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Episode 1539 - ITB myth busting Aug 22, 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 debunks common myths surrounding the IT band. Mark emphasizes the importance of exercise in enhancing function. He mentions two types of exercises: local tissue exercises and functional activities. Local tissue exercises are designed to respect the irritability and stress levels of the tissues. These exercises may include variations of hinge movements, knee bends, or squats that are unloaded enough for the individual to handle. They provide a healthy stimulus to the tissues and help build strength and capacity.

Functional activities, such as step downs, squats, and deadlifts, are also incorporated into the treatment plan. Mark explains that coaching these functional movements is crucial in helping the individual return to their normal activities. By gradually increasing the training volume and appropriately dosing the force, they can both manage symptoms and provide a beneficial stimulus to the tissues.

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 INTRODUCTION Alright, what is up PT on ice crew? Hope you're doing well on this Tuesday morning. I'm Dr. Mark Gallant coming at you here on clinical Tuesday. Lead faculty of the extremity management division alongside Lindsey Huey and Eric Chaconis. Want to talk to you today about IT band syndrome and some common myths. Before we get into that, we've got a few upcoming courses. So I'll be in Amarillo, Texas, September 9th and 10th. So a lot of tickets flying off the shelves for that one. So make sure if you're in Texas and want to check us out on for extremity management, that you get some seats to that. And then the following weekend, I'll be in Cincinnati, Ohio at Onward Cincinnati. So love to see you out there for that one as well. Again, for any of the ice courses, if you have not already signed up for the ice course that you want for the fall of 2023, the courses that are on the website are the only courses that are going to be added for this year. So make sure make sure you hop on there and sign up as soon as you can. 02:38 COMMON ITB BANDS So IT band myth. So IT band syndrome is one of those syndromes that we had a lot of ideas that came out of research from the 70s, 60s, even early 80s that for whatever reason or another have stood the test of time and stayed in our profession for over 50 years. And that's influenced a lot of the way that we treat a lot of the common manual therapy we see, the interventions we see. And we've got a lot better research that's come out in the last 10, 15 years to direct us how to treat these these IT band patients. And so we want to look at that. This is not to bash the researchers that have come before us. So Renee and Ober and those folks that did a lot of the research in the 1970s. We owe everything we know now to them. And I sincerely hope in five years, six years, a lot of you are looking back at these podcasts and go, man, like all all the stuff that Mark was saying or his colleagues at ICE, it seems kind of silly now. That's what we want to happen. We want you all to take everything we're we're looking at now and make it way better over the next five or six years. So so thanks to Ober. Thanks for Renee. And now we can stand on their shoulders and really move forward. So what were some of the common myths that came out of that research in the 70s? Well, the first one is that the IT band, the iliotibial band track starts at the proximal hip with the TFL and glute. And then it has a very simple unidimensional insertion point at Gertie's tubercle. So one single insertional point for that big, massive iliotibial band structure. What we now know is that the the iliotibial band insertion point is actually quite more complex than that. It attaches at the tibia. It attaches at the lateral femoral condyle. It attaches to the patella. And not only does it attach at multiple sites, these attachments are firm. So so that that distal IT band is not really moving very much at all. The second myth is that the IT band is tight. That that iliotibial band is going to get tight and it's going to limit that person's hip adduction. What we now know is that the structures that are most commonly going to limit someone's adduction are the glute medius, the glute men and the joint capsule. So the IT band is rarely going to be the primary driver of limited adduction. And the TFL, the glute max, the structures that it attaches to are also not typically going to be the primary driver of adduction. What we then see is the third big myth that that iliotibial band syndrome is a pain dominant syndrome being caused by a friction of that iliotibial band rubbing along the lateral structures of the knee because it has a unit dimensional insertion point. Because that thing is tight that it's starting to rub. And that makes a lot of sense going after those those old ideas. Right. If you've got a certain kind of problem, you can go to the doctor's office and you can get a prescription. If you've got a single insertion point and there's extra force causing that that to be tight and it starts to rub, certainly we can see tissues being irritated because we now know that it's got a complex insertion that's really firm, that the IT band is rarely tight. What we now know is that the typical pain presentation is often being caused by repeated force due to an increase in volume change in that person's activity and the lack of frontal plane control. So the most common thing you're going to see is someone really picks up their volume of running. They've got they've got poor control over the hip, knee and ankle. And that knee starts to ping in when you get that at a really, really high volume, the opportunity for the lateral structures structures of the knee to become sensitized gets significantly increased. Another one we see it in is as folks who do a lot of downhill running, they increase their trail running their downhill running by by high volume. So you're getting a ton more load into those those structures and you're getting that lack of frontal plane control and those tissues are going to get irritated. So what are we going to do about that tissue irritation? So so like any other pathology that we're going to treat, our first step is to calm things down. We want to put out that fire initially.

05:30 CALMING DOWN TISSUE IRRITATION

So with IT band syndrome, the primary thing that you're going to do to put out their fire is you're going to you're going to get control of their volume. All right, Chris, you were running 10 miles a day, five days a week. We're going to cut that down to five miles a day for three days and see if we can calm that tissue down. So it's rarely full on abstinence. Where we like to start is can we find that sweet spot where your symptoms are starting to calm down and we're still keeping you involved in your functional activity? So whether it's running Olympic lifting, whatever the activity may be, can we control the amount of load, the volume of force that's going into that system and get those symptoms to calm down? In addition, using using our manual therapy techniques to modulate pain. So you're dry needling, your myofascial decompression, your soft tissue mobilization. You're going to base these off irritability. If that person's high on their irritability, then we're often going to needle massage and cup tissues that are a little more distal to where the pain is at that lateral knee. So looking a lot at the glutes, maybe lower down on the ankle. And then as symptoms calm down, we can get at the tissues more more close to that knee, that tibialis anterior, the distal vastus lateralis, the short head of the biceps and really try to modulate people's our patient symptoms and and get those tissues a little healthier. From there at the same time, so we're not waiting until the pain modulation comes down, we're going to start doing some therapeutic exercise to get those tissues to tolerate load better. So we've got to strike that balance of we're trying to lower their symptoms and we want some healthy, good force to go into their tissues. So oftentimes that can be open chain exercises. So they're going to have typically a little less load on the tissue because you're not dealing with so many structures. You're not dealing with ground reaction forces. So keeping that that low to improve the overall tissue health and then progressing them into more closed chain exercises that are going to stimulate those tissues in a little bit closer environment to their typical activity. So things like hip hikes, closed chain clamshells, your side steps, all those sort of things. Then we want to get into some functional exercise. Can we get compound movements that are going to be close to the activity that that person is typically doing with those compound movements for IT band? We're looking at things like step downs, single leg squats, all of those type of activities. Kickstand deadlifts are another good one. 08:25 PT 1.0 & MOVING FORWARD Now we're PT 1.0. A thing that we did in our profession that we would like to move on from now is we said, OK, we're going to do our local tissue stuff. And when you get good enough at the local tissue stuff, then we're going to graduate you into doing these functional components. What we what we know now is we want to get all of this involved as early as possible so that we can influence the nervous system better and make that person less fearful of doing these these more challenging activities. So you're going to hit your local tissue exercises, respecting their irritability, respecting the amount of stress that that tissue can handle. And you're going to start doing variations of functional activities that they can tolerate again with their pain level, their irritability and their stress. So finding a hinge variation that's unloaded enough that the person can perform, finding a knee bend variation or squat variation, single leg squat variation that's unloaded enough that that individual can handle. So that's two components, local tissue with three components, pain modulation with our manual therapy, local tissue exercises to get some healthy stimulus into those tissues. Looking at a functional activity, squats, deadlifts, all those sort of things. All these are happening relatively at the same time. And then the fourth piece is looking at the activity that caused the problem. Was it running? Can we get them on the treadmill and do do a run a run gate analysis? Shout out to Jason, Megan and Rachel in the in the injured runner division. Can we look at their their Olympic lifting? Are they getting IT band syndrome because they started doing split jerks all the time and that position of their knees a little bit irritating? You know, the whole CMFA crew, can you really look at and coach well through a video analysis what that person is doing on their their Olympic lifting and start moving them forward there? So we're going to modulate the pain by controlling their volume. We're going to modulate the pain by using some manual therapy to influence the central nervous system to calm those tissues down. We're going to start exercising, getting good healthy stimulus while respecting irritability into the tissues through open chain and closed chain local tissue exercises. We're going to get a big functional movement, step down, squat, deadlift to start building robustness and capacity overall. And we're going to coach them on the functional activity that may have been the aggravating, whether that's running, downhill running or or their Olympic weightlifting. Now, what this does that's really cool is it positions you as a wildly unique provider to this individual. We are the only profession or one of few professions that are able to control that entire experience for that person. We've got the education where we can control their training volume. We can say, hey, look, I looked at your programming. Looks like you had a huge jump here and all of a sudden you're doing like three times the volume. Let's see if we can cut that back a bit. You can poke them with some needles. You can do massage. You can do myofascial decompression. You can do joint manipulation to calm that lateral knee down. You're the expert in local tissue exercise. You know, if I put this amount of force into this tissue and dose it appropriately, we can both keep symptoms calm down and give a good healthy stimulus to that tissue. You got to know how to coach the step down, the squat, the deadlift to get them back to their functional movements. And we've got to start getting better at being able to do those run gate analysis, video analysis for the big lifts, the Olympic lift, the squat, all those that we can really coach those well. And that will uniquely put you in a position to take that person through a whole plan of care and get them back to the things they love. That will really position you as the best possible guide. So again, to recap, IT band syndrome, we no longer believe that this is a friction based component because we now know that the IT band is firmly anchored to that lateral knee at the tibia, the femur and the patella. We know it's more of a volume increase and a lack of frontal plane control that's really irritating the system. If we can get that frontal plane control by getting a better step down, a better squat, better functional movement, use our local exercise to get better healthy stimulus into that lateral knee so those tissues can tolerate increased stress and improving our efficiency with the movements that we want to do, our running, our Olympic lifting, those sort of movements. Hope this helps. Love to discuss this more in the chat bar. Can't wait to see you all on the road in a few weeks. Hope you have a great rest of your Tuesday.

13:01 OUTRO Hey, thanks for tuning in to the P.T. on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at P.T. on Ice dot 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 P.T. on Ice dot com and scroll to the bottom of the page to sign up.

Episode 1538 - Acute effects of resistance training on the pelvic floor Aug 21, 2023

Show notes

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Christina Prevett breaks down two recent studies, one that is VERY new to challenge beliefs on prolapse, the pelvic floor and strength training. 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 slash guide. Use the code ICEPT1MO at signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show. 01:22 CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the team within our pelvic health division. If you are interested in learning more about our pelvic health division, we have a online newsletter that goes out every two weeks that focuses on the research, which I'm going to talk about today, in pelvic health. One of the things that is so exciting, but maybe a little bit overwhelming about being in public health and being in this area of exercise and rehab in the pelvic health space is that it is constantly changing. The research is coming out at a very fast pace, fast being relative because research is very slow, but we try and focus in on getting that research to your inboxes every two weeks. You can go to PTonICE.com slash resources and sign up for that newsletter. I am writing it this week and it goes out on Thursday. Also all of our online content, our next online cohort, and all of our upcoming live courses, our two-day live course is in that email newsletter. I hope that you all sign up to get all that research straight to your inbox. 02:48 ACUTE EFFECTS OF RESISTANCE TRAINING Today I'm going to be talking about a new study that came out of Carrie Bowes' lab, talking about the acute effects of resistance training on the pelvic floor. And so before I do that, I kind of want to set the stage for you all around some of the thoughts in pelvic health around heavy strength training. Where we have started this journey was that one of the risk factors for pelvic organ prolapse or descent of one or more of the vaginal walls towards the vaginal opening is that occupational heavy lifting. So individuals who lift heavy weights for their job, consistently lifting heavy weights, were shown to be at risk for more objective descent of one or more of those walls compared to those that didn't. And that because we didn't have any research on resistance training was extrapolated and said, well, maybe we shouldn't do any strenuous heavy lifting as females in order to mitigate or prevent the risk of pelvic organ prolapse from occurring. That was kind of the thought. Since then, we have really pushed back against that narrative and said, well, that doesn't really make a lot of sense because it's very different to go in for eight hours a day doing lifting versus, you know, the 30 to 90 minutes that individuals are doing. In your job, you can't control if you're feeling bad or feeling weak and just take a rest day or modify the way that you're doing your exercise. So again, there isn't really that comparison. 04:24 ACUTE CHANGES TO THE PELVIC FLOOR And now we're starting to get more and more research come out that's talking about kind of this acute change to the pelvic floor that we're seeing with different amounts of strength training or different types of strength training. So Carrie Bo came out with a study and what she was doing was she was taking individuals who were resistance trained. So on average, these were individuals who had never had kids. They were Nellie Parris. And so I never had a delivery and were trained resistance trained athletes. So they had on average about two years of experience. They were then put into a crossover design. So what that means was they took half the individuals and got them to strength train first and then took half the individuals and got them to rest first and then kind of compared. So what they were trying to look at was after a high load resistance training session, what was the impact on the pelvic floor? The thoughts were one of two camps. There's two camps in this space. One is that individuals who strenuously lift are going to have bigger pelvic floor muscles, stronger pelvic floor muscles. And the other is that it may actually create damage over time that they're going to see a big change in symptoms or change in vaginal descent. So you kind of have individuals in both of these camps and we're trying to figure out which hypothesis is correct. And so they took, they did a one rep max or a perceived or rate of perceived exertion that was very high in the squat and the deadlift on one day. And then they got them to come back the next day. So after that one rep max test, they kind of flushed out, let the body recover, came back in. Half the group started with a rest window. So took pelvic floor muscle strength measures at the beginning pre, then half of them rested and did a post and then half of them did a four by four strength training session between 75 and 85% of their one rep max on the squat and the deadlift with reps in reserve between one and three and then did a post assessment and then they flipped, they flipped them. So what they saw was that there was no big differences, no statistically significant differences between the rest pre post, but then also the resistance training pre post. And I think that's really interesting because one of the things that we kind of explain around our, our thoughts around heaviness or prolapse are things like that it's a fatigue issue or so maybe it isn't fatigue or maybe it is, but doing a supine assessment, which is our traditional way of conceptualizing pelvic floor muscle strengthening, isn't sufficient to look at this type of, of fatigue, like to really evaluate this type of fatigue in individuals who are experiencing these symptoms. So that was really interesting. The other thing was that, you know, they did see some individuals who complained of urinary incontinence in this sample around 28%, I believe. And so those individuals, the study wasn't powered enough to be able to subgroup those that experienced incontinence versus those that didn't, but there, what it was not just on individuals who were symptom free. I think that's a pro to this study because we can say, well, of course there isn't any fatigue or any downstream effects of individuals who've never experienced pelvic floor dysfunction, but that's not the case in this study. There was a significant cohort of these individuals who did experience leaking with lifting and the study just wasn't powered enough to subgroup this out. So the first step was to kind of take a full circle approach and say, was there any differences? And then the next step is going to say, is there any differences for individuals who do experience pelvic floor dysfunction versus those that don't? And then the next step is those that are multiparous or multiparous, like multiparous, we kind of, tomato, tomato, those who have had vaginal deliveries before or have given birth before vaginally versus those that haven't. And so this is kind of setting up this conversation around the way that we message things. So another study was done in 2016 and I just found it because it was in the discussion section of this paper around vaginal descent. So Carrie said the Bowe study was looking at pelvic floor muscle strengthening, pelvic floor muscle strength and assessment. 09:23 VAGINAL DESCENT AND EXERCISE The next question is around vaginal descent and are you more likely to experience symptoms of prolapse or heaviness post resistance training? And so this study was done in 2016, I believe it was published out of Janet Shaw and Ingrid lab that was looking at CrossFit athletes, those who experience, sorry, those who participate in strenuous exercise. So they got CrossFitters and they got them to do pre-post on the pop cue versus those that participate in non-strenuous exercise. So let's kind of break this study down too, because I think it's important. So in this second, this, I guess it was the first study, what the group from Nygaard and Shaw's lab did was they took individuals who were CrossFitters, got to check their pelvic floor muscle strength and the pop cues. The pop cue is an objective assessment of prolapse that has good reliability that looks at the different segments of the different walls of the vagina. And then as they do a strain maneuver, they see what the range of motion or the amount of each segment of each component of the wall are, and then create a grade based on the most amount of movement in whichever section of the vaginal wall that may be. So they took individuals who were CrossFitters and then they took individuals who participated in non-strenuous, non-high impact exercise and got them to come into the lab. And then the strenuous group was, they did a pelvic floor muscle strength exam and then the pop cue and then in the non-strenuous group, they did the same thing. And then they got the CrossFit group, the strenuous group to do a 20 minute AMRAP of sit-ups, heavy deadlifts. There was an impact movement in there and kind of went for 20 minutes. And then they got the non-strenuous group to do 20 minutes of an exercise of their choice at a self-selected pace. And then they did the pop cue again. Here's something that's really interesting. So the strenuous group was participating in CrossFit for over two years. They had an extensive history of strenuous exercise versus the non-strenuous group. And they kind of conceptualized this based on looking at what they did for exercise and the amount of loading in their bones to try and get some sort of measure of impact, which I thought was kind of brilliant. And they compared them. Strenuous group had done a lot more loading of their bones and musculature and therefore loading of their pelvic floor compared to the other group. And what they saw was that before their pre-exercise, descent in pelvic floor muscle strength was not different. Was not different. So this created preliminary research that the strength, individuals who are participating in strength training for several years, so it was like on average 22 months plus or minus, and they had to have at least, I think, a year of doing CrossFit regularly, three to four times per week to be able to get into the study in the first place, that there was no difference in vaginal descent. They had, there was no differences between the two. So that kind of goes against this argument that resistance training is going to cause a prolapse, resistance training in general for individuals who haven't had a vaginal birth yet. So I think that's interesting. And then post-partum, or post-exercise rather, they did see differences in descent in both groups. So both groups saw a difference in descent immediately post-exercise, which again, I think is really interesting because this does not support that resistance training and high impact is going to lead to prolapse down the line. Now again, we have a lot of work to do within this space. This was one study. I'm not going to just start shouting from the rooftops that all of a sudden, you know, we know all of the things that we need to know. I'm not saying that, but the fear focused language that is coming into this space around resistance training and avoiding Valsalva and all these types of things isn't founded objectively. So the other interesting thing was that there was only one individual, even though there was a change in descent, right? There was some changes pre-post-exercise and they didn't re, they didn't kind of follow them further and further forward. I would have loved to see them do multiple time points to see how long it took before that changed or kind of returned to baseline. There wasn't anything that, that was looking at what, what that change of symptoms were. 12:57 RESISTANCE TRAINING & PROLAPSE And there was only one person with subjective symptoms of prolapse. So again, we're, we're seeing this disconnect between objective signs and subjective experiences, which I think again is really interesting because we are focusing a lot on the grade, like what grade do you have? What grade do you have? And the evidence isn't really supporting that we, that should be our focus. If you are thinking surgical routes, if it is coming past the level of the Hymen, absolutely, because then we're going to say, is this impacting your quality of life? Is there sufficient imaging data to see that a surgery, for example, would be warranted? For individuals in the conservative space, again, we're, we're, we're questioning, does the objective signs matter? And, you know, we can't answer that question, but it is an interesting thought experiment and we're starting to have more evidence accumulate that, you know, there is a big disconnect. And yes, our body is going to change and show signs of fatigue with things like impact, but what's the cost benefit? What is the risk of telling people that they shouldn't be getting strong for their 60-year-old self, for their 70-year-old self, for their 85-year-old self, when we know that strength is such a huge, huge component of independence in later life? So it is so exciting, kind of going through Carrie Bowes where she didn't see any change in pelvic floor muscle strength to some of the research coming out of the Nygaard and Shaw lab that are talking about changes in pelvic organ support with heavy lifting and long-term heavy lifting. I think we're starting to get more and more data that the fear-focused messages aren't warranted, that we're going to start treating the symptoms and that we can expect changes to the pelvic…

Full show notes at the publisher

Episode 1534 - Invisible physical scars postpartum Aug 18, 2023

Show notes

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses three postpartum physical scars that are often invisible to rehab providers. She explores how these scars can impact exercise prescription for clients in the early postpartum period. 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. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today's show. 01:27 APRIL DOMINICK Welcome to the PT on ICE Daily Show. Dr. April Dominic here. I am your host representing the ICE Pelvic Division. Today we'll focus on three postpartum physical scars that are often invisible to the rehab provider. We'll talk about how these scars can affect exercise prescription when it comes to working with a client who is early postpartum. But before we dive into that, let's chat about all things, updates and course offerings for the ICE Pelvic Division. If you're looking for a virtual option to learn all things fitness, athlete, pregnancy Our next Level 1 online cohorts starts September 5th. Otherwise, you can catch us on the road. We've got tons of courses coming up for this fall. And our next one is September 23rd and 24th in Scottsdale, Arizona. This is going to be with the lovely Dr. Alexis Morgan and Dr. Rachel Moore. This course is chock full of literature outlining the ins and outs of pelvic floor basics, pelvic floor dysfunction, the assessment for the pregnant or postpartum fitness athlete that includes an external exam or an internal exam option. We also have a lot of super fun labs that are going to cover core and c-section management. We also have tons of labs on reintroducing or continuing to use the barbell, do rig work and endurance exercise. Please go hop on PTONICE.com. Get yourself in one of our courses. We would love to see you there virtually or in person. 03:23 PHYSICAL SCARS POSTPARTUM Today I wanted to hop on and shed some light on physical scars that a postpartum body endures early on. These scars aren't always visible or front of mind for the rehab provider. So think about it like this. You may have someone who is coming in very early postpartum due to some sort of orthopedic injury like for their hip, their shoulder, maybe their back, or they may be coming in for core and pelvic floor work. So it's important for all of us to be aware of these scars as they heal and the role that they play early postpartum with movement and exercise prescription. So when someone is pregnant, there is usually some sort of baby bump or something that is a visible reminder to others of their condition that they are pregnant. Enter the postpartum period. For many postpartum folks, those visible reminders of pregnancy fade and the physical impact the labor and delivery on the body are invisible to others. When someone is postpartum, there's no physical sign that they and their body have gone through this incredibly challenging feat. There's no cast for like when we have for a broken bone. There's no crutches for that ankle sprain. There's no sling to support the wounds. Unless maybe they have their newborn with them, there's really no obvious physical sign that someone is recovering postpartum. So three invisible scars that we'll chat about today are the uterine scar, the perineal scar, and the lower abdominal scar from a cesarean section. Let's circle back to wound care from school. Remember for our healing stages, our tissue healing goes through four major stages. Starting with the first couple, the hemostasis and inflammatory stages. This is going to be a period of local swelling. Next, the proliferative stage. And that's going to be the stage focusing on covering and filling the wound. And then the remodeling stage is characterized by scar tissue formation, which this can last for a year or two, if not. So let's unpack those three major postpartum scars. The first, the uterine scar. I feel like this is the most invisible. It's as the name indicates, a wound on the uterus. And in terms of time to heal, the uterus typically involutes or returns back to its pre-pregnancy size that's smaller by six weeks. And muscles that may be impacted by this scar, by this wound on the uterus, would be indirectly the pelvic floor and the abdominals. In terms of considerations to return to movement when we're thinking about uterine healing, if someone does some physical activity and there is an increase in vaginal bleeding, then that is going to be a sign for regression that the uterus and body may not be ready for that specific intensity level of physical activity or the duration of physical activity. 07:33 PERINEAL SCARRING Our second scar is the perineal scar. In terms of where it is, it is on the perineum. And the perineum is the tissue that's between the vaginal opening and the anal opening. A perineal scar or injury may occur due to a large stretch on the tissue at the vaginal canal as the baby exits through that vaginal canal. In terms of time to heal, a majority of the stitches are dissolved by about two to four weeks. So there are two ways to tear the perineum. And that's either naturally or via an episiotomy. And that's going to be when the provider actually makes a cut in that perineal tissue. In terms of levels of severity of the perineal tear, there are four. The first degree is the licevier. It's small, skin deep. The second degree is going to involve the muscles of the perineum. The third degree is going to be a tear of the external anal sphincter. And that is what we use to keep poo in or keep poop out, like allow for defecation. And then the fourth degree tear is going to be the most severe. And that's going to be a tear that likely involves the internal anal sphincter, the external anal sphincter, and the rectal mucosa. One time I was talking to a group of OBs and one of them said, you know, we were talking about perineal tears. And one of them said, you know, the vagina is just simply remarkable. It gets to heal in real quick and nobody F's with that vaginal tissue. So that is the one good thing about perineal tears is that the vagina takes care of business. So muscles that are impacted by the perineal tear, the pelvic floor. And then when we're thinking about return to movement with someone with a perineal scar, movements that are wide-legged, like maybe a sumo squat or lateral lunge or really deep squat, there may be some discomfort at that perineum due to that stretch on the tissue in those wide positions. 09:01 C-SECTION SCARRING And then we have our C-section scar. So where is it? I'll talk about the most common cut that is done is called the bikini cut. And then it's about four to five inches long and it's stretched across the lower abdominals. In terms of time to heal, that's going to depend on various factors. But some scars start to close at the skin level as early as two weeks. And then we know by six weeks, generally speaking, the scar is fully healed if there are no complications. And that's about the same timeline that someone is likely returning back to their provider. Some complications with scarring may be hypertrophic scarring or keloid scarring. And the keloid scar is going to be when the body over heals and the scar tissue extends beyond the original boundaries of the wound. So we want to make sure that we are referring them back to their provider if that is the case, if we happen to see that scar on the client. We know that around six weeks, abdominal tissue has only regained about 50 percent of its tensile strength. And by six to seven months, it's approximately in the 75 percent range of its tensile strength pre-incision. And muscles that are impacted by this scar, the C-section scar, are going to be our abdominal group. So the rectus abdominis, internal-external obliques, and the transverse abdominis. 14:01 CORE-CENTRIC MOVEMENTS & EXERCISE In terms of considerations for return back to exercise specifically for a C-section scar, we're thinking we got to watch for that core heavy work, any sort of rig or gymnastics-based movements, or any lifting that may involve some sort of contact at the lower abdomen. So those are the scars. Now let's talk about two movement categories more in depth that may be affected by those scars. We have the return to exercise and then return to intimacy, which we'll dive into. So in terms of movement early postpartum, when dosed appropriately, it can assist in so many areas of recovery. We're talking reduction in postpartum depression risk or reduction in risk of blood clot, promoting tissue healing, promoting getting better sleep. That's just to name a few of why movement is important early postpartum. But when it comes to exercise, variables such as sleep and fuel not only influence the risk of injury and recovery, but they also directly relate to the energy status needed to participate in exercise. So sleep, we should be getting nosy and ask about sleep status. Be realistic and recognize that you're talking to a person with a newborn. So their sleep is going to look a little different given the newborn schedule. But we do want to make sure that the client in front of us is optimizing their sleep. Are they creating the best environment? Is it a cool environment? Can they make everything dark? Can they talk with our partner and be like, hey, I need this chunk of time for sleeping. Can you handle the baby while I do this? And then maybe they switch. In terms of fueling, are they able to nourish themselves with nutrient dense packed meals that are full of protein, packed with plants, reduced processed sugars that have sufficient calories, especially caloric intake is important, especially if someone is breastfeeding. They'll need about 400 to 500 extra calories. Okay, let's talk about return to exercise. Generally speaking, when we're talking about return to exercise for someone who's early postpartum, it's a great idea to start somewhere close to where they left off at the end of pregnancy and then build tolerance from there. Early postpartum, that's a time to determine the body's capacity for tolerating exercise. As a provider, it's helpful to have a conversation with our clients about ways we can manipulate exercise dosage to meet their current needs of their current physical status. These modifications are temporary. This is something that we want to communicate with them. We want to educate them on signs for regression with, hey, they did a certain workout or did certain exercise and then, hey, they experienced some leakage of urine or fecal matter. They had some pain or increased abdominal discomfort or vaginal heaviness. So we want them to communicate this to us so that we can then show them how we can alter a workout if needed through load, through adding rest intervals, maybe modifying the intensity or changing the volume and duration. That way they can still continue exercise without symptoms. So now let's talk about scar types and different types of exercise such as core, impact, or lifting. So during the early days and weeks postpartum, walking, reconnection with the core, the pelvic floor, and breathing is a really great place to start. This is going to be when we are starting to add in a little bit more after the first early days or a couple weeks. So with core-centric movements, as we move towards adding more intensity or load, we want to ensure that that abdominal incision is healed to avoid dehiscence. We can begin to experiment with its tolerance, with the anterior abdominal core walls tolerance to stretch in all planes, specifically going into extension, flexion, side bending both ways, rotation, a combination of all those movements. We want to be mindful of tolerance to pressure on the scar, whether that's pressure from simply just the workout clothes, or maybe they are baby wearing while they work out and they have some irritation there at the abdomen. Or maybe it's increased pressure at the abdomen from a set of dumbbells when they're doing a hip thruster, or when they slam down onto the floor with a burpee, or the rig or barbell making contact with the abdomen during gymnastics movements or lifts. With return to impact exercise, such as walking, running, or jumping, we want to be mindful that someone with a vaginal delivery and significant perineal tearing could experience an increase in their pelvic floor symptoms. Remember symptoms reported may be heaviness, vaginal bleeding from the uterine scar, or irritation of their perineum. And someone with a C-section could also experience these as well, but we're thinking that it may be more common with someone with a vaginal delivery or more likely to happen. So with return to impact, we're going to find their guidepost in terms of how much impact their body can tolerate, whether it's starting with a walk around the block, then adding a few more blocks each day, or if it is explosive calf raises, single unders, or step ups. And then for return to lifting, maybe we start with a PVC pipe, or a light kettlebell, or a barbell only movement. This is going to allow the client to re-familiarize themselves with the movement pattern, say of a clean or any sort of overhead press, and then they will be simultaneously building tolerance and in ranges of motion and load at their perineum and abdomen, where some of their scars may be. So return to any exercise will be person dependent, but knowing their history, mode of delivery, current symptoms, and scar status can help you guide them. And bonus, maybe this is a time that they slow down and dial in on foundational pieces of complex lifts or impact training. 18:07 PAIN WITH INTERCOURSE Besides return to exercise, we also have a different return to movement, and that is return to intimacy, specifically penetrative intercourse. Once cleared by their providers, return to penetrative intercourse, the postpartum person may run into difficulty tolerating that vaginal penetration. This could be…

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Episode 1537 - Post-CrossFit Games for the rest of us Aug 18, 2023

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Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Mitch Babcock discusses that consistency in the gym, combined with attention to lifestyle factors, can lead to significant rewards in terms of fitness and overall health. By being present and dedicated to regular training, individuals can see improvements in strength, conditioning, and cognitive function. Additionally, by addressing lifestyle habits such as sleep, nutrition, and alcohol consumption, individuals can further enhance their fitness journey and ultimately live longer, healthier lives. 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 slash 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 slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 01:26 MITCH BABCOCK Hey, welcome everybody. Welcome to the PT on ICE Daily Show. Welcome to Friday. Welcome to Fitness Athlete Friday. I'll be your host today. Mitch Babcock, lead faculty in the fitness athlete division, all things online and live course. And it's been a minute since I've been on the podcast. So I'm excited to be back joining all of you this morning. So thank you. First of all, if you're downloading us, listening to us on your way to work, if you're on live with us on Instagram or YouTube, thanks so much for making this part of your morning or your evening, whatever it is for you. And thanks for downloading wherever you download your podcast from. We always appreciate it. Don't forget we're the only daily physical therapy show on the market. So thank you for subscribing and liking and signing up for those automatic downloads. It really means a lot to the whole team here at ICE. Before we jump into today's topic, which is post CrossFit Games for the rest of us. Okay, I want to talk a little bit about some of the courses that we have coming up for the live division. We have a very busy September in October and even leading into November and a couple courses in December. So looking at Q3, Q4, we've got quite a bit on the books. The fitness athlete team as a whole was a little quiet through the summer. As our team, many of us on the lead faculty, not us, but others on the lead faculty, welcomed some new additions to their family or kind of spending some time at home. So the summer months were a little quiet and we're excited to ramp up on the road here in Q3 and Q4. So you can find us all over. Zach's going to be out in the Bay Area here in September. The end of September you can find him out in California. I'm going to be out in Seattle, just north of Seattle in Linwood with Joe as well. We got a course in British Columbia coming up, Alabama, San Antonio, Florida, New Orleans, Colorado Springs. We're hitting some big cities and covering a large part of the map this fall. So if I just named off any cities, your cities or near you, please check those out on the PTA On Ice website. We'd love to see you at one of the live courses. 02:16 POST CROSSFIT GAMES All right, let's get into today's show, shall we? If you didn't tune in last week to Kelly Benfey's episode on her post CrossFit Games Reflections, you should definitely do that. CrossFit fan or not, whether you train this stuff or not, you need to understand the level at which Kelly is at in humbly speaking herself. She's not going to give as much credit as she deserves. Making it to the CrossFit Games is a feat 99.9% of people that participate in CrossFit will never achieve. You can be pretty good at CrossFit. You know, you could be pretty good at pickup basketball, but you're not going to make the squad and play with the Lakers. You know, like that's kind of the comparison of which we're dealing with now in the CrossFit sector. And so for us to have someone like Kelly, who's went there, who's done that, who's trained at the highest level, who's rubbed elbows with the best of the best in the game and to get some reflections from her, it's worth the 10 or 15 minutes about what it's like behind the scenes. So great episode, Kelly. But today I want to talk about after the games, what about the rest of us that just train this stuff because we like it? We want to stay healthy and fit. We enjoy getting stronger, but we also have nine to five jobs. We also have families, husbands, wives, kids. We got to shuttle kids off to soccer practice. Maybe I coach the soccer team, right? What is what does it look like setting and reframing goals after the CrossFit Games for the rest of us? Because we still want to be motivated. We still want to be inspired. We watch the games and we see what's out there and we see what people are capable of and and all of that is fun and it's all a great part of the sport. But when it's our time to take the floor, it's important to reframe those goals and context and the things that matter to us and are achievable to what we can set our sights for over the next six, nine or 12 months. And that's really what I want to focus today on. 04:35 SETTING & REFRAMING GOALS What can you reasonably achieve in the next six to nine months or even set your sights on before the next open rolls around? Because we know we're going to throw the hat in the ring and do the open. You know, what are some realistic goals, realistic goals that are going to turn into real change in your health and fitness and overall well-being? And that's ultimately what we're doing this for. We're not most of us aren't going to make the games. Hat tip to Kelly for putting in a ton of work over the last five to 10 years, probably to get to that point where she was able to make the games. But for the rest of us, we're looking to check that box. We're looking to do it safely and effectively and making sure that when we come out the other end, we come out unharmed and we come out healthier and a better person after doing the training than when we started. So here's some goals that I have for you today for post CrossFit Games goals for the rest of us. What part of your training really behooves you to spend time training? 06:30 INVESTING IN FOUNDATIONAL STRENGTH And what I mean by that is strength and monostructural conditioning work. It's really going to benefit you long term to invest hours weekly daily into getting stronger. So I want you to set a goal to try to put 30 pounds on your deadlift over the next year, to try to put 20 pounds on your back squat and to try to put five to 10 pounds on your strict overhead press. Those are realistic goals that are going to require you to train those movements consistently. And because you're training the foundational strength movements, the squat, the deadlift, all of your other movements will then reap a reward from having done so. Your clean and jerk, your front squat are going to benefit from your back squat being trained regularly. All your Olympic lifts and all your other movements are going to benefit from you training your deadlift frequently. Your shoulders are going to be healthier from having done more strict press. So set some realistic goals. I'm going to put 30 pounds on my deadlift, 20 on my back squat, 10 on my overhead press And that's going to require me to make sure that I'm hitting those boxes week in and week out over the next handful of weeks, months, and the better part of the next year. So it really is helpful that you spend time working on the foundational strength. The other thing that's going to benefit you for your gymnastics movements. So spend time benefiting or getting increased reps or getting your first rep of a strict pull up. Many of you in the CrossFit space are still gung ho about your kipping pull ups, your toes to bar technique, all these other things. I want to bar muscle up, but you haven't laid the foundation with the strict pull up yet. You need to stay there. Over the next six or nine months, can you add one or two reps on your max strict pull up? Can you get your first strict pull up by going through a beginning strict pull up progression and over the next six months, get your first strict pull up. Those are going to be big rewards for your long term health in fitness training. The same thing with your push ups. We in the CrossFit space, those of us that coach a bunch, boy, we're used to seeing a lot of crappy push ups, right? Poor midline stability, we can't hold a good plank position, we don't have a strong shoulder position to be able to press out of the end range of extension, and we have athletes wanting to bang out a lot of reps and not even one of them looks solid. So spend time mastering your strict pull up and your strict push up. You're going to be a better athlete and your fitness will reflect that if you do. Master a skill over the next six to nine months. Get better at double unders. Figure out how to climb a rope, right? Finally take some coaching advice from your team at your gym and figure out how to put down a new skill. There's a lot of reward that goes into the neural motor, the coordination, all of the things that come together to allow you to build and develop a new skill. And if there's one that you've been putting off, because let's face it, your ego is kind of getting in the way, you don't like to look like you can't do the thing so you just scale out of it a lot, spend time over the next six months and learn that skill. Just one, pick one. I want to get better at double unders, I want to be able to do 20 unbroken double unders. Cool. Over the next six months you're going to attack that and that's going to be a goal that's going to elevate your fitness long term. You're going to have that skill for a long time and you're going to be able to use that skill in a lot of workouts coming up. So spend a couple of weeks, a couple of months and develop a new skill. And then your model structural work. 10:06 LONG DURATION ZONE TWO WORK Add in one day a week where you're adding in some longer duration zone two, you know, longer duration stuff on the bike or the rower going out for a long paced run. Like we don't do enough of that. And every single expert in the space says from a longevity standpoint, it is so key from a health standpoint, from a fitness standpoint, it is so key that we get more long duration zone two work in. And now some of the research, some of the leading experts are saying 60 to 90 minutes, 120 minutes a week. Look just start easy with one day a week where you stretch it out more than 20 minutes. I mean low hanging fruit one day a week. I need to do a long duration piece that's more than 20 minutes. If we can check that, then we'll start talking about increasing the model structural workload and be able to increase that more. But that's a foundational component to your fitness. That's on the base of the CrossFit hierarchy pyramid that says, hey, we need to be really good at metabolic conditioning. And when we have a better aerobic base, everything else steps up above that. So build that aerobic base. Add in one day a week of model structural work zone two on a bike, on an erg, on a runner and stretch it out more than 20 minutes. So you're prioritizing strength. You're working on a skill. You're getting better at your foundational gymnastics movements and you're adding in some longer aerobic work. 20 minutes one day a week. 13:21 MORE CONSISTENCY IN THE GYM From a class perspective, I would just say it ain't volume. It's not loading that's going to make the difference for you. You don't need to be lifting heavier weights and metcons. You just need to be present more frequently. Just be more consistent. If you normally make it three days a week, try to make it four. If you normally make it four, can you make it five? Can you just add one more day a week making it to the gym? Can you slide in that little Saturday morning class that you typically skip out on? Because you're going to see big rewards coming by just simply the consistency in the gym. You don't have to do anything heroic. You're just more consistent. You're getting five sessions instead of four. And week after week, that aggregates into a lot more training sessions at the end of the year. So bump it one day a week. If you have other skills that are going to make you a much better athlete six, nine, 12 months from now, set a bedtime and actually stick to it. Get the water intake that you need and try to reduce the alcohol. Can we go 30 days with no alcohol and just see what that does for your overall health? See what it does for your sleep, your concentration, see what it does for your overall training, your fitness in the gym? How much sharper am I cognitively when I'm at work? Measure all those things after 30 days of no alcohol. If you make it 30, can you make it 60 days no alcohol? 60, can I go 90 days no alcohol? And just start aggregating these days of optimizing all the little details that you can. And you're going to see such big rewards on your fitness. They're little challenges. They're hard ones. They're not easy, but they're ones that we can bite off and actually stick to for a month, make one month into two months, make two months into three months. The majority of us don't need a new competitors program. We finished watching the CrossFit Games and everybody's selling their hard work pays off, their Matt Frazier program, the new Mayhem Rich Froning style stuff. And while all those are great programs, for most of us, that's not what we need. We don't need additional loading. We don't need more volume or longer duration workouts. What we really need is more consistency in the gym.…

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Episode 1536 - Reschedules, cancels, and no shows: oh my! Aug 17, 2023

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Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses average arrival rates in physical therapy, what the research says about how to improve arrival rates, leveraging technology to improve arrival rates, and creating policies & systems that ensure your clinic still gets paid for missed appointments. 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 Good morning, everybody. Welcome to the PT on ICE daily show. Happy Thursday morning. Hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the chief operating officer here at ICE and the faculty member on our fitness athlete division. We're here on Thursdays. We talk all things leadership Thursday, small business ownership, practice management, that sort of thing. Leadership Thursday also means it is gut check Thursday. This week we have a 17 minute AMRAP, as many rounds and reps as possible in 17 minutes of the following 21 plate ground to overhead. Our Rx weight there for guys 45 for ladies 25. So grabbing a bumper plate, hinging down, tapping one side of the plate between your feet and then up and over overhead, almost like a snatch. Moving into 15 cows on the rower for guys 12 for ladies and then finishing with a small dose nine burpees to plate. So looking for somewhere between three to five rounds of that great workout for home, the garage, the basement, the clinic. Just need a rower and a bumper plate. Great to maybe take out to the park as well and sub the row for some running or something like that. So that is gut check Thursday. Course is coming your way. We have so many about to enter a very, very busy season for ICE here as we get into the fall, get away from the summer, school starts back up, that sort of thing. We have a couple hundred courses coming your way between now and the end of the year. So if you're looking for live courses, head on over to p10ice.com, click on our courses and check out our map to see what's coming to your neck of the woods. Some online courses I want to highlight. Pretty much all of our entire catalog of eight week online courses are starting back up after Labor Day. So if you don't know about our online courses, they are eight weeks online. They are synchronous, which means that you meet with us every week. They are not completely self study, a mixture of lecture, of reading, of homework and of live meetups. They're meant to simulate the feeling of a two day live course, but stretched across eight weeks to make it a little bit more accessible, save you a little bit of money on travel. So online courses, pretty much like I said, all of them are starting after Labor Day. We have ICE Pelvic Online. That's our entry level online pregnancy and postpartum course. That's going to start September 4th. We have Fitness Athlete Essential Foundations taught by yours truly Mitch Babcock, Kelly Benfee and Guillermo Contreras. That's going to start September 11th. The very next day, September 12th, Brick by Brick is going to start very relevant course to this day of the week to Thursdays. We talk all things practice, startup and ownership and management in that course. Injured Runner Online also starts September 12th and then Virtual ICE will open back up September 26th for our next quarter of enrollment. So let's get into today's topic. Let's talk about how do we handle, how do we get better at when a patient reschedules, cancels or no shows. I want to talk today about three main topics. I'm going to talk about what are the average no show cancellation rates, what we would call an arrival rate across the country, across physical therapy, what's normal, what's abnormal. I want to talk about how to improve those arrival rates. And then I want to talk about how to get paid when somebody does not show up for those appointments. 05:46 ARRIVAL RATES IN PHYSICAL THERAPY So let's start at the beginning and let's talk about what is a normal rate. If you have been practicing physical therapy for a while, if you have been practicing in a traditional clinic, you may have heard that the common recommendation for the maximum arrival rate is about 93%. That is to say that 93% of your appointments show up for their appointment that day. That there's some margin of error. We recognize that 100% of people probably won't make it, but pretty typical. 93% is the standard that's set and sometimes enforced by the clinic that you work for. Maybe if you fall below that, maybe you get a warning, maybe you get a talking to, or maybe they actually dock your pay for visits underneath that 93%. What's awesome about this topic is that we actually have a lot of research, surprisingly, supporting the numbers that I'm about to tell you. So we have a great survey back from 2015 of about 7,000 outpatient physical therapists. This is from Bo Kinski and colleagues, sorry if I mispronounced this, of 7,000 outpatient PT's looking at a couple of different things. Looking at finding the average cancellation no-show rate, but also finding what things seem to help fix that. So across the country, we see an average no-show cancellation rate of actually about 10 to 14%. So thinking you may have been told 93% is the gold standard, in reality, somewhere between 85 to 90% is actually probably more realistic. If you had 10 patients scheduled for the day, you could expect maybe eight of them to show up for the appointment. You could expect maybe one to two appointments to be unfilled. I like this survey because it goes a couple levels deeper. It asks why. Now knowing that rate, knowing that 10 to 14% rate, why do people not show up for the appointment? What is the number one cause? The number one reason why patients do not attend their appointment is not that they can't afford it, not that they don't like you, it's that they forgot and that the clinic that they went to physical therapy to had no reminder system. So that's a huge error, that's a very easy fix. When we delineate outpatient physical therapy from hospital-based outpatient physical therapy, so private practice versus hospital-based, we see that hospital-based clinics actually the no-show cancellation rate of a private practice clinic. Why is that? I would imagine it's probably due to having a modern reminder system, but again, that number of 93% isn't the gold standard that we think it is. In private practice, we can expect maybe 85 to 90% arrival rate, a little bit lower in hospital-based, maybe 75 to 80% arrival rate. Now this survey looked at the concept of a multi-method reminder system. What does that mean? That means that the patient received multiple reminders across multiple communication methods. That they usually received some sort of automated phone call reminding them of their appointment. They received probably a text message and then maybe also an email message. So they received two to three different reminders ahead of their appointment across different modalities, basically reminding the patient as much as possible of their upcoming appointment. Now they found that those clinics that used a multi-method reminder system had a significant reduction in no-show cancellation rates, about a 50% reduction. So they cut their no-show cancellation rate in half just by having a reminder system. And we're going to talk about how to set that up at your clinic here in a minute. The second reason that clinics did better with no-show cancellation rate was those clinics who had a 24-hour appointment change policy. That is inside of 24 hours, you will be penalized if you cancel or reschedule or no-show your appointment versus if you give more than a 24-hour notice that you need to reschedule your appointment or otherwise cancel it. So those clinics which had a 24-hour policy and enforced that policy on their patients also had a reduction in their no-show cancellation rate. So that brings us to the question of if 10 to 14% is the mean of the average of no-show cancellation rates across the country, then how realistic is 7%? The answer is not very, right? Even if you are treating one-on-one for an hour and you maybe only have eight patients on your caseload for the day, it's probably unrealistic to expect 100% of those people to show up every day. That we have to recognize at some level that the reason we see so much overbooking in traditional physical therapy clinics is it's just that leadership strategy to limit the impact of those inevitable no-show cancellation rates. That if you see eight patients in a day and 10 to 15% don't make it, you may see five to seven patients. So kind of the aggressive leadership solution here is just to make you see more patients. That if you see twice as many patients and you still have that 10 to 15% no-show cancellation rate, then you'll still see more patients than originally intended and scheduled to and the clinic won't lose as much profit. But that being said, that is an aggressive way. That is a way that puts all of the burden of the work on the therapist and none of it on the ownership, none of it on the leadership and none of it kind of on the backend logistical side of the clinic. Instead of making you see more patients, why don't we just have a 24-hour policy that we enforce? And if we're not using a reminder system, why don't we start using one? Why don't we do some more conservative approaches to reduce that no-show cancellation rate, especially now knowing that we have research that supports, does those actually improve our no-show cancellation rates? So let's talk about that. 08:48 IMPROVING ARRIVAL RATES Let's talk about aside from having a reminder system, aside from strategies to remind patients to get to the clinic and aside from having a policy, how can we approve improve those arrival rates? You know us here at ICE, if you've been listening to us for a while, Jeff Moore, our CEO says it best. The first thing you can do to make patients show up to physical therapy more is make sure that you're focused on getting good and not getting busy. That when people see results, when they begin to associate value with their physical therapy appointment, they come to their appointment more often. I think this is so overlooked, especially in a higher volume clinic where a therapist may be expected to see multiple patients per hour. By providing lower quality care, patients aren't able to get results or they're not able to get results as fast as maybe they want to. They don't really associate physical therapy as a valuable use of their time and it makes sense that they find better stuff to do and that you get that message at 4.55 p.m. that your 5 p.m. patient is not going to make it in today. So really focus on getting good, not getting busy. We also need to recognize that people are not stupid. When they show up to PT and they see that you are working with three other people at the same time and you have forgotten about them in the corner at the TheraBand station or on the recumbent bike or the pulleys, again, that really begins to lower the value proposition that patients have with physical therapy and it's not surprising again that they begin to find better stuff to do with that hour of their time. The counter argument here is that you can get so good as a physical therapist, I'm good enough that I can see multiple patients at once or patients aren't as fragile as we think. We don't need to give them one-on-one care, but we need to recognize that at some level, patients are paying for it, especially if they're paying cash for a one-on-one visit. They are expecting one-on-one treatment. Even if you are an insurance-based clinic and using a patient's insurance, that insurance is still paying you based on one-on-one care. And not only that, but the patient expectation is that you are going to give them the care that they need. And I often relate this to other professions of you would lose your mind if you had a therapy appointment with a psychologist, a mental therapy appointment, if you showed up and there were three other people getting mental health therapy at the same time as you. No one would put up with that, but for some reason, it's just expected and normalized that that's the kind of care that we give in physical therapy. So then it's no wonder that patients, again, find something better to do with their time for the hour. So really focus on getting good and not getting busy, of taking really quality care of that patient that you have on your schedule for that hour. And you'll be surprised how much they come back to physical therapy when they see their range of motion improving, when they see their balance improving, when they feel stronger, when their pain is getting better, whatever their goals are, as they can see progress towards their goals, it's much more likely that they're going to come back to physical therapy. And I think that is often overlooked. My second point with improving arrival rates is to leverage technology, implement that multi-method reminder system. It's 2023. There is no reason why your clinic does not have automated reminders, text, email, phone, whatever. It's all built in to a modern EMR. If your EMR does not do this, you need to get an EMR that does this. If your front desk person is still calling people by hand to remind them of their appointment, you're a little bit behind the curve, right? to do the work for you so that you can focus on treating your patients while the technology sends out those reminders for you. We need to recognize that people are busy and that the more we can be prominent in front of mind with reminders, the more likely people are to attend their appointments. We have research that supports this, right? We can cut these no-show cancellation rates in half with a multi-method reminder system, but also it gives the patient a chance to reschedule if they know they already can't make it, right? That text reminder, when they get that phone call, when they get that email, it gives them multiple chances to reschedule. And if they don't, it also kind of builds the case for you against them that you gave them plenty of chances to reschedule and they still did not. And that makes it a little bit easier to charge them money, which we'll talk about in a few seconds here. So remember, we can cut that rate in half, that no-show cancellation rate in half with a multi-method reminder system. So if you're still using Google Drive as your EMR, if you're still using paper documentation and scanning it into a computer, consider getting a modern EMR. They're not that expensive. EMRs, we're big fans of Jane here, obviously, at ICE, other EMRs, Prompt, PT Everywhere, pretty much all the modern web-based EMRs are going to offer reminders and more often than not, they're free for you to use. So why not use them, right? It's one more push of a button when you're building out that patient chart for them to get reminders. In addition to reminders, leverage technology to…

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Episode 1535 - Balance intervention framework Aug 16, 2023

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Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult Division Leader Christina Prevett discusses the need for falls prevention initiatives to shift their focus towards early identification of individuals at risk for falls. By doing so, healthcare professionals can implement targeted interventions and reduce the occurrence of falls before they happen. Christina emphasizes that outcome measures should be used to guide interventions. She mentions the Mini-BEST as a specific outcome measure that assesses various aspects of balance and mobility. By administering this measure at the beginning of a session, the clinician can immediately identify areas of deficit and tailor their intervention accordingly. For example, if the person shows deficits in dynamic gait and reactive posture control, the clinician can focus on exercises and strategies to improve these specific areas. Overall, the episode highlights the importance of outcome measures in falls prevention and emphasizes that they should not be conducted for the sake of it. Instead, outcome measures should provide meaningful and actionable information that guides clinical reasoning and informs interventions. 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 slash physical therapy. 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, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show. 01:33 CHRISTINA PREVETT Hello, everybody, and welcome to the PT on ICE Daily show. My name is Christina Prevett. I am one of the lead faculty within our modern management of the older adult division, part of our geriatrics team. Everyone, we are flying high this week because we got everybody from our MMOA division to descend on Lexington, Kentucky at Jeff and Dustin's Stronger Life facility, which was beautiful. And we got to show the world some of what we have been working on, which is some revamped material. So we got to really focus on dialing in live to be about lab. We were moving all weekend. It was so fun and so amazing. If you were thinking about joining MMOA live, we have a couple of opportunities coming up in the remainder of this month. So this weekend, Dustin and Jeff are going to be in Bedford, Texas, and Julie and Ellen are going to be in, oh my gosh, I'm blanking on where they are. They're in Minnesota. And then there I was like, I know this. And then the next weekend, Alex is going to be in California. And so if you are looking for where MMOA is going to be, we have a ton of courses into the end of 2023. We are not adding any more locations for MMOA live in 2023. So if you're kind of waiting for one to come closer to you for the end of this year, that isn't going to happen if it's not there now because we're kind of locked in. We have lots of offerings that's going to come up for 2024. So if you're looking to see that live material, that is where to go. 03:29 A FRAMEWORK FOR BALANCE INTERVENTION OK, so today I wanted to talk a little bit about a framework for balance intervention. When it comes to balance, I think it's a bit tougher for us to put this marker of effort or intensity on, maybe more so than other styles of fitness. What I mean by that is when we think about aerobic training, it's easy for us to conceptualize effort because we're seeing that perspiration, we're seeing that heart rate response. And that's correlating to our rates of perceived exertion. When it comes to resistance training, right, the amount of effort is either going to fatigue kind of in those higher rep ranges or our personal preference is getting to fatigue and effort through higher load. And again, it corresponds to changes in rates of perceived exertion. When we're trying to conceptualize intensity and then we're really trying to dial in our balance interventions, it's a bit tougher, right? We don't really have the same magnitude or the same outcome measures with respect to gauging intensity well. And so within MMOA, we really try and create this framework for individuals to help guide them through this kind of thought process and then create a kind of stepwise framework within our mind for how we implement this in clinical practice. The way that we do this is by first looking at the mechanism at which individuals are falling or where they are having near falls. This is important, right? 05:00 FALLS PREVENTION INITIATIVES Our falls prevention initiatives are only preventative if we are identifying individuals early rather than waiting for them to get hurt and then working in secondary tertiary prevention. We want to be able to identify those who are at risk for falls before that fall has happened, which unfortunately is not as common in our health care system as it stands right now. So we want to figure out the mechanism. We want to identify risk factors that are intrinsic to the individual and extrinsic around their environment. And then in order for us to put objective data on those things, we need to take that information from our subjective and use the appropriate outcome measure in order for us to have a good data point or multiple data points in order to guide our interventions. And then we want to make sure that those outcome measures that we are selecting are giving us tangible information, right? We don't want to be doing outcome measures for the sake of doing outcome measures. We want to do our outcome measures so that they can guide our clinical reasoning. And so let's kind of go through this very briefly and speak to the different aspects of this framework. So the first thing is mechanism, right? When we are asking about our person subjective, many times they're kind of cursory with their storytelling. A lot of individuals are when they're speaking about falls. Oh, well, I stubbed my toe and I fell over. What were you doing when you stepped your toe? What was your frame of mind? Were you really rushing to get from point A to point B? Were you really tired because it was late at night? Were you holding something in your hand when you tripped and that created an other barrier or other cognitive load in your mind that created more of a predisposition to not be able to keep your center of mass over your base of support and respond to that perturbation? Was it that there is a visual issue going on and you were having trouble with depth perception? We need to kind of dig really deep into some of these stories because that's really going to triage this risk factor profile in our brain. But you're probably thinking, well, Christina, a lot of my clients just can't do that or they don't remember or they are not able to give us some of that really tangible information. And I hear you. And so when we don't have that information, the next step is for us to go to the literature and look at what are common scenarios that lead to falls in different settings. Right. And how much do those mechanisms and that group of individuals that are being conceptualized in this research study relate to the people that are in front of you? An example is if you're an outpatient orthopedic therapist looking at some of the acute care mechanisms of falls may be relevant, but probably is less relevant to you. So you're going to be wanting to know, well, what is happening for our community dwelling older adults? What is their profile look like? What age group are individuals looking at in this study? And then how does this relate to my current caseload or people that I have that I am seeing right now? And so there is a recent study that came out in 2023 that was doing a prospective. So following older adults forward in Boston that was looking, for example, at mechanisms of falls in community dwelling older adults. So what they did was every month they sent older adults in this study. So they consented to this study. They were in their 70s or older. They sent a postcard to them and asked some questions. Did you have a fall in the last month? If yes, what was the mechanism? What were you doing at the time of the fall? And what was the cause of that fall with what you were doing? And I think this is interesting because they are two different things, right? 09:26 SLIP & TRIP TRAINING So the cause of the fall in our community dwelling older adults over 70, for example, more than half was a slip or a trip. The activity when they were having that slip or trip was walking forward. That gives us a lot of information in terms of where we start with our older adults. We're not going to start standing on one leg. We're going to start with slip and trip training. We're going to look at reactive stepping, volitional step training. Maybe we'll do that in standing first to see where a person's control is, but we want to see what happens when they start having perturbations. And so if that slip or trip is happening going forward, it also tells us that that perturbation is often backwards or lateral. People aren't falling forwards, right? It's that they're slipping and coming to the side or they're slipping and coming back. And that's a really important piece of information for us. And then it's going to guide where we go. So the next thing is now we're going to look at a person's risk factors, right? So extrinsic risk factors when individuals are having slips and trips was, was this in the wintertime and they're slipping on ice? Was this a step? Was this a rug that we know we're never going to get rid of, but we may ask about trying to tape down? These are things that we may be considering when we are looking at these mechanisms or are asking these questions. And so that's extrinsic. So we're taking this mechanism. We're looking at some extrinsic factors. And then the intrinsic people are going to be telling us in their narrative that they may feel like their balance isn't really great, or they're having trouble holding on to objects and navigating around their home or navigating outside. Or they recognize that the pain in their knee is making them not feel as strong or confident in their gait. And it's going to create them to have a hesitation to react when a perturbation happens because they've had times where their leg has given out. Or they they don't feel like they're strong enough to move their feet, right? They're they're telling us these things in their subjective. And so when we take that information, now it's going to guide us into our outcome measures. So if individuals are saying that they're having falls because of a strength deficit or a weakness issue in their lower extremity, we may want to make sure that we have a general mobility or a strength focused measure in our assessment to get a good idea of where our triage list is going to be. So we may use a five times it to stand or a 30 seconds to stand test, or we may go a bit more general and go to the short physical performance battery because the mechanism of their fall is showing us that potentially that being that capacity to move their feet is coming from a weakness issue. 11:54 REACTIVE POSTURAL CONTROL We are also going to want to in this example, look at their reactive postural control. We heavily leverage the mini best because there is a subsection of the mini best that looks at reactive postural control in each direction. So we're going to look at a person's capacity to react to a forward perturbation, backward perturbation and lateral perturbation. Right. If a person is having pain in the lower extremity, they're worried about it and we do a lateral perturbation, they may not move their feet out. They may want to cross because they're worried that that painful knee on that left hand side is not going to support their weight. So their reaction may be a step out to the right and a crossover to the right because of that painful knee. So now we've learned two things, right? We know that their pain is a contributing factor to their falls mechanism. It's an intrinsic risk factor that's creating troubles with clearance. It's impacting their gait, whether it's causing deviations in their gait or it's making them not lift their foot enough and now slips and trips are more common. And we recognize that their lateral posturing, the way that they are moving to the side is impaired. So now we've really dialed in our assessment, right? We've gotten a good idea about what's going on and we've picked the outcome measures that are going to give us that information. Because if we just focused, for example, on a burg. Because that is our go to balance assessment, not only are community dwelling older adults more likely to sealing that out, but it's not really getting to the two really big issues that they spoke to in their subjective assessment, right? They are probably going to be able to stand up once and do a pivot transfer. But that five time or 30 seconds to stand that's requiring a repeated chair stand is going to hit into maybe their pain thresholds that they're going to start having some compensatory mechanisms. And they're talking about having perturbations in a forward movement pattern. So the burg is in capturing backwards and lateral perturbations. So we have to be using those mechanisms and risk factors that they're discussing with us in their subjective and then leveraging the outcome measures that have strong reliability, validity, responsiveness, interpretability in order for us to have a good idea of what the next step is. But we're not going to do outcome measures for the sake of doing outcome measures. The next step is that we need to use those and leverage them in our interventions. One of the reasons why we also love the mini best is that oftentimes the way that we implement this is not day one. It's a little bit more of a longer intervention or sorry, it's a longer outcome measure. But we use it at the beg…

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Episode 1533 - 2023 CrossFit Games Takeaways Aug 11, 2023

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Dr. Kelly Benfey // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Kelly Benfey discusses her experience competing at the 2023 CrossFit Games, the role of rehabilitation providers in competitive sport, and the capacity of the human body for exercise as it ages. 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 What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:33 KELLY BENFEY Good morning and welcome to the PT on ICE Daily Show. It's Fitness Athlete Friday and my name is Kelly Benfey. I just wrapped up an amazing CrossFit season where I got to compete at the CrossFit Games. And so what we're going to get to talk about this Fitness Athlete Friday is going to be a couple takeaways from the CrossFit Games that I think are relevant in the rehab space. Before we jump into that, though, within our Fitness Athlete crew, we have a couple of online courses coming up that I just want to bring to your attention. So we just wrapped up an awesome cohort with our clinical management of the Fitness Athlete Essential Foundations course online. And so our next course is going to be kicking off in a few weeks on September 11th. That course always fills up. So if you're thinking about it, please jump in with us, grab your spot right now. And then if you've already taken that and you're looking to continue developing your skill set, our Advanced Concepts course that's only offered two times a year is also starting September 17th. So rarer opportunity to hop in on that one. So if you've been looking to take this course, that's going to get started quite soon. And then we have a handful of live courses for the remainder of the year. So all of that information is going to be on PTice.com, PTonice.com. So we hope to catch you live on the road. I'd love to see you all. So we'll be getting back on the road for the remainder of this year to finish strong. So let's get into our topic. Of course, I could talk about this stuff all day if you know me. So we're talking CrossFit Games takeaways. A couple of things that I experienced and found were relevant in the rehab space. This is Fitness Athlete Friday, so we get to geek out on all things, CrossFit Games, CrossFit competition, all that good stuff. So number one, I have five different things that we'll kind of work through. 03:35 HUMAN CAPABILITY So number one, I always leave the CrossFit Games feeling absolutely motivated and inspired by what the human is actually capable of doing. So I really it was it was just such an honor to be on the same field as some of these amazing, amazing athletes, be behind the scenes and all that good stuff. So a couple highlights that I saw now just to I competed in the team division. So it actually didn't allow me to watch as much as the individual competition. I'm still working through catching up on that all the live the live coverage that they had. But I got to be within the team division. So one of the athletes in the team division, she clean and jerked 250 pounds and then a couple hours later ran a 5K, 4.5 ish K, 5K in under 20 minutes. So it just always impresses me that people can excel in things that I also excel in the strength events, yet also push their aerobic capacity and monostructural skills to an insane level as well. So it was just absolutely mind blowing to see athletes also just I know how hard we worked on my team and just having other athletes really push the boundaries. I find to be super inspiring as a competitive athlete. And then moving moving towards almost even debatably more inspiring. 04:11 OLDER ADULTS PUSHING BOUNDARIES The age group divisions are always just such a blast to watch. I wish they had a little bit more coverage because arguably that's more these are more the athletes that are relatable and even more inspiring. For example, the 60 plus division, I believe the 60 60 to 64 division, both men and women had bar muscle ups in their last event. So these are our older adults crushing it, doing high skill level at a very high competitive level. Just absolutely amazing. And like I had the opportunity, my mom came and watch. She's going to watch me and have a blast, obviously, but she's not necessarily going to see like watch me and think, oh, wow, that's something I can do. She's going to see something in her age division and then become inspired of, hey, maybe I'm going to start my barbell class in my gym, for example. So I just think the human capabilities, even in our older adult divisions, is just as important as what the individual and team athletes are doing. The professional athletes, if you will. And then we also have the adaptive visions that are starting to grow and the upper extremity adaptive athletes were performing rope climbs. Rope climbs are hard enough when you have two upper extremities to grip onto the rope with. They were doing it with one and we're also sealing our lower adaptive lower extremity adaptive divisions, doing things like box jumps and maxing out their clean and jerk and snatch and really just taking no opportunity to have an excuse to not push their fitness forward and continue to be athletic and competitive in their sport. So I absolutely love seeing those. I wish I got to see a little bit more of it. I wish we got to view a little bit more of it on the broadcast, so hopefully we'll be able to continue pushing that forward. I just saw a couple posts of highlighting those athletes, so keep keep those in the forefront of your mind. That's what's really inspiring to more people, I think, in this world, in our country. OK, so the next three points that I want to kind of work through all kind of build off of each other. 09:20 INJURY RATES & PROGRAMMING So one thing that I thought was really relevant this year at the Games was the programming. And like I said, I have paid attention a lot to a lot more detail of our team division programming, but I just wanted to bring your attention as a rehab professional, as a movement specialist that's working with athletes all the time. I think it was important to note this. So just a couple examples. So in our competition, we had four days of competition. On day one, we had overhead squats at 135 pounds and 95 pounds. Then day two, we had a one rep, one rep max snatch. And then on day three, we had more snatches at 185 pounds and 135 pounds with running. So that's back to back days that we're seeing a barbell shoulder stability type exercise that is very demanding on the shoulders. In general programming, we would probably look to spread the frequency out of when we're doing things like overhead squat and snatching. Being able to do those back to back days can challenge the shoulder and challenges your ability to recover and perform repeatedly. Another thing that I noticed as on our day two, we had a strict ring muscle up to a front support hold. So going through that pole to deep press and hold at the top of the unstable rings is really challenging for the shoulders. And then right into day three, we had 30 synchro ring muscle ups on the long straps, which are tough. And then 63 more parallet bar dips. So that's a lot of vertical pressing for the shoulder to get through back to back days. And so I've personally experienced issues with pressing with shoulder pain. I've worked with a handful of athletes that recently have been that's a common theme in our clinic that I'm working with. So that is I remember if I was in the middle of having a flare up of that shoulder pain presentation, it would be really hard to be able to do that back to back days because you can always push through one workout. Adrenaline is a really strong drug, I would say that helps you get through it. But the next day when you wake up and things are a little bit inflamed, it's really hard to be able to repeat those motions. So that was just one thing I noticed that was not necessarily what I would have expected in programming, just how frequently the same movement is tested. And it's one thing to test the fitness of it, but it's also one thing to test the tissue capacity. So those are things that the my rehab mind was kind of evaluating while I was going through it, which brings me kind of into that next point I want to bring up was injury rates this year. I'm not sure if I just noticed more injuries and pain happening. A lot of KT tape being thrown on our limbs because I was in the background. But there did seem to be a lot of withdrawals from individual and team, excuse me, team athletes this year. We know the injury rates in CrossFit, the highest injury rates that we're seeing are in the shoulder joint. And based on that programming, it kind of makes sense. It makes sense that we're seeing a lot of shoulder issues. And so just from an athlete's perspective, it's absolutely devastating. It's so upsetting to have to withdraw from an injury, whether it's yourself, whether it's a teammate. We put so much time, money, effort and dedication to an entire long season. This started in February. So working day in and day out, making decisions based on that this specific weekend. It's just an absolute shame to see an athlete have to pull out of competition because of shoulder pain or whatever issue they may have. So I know I got to talk to a couple of the teams that had to withdraw. And the common theme that they were telling me was like, oh, yeah, I had this lingering issue for a while. I just retweaked it about two weeks ago. So they weren't necessarily the Roman Krenikov situation where they just, unfortunately, came down and rolled an ankle and had a new injury. This was a couple of these things were like lingering elbow issues that are really tested in the moment of competition with all the stress on board. Exposing to really deep positions of that dip position. If we have lingering shoulder stuff going on when you're pushing to 150 percent of your capacity, it's not likely that you're going to come out OK sometimes. So as soon as some of the workouts were announced, these athletes were like, well, I'm not feeling too great about this. So I take it's just such a shame because I think as rehab professionals, we need to have the skill set to be able to address these issues that our competitive athletes are experiencing and make sure that we're not just getting them back to be able to do a ring muscle up and take an ibuprofen. That's a whole other issue. We don't want our athletes to be doing that, obviously, but we want to be able to get them back to baseline and then beyond baseline because that originally that shoulder with that skill set got injured. So it's definitely up to us to be able to have the resources and provide rehab for these athletes that they find valuable. Not every single one of these athletes has a team of physical therapists that are top notch, that are traveling with them, that are on like on them 100 percent of the time. And so it is very likely that you may come across a CrossFit Games team athlete that's going to need to go through four days of competition with repetitively dips and butterfly pull ups and pulling, pulling whatever it may be. All these really challenging things for our shoulder girl to be able to tolerate. So that just I walked away being thankful that I came out unscathed, essentially, because if you followed any of my CrossFit career, I've had issues with my shoulder before. And strength always is super protective against injury. And I feel really lucky, essentially, to have all the knowledge that I have to put myself in the best scenario. Even within my teammates, we had a shoulder issue that we had to train around a little bit where we couldn't our best choice wasn't to continuing to do 30 muscle ups the week before, for example. But we rehab the crap out of it and put ourselves in the best situation possible to be able to come away without withdrawing by any means and putting up a pretty good performance over the course of the weekend. So that just brings me to want to plug our courses just one more time. So I mentioned the beginning, we have a couple of online courses coming up. I would say 75% of the clinical decision, clinical decisions I'm making on a daily basis are all things that I learned from these courses. The other 25% is probably all the other stuff I learned from my ice courses. So I know I'm biased, but I promise I'm not lying. If you at any point would feel nervous, nervous if I came into your clinic saying I can't do ring muscle ups, help. Please hop in one of our courses. It's really a fun, fun way to spend your eight weeks online. And so the last point I wanted to make kind of along the same theme was the importance of stress and recovery. So if you are an ice in the ice world, I'm sure you have heard us talk about the importance of stress and stress that the body takes on and how it helps us or doesn't help us recover well. 11:04 COMPETITIVE ATHLETES & REHAB And competing in the CrossFit Games this past weekend really made this become like full picture for me. I prioritize sleep, I prioritize what I'm putting in my body, and I prioritize managing stress as well as I can with all of the training that we were doing. But at the CrossFit Games, I will say I was probably at a peak stress level in my life. I don't live there on a daily basis, but the couple of weeks leading up to it, highly stressed and enduring also highly stressed. For example, day one, the volume wasn't really high. We were coming off of two sessions a day, up to two hours per session. So training heaps, I would say. And day one, all I did was three leg assault climbs, 30 overhead squats and then four laps on the bike track, which was aerobically really challenging, but not high impact. And the next day when I woke up, my fitness tracker is showing me my heart, HRV is plummeting. I felt like I did probably triple that amoun…

Full show notes at the publisher

Episode 1532 - Reconceptualizing vacation Aug 10, 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 challenges the common belief that vacations and time off are necessary to decrease stress levels. He argues that the expectations around time off may not align with reality, often leading to discontentment. Jeff suggests reconceptualizing the idea of time off and vacations to have better trajectories and lower stress levels.

Jeff then discusses what creates low stress levels and a healthy ecosystem. He addresses the issue of returning from vacations to a chronically disorganized routine. Jeff explains that when our day-to-day lives lack discipline and organization, we often find ourselves in a cycle of feeling like we need a vacation, being disappointed by its inability to meet our expectations, and feeling worse off as a result. Jeff emphasizes the importance of taking ownership of our day-to-day routines and reorganizing them to break free from this cycle.

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

Alright team, what is up? Welcome to the PT on ICE Daily Show. Welcome to Leadership Thursday. I am Dr. Jeff Moore, currently serving as the CEO of Ice. Thrilled to have you here live via Instagram or YouTube. Thrilled to have you on the recording if that's the way you're taking in the show. It is Gut Check Thursday. Let's get right down to business. What is the workout that all of the Ice Train folks are going to be taking on this week? It is as follows. 35, 25, 15, 5. So we have 4 rounds descending in volume. They are going to be double dumbbell push press but not real heavy, 35 and 20. And then ab mat sit ups are going to be paired with that. Okay, so you've got your 35 dumbbell push press drop down. You get your 35 ab mat sit ups. In between each round, you're going to run 200 meters and the rounds are going to be 35, 25, 15, 5. Okay so you should be able to keep a pretty high intensity up because the volume on those rounds are dropping. Make sure you get a snippet of that. Put it on Instagram. Let us know what's up. Hashtag Ice Train. We love seeing everybody throwing down on those Gut Check Thursday workouts. Real quick, courses coming up. I want to highlight cervical spine. If you want to be out there solving neck pain, radiculopathy, headaches, all the things that come with that upper quarter region, get to this class. We've got 3 options coming up. August 26, 7. It's going to be at Onward Charlotte. September 9, 10. It's going to be at Onward Atlanta. In October 14, 15. Going to be at Onward Greenville. So going to be in North Carolina, going to be in Georgia, going to be in South Carolina. So belt there and hit that course. Learn those skills. Serve those patients well. Okay, welcome back to Leadership Thursday.

02:01 VACATON & WORK-LIFE BALANCE

We are going to have a conversation about why I think we've gotten vacations wrong. And I want to talk a little bit about the origin of this episode. So the other day I posted on Instagram some of the best advice I've ever received. It was from a friend. It was many, many years ago. And he said to me, if you play between the ages of 25 and 35, you will work hard for the rest of your life. If you work hard between the ages of 25 and 35, you will play for the rest of your life. And as I've watched now coming up on wrapping up the second decade of my career, I've seen a lot of people finish off their careers, seen a lot of people start them, myself going through my own. A lot of observation and the amount of truth embedded in that quote has been nothing short of shocking. When you get in the right lane early, and you get to you get with the right people early, you wind up doing what you love and excelling at it. And of course, just like investing, the earlier you do that, the more it compounds. And it really creates a scenario where the back two thirds of your career not only are more of what you love, but really decompress the stress. On the other hand, if you kind of get yourself into a financial hole and you're not in the right lane, and you're nearing the halfway point of your career, it really becomes a tough thing to dig out of. And it just sets you up for a bit more of a grind on the back end. Now we could have a whole episode about that quote alone, but that quote got a lot of feedback. And anytime you talk about working hard, you tend to get a lot of DMs and messages about the need for people to avoid burnout. And specifically that people need vacations and time off to decrease their stress levels.

03:46 EXPECTATIONS AROUND TIME OFF

That's what I want to zone in on because I think that our expectations around time off are really, really aired, if you will. And the problem with your expectations not being aligned with reality is that discontent is the inevitable result of that. So let's see if we can't reconceptualize this a bit and wind up with better trajectories. So think about what creates low stress levels. So if we're going to talk about stress levels, what creates low stress levels? What creates a healthy ecosystem? The answer is the following. Now we could put nine bullets here, but let's go with the really, really big rocks. That when you have them dialed in, your stress levels tend to be low, your nervous system tends to be really under wraps, you tend to feel really dialed. Probably the biggest one we'd all agree on is sleep quality. The consistency of it we know is the primary driver. But the other small things, having it cold in the room, having it dark when you're eating food, not having those late meals, sleep consistency is probably, or sleep quality, driven primarily by consistency, is one of the biggest drivers to day to day having low stress, having more energy. Number two is a regular fitness routine. You're getting to the gym at the same time that you're engaging in quality fitness. Number three is nutrition, that you're eating a quality, clean, well-balanced diet. Sufficient in protein, void, hopefully, of a lot of nonsense and processed foods, that you're eating quality nutrition. When you're doing these things that we preach about all the time, your ecosystem tends to be optimal, your stress levels tend to be low, you tend to feel your best when those variables are dialed in. Now think about how those variables fare when you're on vacation. And I think we would all agree the answer is poorly. You're sleeping in a totally foreign environment, your consistency of your sleep is all over the map, you're trying to get some fitness in but it's random, it's not nearly as structured as usual, and your nutrition, let's be honest, leaves a lot to be desired. It's usually very fun food, you're usually trying a lot of new things, but you tend to be eating late at night, it affects your sleep quality, all of the primary metrics that create that really well-defined healthy, low-stress human are significantly disrupted, specifically when you're on vacation. Now does this mean, right, and I think it's worth saying that if that's not the case, if those things, if your sleep quality, your gym routine, your nutrition, if those things are better when you're on vacation, your day-to-day routine needs a serious second look. So if you don't have those things dialed in better on your day-to-day and your usual environment compared to when you are out in some random state or country where you've got no control of the other variables, if you do better on those things out there, you need a serious look at your level of discipline and organization on your day-to-day life. But I think for the vast majority, as we would agree, those things are pretty dialed when we're at home and they are very erratic when we're on vacation. Now does this mean that we shouldn't take vacations? And the answer to that is of course not, right? A lot of the coolest memories in your life, right? The things that you're going to do that you're going to look back on and say, gosh, that was crazy or do you remember that? And the stories that fill your life, a lot of those things are going to be formed when you're on vacation. Your perspective will expand, right? You're going to be in new environments. You're going to be seeing new people. You're going to be looking at things differently because you're outside of your usual routine. Your relationships with those that you go on will often deepen, whether it's your partner or your family or your friends, right? You rarely spend that kind of concentrated time and it creates incredible opportunity for those relationships to deepen. All of these incredible things are going to happen when you're on vacation. What will not happen though is usually that your stress level will drop because the things that drive that are generally disrupted. So then what's the secret sauce?

08:18 DEVELOPING A ROUTINE FOR VACATION

The secret sauce is developing a routine that allows you to look forward to, but never need a vacation. That's the most important thing, right? You can't wait to do it. It's going to be a blast. You know those memories are going to be formed, but you don't need it because your routine day to day is so dialed that you feel outstanding, even under the presence of high workload because you've dialed in those metrics. So developing a routine that allows you to look forward to it, but not be desperate for it, not require it. And number two enables you to bounce back upon your return because if you do vacations right, a lot of that stuff is probably disrupted and you're probably coming home, hopefully thinking the classic quote, I can't wait to get back into my routine. That is a very healthy thing to be thinking, right? Like, hey, we went out there, we collected incredible memories, we got new perspective, we deepened relationships, we did all of the enriching things that vacation can bring. But now I'm pumped to get back into my dialed in routine because that's what's going to drop back down my stress level. That's what's going to allow me to perform optimally. So hopefully you're coming back to a routine that's dialed that not only did you not even need the vacation in the first place, you're bouncing back in two to three days, as opposed to having that post vacation hangover for weeks on end where you can't get your act together, which only increases your stress, which makes you need to step away again. And now you're in this vicious cycle of trying to survive when you're there and always wanting to be gone. The exact opposite should be true. You should love when you're gone and be taking a ton from that, but you should be strengthening while you're home to be able to enable that. Not weakening while you're home, hoping that it can do something that it can't when you step away. That's the challenge. The bottom line is people need more disciplined lives to decrease their stress levels. And people need vacations to enrich their existence. Unfortunately, a lack of discipline in our day to day lives requires a need and a desire for vacations chronically and a hope that they can do something that they usually won't. Simply because the organization of them doesn't tend to organize our nervous system. It tends to disrupt it, which in the right amount, when you've already got it balanced, is an amazing stimulus to get you to think differently, to get you to freshen up, if you will.

11:14 TAKING OWNERSHIP OF ROUTINE

But if you are coming back to a routine that's chronically disorganized, you're going to be in that vicious cycle of, I feel like I need a vacation. The vacation didn't do what I wanted it to do. Now I'm a little bit worse off. And we go back and forth and back and forth. And there's really no getting out of that wheel until we reorganize and take ownership of what we're doing on the day to day. Then we can enjoy the vacations and be strengthened by our routine. So just want to put that out there because so often people are saying that people need vacations to decrease stress. I think we can live in a way that we don't need that at all. And yet we do get great things from those breaks and can certainly take them as opportunity allows. Hope that makes some sense. Had some great conversations this week. Feel free to continue those in the comments. Everybody have a wonderful Thursday. Thanks for being here on Leadership Thursday.

Episode 1531 - Intensity, muscle volume, and inflammation Aug 09, 2023

Show notes

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult faculty member Jeff Musgrave discusses a randomized control trial that investigates the impact of inflammation and different intensities of strength training on global inflammatory load and immune response. The study involved 81 participants, aged 65 to 75, who underwent a 12-week strength training program at varying intensities. Thigh muscle volume was measured using computed tomography, and blood tests were conducted to assess inflammation markers. The results of the study revealed that moderate and high intensity strength training yielded superior improvements compared to moderate and low intensity training. Participants in the moderate and high intensity group experienced a 15% increase in thigh muscle volume, while those in the moderate and low intensity group only saw a 9% increase. Furthermore, the moderate and high intensity group exhibited reduced thigh fat volume, decreased pro-inflammatory cytokines, increased anti-inflammatory cytokines, and elevated free floating leukocytes. Jeff underscores the significance of incorporating moderate to high intensity strength training for older adults, particularly those in the 65 to 75 age range. He highlights the sedentary and overweight state of many older adults in the US, emphasizing the need to address frailty in this population. Jeff also discusses the risks associated with not implementing moderate to high intensity strength training, including increased inflammation, decreased muscle volume, and heightened body fat. 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 slash physical therapy. 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, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show. 01:43 JEFF MUSGRAVE Welcome to the PT on ICE Daily Show. It is Wednesday, so that means it is all things geriatrics. We like to call this Geri on ICE. So can't wait to get into a deep dive of this randomized control trial that just dropped last month in July, talking about inflammation, various intensities of strength training, how that impacts our global inflammatory load, as well as things like our immune response. And then we're going to deep dive after the article into what happens if you don't follow the results of this study and if you do, what the opportunity is for your patients. But before we get into that, we've got lots of opportunities. If you want to continue the learning process, if you want to sharpen the sword when it comes to working with older adults, we have got just a handful of seats left in Essential Foundation. So if you want to jump in, you need to do that quick. There are only a few seats left. We can still get you on boarded. You're not going to miss a thing. If you want to hop in for advanced concepts, you've already had Essential Foundations. The next cohort is going to be October 10th. And then if you want to see us live on the road, the revamp is releasing this weekend. I cannot wait. All of the faculty of the older adult division are descending on Lexington, Kentucky. We're coming to the bluegrass to show show out with this new content. It's going to be super fun. If you miss getting your seat for that this weekend, next weekend, we're going to be both in Bedford, Texas, as well as in Minneapolis, Minnesota. 06:20 IMPACT= OF MODERATE AND HIGH INTENSITY STRENGTH TRAINING FOR OLDER ADULTS So as promised, the study, Intensity Effects of Strengthening Exercise on Thigh Muscle Volume, Pro and Anti-Inflammatory Cytokines, Immunocytes in the Elderly, a randomized control trial. So this trial had 81 participants. We've got adults 65 to 75 years old. 39 of those were male. 41 of those were female. And they were taken through a 12 week strength training program at various intensities. Baseline measures were thigh muscle volume via a computed tomography and blood test. They also did their due diligence. We know how important nutrition is to get an idea, at least of their caloric intake. Now, did not go into detail of how much protein, how much fat, how many carbs. Didn't look at macros, but they did identify that all the adults in the study were consuming about the same calories on average. So the control group spent 10 to 15 minutes doing meditation and stretching. Not things that are awful, but definitely the control group when we're talking about effects of strength training. The experimental group did 50 minutes of exercise three days a week. They had squatting, they did pressing movements, spine flexion and extension on Mondays and Fridays. On Wednesdays, they hit those knee flexors, extensors. They did ankle planar flexion, chest flies and rows. All of this was primarily done on machines, machine based exercises. And then when they broke down the different intensities, what they did is they recalculated each month and they worked them off different repetition maxes. So the low intensity strength training group worked off of a 10 rep max, a 9 rep max and then an 8 rep max. If you're looking consecutively across those three months as it was a 12 week study. The moderate intensity group hit 10 rep max, 9 and 8 rep maxes and recalculated their strength each month. And then the high intensity group worked off an 8 rep max, a 7 rep max and a 6 rep max. So I thought that was pretty cool that they recalculated their strength and then they used the same measure there of course to calculate their intensity for their strength training. So, after 12 weeks of strength training, the moderate and high intensity strength training group had superior improvements in their thigh muscle volume. Their thigh muscles got larger at a percentage of about 15% versus 9% on the moderate and low side of things. They showed reduced thigh fat volume, reduced pro-inflammatory cytokines, increased anti-inflammatory cytokines as well as increased their free floating leukocytes. Lots of $10 terms in there, but the reality is when we're looking at the impact of moderate or low intensity versus moderate and high intensity. It was statistically significant that moderate and high intensity strength training for older adults superior. Whether you're talking about adding muscle, reducing fat, reducing inflammation and even bolstering the immune system, which really I thought was super cool. So that's the basics of the study. If you've been hanging around the Institute of Clinical Excellence in this community, you're not going to be surprised to hear the results of the study. But what I want you to do is I want us to go a level deeper. 09:30 AGING & STRENGTH TRAINING INTERVENTIONS I want you to think about your patients on your caseload that are 65 to 75 years old. The state of the union on older adults, especially in the US more so than other places in the world, is we are inactive. We are overweight. We are not hitting ACSM guidelines. Most older adults in that 65 plus category are on somewhere on the continuum of frailty. They have low physical reserve. They have low physical resiliency. They are vulnerable to injury and decline, losing their independence. So most of our clients are on this very rapid downward trajectory. And we have got at our hands the tools, rehab clinicians. We are able to intervene with strength training intervention. If we will go moderate to high intensity, we know we can increase their muscle mass. We can reduce reduce their body fat. We can reduce inflammation. And let's think about some of the conditions that are on board outside of low reserve, low resiliency. We like to think about a thing called one repetition max living. They are very near their 100 percent capacity to get out of a chair. Think about your client who cannot stand from their normal chair without using their arms. Their one repetition max squat is less than body weight. And think about how many times they have to stand up and sit down throughout the day, giving a near one repetition max effort. Crazy! How exhausting is life for those people that are barely able to do their activities of daily living? I want you to also think about some of these global inflammatory conditions. These inflammatory markers increase the risk of progressions in arthritis, cardiovascular disease, metabolic syndromes like diabetes. Think about how many of our patients are sitting in this very vulnerable situation. So we've got this picture of our older adults on the decline, probably on the frailty spectrum. If they're on our caseload, probably have arthritis, probably have inflammatory conditions. Then we think about the opportunity that we have if we just add high intensity strength training intervention. Think about the change that you can make for them. How you can bolster their strength, their function. Get them away from that line of independence where they can just not barely get through their activities, but start building some sizeable reserve. Think about how much we can do if we hit moderate to high intensity. If they don't have inflammatory conditions yet, think about isolating them from that risk. And then not even covered in the study because these were not primary measures they were tracking, but just knowing the literature for older adults. 12:06 FRAILITY & AGING INTERVENTIONS Think about the benefit of heavier loads that's not even discussed in this study. Think about their bone density. Think about their confidence. If they know they can lift way more than they have to in daily life, is that going to impact their confidence? Is having more confidence going to help them lift with better mechanics more confidently? Is it going to help them balance in unusual scenarios more confidently? Absolutely. Confidence in that psychological impact. Don't count that out. So just think about all the opportunities with heavier load. And then what I want you to think about is maybe you're still on the fence with this stuff and you're like, I don't know if that's safe. I'm a little concerned. Maybe you don't feel quite equipped or you've not seen that modeled before and you're a little bit nervous. But I want you to think about this. I want you to think about the risk and what happens to these older adults in a very vulnerable situation if you don't. If you don't hit them with moderate to high intensity, I want to outline some of the results of the control group. During just that 12 week period where they did not perform moderate to high intensity or any strength training whatsoever, their resting inflammation went up. Their muscle volume went down. Their body fat went up. Their leukocytes went down. They became way more vulnerable in a 12 week period, just 12 weeks of not doing what they should be on the strength training train. Think about what happened to markers that were not tested. Think about their bone density. Think about their ability to get through their day with enough reserve and enough strength to really make it through the day. Just think about all the missed opportunities. I'm going to recap real quick. I know I'm super pumped about this. This is what it's all about, team. But I want you to think about the opportunity with moderate to high strength training interventions. Based on this randomized control trial, we can feel confident that we're going to increase their muscle thigh volume. Thinking about things like sarcopenia, frailty, all those categories. We can reduce their body fat. We can reduce pro-inflammatory markers. We can increase anti-inflammatory markers. We can bolster the immune system. Just based on this study, forget about bone density. Forget about one rep max living. Forget about confidence. We know those things just from this study. Then I want you to think about what you can do for your patients if you start these interventions. Think about how powerful of a tool you have. You have the keys to the castle in your pocket. If we can just go a little bit heavier. Remember, it's relative. It is relative. Yes, I will be sharing the link to this study in the caption. What happens if you don't? If you don't, we know this steady decline of frailty, deconditioning is going to continue. We know based on this study that if we don't intervene here, our older adults are going to become more frail. They're going to lose reserve. They're going to lose more muscle mass, be at higher risk of sarcopenia. We know that they're going to have higher inflammatory markers. They're going to be more at risk for progression in arthritis, metabolic conditions, cardiovascular disease. Just think about what processes you're allowing to hasten on. What's going to happen to your client if you don't get on board? Team, super spicy, super pumped about this. Got a little impassioned about this. I'll be sharing the link to this study in the caption. Super cool. Lots to think about here. Would love to hear your thoughts. Would love to hear if you have any success stories of clients that you've been using, moderate to high intensity strength training, and what the results have been. Otherwise, team, I hope you have a wonderful Wednesday and we will see you soon. 14:10 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. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Full show notes at the publisher

Episode 1530 - Hip thrusts versus back squats Aug 08, 2023

Show notes

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses recent research evaluating the effects of training programs that prioritize the back squat vs. the barbell hip thrust.

Take a listen or check out the episode transcription below.

EPISODE TRANSCRIPTION

00:00 INTRO What is up PT on Ice Crew, Dr. Mark Gallant here having some trouble with YouTube webcams this morning so we're going to be solely on Instagram and we'll get it downloaded for you on the on the back end for the YouTube. Again, I'm Dr. Mark Gallant, lead faculty with the Ice Extremity Management Division alongside Lindsey Huey, Eric Chaconis. We're going to get into some hip thrusts versus back squats today. Before we do that, if you've been looking to sign up for an ice physio course, the courses that are on the website now are the only courses that are going to be there for the remainder of 2023. So if you've been on the fence thinking about jumping in, those fall courses are the fall courses. So go ahead and get that dialed up and come join us on the road. If you've been looking to join the extremity management faculty on the road, Lindsey is going to be in Rochester Hills, Michigan this weekend. So if you want to it's a beautiful time of year in Michigan. If you want to jump up there, grab a seat. The course with Lindsey that's still available. And then I'll be in Amarillo, Texas September 9th and 10th. So I'd definitely love to see you all out on the road. One of the things that Lindsey and I and Cody and Kristen and all the staff for extremity management, one thing we're always trying to help do is to simplify our exercise selection and dosage so that for any n equals one patient that comes into the clinic, it's a bit easier for us as clinicians to go like, based on these parameters, this will likely be the best choice exercise and the best choice dosage for this individual. 02:39 HIP THRUSTS VS. BACK SQUATS And we had an article released last month. It's not even published in a journal yet. It came out of Auburn University. That's going to help us do just that. So the lead author on the paper is Daniel Plotkin with Brett Contreras, aka the glute guy, also being an author on the paper. And what they did in this paper is they wanted to compare. If we gave a group of people hip thrusts for nine weeks, and we gave another group of people back squats for nine weeks, of those folks getting those individual programs, who would have the greatest strength gains and who would have the greatest hypertrophy gains to the glute max specifically. So that's what they looked at. They took a group of individuals, about 34 individuals, who were 18 to 30, who had not done any significant training in over five years and were relatively healthy. So BMI under 30. So relatively young, relatively healthy and under trained. At baseline, what they assessed was they assessed three rep max for their back squat. They assessed three rep max for their barbell hip thruster, three rep max for a deadlift, and hip extension against a force plate to see how much output that glute max was doing. They also, which is kind of cool, they threw them through an MRI tube. And that's how they got a measure of how dense and how robust their glute max tissue was. So they threw everyone, day one, through that MRI, got an assessment of how thick their glute max was, how thick that booty was, and then they reassessed that after nine weeks. The final piece they assessed was they took EMG output for both the back squat and the hip thrust. So what did they do for an intervention? So over the course of nine weeks, one group got hip thrusts and one group got barbell back squat. Each group did nine weeks. Week one, they did three sets of eight to 12 reps. Week two, they did four sets of eight to 12 reps. Weeks three through six, they did five sets of eight to 12 reps. And then week seven through nine, they did six sets of eight to 12 reps. So over the course of the program, they were getting a lot more volume as time went on. The way they controlled for the intensity, if a person was able to do more than 12 repetitions at any given set, they bumped the weight up. If they were unable to get to eight reps, they lowered the weight down. So they always wanted to keep it between those eight to 12 reps while making it approaching failure. So getting close to failure for each of those individuals to really challenge those tissues overall. So each group did twice a week, only back squat for the back squat group, two days a week with those loading parameters. Hip thrust, twice a week, only hip thrust for that nine weeks with those loading parameters. 05:12 THE LAW OF SPECIFICITY What shook out at the end of the nine weeks was pretty cool. We're starting to see some strength and conditioning principles that are becoming clearer for us as better studies come along, as time goes on. The number one thing that we continue to see is the law of specificity. If you want your client to get better at back squats, have them do back squats. If you want your client to get better at hip thrusts, have them do hip thrusts. If you want your client to get better at deadlifts, have them deadlift. You want them to get better at step ups, have them step up, so on and so on. And that's exactly what we saw in this study. The group that did barbell back squat got significantly stronger at their three rep max back squat at the end of that nine weeks with only minimal gains in their barbell hip thrust, in their deadlift, in their force plate. They made gains in those other things. They were not nearly as significant as the gains as they made on the specific exercise they were doing. Same for the barbell hip thrust. The group that did the barbell hip thrust made significant gains in their three rep max on the barbell hip thrust. We did not see the same significance in their back squat, in their deadlift, and in their isometric hip extension against the force plate. Again, they made some gains, not as significant as the specific exercise. So again, we're seeing this article reinforce. If you want to get better at a specific thing, that person will need to do that thing as soon as their tissues can tolerate it, as soon as they're ready. Get them doing the thing that they desire to get better at. The other cool thing about this paper was hypertrophy. What we saw with hypertrophy with this study is both groups hypertrophied their glute max equally. So it didn't matter whether you were in the back squat group, whether you were in the hip thrust group, both groups showed glute gains. 09:58 HYPERTROPHY AND EXERCISE SELECTION And what we're seeing in a lot of the hypertrophy research is exactly this, where as long as the tissue is being stimulated at a challenging level and enough volume, that's good enough for the tissue to grow. So this study met those two criteria. It had an extreme amount of volume. So getting up to six sets of eight to 12 reps is a ton of time under tension for a tissue. And by controlling that they always wanted those folks to be approaching failure at a challenging range between eight to 12 reps, we got both high volume and high intensity. If those two parameters are on board and the tissue is getting some stimulus, almost always we're going to see some local tissue change or some growth. So again, law of specificity, do the thing that the person wants to do. And if you're looking for local tissue changes, hypertrophy, it seems to not matter as much which specific exercise. As long as the tissue is being challenged at an appropriate volume and at an appropriate intensity. The other interesting thing about this study was the EMG output did not seem to matter. So the barbell hip thrust had a higher EMG output for the glutes and that did not correlate to either strength gains or to more hypertrophy. Again, the strength games came from specificity. The hypertrophy gains came on board because the intensity was appropriated up. Now, looking at any study, we always want to be aware that there's problems with every study or challenges to any study that comes across the board. There are no perfect studies out there. The challenges with this study were it was a relatively low population. So there were 34 individuals, 18 in the hip thrust group, 16 in the squat group. So a fairly small population. They were all young and relatively healthy, which is going to be different than our general physical therapy population. And they were all significantly undertrained. So no one that was accepted in the study had more than one day a week for over five years of weightlifting experience. So appreciate that likely these gains that we saw in strength and these gains that we saw in hypertrophy are somewhat attributed to that. These folks were so significantly undertrained. And we've all seen that the more undertrained the person is, the easier it is for them to adapt early on. Also, with this, nine weeks is a fairly short amount of time to have a strength and conditioning or a hypertrophy program show results. It's likely that because they were undertrained is why we saw results in nine weeks. With our general physical therapy clients, some of whom may have been weightlifting for 15, 20, 30 years, we would expect a bit longer time to get true tissue adaptations and to get true strength adaptations. So again, to recap, study showed hip thrust versus barbell back squat. If you want to get better at the hip thrust, do the hip thrust. If you want to get better at the barbell back squat, you want to get stronger at that, do the barbell back squat. If you want to hypertrophy, whichever exercise you want to choose is great as long as you've got the intensity and the volume. The final cool thing that this study showed was that when someone did the barbell back squat, they had a ton of adductor activation and ton of quad activation and a ton of glute activation versus the hip thrust, which had primarily glute activation with far less hip adductor or quad activation. So if you've got a patient who comes in and they're in a lot of pain and you say, man, they've got some knee pain on board, their adductors seem a bit irritable, those quads are all gummed up. And we want to make sure that that athlete or that client is maintaining powerful hip extension, which is one of the most important movements for all humans. Then let's bias early on to the barbell hip thrust because it's not going to challenge those adductors and those quads. When that patient starts to get better and their adductors and their quads are not as irritable and they're not as gummed up, then let's go straight after that squat. Or on the flip side, you have no tissue irritability on board and that person's daily life requires a lot of squatting. It's going to behoove you to go right after that squat instead of spending time on the hip thrust early on. In reality, we've beaten a dead horse with this saying over the years and not more. For most of our folks, you're going to want to program hip thrust. You're going to want to program some squats. You're going to throw your deadlifts in there to have a nice well-rounded program. Law of specificity. Make sure the intensity is good. Make sure the volume is good. Have a great Tuesday treating clients. Can't wait to see you all on the road. Have a great rest of your day. Always grateful to be speaking on this podcast and hope to see you all soon.

11:37 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 CU's 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.

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