them. Your pelvic floor, we can't see it, right? We can see how our shoulders move and how our neck moves and head moves. We can see that. We can't see how our pelvic floor moves unless we're laying down with a mirror between our legs doing an active Kegel, and that's not realistic. Also, knees go over toes when squatting. I hope everyone has a great Monday.

    08:13 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 1567 - Don't be a JERK with your jerks Sep 29, 2023
    Show notes

    Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com

    In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock takes a deep dive into the jerk, discussing the importance of learning a strong leg drive, improving shoulder mobility, and committing to a strong finish with the movement.

    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 INTRO

    Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app.physicaltherapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show.

    Good morning, everybody. Welcome to PT on ice Daily Show. I'm your host, Mitch Babcock from the Fitness Athlete Division. That means it's Fitness Athlete Friday, and I'm stoked to be back on the podcast, bringing to you another episode, this time going into some nuanced stuff around the jerk. So stay tuned for some more details around how to make your jerk a little bit better. Today's topic, don't be a jerk with your jerks. Before we get into that team, first of all, I'm wearing my Lions shirt. Did you watch the game last night? Of course you did. Thursday night football. Let's go Lions. It's been a long, hard existence being a Lions fan. So we're out here stoked that we got t01:27 MITCH BABCOCK

    hree wins already on the season. Other news, non-football related, is that the fitness athlete team is going to be around the country coming up real fast here next weekend. Joe and myself are going to be out in Linwood, Washington, and we're rocking a big course out there. So if there's still time, if you want to slide in just under the cap of that course out in Linwood, if you're in the Seattle or greater Seattle area, we'd love to have you out at that course. We also have some courses coming up in the southern region. We've got San Antonio, Texas. And we've got Anna Maria Island in Florida. So if you're looking at Florida or a Texas course, we've got two of those in store for you coming up in the month of November. So otherwise, welcoming in the fall season here today.

    01:43 MAKING YOUR JERK BETTER

    And today's topic around don't be a jerk with your jerks. We just finished up a nice May cycle where we did a lot of snatching and clean and jerking for the last eight weeks. and giving my members of the gym as many helpful tools as I can as a coach and an athlete of what's helped me with my shoulder overhead, specifically the push jerk in this cycle, but all of these principles also apply for the split jerk as well. And I see this done wrong or at least thought about wrong a lot. I figured it was helpful to share with you guys, whether that's from a personal standpoint as an athlete, you're out there training in the gym yourself and you're like, hey, This is sweet. I hate jerks. I hate split jerks or push jerks. And I want to get better at those. Or if you want to be able to pass that on to your clients or members, hopefully this will be helpful. So the first thing I want to talk about is what not to do. Don't press your jerks.

    03:37 THE JERK HAS LITTLE TO DO WITH ACTUAL PRESSING

    The push jerk and the split jerk is not about how much you can press vertically. It has little to anything to do with actually pressing the bar vertically over your head. Think about what your one rep max strict press is. Ladies is usually somewhere in the ballpark of 60 to 100 pounds. Men, somewhere in the ballpark of 100 to 200 pounds of a strict press. And yet people are able to do almost twice as much as that when it comes to a jerk movement. It is not about your strength to move the bar off of your shoulder and press. So stop thinking of it like you need to push the bar up. The jerk is about pushing yourself under. That requires a couple things. One, specifically the legs. You need to start thinking about your legs way more than your shoulders on your jerks. It is all about your legs' ability to launch the bar off of your shoulders enough that you can then press your way under the jerk. Again, goes for the push jerk or the split jerk. So when you're in setup position, you've stood up that heavy clean and you're ready to make the jerk. Hopefully make the jerk. You need to be thinking about how much leg drive can I create vertically on this bar right now to launch this thing as far off my shoulders as possible. That means I need strong legs. I need to be better at my front squat. Specifically, when I stand up out of a heavy front squat, I need to be powerful in the finish as I'm standing and finishing that lift. So that's something that you can be training on days that you're not jerking at all, but be thinking about that last little third of the squat. Standing it up with a little power, with a little speed, and learning how to create really rapid short triple extension. Power cleans, same thing. Rapid triple extension at the top, but all we're trying to create here is more powerful legs. You can work on just dip and drives. It's a very common drill for Olympic lifters to work on. Get a bar in the front rack position. You just dip, hold, and just create a slight little bit of triple extension coming out. Dip, hold, create triple extension coming out. The focus point on the jerk needs to be on a strong leg drive. Now, once you get that to occur, then the press is actually you pushing your body under. It's just pushing myself down to a supported arm position. The shoulder is strong if it can meet the load in its locked out position. It's significantly less strong when it has to do any sort of motion to try to press out that kind of weight. So the quicker you are to press yourself down and support, the heavier of a jerk you'll be able to have, because it's just about supporting the load, not about pressing the load.

    07:01 SHOULDER MOBILITY & THE JERK

    That requires shoulder mobility. And this is the big downfall to your split jerk is likely either A, you've been thinking about trying to press it over your head this whole time instead of jumping over your head. And B, your shoulders are too dang tight to really get into that full 180 degrees of flexion lockout arm position. You're trying to press it out in front and that's killing you, right? So you gotta open up that shoulder mobility. And you guys are the experts at doing this. Mitch, what do you like to do to open up your shoulders right before I'm weightlifting. I'm not talking about a PT session. I'm talking about something members can do out in the gym, boom, in real time to open up that double arm overhead position. I want to use a green band, but I don't want to do a single arm. I want to do double arm. And so rather than looping the band and attaching it to the pull-up bar like we normally do, I want to drape the band around the bar in this fashion. This is a poor example, but you get what I'm trying to say. I just, I don't want to half hitch it at all. I want to just loop it over the bar and have the band hanging down. I'm going to put both my hands through the band and I'm going to spin around. If you're watching this, this is a great I hope you're having fun with this because I'm spinning right now. I'm going to do like three circles and what that's going to do is wind up that band. So I've got it looped over the bar and I wound it up by doing three circles in it. My hands are now held in this double overhead position and I'm going to kneel down on the ground from that position. I'm going to start to have the band pulling my shoulders, essentially both arms, right near my ears at this point. When I'm down there kneeling on the ground, hands overhead and hooked to the band, now I can start to add some side bending into this position, which really starts to peel on this lateral seam of my arm, coming down to thoracolumbar fascia, up into the tricep area. I can side bend left, side bend right, and even add in a little upper back T-spine extension to that drill. It is the best opener I have found recently to get my shoulders ready to push jerk. because I'm hanging out in the exact position, an exaggerated version of it, but the exact position I want to finish my jerk in, which is the head through, the T-spine up and extended, and the arms behind my ears. So when you're thinking about pushing yourself under the bar, make sure your shoulder mobility is opened up so that you can do that. Okay, so what do we got so far? Strong leg drive, Don't press your jerks. Instead, push yourself under your jerks and make sure your shoulder mobility is on board for you to do that really well.

    10:47 IMPROVING JERK TECHNIQUE

    And the last thing you need to think about, the only really cue I'm thinking after I think jump is I think head through. I think jump and I think head through. Too many people are scared to put their head through on a heavy jerk. They're committing to failing it and therefore they're committing to self-preservation. And so what they do is they jerk and they leave their head back behind the bar and they're like, if it works, cool, then I'll bring my head through. But if it doesn't, I can bail quickly and easy. That is just committing to failing the rep right from the start. You have to know that if this goes bad and I'm still pushing my head through and I can quickly get out and underneath the bar if I fail it. You're, trust me, you're athletic enough to move out of the way of the bar. I've seen it a number of hundreds and hundreds of times of athletes trying to get the head through, fail the rep and are still getting out from underneath the bar. You've got to commit to that head coming under and through the window. Because if not, the bar is going to be out in front of your center of mass. And it's way too heavy for you to hang on to out there. My max jerk is 350. There's no way if I don't get my head through that, that I can hold that kind of load overhead. I've got to bring the head through and I've got to bring the arms behind my head. And that's when I close my eyes and say a little prayer. Oh, I hope this goes good. But the head is forward. I'm not looking at the bar. The head's got to be forward and through. So the only two cues, if you're thinking about anything, it's jump as hard as I can and push my head through that window and pray for the best. Shoulder mobility needs to be on board. It's all about the legs. It's not about the shoulders. And it's about getting your head through the bar. And if you do those three things, you go out in the gym today, right now, and you start practicing those three things, I promise your jerks are going to feel faster, snappier. You're going to reach lockout a lot quicker, and you'll be able to PR that push jerk or that split jerk, whatever you're doing. And hopefully add 10 pounds on it. Don't forget to tip your caddy when you do. All right. I'll open, I'll share my Venmo below. Don't worry. That's how to not be a jerk with your jerks. I hope that stuff helps you. I hope that gives you some things to think about maybe for your athletes you're working with or cues that can help them and restore that overhead position. I think I should probably film a video of that shoulder mobility opener. I got a feeling I'm going to get some comments or questions about, Hey Mitch, I had no idea what you were trying to explain. Can you drop a video? So I'll walk right out in the gym. I'll film that and I'll do my best to drop a link to that video in the best place possible. Maybe over on my Instagram. Head over to my Instagram, Dr. Mitch TPT, follow that. And then, uh, I'll drop that video there for you guys, man. So glad you guys are here. Happy Friday. Go lions three and one and one and O in the NFC North. It's a good time to be a lion's fan for the first time in about seven years. Team. I hope you have a great weekend. If you're taking a nice course, let us know if you're taking a nice course next weekend, we'll see you out there. And if you want us to head down South, come find us in San Antonio or find us in Florida. and we'll be hanging out down there in the month of November. Have a great weekend, everybody.

    01:27 MITCH BABCOCK

    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 1566 - Trust the process? Selectively Sep 28, 2023
    Show notes

    Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes emphasizes the importance of trusting a proven process for success, particularly in the later stages of a business or any endeavor when uncertainty arises. He cautions against blindly trusting any process and encourage listeners to thoroughly evaluate its merits before putting their trust in it. Jeff acknowledges the prevalence of outrageous claims and self-proclaimed experts in today's era. He cautions against falling into this trap and emphasizes the need to dig deep and evaluate a process before trusting it. He suggests spending ample time observing and studying someone who has achieved desired outcomes through their process before fully committing to it. This advice applies to various domains, including clinical practice. If someone is considering adopting a specific treatment approach or following a mentor's guidance, they should first spend a substantial amount of time observing the mentor's success with a wide range of patients. Only after extensive evaluation and proof of the process's effectiveness should one trust and implement it. Overall, Jeff emphasizes the importance of trusting a proven process but stresses the need for thorough evaluation and proof. Blindly trusting any process without proper evaluation may not lead to the desired outcomes. 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 JEFF MOORE Okay team, what's up? Welcome to Thursday. Welcome to Leadership Thursday. And welcome back to the PT on Ice Daily Show. Thrilled to have you here. I am Dr. Jeff Moore, currently serving as a CEO of Ice, and always happy to be here on Leadership Thursday, which, as always, is Gut Check Thursday. Let's start off every Thursday how we always do. Let's talk about the workout of the week. Here's what we've got cooked up for you. We've got 21-15-9. Couldn't be a more classic rep scheme. We've got thrusters and bar-facing burpees. So hopefully the first thing you're thinking is it looks a lot like Fran, right? We've got two movements, we've got that classic rep scheme, but I'm going to argue it's going to be a bit worse. With Fran, we've got push-pull, right? So at least you're pushing that thruster and then you're pulling up on that rig. Now we've kind of got push-push, right? So we're going to go thruster and then hitting that push-up motion during that burpee. It's probably going to be a little more painful. Additionally, you're probably not going to be able to sprint through quite as fast, looking at how long a burpee takes compared to a pull-up. So in Fran, you might be able to out sprint the darkness, right? You might be able to get done with the workout before that darkness really catches up to you. Here, I think you might be living in it for a while. So just let us know how it goes. Make sure you tag us, Ice Physio, hashtag Ice Trained. Let's have some fun with the workout over the next couple of days. As far as upcoming courses, the thing I want to highlight this week, is that virtual ICE is open. So as you all know, our virtual mentorship, we only open it every quarter for a couple days, bring in a new group, add into the crew, and then launch, close those doors and launch for the next quarter. We are trying to hold that price steady. It's been 29 bucks a month forever. It's still 29 bucks a month. Yes, it's CEU eligible, but more importantly, it's a great way as you're going through ICE courses to be able to be in that group, hold you accountable. Every Tuesday we meet, going over case studies, new thoughts that aren't built into our courses. It's a way to deepen your knowledge and really make it more clinically implementable, if you will, by every week revisiting and expanding on some of our concepts. So if you want to jump in, go to Virtual Ice on the website. PTOnIce.com, as always, is where everything lives. 02:37 TRUSTING THE PROCESS Let's talk about trusting the process. So trust the process, absolutely, right? You should totally trust the process. But I wanna unpack a couple things around this conversation that aren't talked about enough. So number one, trust the process. Everyone speaks of this in the early stages. Okay, so kind of a classic conversation around this topic is, hey, when you're just getting started, you might not see gains right away, don't worry, trust the process, it'll show up in time. That's clearly very relevant. And certainly when you think about areas like fitness where we often talk about this, yes, you're not gonna stack on a ton of muscle in the first couple weeks of training. You've gotta trust the process and those gains do show up down the road. There are certain areas where that early phase This concept is the most important, but I'm going to argue today that in the world of business, it's really in the later phases where I think this concept becomes significantly more important. 05:29 LOSING CLARITY ON CAUSE & EFFECT So let me, let me build the argument. So early on in business. The connections are very, very clear, right? You don't need nearly as much trust that what you're doing is reaping a reward simply because cause and effect are much clearer early on. For example, If you're building a practice and you form a new relationship and you see an increase in customers, it's pretty obvious that those increased customers came from that relationship because you don't have a ton of relationships yet. And any increase in customers is really obvious because you don't have a ton of customers yet either. Additionally, it's really easy when you run an ad or something of that nature to see again that swell of business following that ad is quite noticeable and it's very clear where it came from. Following up with your customers is a lot easier. Number one, there aren't as many of them, so it's easier to dive in and figure out, hey, how did you wind up here? Where'd you come from? and there aren't as many people delivering your service. So you don't have to bring everyone together and try to kind of coagulate the data and see, hey, where's everybody coming from? The connections are simply clearer. There's not as much noise, little changes make very obvious results, and it's not as hard to collect or aggregate the data, because there aren't quite as many people delivering the service. Early on, you don't need as much trust. Five years down the road, it's much harder, right? It's much more challenging. You often find yourself saying things like, I have no idea where that person came from, right? There's so many more things going on. There's so much more noise that it's much, much harder to prove. Did this action result in a certain effect? Now we fight this valiantly, right? Everybody, and you should, is trying to track everything, right? Whether it's where a customer landed on your website, or if you're running an ad, you're putting a tag on there so you can see, hey, when that person came to the website, if we track them through to the commerce side, did they actually convert? You're doing your absolute best to track everything. But the larger you get, the more mature the organization, it becomes significantly more challenging to definitively prove that any individual action resulted in any significant outcome. There's simply too many variables. You don't know, did it come from word of mouth? You really can't track that all that well. There's so many things going on that it's tough to have that clarity that you had early on. The reality is growth results in necessarily losing some clarity on cause and effect. The more mature the business, the more true this is. So what's the answer? The answer is to very much embrace and trust the process. In the absence of proof, You're just gonna need to check the boxes of what's known to work. I would argue the earlier that you can do this, the earlier that you can stop wasting your time demanding proof of every single action that you did having a reward or a response, the more efficient you're gonna be and the faster you're gonna succeed. The earlier that you can say, I no longer need to see proof that this thing that I'm doing is reaping a reward, I'm just gonna do all of these things with absolutely ruthless consistency, and I'm going to trust that by doing so, the end result is going to be additional growth and more progress. The earlier you can trust the process, the more efficient and more successful you're gonna be. But there is a catch here. It's got to be a proven process. And this is what I want us to really think about this morning. 07:39 OUTRAGEOUS CLAIMS & TRUST Team, we are living in an era of outrageous claims, right? We are living in an area where A huge amount of people that can't do are claiming to be able to teach, right? They're claiming to be able to get you unbelievable outcomes, even though they themselves don't really have a track record of being able to do so. That is the era in which we live. Heavily marketed, thinly veiled, outrageous claims. That is really where we are. Because of that reality, you need to dig deeper. The passion behind this topic is coming from having seen so many people over the years come to me and say, here's where I'm at. And me thinking, dude, how did you fall for that? Like that person, there was no reason to believe that those claims were being backed up by any significant track record of proof. The person simply did not dig deep enough. And that's what I wanna say to you today. 12:50 SHOULD YOU TRUST THE PROCESS? Should you trust the process? Yes. after you have went through extensive lengths to prove that that process actually results in the real world, in the outcomes that you're seeking. This is across every domain. Clinically, if you're gonna choose a mentor, if you're gonna lock into somebody and say, I am going to treat the way that person treats, I'm gonna ask that person what the big rocks are, and darn it, I am gonna implement those in every patient that I see. If you're gonna do that, You better have spent a solid year around that person, watching them day in and day out succeed with patients. A wide variety of patients, a wide range of complexity of patients, until you get to a point where you're like, look, that person gets it done. Better than everybody else I've seen, almost regardless of who shows up in front of them, the methods that person's utilizing month after month after month after month consistently work. I buy it. That person can actually get it done. I am going to trust their process. In Con Ed, at ICE, I hope you never sign up for a certification until you've taken one of our courses and went back into the clinic and implemented and decided for yourself, do the tools that I learned in that weekend course or that online course when I went back in my clinic, was I demonstrably better? Was I more efficient? Was I having more fun? Did it actually work? Until we prove that to you, I don't want you to sign up for some long series of courses. I want you to test us, and I want you to go and see, does it actually work? That's the kind of level I want you digging in on everything. In business, you don't buy that someone can grow your business until you have talked to a bunch of people who aren't affiliated, who maybe have done some of their mentorship, but are not actively in their program, and you reach out in your private circle and say, hey, has anybody worked with so-and-so? I want to have some conversations. And you dive in and say, is it really as good as they say it is? Were the principles that they taught able to grow you? Anybody can put that on an Instagram ad. Did it actually work for you? Is your business three times bigger now than it was a year and a half ago like they said it would be? Dive deep and ask the hard questions. I love it when people reach out to me. And they're thinking about opening it onward, right? And they say, look, I want to talk to a couple other owners. I love it. They want to hear from the people. Did they actually deliver? I love when people who are getting coached up to become faculty at ICE, I hear them reaching out to other lead faculty. They're not offending division leaders by doing that. They're just going out and saying, hey, here's kind of what I'm being sold. Did it actually shake out like this? In looking for multiple sources. Business leaders, I hope you all are never offended by that. People are not second guessing you. Yeah, they are, but they're not disrespecting you. They're just doing the work. They're saying, look, I heard you, but now I'm gonna go see across multiple sources if what you're saying historically has added up. Are you actually able to get the job done? Have you proven that? Or are you just saying that because you want your business enterprise to grow? Do you have the goods? Team, in fitness, to me, with CrossFit, I had never heard of it before 2013, 14, but as I got into it, I looked around for proof. In the first thing I saw, in the second thing, in the third month, in the second year, is that everybody who just consistently did what was on the whiteboard and showed up five days a week had what I wanted, meaning tremendously well-rounded fitness. I was shocked by where they wound up. They had tremendous cardio engines. They were strong as all get-out. They had tremendous skills in gymnastics and mobility. The people who did the whiteboard, as written, five days a week, as hard as they could, and used that process, wound up exactly where I wanted to be. You can only watch that so many times until you're ready to say, okay, I believe it. I buy it and I'm all in. So yes, right, trust the process. And yes, put your head down and check the boxes. But after you've established certainty. Now I want to finish by saying here's why this is so critical. Here's why doing the legwork to prove to yourself to be fully committed that this person can actually get it done and that it should thus be transferable to your success. The reason it's so important is two things. Number one, once you do put your head down, and I am totally advocating for you to put your head down, right? Head down, stop looking for proof of every single thing, and just check the boxes with absolute rigor. I'm encouraging that. But once you do that, there aren't a lot of checkpoints. So once you've committed and you've said, I'm just gonna keep checking these boxes and I'm gonna trust the process, you're not really looking for proof, right? Because we've just established it gets harder and harder to gain any, so you've just simply gotta trust. The problem is if you're wrong, there aren't a lot of checkpoints to reveal to you that you're wrong. So you're gonna go a long ways down that trail. There is…

    Full show notes at the publisher

    Episode 1565 - Shoe recs for older adults Sep 27, 2023
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    Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses evidence based recommendations on shoe wear for older adults. 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 INTRO What's up, everybody? Welcome back to the PT on Ice Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app.physicaltherapy.com. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code IcePT1MO. When you sign up is that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:43 DUSTIN JONES Welcome folks to the PT on Ice daily show. My name is Dustin Jones and today is Wednesday where we're going to be talking about all things older adults in particular. shoe recommendations for the older adult population. Shoe wrecks, heel drop, doesn't matter, barefoot, minimal, conventional shoe, what the heck's the deal with the toe box, what in the world is a shoe last, we're gonna talk about all these things, what the evidence says, and then what we're kind of seeing out in the real world, right? Many of us are seeing in clinical practice or in the context of fitness. Before we get into the goods, just a few quick announcements. Our online MMOA Modern Management of the Older Adult courses are going to be striking up here within the next couple weeks. So Essential Foundations, that is our foundational online eight-week course, is going to be starting October 11th. And then our Advanced Concepts course is going to be starting on October 12th. That's just for folks that have taken Essential Foundations. We've got a bunch of live courses coming up through the fall across the country. The one that I really want to point your attention to is Falls Church, Virginia. That's going to be the weekend of October 7th. 02:51 SHOE RECOMMENDATIONS All right, shoe recs. This is a topic that I really enjoy digging into. I've got a decent amount of experience around shoes. I used to sell shoes right out the gate of PT school. I was working in outpatient PT clinic and then working in the first kind of barefoot style shoe store in the country. Two of his treads out of Shepherdstown, West Virginia, currently in Charlestown. And just had a lot of, made a lot of mistakes, learned a ton, met a lot of interesting folks that were in this space that were really challenging a lot of conceptions. around shoes and what is good for individuals. And I was very dogmatic at one point and I've kind of come to the middle a little bit in terms of what I perceive to be beneficial and the evidence is starting to show that as well. 03:55 THE OLDER ADULT FOOT So when we talk about recommending shoes for older adults, I think the first thing that we need to acknowledge is that the foot is different in an older adult than when you're younger, right? We see age-related changes typically in the older adult population that warrant us to really question the shoe that they're in, right? The reality with the footwear industry is that many of the shoe lasts, lasts being the shape of the foot where they basically create the shoe from. The shape of that shoe last largely mimics what you may see in a younger individual, not necessarily the common things that we will see in older adults. What do we see in older adults? Typically, you're going to see a larger circumference of their midfoot. larger circumference compared to when they were younger, you typically will see a lowering of that arch in many older adults. We often do see that the angle, the toe angles of that first and fifth toe typically do go in, which we're well aware of all the issues associated with that. And we see these changes yet 99% of the shoes out in the market are looking at a younger foot and creating the shoe around that as opposed to an older adult individual. So we need to acknowledge these changes because that is what's going to influence the current evidence-based recommendations. So what I'm going to go through is kind of what the current evidence says, the most recent systematic review looking at shoe recommendations for older adults, and then I want to dive into the whole minimal barefoot shoe versus conventional shoe debate, particularly for this population. So what do we know to be true in terms of some key characteristics of shoes that are gonna be helpful for older adults. One, and probably the biggest issue, is that it fits. I know it sounds super simple and silly, but if you check the fit of many of your patient's shoes or your client's shoes, you will see some very ill-fitting shoes. Whether it is the shoe is too big, there's a lot of wiggle room, their foot is moving a lot within that shoe, or it's the opposite, right? The shoe is way, way too tight for that individual, and that creates a whole host of issues related to skin breakdown related to performance breakdown as well. And so we want to be very aware that it fits well, all right? So that's the first thing. Next thing is that it has fixation. A shoelace system, for example, we could say Velcro as well, but laces are typically better, is that if that shoe is properly fit and it's fixated to that foot, that is going to allow them to do what they need to do when they need to do it, all right? The second thing, third thing is going to be a firm supportive heel counter. So I've got a shoe here. If you're listening on the podcast, you can come to YouTube or Instagram to see the video. So this is just a Reebok Nano. I can't remember the model of this one, but back here, you know, is a pretty solid heel counter. So it's this back portion of the shoe. And so you want this to be firm and supportive. and snug when people put this on so you don't want a ton of room around the heel with this heel counter you want to be nice and snug and that's why trying shoes on is super super important. Next thing is around a 10 millimeter heel drop and this is where some of y'all are going to say no Dustin it needs to be just a zero drop shoe Current evidence shows that 10 millimeters around that range that older adults do really well there. If you start to go above that, particularly above 15 millimeters, you see an objective change in their balance performance through different outcome measures and their postural stability as well. If you're not familiar with heel drop, it's the difference of the thickness of the heel to the forefoot. This information can be hard to find on most websites when you go to look up shoe specs. That's why you want to look up the reviews of that shoe. Typically, a running world, there's a bunch of running related sites that will do all kinds of shoe reviews and they will give you some of those specific specs. When we worked at Two Rivers Treads, we would literally get a demo product and then we would cut the shoe right down the middle and we would measure the heel drop because a lot of those numbers weren't being published. We found some really interesting things. What the trend in the heel drop realm You know, 20 years ago, it was very, very common to see heel drops north of 10. You know, you'd be going, you know, 14, 17, 18 range in a lot of running shoes in particular. And over the past 20 years, particularly the past 10 years, that that average has gone down and down and down to where it's pretty normal to see a four to five millimeter drop from the heel to the front. That was not the case 20 years ago. So that has changed tremendously in the footwear industry. So around 10, excuse me, around a 10 millimeter heel drop. Next is a firm midfoot. So when we're looking at kind of the sole that it is relatively firm, you will typically see firmness in the midfoot and the forefoot is going to, excuse me. All right now, the forefoot is going to be a little more flexible. That allows for, you know, terminal stance, that we have a lot of extension, big toe extension is a big one, but that midfoot, a kind of firm, medium thickness is a good thing for older adults. In terms of the traction, a slip resistant sole that's multi-directional and tread. There's not a lot of evidence to support, you know, super thick, aggressive tread like you would see in something like a trail shoe. but some tread that is going to allow them that slip resistance in several directions, not just anterior to posterior. The next thing that you are going to want to look at is the beveled heel and then a rocker angle. All right. So this is really important for older adults that you typically want to see around a 10 degree beveled heel. So towards the back of the shoe, when we're going towards the very back of the heel, there's kind of that upward curvature. So it's not completely flat, but there's a little upward tilt around 10 degrees is really great. This allows or decreases the amount of them kind of catching their heel, especially during that swing phase. On the other side of the shoe, the front of the shoe, we have our rocker angle. You also hear this referred to as a toe spring. Now, not the fact that there is a spring in the toe or the front of the shoe, it just references that upward slope that you will see towards the front of the shoe. around a 10 to 15 degree rocker angle or toe spring is really good for older adults. The reason being is that when you're going into that terminal stance, you need a good bit of big toe extension, right? Some more ankle dorsiflexion as well. Usually you need about 45 to 65 degrees of big toe extension. And if you don't have that or it is painful, then having that upward slope basically gives you some artificial big toe extension. It can be really helpful with walking, but particular activities that require a lot of big toe extension, think going uphill, think lunging or getting to and from the ground, that rocker angle is priceless. And then last but certainly not least, we want an anatomically shaped toe box and this has changed dramatically over the past 20 years as well that we typically saw the shoe last kind of curve inwards and now you're starting to see that wider toe box to where the widest part of the shoe is almost towards the very end of the shoe or the front of the shoe. Now don't mistake a wide toe box to be a loose fitting shoe, because you will have a little bit of room to wiggle your toes in a properly fitted toe box. But if you have good fixation, particularly around the waist or the middle of the shoe, it is not a problem to have some wiggle room in the toe box. So we're talking length, but we're also talking width as well. so that is really important so when you look at all these characteristics hopefully you're starting to say oh my gosh that's a lot to think about this is why it is so so important for two things one to have a good relationship with A local, particularly running stores are usually the best around town. If you have an awesome local running shop to where you can send your folks, they have a solid fit system and they have some solid recommendations that can meet some of these characteristics. you're going to refer your folks and they're going to be in good hands, right? But it's also important to encourage folks to not just go to Amazon, to not just go and buy the shoe online, but you need to try this on. These characteristics, but then also that shoe feeling comfortable is very, very important. All right, so those are kind of the current recommendations. That is based on a systematic review that was released in 2019. I'll drop the citation for that in particularly the Instagram post. I'll do that there. 12:39 MINIMALIST SHOES: PROS & CONS All right, now let's shift gears a little bit and let's talk about the whole minimal shoe, barefoot shoe versus conventional shoe debate. Once again, I will say I was so dogmatic about this. I was the guy that ran half of a marathon without any shoes whatsoever. And the first half I wore Vivo barefoot because we were running on gravel, right? Like I was that guy. I drank the Kool-Aid hard, um, and then learn some valuable lessons along the way. And I've changed my stance a little bit. I'd say a lot actually on this, but let's talk about some of the pros and cons of particularly older adults wearing a barefoot style shoe. The first one is, there is evidence that a barefoot style shoe, when I say a barefoot style shoe, some of the key characteristics, typically it is a zero drop shoe. What I'm holding now is a Merrell Vapor Glove. I've bought three pairs a year of these things ever since they came out back in the day. I love these shoes. So it's typically a zero drop, a very flexible sole. So if you're not watching the video, I can roll it up like so. and it typically has a wide toe box. So the widest part of the shoe is going to be towards the front. That's kind of the typical characteristics of kind of a minimal barefoot style shoe. It also has a very low stack height in terms of how high it is off of the ground. So there are a couple studies, particularly with older adults, looking at how that's influenced some different parameters. And what they found is that when they wear a barefoot style shoe compared to a conventional style shoe, is that it does improve their postural sway. How does it do this, right? So think about the somatosensory input. You get a lot more input from that system whenever there's less stuff between your foot and the ground. You also have a lower center of mass, which can be very helpful for balance. And also, without that heel slope or heel drop, it doesn't shift your center of mass anteriorly. And so based on a couple studies, postural sway was improved significantly compared to conventional shoes when wearing those minimal shoes. So less sway, less postural deviation when folks were in static and dynamic situations. 15:07 CHANGES IN WALKING GAIT The next thing is that when folks put on that barefoot style shoe, they adapt their walking gait, running gait as well, right? Like we'll have the endurance crew talk about that all day, but I'm mainly talking about older adults…

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    Episode 1564 - Frozen shoulder myth busting Sep 26, 2023
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    Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses common myths related to the diagnosis & treatment of frozen shoulder presentations based on outdated & low powered research. Mark offers a newer, evidence-based approach which includes addressing diet & lifestyle factors, including judicious manual therapy, and load. 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 00:18 MARK GALLANT All right, what is up PT on ice crew we got Instagram over here we're getting YouTube Pulled up over here. Make sure I get everything set All right, we are live on both platforms now. Looking good. I'm Dr. Mark Gallant, lead faculty with the ice extremity management division alongside Lindsey Huey, Eric Chikones. Want to come at you today on clinical Tuesday talking about frozen shoulder. It's another one of those areas similar to IT band that we talked about a few weeks ago where there are a lot of things that based off research from almost 100 years ago, have stuck around for a long time. So we want to dive into where the problems lie and what we can do to solve those issues. Before we dive into that, few course opportunities coming up to catch us on the road. You can catch us. Cody is going to be in Rochester, Minnesota here in two weeks. So if you're if you're up in the Midwest or that North area and you've been looking to catch us, definitely look at Cody there. I'll be in Atlanta early November and then we've also got another course coming up in California. So we're so we're hitting the Midwest, the Southeast in California. If you're looking to catch us in the rest of 2023, if not, definitely look at those courses for 2024. There's a bunch of opportunities to catch us in 24 and those seats are filling up fast. So so jump on it right now. 02:46 DIFFICULTIES OF UNDERSTANDING FROZEN SHOULDER So As far as frozen shoulder goes, it was said that frozen shoulder is difficult to treat, difficult to define, and difficult to explain. That was said by Ernest Codman in 1934. And we would argue that 90 years later, after Ernest Codman said that, it's unsure how much better we are in understanding frozen shoulder It's definitely a challenge to treat. And for any of you who have tried to explain it to patients, it's one of those ones where you feel like you're going around in circles as you're trying to explain it. We don't know really what the true mechanism is. We've got a lot of theories. We're narrowing the buoys, but we really haven't narrowed it all the way down. And we really don't know what the primary tissue areas are that are really creating this pathology. Again, it makes it difficult to treat, difficult to define, and certainly difficult to explain to patients. Who are the people that are going to come into your clinic that are going to have frozen shoulder or meet that presentation? Well, the main thing is oftentimes they're around 50 years old. It tends to be our 50-year-old folks that have this most often. And what you're going to see is active and passive range of motion are both going to be limited in their shoulder range of motion. At least one of those has to be external rotation. glenohumeral external rotation is the the area that we find to be most limited early in a frozen shoulder presentation so we're really looking at about a 50% reduction side to side of that active and passive external rotation early on in this presentation and then oftentimes you'll see other other motion areas start to be limited so 50 limited shoulder range of motion specifically external rotation the other thing that tends to be tied with frozen shoulder is It's often folks who have diabetes in their medical history as a comorbidity and thyroid disease, which matches that unhealthy tissues are oftentimes attached to unhealthy humans. So if they've got some serious significant comorbidities, especially those metabolic comorbidities, this is another group of folks you want to take a look at and think maybe this could be a frozen shoulder presentation. So what are some of the old myths or some of the problems that we've had with frozen shoulder over the years? 07:18 SUPERVISED NEGLECT Well, the first one is going to be supervised neglect. So there was this idea that if you look at someone who had frozen shoulder early, you say to them, you know what? This is a presentation that runs its course in about 18 to 24 months. Here's some exercises. Go home, sit at the edge of a counter, spin your shoulder around a few times, and let us know how you're doing in 18 to 24 months. Unfortunately these were based on very limited studies so if you go back to again the 1930s 40s 50s with Ernest Codman a lot of his studies were based on on 6 to 12 people so a very limited cohort and he was giving wildly aggressive treatments like he would hospitalize these patients and basically pin their shoulder into end range rotation and flexion for up to 20 hours a day. And then he said, oh, almost all of these people get better. Well, certainly maybe with what he was doing with that aggressive treatment, but it would be, you'd be hard pressed to say like with a cohort of less than 10 folks that, that everyone with this presentation is getting better. If we go to the early 2000s, another popular study is Dirks et al that showed that folks who were just sent on their way with some basic exercises versus folks who were given physical therapy, that the folks who were given exercises and told to check back in at two years and four years, that they actually did better. Well, if you really dive into that study, from a quality perspective, it was not the most robust study. Only 77 people, very poor quality control, and it's really not demonstrated anywhere in that study exactly what the physical therapy group was doing. Again, based on limited research, we would be hard pressed to say that it's truly supervised neglect is the best method to just send these folks on. The other challenge that we run into is, like Codman said, 18 to 24 months, all these folks are going to get better. That does not seem to be true as we dive more into the literature. What we're looking at now is more that These folks can oftentimes have their presentation up to 48 months, so four years of dealing with this. And the only reason we say 48 months is because that is the longest that anyone has ever looked at it. That a large percentage of folks, when you look at them four years later, they are still having some pain or some limitation in their shoulder mobility at four years. And again, We say four years because that is the longest it has ever been looked at. And if you're really thinking about a presentation that is as uncomfortable as frozen shoulder is, especially early on, and we don't know how to define it, we don't know how to explain it well, and it can last up to four years, and potentially a lifetime of increased dysfunction of that shoulder, It's really hard to say to someone, hey, this is all we know. Good luck for the next four years. They're in a lot of discomfort. They've got a lot of shoulder limitation. This is another human being in front of you. We want to do our best to come alongside those people. We really want to walk the line with these folks to help them out. No one wants to be told, see you in two years. That's only going to increase fear and anxiety overall. and there's a new clinical practice guideline coming out for frozen shoulder it has not been published yet but hopefully sometime in the next you know six months to a year it'll come out one of the authors on that ellen shanley done a ton of research in the shoulder space and what their group is finding is that if we get them early physical therapist and we give them a good solid treatment during that first year most of those folks have a better overall prognosis and presentation as time goes out. So again, it does not seem that supervised neglect really helps because so many people really have this problem beyond four years. And we are starting to see new research that that if you get in there and you can help them calm symptoms down some, if you can restore whatever range of motion you're able to restore, that those folks are going to have a much better prognosis. So getting them in with you. And again, no human wants to have that vague of a presentation and be on their own. So us acting as a guide is always going to be very important. So that's the big one, supervised neglect based on poor research, we're showing that the outcomes of supervised neglect are not what we may have thought they once were. And we want to be good humans first and foremost, coming alongside those patients and really helping them out and guiding them along. 14:06 STAGING THE FROZEN SHOULDER The second piece is the idea of staging for frozen shoulders. So historically it's been freezing, frozen, thawing. And a lot of times when the research, these were based on a timeline. So you would have a few months of the freezing phase, a long frozen phase and then coming out of it that last sometimes it was written as 18 to 24 months as their thawing phase. What we see now is those phases are very unreliable and it's rare that someone is going to fit into that nice bucket of freezing frozen thawing. what we're seeing more now is that we really to simplify things both for patients and for ourselves is as complex as frozen shoulder appears to be we want to have the simplest buckets possible so what we're going to look at is is this shoulder more pain dominant or is this shoulder more stiffness dominant and if we keep people into those two buckets it will really ease our mental burden and the patient's mental burden on how to treat those out effectively so So oftentimes early on, it's going to be more of a pain dominant presentation. You're going to be doing things that calm that person's symptoms down as much as possible. Sometimes that shoulder is so irritable that you're not actually going to get into the shoulder to do any direct tissue treatment. Things we like in that case are breath work is a wonderful way to calm the nervous system down. Specifically, if you can have the exhale slightly longer than the inhale has really been shown to calm the nervous system down. Can we get them doing some other sort of mindfulness practice other than breathing? Can we get their diet more dialed in? Again, unhealthy tissues are attached to unhealthy humans. Can we lower the sugar? Can we lower the processed foods, the alcohol? Can we get them doing some general fitness that does not involve the shoulders? So getting them on the bike to pump a lot of healthy blood flow to those tissues and doing our lighter exercises to the area so higher dose higher volume with low tensile load in their available range to pump a lot of good healing blood flow and fluid to those tissues and pump out whatever chemical irritants may be and then lower load isometric long hold lows to get some non-threatening stimulus to those tissues are some of our favorite things for that pain dominant presentation. Now the stiffness dominant presentation What we want to do then is now we're saying that their pain is below that 3 to 4 out of 10, their psychological irritability is down. Now we want to get into those end range tissues. We want to hit our end range mobilizations, followed up with eccentric exercise to really start to own that end range tissue. So oftentimes this is where you're going to do your really long hold stretches and mobilizations and follow them up with some decently loaded eccentric load so that they can learn to control that new range of motion and access new range of motion. Again, that would be once symptoms have significantly calmed down. Now, historically, looking at treatment for the frozen shoulder, this is one of those areas where we would often tell patients, well, hey, we're going to have you grit and bear it, Todd. You know, Tom, we're going to set you on the table and I'm going to crank on your shoulder for 45 minutes and we've got to get through this. And what we know now is that that was likely creating more irritability, both from a psychological perspective and a tissue perspective. The tissues were likely not really ready for that in-range, very vigorous stimulus and our patients, Tom, certainly was not ready. for that vigorous stimulus. And what that led to was not only tissue irritability and potentially delaying healing times, it also led to some psychological irritability. That's where folks like Tom would say, physical therapy, man, it's so painful. I needed to take 10 Advil before I went to physical therapy. They're afraid of physical therapy. They become apprehensive of loading. We were creating a lot of fear and apprehension. We want to meet these folks where they're at. We want to meet the tissue where it's at and get where we can out of it. This does not mean that we don't believe in intensity. We believe in intensity as the ultimate. It's intensity matching that patient's tissue tolerance and symptom profile. And once we can match that symptom profile and tolerance, then we want to maximize intensity when it's more that stiffness phase. Early on, we've got to respect that psychological irritability, the tissue irritability, do the things like breath work, light mobilizations, until we can progress them to those more vigorous exercises. In addition to that, the amount of force that it takes to move the shoulder capsule is absolutely ridiculous. It is almost 2000 pounds of pressure. to actually make changes to that capsule. So what we think we're doing with our manual therapy is unlikely true. We were likely often getting tissues like the subscapularis and other shoulder tissues to calm down and relax a bit with our mobilizations, not making true collagen changes, which would require much more vigorous load that could create injury to other tissues or really long sustained hold. So again, much more beneficial for us to lower symptoms, really manage their pain well early, get what we can out of the tissue, and then when symptoms are down, then really dial up the intensity, your long hold stretches, your eccentric loading, and really getting after those tissues overall. Love to discuss this more. Frozen Shoulder is such an interesting conversation. Again, to recap overall, supervise neglect, What we want to focus on more is coming alongside those patients, helping them calm their symptoms down, helping educate them for whatever stage they're at. When we're looking at staging, pain-dominant or is it stiffness-dominant? If it's pain-dominant, breathwork, diet, nutrition, general exercise, lifestyle, light load to create a pump to the shoulder, getting some light isometric load in, getting those tissues as healthy as we can. If it's stiffness-dominant, that's when we want to get more intense, get after those tissues, long and range hold with our mobilizations and eccentric exercises to get after this. Hope it helped. See you all in a couple of weeks. Hope to see you all out on the road. Have a great Tues…

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    Episode 1563 - Is it ethical to restrict resistance training during pregnancy? Sep 25, 2023
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    Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett Addresses the fear of exercising during pregnancy and how it can hinder the care provided to pregnant individuals. Christina shares that she has received messages from pregnant individuals expressing their concerns and uncertainties about exercising while pregnant. The fear of exercise causing harm is often the primary concern that arises when someone discovers they are pregnant. Christina emphasizes that this fear is not supported by scientific literature and believes that removing this barrier can lead to a significant shift in the way pregnant individuals are cared for. She argues that the medical system has contributed to this fear and stress the importance of reframing the conversation around exercise during pregnancy. Instead of focusing on the potential harm, Christina suggests highlighting the health-promoting aspects of exercise and removing any obstacles that may prevent pregnant individuals from engaging in physical activity. Christina also points out that society does not have a movement problem, but rather a lack of movement problem, which is often observed during pregnancy. She highlights that the fear of harm is one of the factors contributing to the decrease in exercise during pregnancy. Overall, Christina emphasizes the need to address and alleviate the fear of exercise during pregnancy in order to improve the care provided to pregnant individuals. By reframing the conversation and focusing on the health benefits of exercise, pregnant individuals can be empowered to continue exercising during pregnancy and set up for success. 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 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor, Jane. If you don't know about Jane, Jane is an all in one practice management software with features like online booking, scheduling, documentation, and a PCI compliant payment solution. The time that you spend with your patients and clients is very valuable and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms, that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app.com. Use the code icePT1MO at sign up to receive a one month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on Ice daily show. 01:26 CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the faculty within our pelvic health division. If you did not see, we had an absolutely packed house in Arizona for our two-day live course, and we have a couple of live courses coming up through the end of the year. Importantly, we're taking the move up to Canada and we are trying to see if we can take some of these courses up there. So I am going to be in Ontario this next weekend, the 31st first or 30th first. in Hamilton, Ontario, which is close to Toronto. And then in December, I'm going to be in Halifax, Nova Scotia, in the east side of the country. So if you are a Canadian who keeps saying, why aren't we bringing these ice courses up to the north into Canada, we are trying to do that. So I hope that I will see some of you in our Canadian courses towards the end of this year and this weekend. Okay, so this is kind of a little bit of a punchy topic where, and I've been thinking about this a lot. 02:40 ETHICAL RESISTANCE TRAINING RESTRICTIONS So to give context, so today we're going to be talking about, is it ethical to put resistance training restrictions on women that are pregnant? Where this comes from, so we are in this space of exercise, and to this day, very commonly, there is a restriction that can sometimes be placed on people that are pregnant that tell you that you should not lift more than 25 to 30 pounds during your pregnancy. And if you have seen me in the geriatric division, We've done a lot of pushback against putting restrictions on the amount of absolute load that is on an individual because of these preconceived notions that individuals of a certain age are not capable. I've had conversations before where people think that the two divisions that I'm a part of, the geriatric and the pelvic health division, are very different, but they both have one key concept that are kind of overlapping with them. that is under dosage of an under prescription of exercise. And so my PhD in geriatrics looked at high load resistance training for at risk older adults. I have since shifted some of my research into the pelvic health space looking at high load resistance training during pregnancy And that is where this conversation came up. So the motivation behind this episode was a conversation that I had with Margie Davenport, who I'm doing some postdoctoral research with, where we were talking about a systematic review that we are working on with Jess Gingrich, who's part of our pelvic team, on resistance training during pregnancy. And so part of the things that we are reporting on are things like what was the frequency, intensity, time, and type. exercise prescription principles for these randomized control trials or these exercise studies that were done in individuals who are pregnant. And I've talked about how understanding the context where these prescriptions come from, saying don't lift more than 20 or 25 pounds, have come from the fact that we do not have research in this area over a certain prescription, hence some of the cross-sectional data that we're doing, hence some of the follow-up studies that we are doing. So that's where this came from. But the reframe that really came into my mind over the last little bit was when Margie said, is it ethical to put restrictions on pregnant people for lifting? And so let's talk about that. So when it comes to these restrictions or when it comes to our recommendations, they come from the foundation of do no harm, right? no harm. We are trying to make sure that we are keeping our pregnant people safe and we are making our recommendations and they tend to be more conservative because this is a very protected time in a pregnant person's life. And so because we don't have any research in pregnant people, we say don't do it. But when it comes to the research, where we have to go is looking outside of the research, blending it with what we know in our current patient population, and then take the wants and desires of the person that is in front of us. We know that strength is protective at every single point in our life. We know that being stronger makes you more resilient. We know that it prevents chronic disease. that it keeps you with higher amounts of quality of life for longer. It helps protect you and give you reserve if you are sick. There are so many reasons why strength is protective. And it has been shown across almost every single patient population at every age. It is shown that strength is protective. When we have our pregnant population, we use these restrictions because we don't have anything above. But when we come down to the foundation of strength is protective, And we think about the lens of these restrictions, don't lift more than 25 pounds. We have to ask the question, are we going by do no harm? Because it's not that we have evidence that going above 25 pounds is harmful. It's that we don't have evidence at all. And so when we don't have evidence at all, we have to take a look at other areas or other amounts of the lifespan of the woman. And we have to think about, are there any harms that we can think of that are specific to pregnant physiology? And then kind of blend these two things together. 08:16 RESISTANCE TRAINING DURING PREGNANCY And from a pregnant physiology perspective, the theoretical constructs that are driving some of these recommendations are things like the change to fetal heart rate and placental blood flow as a consequence of lifting heavy weight, and the shunting of blood away from the uterus that happens when we resistance train towards the working muscle. And we don't have any evidence from our acute studies that have looked at hemodynamics in the cardiovascular response to resistance training at a variety of loads to show that there is any adverse event that happens to mom or baby hemodynamically that would insinuate that there is some type of harm to fetal inflows and outflows as a consequence of resistance training. When we look at high load resistance training across the lifespan, we also have to think of what happens if we start to make women afraid of resistance training. What happens when we say don't lift more than 25 pounds or don't lift this heavy weight because you're going to prolapse or don't lift this heavy weight because it's going to cause incontinence. We don't have to just think about this snapshot in time where we're trying to maybe circumvent some leakage. We have to think what is the internal dialogue that starts to happen in that woman's life that is going to impact her at 65. where we think that we shouldn't be that resilient or we shouldn't be doing that much resistance training, we shouldn't put that muscle on us anymore because we are going to cause pelvic floor issues or we are going to harm our baby. What does that internal dialogue do to exercise selection in the postpartum period, in the midlife period, in the perimenopausal period, in the older adult period? Is me saying that you shouldn't be resistance training going to impact what I'm working with older adults down the line? and this may seem like a bit of a stretch but when we don't have evidence around fetal hemodynamics we don't have any case reports that have shown that an individual who's lifting heavy weight goes into a hypertensive emergency or that there's any type of pre-eclampsia that happens acutely or that after going to the gym an individual has had a fetal death which would be a case report that would come out in the literature as a special kind of This is something that happened that we should keep our eyes on that's how we start developing levels of evidence to start investigating different phenomena Because we don't have any of those things This reframe I think can be super important of Not what is the what is the harm of resistance training? it's how are we setting our moms back if they don't resistance train during their pregnancies? And you know I've talked to moms who've been placed on activity restriction or bed rest and they say like I had a complication that caused me to have to be in bed and let me tell you being weaker going into that postpartum period was painful for me. It was a lot harder for me. It was not something that I would wish on anyone to have to feel so weak and vulnerable in a time where you already feel weak and vulnerable. So instead of saying what is the risk of us doing resistance training during pregnancy, It's what is the risk if we decondition our moms to be and have them, are we setting them up for success in the postpartum period by purposefully deconditioning them? And you may think that that is a strong statement of purposely deconditioning, but when you are making a recommendation that they are not allowed to lift their toddler up or that it is somehow dangerous to do that, We don't want to acknowledge that while we are removing a stimulus, that we are actually promoting deconditioning. We are promoting deconditioning of the musculoskeletal system. And when we look at return to exercise postpartum and we look at persistent issues in the postpartum period, for example, diastasis recti, we know that those with diastasis recti are weaker across their abdominal musculature than those that aren't. We know that one of the biggest issues to returning to exercise is pelvic floor dysfunction, but it is also lower extremity musculoskeletal pain where our body has not had that type of stimulus or impact. It hasn't remained as strong as it was before pregnancy. And now when we're trying to return to activity. we're having lower extremity pain. 12:22 MOM WRIST & MOM KNEE Why do we have so much mom wrist and mom knee, which we now have evidence are not actually physiological changes that occur within a female's body that are a consequence of the hormones of pregnancy. We see a weakness issue that comes into pregnancy, a certain amount of deconditioning that is expected as a consequence of pregnancy, but we do not promote, uh, blunting of some of that deconditioning by promoting resilience and resistance training. And so I feel like there is a paradigm shift that is happening, and it starts with reframing our questions. Instead of saying, what is the harm of resistance training? If we flip that and say, what is the risk of deconditioning a pregnant person? that changes the game. It changes the way that we frame exercise and what we consider to be bad. We don't have evidence at any levels of intensity in any modality of fitness that high intensity resistance training or aerobic training is bad for a developing fetus. or for a pregnant person. And in fact, it is creating a cardiovascular training effect to strengthen the fetal cardiac system when individuals are participating in aerobic training. And so how do we set moms up for success? Instead of saying, what is the fear? of exercising because that's the first … I literally had somebody message me yesterday saying, I'm four weeks pregnant and now I'm so scared. I have all these questions. I do all this strength training. I do all of this aerobic training and I don't know what I'm allowed to do. We have created that system where you get a positive pregnancy test and the first thing that you question and the first thing that you start to be fearful of is, is the exercise that I am currently doing going to cause harm? Our medical system has created that, and we need to work tirelessly to remove it, and instead say, what are the health-promoting factors, including exercise, that I enjoy, that I want to do, that I want to continue in order for me to feel strong, for me to feel healthy, for me to feel happy, for me to have strong mental health and resiliency, and that is going to tric…

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    Episode 1562 - Competition prep 101 Sep 22, 2023
    Show notes

    Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko stresses the need to maximize preparation and recovery for a successful competition. He emphasizes the importance of preparing for the week before the competition, the competition day itself, and even the week after the competition. Joe encourages individuals to focus on their game plan, proper nutrition (including carbs, protein, and electrolytes), fluids, and electrolytes. Additionally, He highlights the importance of keeping the body moving between events to avoid stiffness and stagnation. The ability to warm up, maintain a good heart rate, and perform at a fast 100% effort is crucial for success. On the day of the competition, Joe advises sticking to one's game plan and not letting others dictate it. He mentions that CrossFit is about being able to adapt on the fly, but it's important to trust one's strategy and see where it takes them. Joe also emphasizes the importance of nutrition during competition day, stating that eating is necessary and what one eats matters. He provides the example of an elite athlete who consumed multiple Snickers bars for fast carb and glucose intake to replenish muscles, but notes that this strategy may not be applicable to everyone. After the competition, Joe discusses the importance of the follow-up week. He suggests focusing on recovery during this time and allowing the nervous system to recover and do what it needs to do. He highlights the significance of giving oneself time to recover, as it is an important part of the overall competition process. Overall, the episode emphasizes the importance of preparation, execution, and recovery in the context of a competition. It highlights the need to have a game plan, trust one's strategy, focus on proper nutrition, and prioritize recovery to maximize success. 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 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app.physicaltherapy. Thanks, everybody. Enjoy today's episode of the PT on ICE Daily Show. 01:26 JOE HANISKO Good morning, everybody. It's PT on Ice, daily show live. It's Friday, I would say September 22nd, getting close to October already. It is Fitness Athlete Friday. I'm Joe Hanisko. I'll be your host today. One of the lead faculty of the clinical management of the Fitness Athlete crew. Today we want to chat about competition. So CrossFit competition prep 101. Just the basics. We get either personally ourselves or some of our clients who are signing up for local or online competitions and we want to make sure that we're preparing them and that they understand what their expectations are for getting into that competition. the week before, the actual date of, and then even that week after, like making sure they maximize their preparation and their recovery for a successful event, especially when really all that we typically have to see in comparison is these elite athletes who are going to be doing things similarly, but also different because of the amount of training they've put in and just the fortitude that they've built up in terms of an athlete and the resilience that they've earned in an athlete. We'll talk about that CrossFit Competition Prep 101. Before we get going, I want to make a couple of call outs to the CMFA Live agenda that's coming up for the rest of the year. Both of our Essentials and Advanced Concepts course took off online in the last week or so. So those are going to be going through until the end of the year and we'll get those going again at the beginning of 2024. But in terms of live courses, we have a handful coming up in the next few months to close out the year. So if you're looking to get into any Con Ed courses, we are going to be in California. Washington, Alabama, the state of Texas, down in Florida, New Orleans, and Colorado, all before Christmas. So from now until Christmas, we have six or seven CMFA Live courses that will be out there. So grab a seat if you're looking for that. Hop on to theptnis.com and you can find all of our courses there. All right, CrossFit Competition Prep 101. 03:45 PREPPING FOR COMPETITION WEEK Let's talk about the week of. So you're going into this weekend of competition. What do we do that week before? I would say that at this point, We're not talking about the prior weeks and months of training. That's a whole other conversation. But at this point, whatever you've done to earn your right to sign up for this competition, you've done it, you've earned it. You can't really gain a whole lot more in one week of training, but you can lose a lot in that one week. So we want to make sure that we take that week leading into competition pretty seriously. If we're assuming maybe competition day is on Saturday, which is most common for a lot of local events, I would say that those first two to three days of that week, Monday, Tuesday, Wednesday, per se, I would focus on training as normal. Keep things consistent. If you guys have specialized programming through your gym and or you're using some sort of online platform like Mayhem, Days one, two, and three can stay pretty consistent. We don't have to change a whole lot about that. It allows us to stay moving, feel good, test some things out, and it's not until day four and day five that we really start to maybe change some things there. Day four, I would say, is a great opportunity to just take a complete rest day, figure out how the body is feeling, let things calm down. Maybe we focus on just a nice walk outside, maybe we do some mobility work and some soft tissue work to kind of prep the body but I'm cool with day four-ish in that time frame being a complete rest day if that works out into your calendar. It gives us time for the body recover for the nervous system to recover and then it gets us to day five the day before competition. I would suggest that the day before competition you don't do absolute rest. I think it's kind of nice to low level prime the body for movement especially when you're about to do something at a pretty high intensity the following day. So this could be super easy, like moderate EMOM style work, where you're doing a lot of body weight or simple movements. This could be just a zone two kind of monostructural day where we hop on the erg, sorry about that light there, hop on the erg, get some of our heart rate into that zone two level and just do a nice 20, 30, 40 minute cruise control type of workout. But I like the idea of the day before competition, moving the body and taking that rest day, maybe a day or two before competition. opposed to resting right up until that point there. So in terms of our basic agenda, days 1, 2, and 3, you can stay pretty consistent. Day 4-ish, probably 3 or 4-ish, we're going to take a complete rest day and let the body completely recover, maybe focus on soft tissue mobility. And then day 5, we want something smooth and easy, get the body feeling good. If you have any you know problem areas we're doing a little bit of accessory work to tune those up but we're not hitting a hardcore CrossFit style event the day before that competition. A couple other things that I would maybe not do in that week before is I would not go above 75 80 percent of your maximum volume in terms of load so if your programming calls for deadlifts, squats, whatever it might be, some heavy loaded exercise, no matter what, keep that in that moderate, upper moderate range there. I feel like being in that 60, 65, 70, maybe 75% range at the most gives you an opportunity to load those tissues, feel like you're getting something out of it, but also not blasting the nervous system. Our nervous system is probably one of the most undervalued parts of our recovery because it's hard to sometimes assess until you go and perform. But when the nervous system is down, our actual performance will be down as well too. And typically what drops the nervous system is high volume training and high loaded training because we only have so much of the tank to give before we need to recover. So I would avoid hitting heavy, heavy weightlifting the week of. Keep those 75-ish percent or lower. That being said, too, another thing I've seen a lot and had a lot of education on is if your event calls for some sort of weightlifting complex, like a hang snatch to overhead squat to hang snatch complex, I'm just making something up, don't go out and test that thing at max capacity over and over and over again. One of the biggest flaws that I see with our novice CrossFit athletes is that it's something new. It's like, oh, I haven't done this exact complex. I don't know exactly what it's going to feel like. Well, go and test it at that 50%, 60%, 70% maybe. but I see so many people the week or two prior doing it three or four times and what they're doing is depleting their nervous system and when it matters on that Saturday when competition is there, you may in fact lose some by having tested that so often before. So I would, I'm not saying don't trial it to see what it feels like, but I'm saying you should have a good understanding now with all the training you've done before to earn your right to be in that competition, roughly what your capabilities are, and then testing that complex at lower to moderate weights will give you a little bit of an insight to where you think you can be, but you are not going to get stronger by practicing that over and over again in a week or two before that event. So get familiar, but don't blast yourself with those complexes. Yeah, and then the other thing I was gonna say is just don't, in terms of testing, going a little farther, don't test all those workouts that you're about to do at max capacity multiple times either. I'm on board for learning, for strategizing with team, if you have a team event, I think that is great, but do those several weeks in advance. Don't go and blast your body the week of testing an event that you're probably gonna do because that's where we'll see decreased performance and potentially injury risk that will increase when we're doing that stuff there so recap of the week of the week of you're going to train as usual for the most part days one two and three Day three and or four, we're going to take a rest day and let that body completely recover. Just focus on mobility, recovery style stuff. Day five, we want to move a little bit. Lightweights, bodyweight style exercises, throw that into an EMOM format. Get yourself on a ERG machine and do some zone two monostructural work. We want to avoid max effort loads throughout the week to keep our nervous system healthy. We don't want to test everything over and over again. Save yourself for Saturday. You will not lose by not training, but you can lose by overtraining in that week before. All right, so now you're in the day of. Day of competition. This looks a little bit different to everybody, but a few little pointers that I have, some of them will be obvious, but just reminders, is that just stick to your game plan. Hopefully you've thought your process through and trust it. You know yourself as an athlete, your team hopefully has connected, or your training partners, and you know each other fairly well. Don't let other people dictate your plan. Stick to your plan. CrossFit's all about being able to adapt on the fly, which you will have to do sometimes, but don't go in constantly thinking that you have to change your strategy. Trust your strategy and see where things take you. 10:37 NUTRITION ON COMPETITION DAY In terms of nutrition during competition day, I feel like we need to be eating. I think that's an obvious thing to say, but what we eat matters. We see people, Matt Frazier was a good example, who would just slam multiple Snickers bars in a day of competition because he was looking for fast carb glucose intake to replenish those muscles. It's actually not a terrible strategy, but we're not Matt Fraser either. There's got to be probably some moderation to that. I do believe having easily digestible carbohydrates, which may include some sugar and that's fine. A couple little gummy worms here or there, some fruit, maybe some of those protein bars or energy bars that have some carb in it, built in it. things that taste good and that are easy for you to digest are probably best. We need carbs to replenish our muscular glycogen system and just our overall metabolic system. I think getting some protein in is fair, but we don't need to heavily douse protein. We don't need to be eating like multiple burgers that will sluggishly kind of slow you down. So lean proteins, beef jerky, a little bit of pulled chicken, something like that can be a fairly easy type of protein to digest. And then I would say a third thing being fluids and electrolytes. So this is where getting salt waters of some kind, like a element for an example, or your own homemade version of that, getting that electrolyte balance into our body is crucial. You're going to be pumping fluids out, And you can get really scientific with this and weigh yourself before and after an event like some of these higher level athletes do. But I don't think that we have to be at that level. But do replenish your fluids. Be drinking water. Get some sort of electrolyte back into that system. And I think these are going to be two really crucial things in terms of adjusting fluids that are important there. Some of these sports drinks, just read the back. Get smart with these guys. Like read the back of some of these labels and you'll realize that you could make yourself a way better…

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    Episode 1561 - (Re)negotiating your lease Sep 21, 2023
    Show notes

    Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall delves into various lease terms, including flat rate leases, triple net leases, and percentage-based leases. 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 Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day is off to a great start. Thanks for being here today on Thursdays. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as the Chief Operating Officer here at ICE and a lead faculty over in our fitness athlete division. Today, Thursdays, Leadership Thursdays, we talk all things business management, clinic, and practice leadership. Thursdays means it's Gut Check Thursday, so let's talk about this week's workout. We have a little couplet of power cleans and push jerks with a low to moderate weight barbell and some running. So we have 20, 15, 10, 5 power cleans at 95-65 and push jerks at 95-65. After each round you're going to run 200 meters. 20 power cleans, 20 push jerks, go for a run, 15-15 run, so on and so forth. When I sent this to our CEO, Jeff Moore, last night, he said, wow, that seems like a heavy, high-volume barbell workout. And I don't agree at all. This should feel about a 10-minute workout as usual on Gut Check Thursdays. You should be able to pick a weight on that barbell where you can really cycle big sets of power cleans. Maybe for some of you, even hang on to all of the power cleans and go right into your push jerks and really get a high intensity stimulus out of that workout and hit some quick 200 meter runs in between. So goal time, 10 minutes, scale to do big sets on that barbell. I love workouts like this because they're really easy to modify. This is the type of workout that I'll probably give to a patient in the clinic, right? If we can ditch the barbell entirely, we can do some dumbbell cleans and jerks, we can do some kettlebell swings and some landmine press, we can run, row, bike in between. It's a workout where you can take kind of the stimulus and manipulate it a number of different ways to achieve the same result based on the equipment you have and what your patient or athlete can do in front of you. So have fun with Gut Check Thursday. Course is coming your way. I want to highlight our pregnancy and postpartum division as we're rebranding to Ice Pelvic Health. So we have one live course and one online course with a second online course launching in 2024, a level two course, an advanced course. So you can catch that Level 1 course. The next chance to catch that will be January 9th. And then that Level 2 course, which will require the Level 1 course as a prereq, will be launching in 2024. And then some live courses are coming your way between now and the end of the year. This weekend, this weekend coming up, Alexis and Rachel will be down in Scottsdale, Arizona. The weekend, next weekend, September 30th and October 1st, Christina will be up in Hamilton, Ontario, up in Canada. The weekend of October 14th and 15th, Alexis will be in Milwaukee, Wisconsin at Onward Milwaukee. Out in Bozeman, the weekend of November 4th and 5th, again, Alexis. The weekend of November 18th and 19th, again, Alexis will be on the road, this time in Bear, Delaware. That'll be out at CrossFit Bear. That's actually ICE faculty member Lindsey Huey's gym. And then your last chance to catch the ICE public live course this year will be the weekend of December 2nd and 3rd. Again, I'm in Canada with Christina. That'll be in Halifax, Nova Scotia. So check out that course. Our goal with that course, bringing on the second online course, is to have a three-course series that results in a certification and management of the pregnant and postpartum athletes. So that's what's coming your way from the Ice Pelvic Division. 04:31 IMPORTANCE OF LEASE NEGOTIATION Today on Leadership Thursday, we're going to talk about negotiating your lease. And maybe for some of you, this is a thought you have in your mind as maybe you're thinking about beginning your practice of what does it look like cost-wise, what does it look like in practical application to buy or rent a space such as a clinic space where you can set up your practice. And maybe for some of you who are working for somebody else, or maybe already working for yourself, and you are maybe going through lease renegotiation, you're thinking about moving locations, of what are the essentials to look for in a good lease, what are the different options available to set up a lease, and what are some things that we look out for. So let's talk first about what and why this is so important. Of all the expenses that a business can have, your lease or your mortgage, the money you pay for your physical space, is going to be one of your highest expenses, but it's also probably the one that is the only one of all your fixed expenses that actually has room for manipulation. When we think about paying for internet or paying for maybe a fax service or something. Those are fixed costs, but they're unlikely to budge, right? You can't really call up the cable company. You can't call up Comcast and say, Hey, you know what? I think I paid too much for this. I'd like to pay half as much, right? They're just, they're going to hang up on you, right? They'll probably talk to you about bundling or try to give you a 5% discount for six more months or something, but you're really not going to be able to move the needle on that expense. Likewise, payroll, paying our folks is another big expense that's fixed. And that's also not an area where we can really budge the needle on expenses. If you don't believe me, go ask the folks that work for you if they would work for you for half as much money. Again, you're probably going to be met with maybe some laughter or maybe anger if they think you're serious. but that's an expense that we're unlikely to be able to significantly manipulate. It's very different with something like a lease. Based on the current commercial market for commercial real estate, based on even zip code, it may only be a five minute trip down the road to a new location, but based on zip code, based on a number of different factors, there tends to be more room here to hopefully reduce that expense a little bit. So I want to talk about ways to do that. and ways to set up your lease terms and maybe terms you have not even heard of yet. So let's start with there. Let's start our first point. Let's talk about what are the typical terms of a lease. So the most common, the one we're all probably very familiar with, even if you've never leased commercial real estate, you're familiar with this because you've probably done this with an apartment. It is a flat rate lease. This is paying X amount of dollars per month based on the lease terms. We're very familiar with renting apartments, maybe renting townhomes or condos of hey, it's $900 a month and it's a one year lease, right? And usually at the end of that lease, the price probably goes up a little bit and if you're still gonna live there, you renew that lease and you're kind of in that fixed rate lease cycle. 07:36 GRADUATED LEASES The next is really kind of unheard of and very uncommon and falls on you, the person looking for a space to really inquire about it as if it can be an option for you. And that's a graduated lease, where you're eventually going to arrive at a fixed price per month that does not change, but you're not going to start out there. So an example might be you pay $500 a month for the first three months of your lease, Maybe the second three months of your lease, you pay $750, and maybe the last six months of your lease are built up to maybe $1,000 a month, as a quick example. So we're slowly graduating to the full terms of that lease. Why is this helpful? Obviously, it's less money over the 12 months. That's the number one reason. The other way is this is really helpful when you're first beginning your business. When you first hand your shingle, you probably don't have a full clinical caseload, which means the revenue coming into your business is probably not where you would want it to be to maybe even pay the full amount of that fixed rate lease. So negotiating for a graduation of the understanding of, hey, I'm not making 100% of the revenue I believe I can make currently. Can we kind of step up to that amount over time? This is a great idea, a great model to pitch, especially if you're not renting your own building or space. If you're thinking about starting up a side hustle in the corner of a gym, and you're literally just getting a portable treatment table in the corner, you're not getting a lot for your money, so the idea of spending maybe $1,000 a month to have 20 square feet in a corner is less than ideal, especially when you're first starting, of hey, can we just see where this goes? Can we do $200 a month for the first three months? Can we do 400 for months four to six? can we do 600 months six through nine and then maybe months nine through 12 we're at 800 a month and then we can revisit at the end of the year what changing to a fixed rate amount might look like. So this gives you some breathing room that you don't have to rush out and think about stressing and worrying about maximizing your revenue from day one. It gives you that kind of room and time to go out and market your clinic and not just thinking about maybe I need to be working in home health or something to even pay for this lease and I don't actually even have time. to see patients at my own clinic because my lease is so high. So graduated lease is a really great option that's often not really thought about, not really offered, something you may have to ask about, but something that a lot of business owners, especially if you're subleasing a space, might be very open to because for most of those folks, that space is empty anyways and they'd rather have you paying more and more and more over time than paying nothing at all for that space. 11:01 TRIPLE NET LEASES The next type of lease is something that almost no one is familiar with unless you live in a really big city or you deal with really serious commercial real estate, and that's called a triple net lease. How a triple net lease works is you pay a little bit of money for the actual principal on your lease, but a lot of the cost of your monthly payment is a shared split of usually the insurance for the building, the maintenance costs for the building, and the taxes for the building. So this is very common in bigger cities where you have multiple businesses inside of the same building, where you have a shared entryway. When I think of a triple net lease, I think of the flagship Onward and Onward Charlotte, where there are, I think, 12 businesses in a three story building, a couple businesses per each floor. That is usually where you will see a triple net lease of the taxes, the insurance, the maintenance costs for that building, are all kind of added together and then divided among the number of leases inside of the property. So this can be a great way to get a cheaper lease, especially the bigger the building. Yes, more maintenance costs, more taxes, more insurance, but more people to spread the cost across. So overall, a pro to this approach is we tend to see cheaper rent and overall a cheaper lease payment because those costs are shared. Now there are some downsides here that we need to be aware of. If you're the first tenant in a brand new building, you have no one else to share your costs with, right? So asking if that does happen to be you and the lease is a triple net term of how does that work with the sharing of this cost? Am I expected to pay 100% of it because I'm the only business in this building currently? That's not ideal. Or is the landlord going to assume the majority of that as more and more businesses open up inside of the common building? The other concern there is that overall physical therapy is really low maintenance. When we look at actual property wear and tear, maintenance, that sort of thing, we don't tend to damage a lot of the buildings we're in. We might have some scuff marks on the door frame from maybe folks coming in and out with with walkers and wheelchairs and things like that. But you don't tend to see a lot of big property wear and tear in a physical therapy clinic, which means in a triple net lease, you could make the argument that we're probably paying more than we need to because we use such a small amount of the shared spaces, especially in something like the bathroom as well. physical therapy clinics are not nearly as business busy as a business like a gym or a restaurant where maybe hundreds of people per hour are coming and going and if they're using maybe shared bathroom spaces they're really causing the majority of the maintenance costs for that compared to your clinic. So just being aware of how many tenants are in the building and also what are their business types. Is there a lot of foot traffic? If so, that's going to jack up the overall maintenance cost of the building, which is then gonna be passed on to you as one of the tenants in the building. So be aware of those factors if you're thinking about a triple net lease or you're being offered a triple net lease. The last type of lease type available is something we should never do, which is a percentage-based lease. We should never do this, first of all, because it's illegal for us to do this as healthcare providers. Getting into a negotiation where you pay 10% of your monthly revenue as your lease, what that looks like, how that functions, is essentially kickbacks. We are not allowed to be involved in any sort of kickback system as healthcare providers. Does it happen? Yes, but part of being a business owner is managing risk and one of the biggest things you get in trouble for. is something like that. So knowing that you should not do this, this also just becomes weird of now if your rent is based on a percent of your revenue. First of all, the payment is different every month. It's not going to be exactly the same. It's going to fluctuate up and down. So that's always a little bit awkward. The other awkward part is now you have to sit down. You either have to give complete access to your landlord, to your financials so that they can look and say, I will be the one that calculates how much you owe me. Or you need to sit down monthly and give that information to your landlord. And that just doesn't feel good for one business owner to just be laying open how they do their operations and financials to another business owner. The issue with this, aside from it being illegal, why it's not good for business, is that in general, a physical therapy clinic can expect linear growth. As my caseload gets more full, I see more patients, my revenue increases. When I reach the point at which I have no more time, in my…

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