#PTonICE Daily Show

Dr. Cody Gingerich from ClinicalTuesday shares tips on building the perfect HEP: Time availability, equipment availability, and dosage. The podcast explores efficiency in program design, tailoring exercises for optimal tissue response, and customizing programs to individual needs and resources. It also emphasizes optimizing exercise dosage for effective rehabilitation.

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses the CrossFit hero workout "Murph", including modifications & considerations for pregnant & postpartum athletes. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at signup to receive a one month free grace period on your new Jane account. RACHEL MOORE My name is Dr. Rachel Moore. I am here this morning on Memorial Day to chat with you guys about the MRF workout and reflections for the MRF workout as a prenatal or maybe postpartum athlete. So whether you yourself have been that athlete and been prenatal or postpartum while doing MRF, or maybe the population of patients that you see is this prenatal space. I want to dive in to some reflections on that today. So first of all, we're going to kick it off. If you are not familiar with the CrossFit space, you're not in the CrossFit space. What is the Murph workout? So Murph is a workout. It's called a hero workout. it's done typically on or around a memorial day so whether memorial day weekend or memorial day itself it is a hero workout which is a named workout in the crossfit space for somebody that has given the ultimate sacrifice and paid their life for whatever the reason so michael murphy Um is who this workout is honoring he was a navy seal and he died in the line of duty So the workout itself is a one mile run 100 push-ups or sorry 100 pull-ups 200 push-ups 300 air squats and then you cap it all off with a mile run and the rx version of this workout is wearing a weight vest 20 pounds for guys 14 pounds for ladies If you have never done this workout, it's a long one. Most people kind of fluctuate like earlier times or fast times or sub one hour, but a lot of people tend to hover around that one hour a little bit more mark if they're doing a quote unquote full Murph. We also can do a half Murph, which is where we take that workout. and cut that volume in half. So the Murph itself is one of those workouts that is a really powerful symbol within the CrossFit community. Typically, most gyms are getting together, whether it's on that Saturday or on that Monday. It's a large community event. It's a really exciting thing to be a part of and a really exciting thing to come together. A lot of people really look forward to this workout every year. not only for the reason of what it represents and the fact that we're paying honor and tribute to people that have given that ultimate sacrifice of their lives so all of us have the freedoms that we have. but also because it is a pretty big test of fitness. And depending on what season of life we're in, sometimes those tests of fitness can be hard. Whether it is physically hard or emotionally hard, regardless, it can be tough. And in one of the largest seasons where we see that is in the perinatal space. So when somebody is pregnant or when somebody is maybe newly postpartum, and they're trying to figure out how to tackle Merv. it can be tough to set aside that athlete brain. It can be really hard to turn that off, especially if you're somebody that's done Murph maybe in the past, and you want to know where you shake out. Or if you're brand new to CrossFit, maybe you started doing CrossFit, found out you were pregnant shortly after, and you're seeing everybody in your gym get super excited about testing their fitness and seeing where they're at, seeing how they compare, maybe doing it for the first time, and knowing that you can't do it the way that you would quote unquote like to. So let's unpack that a little bit. For one, we at Ice really preach that we don't modify unless we need to modify. Just because we're pregnant, quote-unquote, is not a reason to modify MRF. If you're somebody that this workout is in your wheelhouse, maybe you are doing pull-ups and have been doing pull-ups in the gym. maybe push-ups are not bothersome to you, you're early enough on in pregnancy that your bum's not getting in the way, you feel good doing all those push-up volume, air squats feel great, running hasn't gotten to a point where it's bothersome at all, then there's no reason to modify the workout. We don't modify the workout because of pregnancy. We may be able to tweak it slightly, so maybe you partition instead of doing all of the reps in a row to save some of your core fatigue, So instead of doing 100, 200, 300, you do 5, 10, 15, and just give yourself some breaks in between. But if none of those movements are problematic for you and the volume isn't problematic for you, then it's okay to just do the workout, maybe a little bit slower than you otherwise would have, but it's okay to send it. If you're somebody who has issues with one of those movements, whether it is the pull-ups. You don't have that midline strength and stamina anymore and you're seeing a lot of that coning repeatedly over time and it's something that's bothersome to you or maybe the push-up volume is way too high for you or squatting below parallel triggers some pain. It's also okay to modify the workout. Modifying a Murph is not a sign of shame. Doing the Murph in and of itself is huge. modifying the MRF, whether that is because of pregnancy, whether that is in the postpartum season, or whether it's because of an injury, or you're a new CrossFitter, it's okay to modify when we have a reason to modify. It's still exciting to show up. It's still exciting to be a part of your community and do that workout. I have done this workout myself. This was my sixth MRF this year and I did it as a new postpartum. So it was three months postpartum and I was a newer crossfitter. I've done it as a, I think 18 week pregnant crossfitter. I've done it as a year-ish postpartum crossfitter, and then I've done it Rx twice. And in each of those seasons, the challenges were different. When I was a pregnant athlete, I wanted so badly to send it. I wanted to do a full MRF. I wanted to do the entire volume. But my body didn't feel great with that. And so that year, my husband and I ended up splitting the MRF. So we ran the mile together. It was a little bit slower than I otherwise would have ran. and we did you go, I go rounds and we took turns so that I had some built-in rest breaks because for me at that stage in my pregnancy, my heart rate was skyrocketing and I was having a really hard time managing that much volume with that high of a heart rate for that long a period of time. That was a challenging year for me. It has nothing to do with the physical side. Honestly, when we finished our MRF that we split, I was just like, okay, like that was fine, I guess. I'm excited I was here. But physically, it didn't feel like that much of a challenge. But that was the most mentally challenging year. On the flip side, the very first time I did MRF, I did a similar thing. I split a Murph, quote unquote, with a friend. We did you go, I go rounds. I was a newer CrossFitter and I was postpartum. So I scaled the pull-ups for ring rows. I did push-ups for my knees and I did air squats, but I did it all with a vest because I wanted to know if I could. So half a Murph shared with somebody, quote unquote, with a weight vest on, so reduced volume and scaled movements. And I have never felt so powerful than when I finished that workout at three months postpartum. It was awesome. So those are two very different seasons, two very different iterations of the workout from the standpoint of RX movements versus scaled movements, weight vest versus non-weight vest. And the outcome was different. One, I felt physically strong, mentally strong, felt super empowered. And one, honestly, was a really hard mental load for me because I wanted to do what all of my friends were doing in the gym and I wanted to be able to push myself. that athlete brain is tough to turn off. So if you are one of these patients, or one of these people that is doing MRF this year, or has done MRF by this point at 9.20 on a Monday Memorial Day morning, and you struggled with that, it's okay. If you have patients coming in in the future, and they're talking to you about, I wanna do MRF this year, but I just don't really know what to do, it's okay to tell them to modify. It's also okay if they wanna send it. At the end of the day, we're not modifying just for the sake of modifying. We had a gal in our gym last year who was in her 30th week of pregnancy. She's a former CrossFit Games athlete. She crushed it. She swapped out the pull-ups for ring rows, but otherwise did everything else RX and did fantastic and felt fantastic for her body. that challenge and that load was appropriate. We've also had people like myself who at 18 weeks pregnant decide that I need to modify. I'm not going to do a full Merv and I'm going to scale the movements. All of these options are okay. The beautiful thing about this workout is there are so many ways to modify it. There are so many ways to modify the movements themselves. There are so many ways to break up the volume. There are so many ways to cut the volume down. And at the end of the day, showing up and being a part of the community is what is really key this weekend. Being there, paying that tribute, showing that respect, and getting to be a part of your community is huge. If you're somebody that's been in this season and wants to chat more, shoot me a message. I would love to talk with you more. This is a topic that I'm super passionate about because I've been there. I've been in those shoes. And sometimes, you know, we just need to commiserate together about how hard something was. SUMMARY If you are looking to join any of our pelvic courses, we have got, we're about halfway through our L1 and our L2 cohorts. So we've got another L1 cohort kicking off. Our next L2 cohort is not until the fall. If you're interested in that, hop into it because it's going to fill out. Catch us on the road this summer. We've got a lot of opportunities to get to the live course where you can sit for that cert test and become ice pelvic certified. I hope you guys have a great rest of your day. If you did MRF today or at any point this weekend, make sure you take care of yourselves. Hydrate get your electrolytes in make sure you're getting protein in take care of your bodies And I know I'm feeling a little bit sore from my Saturday Murph So just know that in the next couple days you may be feeling some type of way, but it's temporary and it'll pass See you guys around OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall, Fitness Athlete division leader, discusses the shift towards salt-based hydration drinks, evolution of Gatorade, health risks of sports drinks, and benefits of sodium-based recovery drinks. Emphasizing the importance of replenishing lost salt for active individuals.

Alan Fredendall, ICE COO, discusses transparency, pay, and communication when changing positions. Topics include job dynamics, pay transparency, and workplace communication. Key considerations for clinic settings are hiring for fit, communication, and engagement with leadership.

Dr. Dustin Jones, physical therapist, discusses a holistic framework for assessing and improving balance in rehabilitation, emphasizing the importance of personalized balance programs and risk factors. He explores addressing visual deficits and vestibular screening for effective balance exercises, as well as tailored approaches to improving balance abilities. The podcast also delves into precision assessment and intervention frameworks with dedicated resources, highlighting the importance of evaluating individual deficits for precise interventions.

In this episode, Dr. Zac Morgan discusses assessing and treating upper traps for neck and headache symptoms. They explore the impact of stress on muscle tension and detail hands-on techniques for soft tissue assessment and treatment. The discussion includes specific methods like pinning, depression, and stretching, along with techniques to relieve tension in the upper trapezius muscles. Furthermore, the importance of evaluating the upper trap in conditions like neck pain and upcoming spine courses are highlighted.

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the benefits of birth control and when we should be thinking more positively about these medications and methods Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. CHRISTINA PREVETTHello, everyone, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty in our pelvic divisions. And I am coming to you from a hotel room. I'm about to get back after teaching MMOA Live here this weekend. So you got my hotel version of today's podcast. Today we're going to be talking about advocating for birth control. And so this might be a bit of a hot take hot topic, because in the allied health or birth provider space, there has been a lot of anti birth control messaging. And so I want to kind of play devil's advocate a little bit. and speak to some of the potential pros of birth control, and then really try and loop this into why it is so important, especially as healthcare providers, that we become more nuanced in our approach, right? It is so easy with social media for us to be thinking in 30 to 60 second snippets. But one of the reasons why I love the podcast is that we're able to kind of dive into nuance a little bit more. So firstly, the development of the oral contraceptive pill was one of the big revolutionary medical marvels that allowed women to have reproductive choice in a lot of ways, right? The idea behind oral contraceptives was that females could have some, you know, obviously when they're having intercourse, but like they were able to prevent unwanted pregnancies and that gave them some sense of control in a lot of ways. So the development of oral contraceptives outside of barrier methods was truly such an amazing medical advancement that paved the way for a lot in reproductive healthcare. With the use of exogenous hormones, what we have also seen with the use of oral contraceptives is that it has been used in the management of different gynecological conditions. So here's where we get to messaging numero uno. When people take birth control, they aren't actually balancing their hormones. Something is doing it for them and it is a band-aid and it's making all your sex hormones go down. This is the messaging. So we shouldn't be giving people birth control because it's not fixing the problem. So let's talk about an argument where that works, and let's talk about an argument where it doesn't. Okay, so in our pelvic division, we talk a lot about relative energy deficiency in sport. This is for individuals with primary or secondary amenorrhea, where because they are not fueling their body appropriately, their body goes into battery saver mode, which means that they are not doing any bodily processes that require excesses of energy out like energy out because they don't have enough energy coming in, which can include pregnancy. And so we suppress the HPT access to prevent ourselves from ovulating because right now we're not taking in enough fuel for our body to function. We're definitely not taking in enough fuel to support a pregnancy. In those circumstances where individuals are not getting their period because of under fueling, sometimes birth control can be recommended and The argument can be made that. we're not getting at the root cause for the hormonal imbalance, because you need to have that fuel to the root cause, and we should see a hormonal re-regulation, and reds from the literature that we have right now is reversible, right? So that makes sense, right? If individuals are highly active, they're in low energy availability, and they're not screening for root causes of issues with hormone status, and we give birth control as a knee-jerk reaction without doing the proper investigations, I can see where that argument of it's exogenously balancing your hormones would work. But here's where it doesn't. Okay, here's where it doesn't. So birth control is also used as a frontline treatment for a lot of fertility-impacting conditions or gynecological conditions, such as PCOS, endometriosis, and fibroids, right? PCOS, is a androgen excess and it is a chronic disease. It is a chronic disease. It is a chronic disease that has no cure. So there is no cure to be able to balance your hormones naturally with PCOS. Does health promotion potentially help with becoming more regular with your menstrual cycle? Does it help with bringing you to a more regular cycle where you may be more ovulatory with PCOS? Yes. Are you going to change to a, within normal levels, your androgen access? Probably not. So guess what? The birth control pill is being used to bring androgen load down, right? And that is how we treat chronic diseases, right? I don't give a person, oh, I'm not, I'm not a physician, but physicians don't give a person a blood pressure med and we get mad at the physician for giving them a blood pressure med because they're treating the symptom of the high blood pressure, but they're not getting to the root cause of the issue, which is cardiovascular disease, right? These medications are given specifically to manage the symptoms. which is the exact same logic that we are seeing with individuals with gynecological conditions. We are not giving oral contraceptives in order to balance their hormones because they are chronic diseases, right? Outside of excision for endometriosis and fibroids, where we may see a reduction in symptoms, that is not a guarantee. And the only known cure for true 100% cure for endometriosis and fibroids is a hysterectomy. So if we have individuals with a high amount of symptom burden, heck yes, we are going to treat the symptoms, right? And so we can use oral contraceptives to treat those symptoms, right? If I wanted to pull this into our physiotherapy logic, that would be like saying, well, this person has a disc bulge on MRI. If we can't fix the disc bulge and get it back in that spinal alignment, then all of our interventions for pain don't matter because we're not fixing the root cause, right? So, but, PT we say you are not your image like we're not just going to treat you mechanically we're gonna treat how you're feeling within your own body and yet we flip that in our health care providers spaces when we talk about birth control and we make women with heavy menstrual bleeding with heavy periods with individuals who are suffering from fatigue and lethargy because they have anemia we have cyclical pain that could be treated with oral contraceptives and we make them feel bad that they're using it or make them feel fear that they shouldn't be using this because they should be able to balance their hormones regularly and so inadvertently in an attempt to help we're kind of gaslighting them, right? And, and I, I mean this in a very, like, I want to have a fruitful conversation about this because I have seen this messaging over and over and over again. And when individuals have gynecological conditions, birth control can be a management strategy. Should it be a knee-jerk reaction for everybody without the need for further investigation or evaluation? No. Are individuals oftentimes dismissed with birth control because they're not actively trying to get pregnant? Yes. Do some people not tolerate certain types of oral contraceptives or different types of birth control methods? Absolutely. But it is a trial of treatment that has some evidence to back it up. and it can be helpful in some circumstances with some individuals. So having this knee-jerk reaction and saying, well, it's not getting to the root cause or it's not balancing our hormones in the background of a chronic disease with no cure, we are missing the mark on our messaging. And so many of our clients come to us as pelvic PTs and they trust our opinions. And we are trying to lock shields with physicians, not battle with swords. And we need to be mindful of that, that by being very dismissive or not getting to the nuanced approach to contraceptive care or using birth control methods, we are not doing ourselves any favors and we're not helping our clients by not getting into the nuance of it. So the first argument that we see a lot is you aren't balancing your hormones, like it's doing something for you. It's taking your HPG access and bringing it down to nothing, right? That's not always the case and not always the method of oral contraceptives. It can blunt the HPG access, but it doesn't make it go down to zero. And then the secondary piece that individuals have fear on when thinking about oral contraceptives is future fertility. So, There was a cross-sectional study that said that almost 70% of females surveyed were worried about long-term fertility because of oral contraceptive use. We do not have evidence. We actually have multiple systematic reviews and meta-analyses that actually demonstrate that there are no changes in fertility upon cessation of long-term birth control utilization. All right, let me repeat. We do not have evidence that being on birth control negatively impacts future fertility. It does not. What we see is that using hormonal, non-hormonal IUDs, oral contraceptives and patches, the rates of live pregnancy or positive pregnancy rate for contraceptive versus non-contraceptive users in age-matched cohorts appears to be the same. where we can kind of get into this bias, this selection bias, is based on the reason for individuals going on birth control. So if you were a person who went on oral contraceptives in order to prevent pregnancy, but you did not have any fertility related concerns, and that wasn't a factor in your prescription, once you stop taking oral contraceptives, maybe after a couple months things will kind of re-regulate, you should have no future impacts on your fertility. Where you can have downstream fertility related issues is based on the reason for being on those oral contraceptives. So if you are on oral contraceptives for heavy bleeding or cyclical related pain, or hirsutism or clinical androgenism as a consequence of PCOS, we know that PCOS, endometriosis and fibroids can negatively impact your fertility and increase your chance of infertility. So in those situations, because we were treating the symptoms of your condition, we do not have the capacity outside of excision and endometriosis and fibroids to cure these conditions, that downstream fertility consequence is still going to be present upon removing your birth control method or upon removing oral contraceptive use. So it is not the pill itself, it is some of the reasons why you were on the pill that can negatively impact future fertility. And so I have now been talking for about 11 or 12 minutes on the nuance of birth control. The final thing that I will say is it is hysterical to me that the clinicians who are absolutely adamant against birth control for reproductive age individuals, are big advocates for using topical estrogens and hormone replacement therapies, menopausal hormone therapies, for individuals going through the menopausal window, because they are treating the symptoms of menopause, right? We are not trying to fix a person's hormones. We aren't gaslighting them and saying, oh, well, you know, this is your natural aging consequences, so you're just gonna deal with your menopausal symptoms. No, we're at the forefront advocating for topical estrogens and the use of exogenous hormones to be able to help individuals at the end of their reproductive window. So then why are we telling individuals with chronic diseases like PCOS that we can't or shouldn't use, that we should be fearful of using oral contraceptives in their reproductive window when they do not want to be pregnant? Right, and we know that it is a chronic disease that has no cure, and we make them feel bad for treating the symptoms with these exogenous hormones. So we just need to be so careful in our profession about how we are catching onto these trends. I always talk about the fact that I am scrunchy, not crunchy. I am a huge advocate in holistic care. And I think that holistic care can come alongside Western medicine in an evidence-informed way. All of my research is in health promotion, which means that I am in the science-based crunchy. So we just need to be mindful about not having this knee-jerk reaction and saying that birth control is bad. That is the messaging that I'm seeing. And that is absolutely not true. In the messaging, the logic in the messaging is flawed. When we're thinking about gynecological conditions, many of them are chronic conditions that do not have 100% curative rate. PCOS is a chronic disease with no cure. Endometriosis and fibroids can have excision, but the only thing that's going to guarantee that you are not gonna have another growth is a hysterectomy, which is not obviously a viable option for individuals who wanna get pregnant. And therefore, using oral contraceptives for managing signs and symptoms of those conditions is a evidence-informed utilization or medication that people can do. That does not mean that it is for everybody. That does not mean that people can self-select. It's okay for them to self-select away from it. We just wanna make sure that they're getting the right information about what it is and what it isn't. Birth control does not impact your future fertility. We now have multiple systematic reviews and meta-analyses that pending normal reproductive status, normal fertility rates, that we have no infertility-related conditions that there is no difference in conception rates once getting off birth control. And then we are huge advocates for the use of supplemental hormones through menopausal hormone therapy at the end of a person's reproductive window. All right, that was my rant for the day. I hope you guys found that helpful. I really just wanna get into the nuance of this, right? Like we wanna make sure that we are being mindful of our messaging and we are not, inadvertently shaming people or making them fearful or Gaslighting them and saying you don't need birth control you can use all these natural methods When we don't have the same effectiveness data in some of those health promotion technology or health promotion interventions SUMMARY All right You probably wonder why we're deep diving into this. This is because of level two, right? We have a huge role, right? We are doing level two right now for our pelvic course, and we are trying to do fitness-forward pelvic PT in a variety of different conditions. Fertility, baseline fertility, infertility-related conditions, and our role coming alongside those who are going through assisted reproductive technologies is in our curriculum. So we are in the weeds of that research and talking about the ways that we can be involved in rehab. And then if you guys are interested in seeing us live, we have two courses going June 1st and June 2nd. I am in Highland, Michigan, and Alexis is up in Alaska with Heather. And then June 8th and 9th, I'm in Mineola, New York. I'm near New York City at Garden City CrossFit. So if you are hoping to jump into a pelvic live course, I hope that I can see you at the beginning of June. Otherwise, have a really wonderful week, everybody. Hopefully I won't be so nasally and sick the next time I'm on the podcast. One can only hope. And have a really wonderful week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the difference that one degree can make when performing adjusts to a cyclist's bike fit. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. MATT KOESTER Okay, we are live on Instagram and live on Facebook. Good morning, everybody. Welcome to another episode of the PT on Ice daily show. I am your host today, Dr. Matthew Keister. I am an elite faculty in the endurance athlete division with a specialty in bike fitting. So today I definitely am excited to step in and have a conversation about one of my favorite aspects of bike fitting. And that is the really nitty gritty small details that we love and we talk about every course and we get really into the weeds on. But I think sometimes to the outsider can be a little confusing. Before I step into that realm, though, I do want to take a second and highlight a few upcoming courses. This weekend, Jason London, my co-faculty, is going to be in Minnetonka, Minnesota. That course is pretty darn full. If there was any spots left to grab, it's probably the last second to do it, and they might not even be available. The next course we've got is in Bellingham, Washington. That is June 1st and 2nd. That course is sold out, and we're currently building out a wait list. We're also working on setting up a second course offering for that in the fall right now, but there's more details to come on that. And then we have another course set up. Next one coming in is July 27th and 28th in Parker, Colorado. That is going to be an awesome course. Just an easy place to get to in Denver. Always good to ride around there and get some time outside in the mountains. So super stoked for that one as well. That's it. That's it for the upcoming courses right now that I wanted to talk through. THE DIFFERENCE OF ONE DEGREE WITH BIKE FITTING Let's get into the title of today. I called it one degree away and I think When we think about like one degree, first of all, the margin of error for that with our measurements is often really, really hard to overcome. It can be incredibly hard to take a look at somebody and say, I'm going to make a one degree change on this and think that that's going to be clinically significant or meaningful to their pain or their experience. It gets a little bit different when we talk about bike fitting, though. When we talk about bike fitting, we're often using a little bit more precise measurements. We're using laser levels. We're using digital electronic levels, things that give us really specific data. And then when we think about the other part of bike fitting, when we make that adjustment to whatever componentry it is on the bike, and I'm going to talk through two specific cases in a moment, but whether it's the pedals or it's the seat, when we go to make adjustments there, that adjustment, while small at the instrument, one, two degrees, has upstream effects or downstream effects that are pretty pronounced when you extrapolate that one degree as it gets further and further away from the axis in which you made the change. So I think sometimes that's the missing piece when we try to have conversations about making a one degree change or a two degree change to something really small. So I mentioned we're gonna go through two different cases and I think the first one is the one that is oftentimes the trickiest when we're actually at the course. We spend a ton of time in the course talking about the art of trying to improve somebody's pedal stroke so that their legs are driving more up and down like pistons and less with dynamic changes or aberrant motions that are in the frontal plane. So knee valgus or going more into abduction. We try to kind of eliminate those things because any power that isn't going straight down the pedals is wasted. So one of the ways that we typically will make a change to get somebody into a better position or consistently riding in a better position is we'll add shims to their shoes. The shim is like, I mean, think about it the way like you would shim anything. It's a, it's a little wedge. It's thicker on one side than it is on the other. And it goes right underneath the shoe or sometimes inside the shoe. We can put that on the medial aspect of the foot. If we want to push that knee out a little bit into more abduction and stop a little, stop some of that abduction or potentially dynamic valgus. We can also, for the individual who rides with their knees pushed out a little bit, We may have to solve other things around the hip and the low back, but for that individual, we can also shim laterally and drive the knee in some to create some stability and drive them into the more neutral up and down position. Every single time that we break out one of these wedges though, they seem like, how could that thing make the change? It is one degree or it's one and a half degrees. And I think that's where things get lost a little bit. It's not the one degree made at the foot that makes the impact. It's what that one degree does when you extrapolate that 12, 18 inches up through somebody's shin bone. When you take it up through all that to the knee, we see some changes. And I grabbed this old-fashioned measuring tool. I had to pull it out of the dirt to get it here. But if we have our goniometer, we have it set up, and I make at the bottom, from a perfect 180, if I make a one degree change and I push that thing over. Down here, that is almost a non-measurable, hard to even see that change happen. But when we get up here towards the top, it's pretty crazy how that one degree change, just in this amount of space, moved us out probably four to five millimeters. Or for those who like freedom units, that's more in the quarter inch range. Many people's tibias are not this length. They'll think even further, take that out even more. All of a sudden now that person whose knee was riding like a half inch or a little bit more outside of what we'd want in a neutral position, as one degree change down here might have a dramatic shift at the knee. So it's really cool when you actually see it. And every time we put it, we put one underneath the client's shoe as fit as ourselves. I think we're constantly amazed. that we put that thing in and we're like, well, we'll see how this goes. And then it's amazing how much different it is and the patient can feel it too. They'll be like, yeah, that feels really good. My foot feels really supported. And you're like, okay, that one degree really did it, did it great. Another really key case for this, there's been research done by Andy Pruitt, who's kind of the godfather of bike fitting. He's done a ton of the leg work for the style of fitting that we do nowadays. When he was early on in his career and he started to really put a lot of content out for this and put a lot of effort and research behind it, he got partnered with Specialized. They're one of the largest bike brands in the country and they wanted him to help create what they considered their body geometry line. The body geometry line was essentially a best attempt to create the best contact points on the bike possible. So that's the cleats, or the feet, so the shoes, the seat, and the handlebars, or like the grips. So they put a ton of effort into their shoes. What they found after just time and time again testing folks, they found that everybody benefited from some level of a medial shim in the shoe. So they were like, over and over and over again, if everybody's benefiting from this and we're getting less adduction and a more piston-like vertical motion, why don't we just build this into the shoes? At this point, they actually do. Specialized, with all of their shoes, the Torch is one of their most, like their flagship and most consistently sold shoes, is baked in with a three degree medial shim to take up some of that flexibility in the foot so that the power we're putting down isn't lost in these aberrant motions, it's more direct into the pedal and it's nice and sturdy. So, that's one of the main changes that came out of the research from Andy Pruitt and Specialized. And I think it just kind of goes to that point of, we know how impactful a degree can be. The person who's dealing with knee pain that is definitely coming from these constant, shifty, aberrant motions, we start to clean that up. We start to get a cleaner picture of what's going on. That all starts with a one degree change. Now, I think the interesting one and the more pronounced version of this is actually at the seat, though. So we're not talking about now adding components or putting new things onto somebody's bike. We are talking about just making an adjustment to tip or tilt the seat. If we bring the nose down, which is a pretty common change for a lot of riders, it makes pretty pronounced changes in low back pain as well as some of the perineal pressures. So you can imagine that if this was the front of my seat and it's tipped up, there's going to create a lot of excess pressure in the perineum. This is a great conversation for any of our pelvic physical therapists to step into because the ramifications of sustained pressure in those areas is definitely in their ballpark and certainly outside of mine, especially if I make the changes and it doesn't quite get what I want. However, when we bring that seat down to try and fix those problems, we want it level or potentially slightly nose down. It's usually like one to two degrees. The reason we want that one to two degrees nose down is because what it allows the person to do is achieve a more relative anterior tilt. They're able to get out of this posteriorly locked lumbar flexion and roll a little bit forward and get into a little bit more favorable position to take stress off the low back when they're riding. This is a space where you go to make your adjustment and you put a electronic level on their seat with a nice level platform on top, and you might make a tiny little adjustment, one degree down. And in that moment, the client is sitting there going like, why did I come in here for this? That was the tiniest little adjustment I've ever seen. And then they hop back on and it's incredible how much better they feel. And the reason for that is the same thing that I already explained at the knee. When we're talking about a one degree change at the axis where you make the change, it has a lot of ramifications upstream. So I'm gonna use my Sangoniometer example. If I look at a one degree change, so let's just say I wanted to get somebody's shoulders more upright, get their back out of some flexion. I make a one degree change nose down. At this point, I've got my quarter inch, maybe a little bit more at this point. Think about somebody's torso being almost double this. and then consider the fact that we might have made a two degree change. I've already got a half inch here. By the time I get to the shoulders, I've probably got a full inch or more change. And that's just a rough estimate, assuming that the person's body was a super rigid straight line. Think about the fact that we have this chain link of vertebrae going up. If you can reduce stress up each one as it goes, you actually can get even more range of motion out of that. So it's pretty profound when you take somebody from a locked out lumbar spine position make a one degree change to something that's sitting right underneath their pelvis. It allows their pelvis to get into a one degree better position, but what it does up the chain is pretty incredible. You'll have somebody immediately go, Oh, that feels so much better. Like I don't feel that pressure underneath my butt anymore. That was really giving me numbness. Oh, I already don't feel that tension on my back. I don't, I feel like I can like get myself upright a little bit. I can get myself into a more neutral position and neutral coming in air quotes there. Cause it's a little bit different. Um, like we're not actually in lumbar spine neutral, but they get closer to it. And that can be the thing, getting out of that fully locked out position, getting into a slightly more neutral position is something that happens with a one degree change. So when we're talking to these folks and we're talking about the adjustments we want to make, it can almost sound really unexciting when we do our wrap up. We're saying, hey Sally, when you came in today, we made some adjustments to the bike. The first one we did is on your shoes, we actually added a shim to them. I put a one degree shim in there. And then when we went to the seat and we made our adjustments, we made a one degree change nose down and we actually slid it forward two millimeters. Those things don't sound really exciting when you say them out loud, but when you start to put together what those things are doing throughout the chain, throughout the whole body, bike fitting ends up becoming one of these things where we can make a very minute change now and have immediate, immediate reductions in pain, immediate improvements in performance, immediate changes in posture and positions and access to those positions. So getting into the nitty gritty, getting into the details, knowing that if you're going to make a one degree change or a two degree change, that it's going to have even bigger effects, talks even more to how important it is that we're accurate with those changes. If you are really, really interested in learning about making those changes, how to keep them accurate, how to make sure that we're not Throwing something else out of whack while we make one adjustment, I highly suggest you join us on the road. The BikeFit course is probably one of the most unorthodox courses in all of ice. It is the most niched down, it's just a bunch of people who love riding bikes and love tooling on bikes. And it's also folks who have absolutely no experience turning wrenches. People who come in who's first time using a torque wrench is in the course and we love that. It's a beautiful thing to have in the clinic and this is one of the main reasons why. It's those tiny adjustments that give us access to positions that we never would have had access to otherwise or would not have been able to fix even if we'd spent a ton of time in rehab when we could have just made the one degree change. Thanks y'all. Appreciate ya. 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. 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