#PTonICE Podcast

Dr. Ellison Melrose // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty member Ellison Melrose discusses how to dry needle the occiput to address headache complaints. Elli orients listeners to the anatomy of the occiput as well as muscles to target when needling. She also discusses what stim parameters to use when treating headaches. Take a listen to the podcast episode 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 dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling, Lower Body Dry Needling, and Advanced Dry Needling. EPISODE TRANSCRIPTIONINTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. ELLISON MELROSE All right, good morning, Instagram and YouTube. Welcome to the PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division. We're gonna dive right into things today. I am here to bring you dry needling for the suboccipital headache. And why I say that in quotations is because oftentimes when people are complaining of headaches at the base of the occiput, If we actually take time to palpate those tissues, it's not the true suboccipitals, okay? So we are thinking about the occipital insertion of things like upper trap and semispinalis. Those are our two main culprits when we have patients that complain of the headaches that start at the base of their occiput. So before we dive in, first of all, I have already cleaned the tissue of my patient here. but let's orient ourself to the anatomy of this occipital area. OCCIPITAL ANATOMY So in order to do so, we are gonna start by palpating for the external occipital protuberance, which is the protuberance, which is the nice bump on the back of our head here. So that's going to give us that orientation of where that superior nuchal line is, okay? Superior nuchal line is going to be the superior border of those occipital insertion of upper trap and semispinalis. We can follow that superior nuchal line down towards the mastoid process here. That's going to give us our, again, superior border of where those needles live. If we follow the mastoid process medially, it dives deep, but the inferior nuchal line is going to be the inferior most border of where we're needling today. What I want to do is I wanna take some time to find where the true suboccipitals live as to avoid needling in this area. So in order for us to do that, we're going to, there's a couple ways to find this region. First, we can palpate that EOP, external occipital protuberance, and drop down. The first spinous process we come in contact with is going to actually be spinous process of C2, as C1 does not have a spinous process. So that is going to be the inferior aspect of where the true suboccipitals live. Let's come back towards the mastoid process. From there, if we drop just distal, feeling the lateral like pillars of the neck, that is going to be the transverse, the first thing we palpate there is a transverse process of C1. So the true suboccipitals live between the spinous process of C2, transverse process of C1 and that inferior nuchal line. So we do not want to be needling in that area today, as it's a little bit more of an advanced technique. And I think when we're talking about the headaches that present at the base of the occiput, it's actually not the true suboccipitals. So for orienting ourself to where the muscles are, we have two main muscles, but we have bilateral tissue. So we're going to be treating bilaterally for this headache presentation. We are going to find that external occipital protuberance. If we step just about a finger breadth lateral to that, we can palpate a tootsie roll shaped tissue, and that is going to be your upper trap insertion on the occiput. When we're needling this area, we want to be mindful of some sensitive structures around this tissue. For example, what kind of is around the upper trap insertion is going to be greater occipital nerve. Essential anatomy is going to make it really seem very easy to find and it's not necessarily easy to find. One way that we can avoid too much interacting with this nervous tissue is going to be limiting our pistoning in this area. NEEDLE INSERTION ONTO THE OCCIPUT So for treating these occipital insertion musculature, we want to be using our E-STIM with pain modulating parameters. Okay, so EOP, first step lateral, is going to be that tootsie roll of upper trap. From there, we can take another finger breath lateral to that and we can find semi spinalis muscle belly as well as it inserts on the occiput. So let me do that on the other side. EOP, upper trap, we got a good old tootsie roll here. And then just stepping just lateral to that, we have semi spinalis. There is an area we want to avoid in this area, region as well. And it's going to be, if we find the mastoid process, about one finger breadth medial to that, there's a little sulcus. That sulcus is where the occipital artery lives. And if we go too deep there, we can interact with things like the vertebral artery and such. So we don't wanna be interacting with that tissue there. So we are gonna be keeping, it's pretty small territory here, but keeping our needles about, you know, two finger breaths away from that EOP is where those needles are going to be living. Let's talk about needle application. So in this area, the occiput is kind of diving anteriorly, right? So we want to have a bony backdrop for these muscles, and that's going to be on that occiput. We want to be using a firm palpation to mitigate the sensation of the needle inserting into the tissue. There's a lot of tendinous tissue here, so sometimes it can be a little bit more sensitive of an area to needle. So we can mitigate that sensation with increasing our palpation and our compression there. Our needle angle, let me just grab a guide tube out and we can kind of go over that. Our needle angle is going to be almost perpendicular to that occiput. So if we're thinking about the needle angle is like so. So for upper trap, we're thinking about angling that needle almost towards the eyeball or on that ipsilateral side of that muscle. For the semispinellas, it's a little bit more lateral. The occiput is diving, again, anterior. So there's some 3D anatomy here. We wanna be inserting, again, perpendicular to that occiput. So our needle angle, may look a little bit more flared towards midline, or that needle angle is going towards the contralateral eyeball, okay? So, again, let's orient ourself, and we'll then start placing some needles, because that's why we're here, right? So, palpating external occipital protuberance, stepping just distal to that and lateral, so we're underneath that superior nuchal line. If we are at the level of the EOP, we're going to be in more tendons. We wanna be a little bit more distal between superior and inferior nuchal line. Finding that tootsie roll, that's going to be upper trap. We are using a firm two finger digital compression to rock climber grip that upper trap against the occiput. We're using some short needles here. So I have 30 millimeter needles, and that should be sufficient enough to access this tissue. My needle angle for upper trap is going to be, compress, create a small treatment window between my fingertips, and I'm letting that needle settle. My needle angle is directly towards the eyeball on the ipsilateral side. Firm tap, and then we're going to advance our needle towards a bony backdrop on that occiput. So there we have upper trap on the patient's right side, And then our semi-spinalis is going to look very similar to that. We're just thinking just lateral to that insertion of upper trap, okay? So this is a petite anatomy here, so we don't have a ton of space between that kind of mastoid process and the upper trap needle that we just placed, right? So what we're going to be doing is the same sort of thing, hook, rock climber grip, Now my needle angle's a little bit more flared towards the midline, towards the opposite eyeball. Firm tap needle towards occiput. So now we have placed both upper trap and semi spinalis needle on the patient's right side. For treatment purposes, I would be doing bilaterally. And we can walk through that if, let's do it. Why not? Let's do it again. So, again, we're gonna find EOP, drop just distal to that, just distal to that superior nuchal line, stepping one finger breadth laterally, that's gonna be our upper trap insertion. Needle direction is towards the eyeball, perpendicular with the occiput here. Two finger digital compression, firm compression, creating a small window between our two fingers, firm tap, advancing the needle to a bony backdrop on the occiput. Again, we're limiting the pistoning in this area because we have some sensitive structures like that greater occipital nerve, really close to the upper trap insertion there. We are then going to step just lateral to that to interact with the semispinalis insertion at the occiput. So again, one finger breath lateral to that, avoiding that sulcus between the mastoid process and this muscle tissue, compressing tissue. Now my needle angle is a little bit more towards the contralateral eyeball. And we're again, looking for a bony backdrop here, maintaining that depth as we let that tissue recoil. So again, optimal treatment for these muscles is going to be setting up a circuit for pain modulation, and treating that tissue there. We want to limit pistoning in order to mitigate interaction with some more sensitive structures, including the greater occipital nerve. Again, for these suboccipital headaches, we are not treating the true suboccipitals. We are a little bit more proximal to that. We are thinking we are at the occipital insertion of upper trap and semispinellis. We want to orient ourself to this anatomy by finding the EOP mastoid process, and the region of the true suboccipitals as to avoid that area. We're using a firm compression to mitigate the sensation of the needle insertion. Upper trap is going to be perpendicular to the occiput. Needle direction is towards the eyeball, ipsilateral eyeball. Semispinalis is just about a finger breadth lateral to that, and we are angling the needle towards the contralateral eyeball. So there we have the needling technique for treating the suboccipital headaches. Um, there's actually the occipital insertion of upper trap and semi spinatus So that's all I have for you guys today. If you guys can catch us out on the road next spring We have some upcoming live courses in january. We're kicking off the the new year strong I will be teaching in rochester, minnesota the second weekend of january. I believe that's the 12 through the 14th, and Paul will be up in Bellingham, Washington for our first advanced course that same weekend. Then you can find me teaching the upper quarter in Longmont, Colorado two weeks later, so the last weekend in January. And Paul will be continuing some courses out in Seattle. So feel free to hop onto PTOnIce.com to check out where we are on the road. Again, this is We're starting the new year off really strong with some upcoming courses and our first advanced concepts course that Paul will be leading in Washington. So hope you guys have a great rest of your Thursday and I am signing off. See 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. 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.

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

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