#PTonICE Podcast

Alan Fredendall // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the "golden triangle" or the foundation of personal & professional success where time, money, and autonomy overlap. Alan shares research supporting a direct relationship between money earned & happiness, as well as the importance of respecting time & autonomy in the workforce. 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 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 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. ALAN FREDENDALLTeam, good morning. Welcome to the PT on ICE Daily Show. Happy Thanksgiving. We hope your Thursday morning is off to a fantastic start. We're here on Thursday, Leadership Thursday, talking all things small business management, practice ownership, that sort of thing. Thursday, Thanksgiving Thursday, still means it is Gut Check Thursday. This week's Gut Check Thursday is a little bit of a tradition around here at ICE. We are gonna do a hero workout called Burp. This is a very long bodyweight workout. Starts with 50 burpees, a 400-meter run, 100 pushups, a 400-meter run, 150 walking lunges, a 400-meter run, 200 air squats, a 400-meter run, and then now we're going to come back down that pyramid. 150 walking lunges, 400-meter run, 100 pushups, 400-meter run, and then finally finishing with 50 burpees. So, very long workout. This is gonna take most human beings about an hour to finish. Obviously, you can tell a lot of redundancy in there with the running, the lunges, the air squats, and then the burpees and the pushups. So, if you do not have an hour today to work out, scale this. Cut all the gymnastics reps in half. Maybe cut the runs down. If you know you're a better biker than a runner or something like that, sub out a rower or a bike for the run. Obviously, the more you reduce the volume, the less time it's going to take. This workout is not for the faint of heart. This is going to make your upper body and lower body sore between all the lunges, squats, pushups, and burpees. But it is challenging. We love how simple it is. You don't really need to warm up or really have any sort of particular skill or range of motion to do this workout. So that's why we love Burp. Courses coming your way, I don't want to bother you with those today. Check out p10ice.com, click the Our Courses tab, and see what's coming your way. We do have a couple more weekends of live courses starting back up again next weekend before we take our final holiday break over Christmas and New Year's. So check out ptonice.com and click on our courses if you're interested in jumping into a live course before the end of the year. THE GOLDEN TRIANGLE Today I want to talk about a concept that I call the golden triangle. Talking about when folks reach out and they describe maybe an employment situation that they are not happy with. This is kind of how I evaluate what I think of the three pillars to success when you are not only working for someone else but just working in general. Even if you are self-employed, even if you do run your own business, carefully managing the three sides of this triangle, I believe is really important for your own personal and professional success, but also for those of you leading others in charge of others, I think even more important to fundamentally understand these concepts. So those three concepts are money, time, and autonomy, and we're gonna break each of those down here in a little bit. I want to start here though first, and this may be a weird place to start, but I promise we'll bring it back around again. I want to talk about what is the role of the human brain. A lot of us may think the human brain is for high-level computations and calculating the physics of a black hole, but that's not how most people's brains work. That's how very few amount of people's brains work, but for most of us, Our brain is a survival mechanism. It is a comparative analysis engine. And it's really good at making comparisons. Your brain is making one billion billion calculations per second. That's a one with 18 zeros. That is a million times faster than today's standard cell phone laptop or desktop computer. We call that an exaflop. It is the most powerful processor on the planet. It is always gathering data, both internally and externally, and making comparisons. Am I hot? Am I cold? Am I hungry? Am I thirsty? Am I not making enough money? Is my coworker making more money than me? Is my boss doing better than me because I noticed that he just bought a speedboat? Those sorts of things. Yes, very basic survival mechanisms, but also higher-level stuff. And that kind of brings up the next point of Maslow's hierarchy of needs. If our brain is this comparative analysis engine, what is it really focusing on? Well, psychologists would say it's focusing on comparing ourselves on this pyramid, this hierarchy of needs, where at the base we have our physiological needs. Am I hungry? Am I thirsty? Am I tired? The next level up is safety and security. Do I have a safe place to rest and sleep at night? Do I have a place maybe that in my mind when I compare to others I call my home? The next level up, the third level, love and belonging. Do I have friends? Do I have a family? Am I raising children? Not only do I have them, but do I feel like I'm thriving in those relationships? And now as we get to the top of that pyramid and we approach that peak, the fourth level is esteem and the last level is actual actualization, self-actualization. So do I feel like I am doing something meaningful, and do I feel like I'm doing something meaningful very well basically You know what is my life's work, and how am I doing at that? And now the brain is always comparing both to environmental factors and to other human beings where we sit on that hierarchy. Trying to chase the top tiers before addressing the bottom, I think is the cause of a lot of dissatisfaction in our daily lives. So shelving that for a little bit, the brain is a comparative analysis engine and hierarchy of needs. Let's get back and talk about the golden triangle. MONEY The first I want to address is money. Money is uncomfortable for some people to talk about. It's often a pain point for almost every single one of us. I think really understanding that about three-fourths of people live paycheck to paycheck and about half of all people now work two or more jobs. really helps us understand that we're not alone in being concerned about money. Most people are concerned about money, but also that it's okay to be concerned about money, right? That kind of sits at the base of that pyramid of those physiological needs, that safety and security. We do need money in modern society to do things like buy food and pay the rent on our apartment or the mortgage on our house. There's often an adage of don't focus too much on money because money can't buy everything or money can't buy happiness. And I would refute that. I would say that that is categorically untrue. We have some really interesting research from the 90s and 2000s that found money and happiness do correlate. There seems to be a plateau, at least in the earlier research, of around $100,000. Research from the 90s and early 2000s found that if you make about $100,000 a year, The more money you make. beyond that doesn't really seem to increase your happiness. Now, the thing to recognize is that if you're not making that, there is room for happiness between that and $100,000. New research, specifically from this year, an article from Killingsworth, I love that name, Dr. Killingsworth and colleagues, this year, March 2023, from the Journal of Psychological and Cognitive Sciences, titled, Income and Emotional Wellbeing, a Conflict Resolved. Strong title, I like it, let's talk about it. These folks repeated the studies, some of it their own research from the 90s and 2000s, and they're looking specifically at the relationship between income level and happiness. What they found this time is interesting that folks tend to fall into categorization buckets. Hey, we know all about that in physical therapy, right? What are these buckets? Well, human beings tend to fall into three different buckets. The first bucket is what they labeled as the least happy group. These were folks who kind of demonstrated the same results as the initial studies, where these folks seem to have a happiness plateau at about $100,000. What does that tell us? That tells us this group of people is probably motivated enough by money that once those initial levels of the pyramid are met, they're able to feed themselves every day. They're no longer worried about their next meal or making the rent or paying their bills. Beyond that, they don't seem to get any more happiness from an increased amount of income, right? So this could be somebody who, I imagine these people is the folks from the documentaries that have to you know free climb El Capitan or summon a mountain or something of that's really what drives their brain and kind of their intrinsic motivation and having enough money to do that stuff gets them to the level of happiness where they can pursue other things. The next group of people they labeled, the researchers labeled the medium happy group. These folks had a linear increase even beyond $100,000 a year with happiness and income. And then the highest happiness group had an exponential increase with income beyond $100,000. They could not seem to get enough money. Money on the opposite side of the least happy group, these folks seemed to be almost entirely intrinsically motivated by accumulating wealth, right? So these are our oil barons and our real estate moguls, our Warren Buffets maybe, folks who have a high value on money and its worth in their life. And then most of us are probably in that medium happy group. As we continue to make more money, we're able to buy nicer things, but it doesn't necessarily define us, but we do like to have that money. All that being said, there is a direct relationship between money and happiness. It's really important we recognize that paying people well, of feeling like the work that you do is rewarded with the amount of money that you place value on, is recognized both yourself personally, but also when you're leading others. What I found over my career Keep in mind, I've been working full time since I was 12 years old for about 25 years, is that the folks who tell you there isn't money for a raise, there isn't money for bonuses, or even that they maybe need to take money away from you, are telling you that because they don't want to give you more of the company's money, right? There is always more money, especially in the context of physical therapy, for an increase in your wages. We all have what we would refer to as a revenue-neutral position, which means the revenue you generate from the work you do is creating more wealth than what you are taking back from the company. I can't imagine a situation where a physical therapist would be getting paid more than what the clinic is collecting in revenue for those patients being seen. So it's really tough to talk about. I recognize that it can be awkward. It can be weird. It can be upsetting to personal and professional relationships, but I promise you when you draw a firmer line than the sand around what you're paid, when your comparative analysis engine is telling you, you're not being rewarded for the time you're putting in. That can be a pain point for dissatisfaction and the research would support that you are not wrong in believing that the money you're currently being paid and the money you think you would like to be paid is creating a happiness gap. It literally is, right? Killing's worth 2023. Messing with people's money on the leadership side is a recipe for disaster. It is never okay to cut someone's pay, to inflict some sort of monetary penalty aside from something catastrophic, right? Dave accidentally drove his car into the clinic and destroyed the clinic. Okay, Dave, you got to pay for that, right, man? But aside from really rare, unbelievable, catastrophic stuff like that. There's no reason to inflict a monetary penalty on someone or to take their benefits away. An example I have of this is my time in the army where if you messed up, if you were late to duty, If you didn't shave, you could be punished monetarily for that, right? It was called in Article 15, it is non-judicial punishment. That means usually you have to work extra duty and it usually means that they cut your pay that month. And that really puts a strain on people, especially in the context of the military where they're not already making a lot of money. And I fondly remember watching people have half their paycheck, all their paycheck taken away, and just instantly how it ruined that person, it ruined their career trajectory. So without a doubt, as a leader, that's something you do not want to mess with. We saw that mess with a lot during COVID-19. We saw pay being cut, and we saw benefits being removed, and then not returned. And it's no surprise that now, several years removed, we have the era of time that we now live in, what we call the Great Resignation, where folks are more than happy to say, give me a raise or I'm leaving, and they will literally leave, right? And for us as practice managers and owners, that's devastating. Attrition is one of the highest costs you can encounter, and you need to avoid it at all costs. When someone leaves, it's going to cost you $3,500 for every $10,000 that person makes. That's money you won't get back on maybe trading you did with them, time you spent with them, money and time you're now going to need to spend trading somebody else. And then of course lost revenue because that person is no longer working for you generating revenue. So keep that in mind when you're thinking, I'm going to withhold raises, I'm going to withhold bonuses, I'm going to otherwise inflict some sort of monetary penalty. It never goes well. And again, it's okay if money is a pain point for you personally, and if it's a pain point for the people underneath you that you're leading. Pay should always increase over time to match inflation at the minimum. I have said this a thousand times and I will say it a thousand times more. Every year you do not get a raise, you are taking a pay cut because everything in your life now costs more money to buy. So keep that in mind. I will beat that dead horse until we're all on the same page about that. And finally, I think this is something no one wants to hear. Both those of you who are maybe unsatisfied with your position because of the money and those of us leading others it is okay for people to leave a position if it's not working out for them financially, right? You cannot feed your kids with the promises of potential future money. Your landlord will not accept the ambitious dreams of your clinic owner and payment for your mortgage. and you cannot get any sort of retirement return on zero dollars invested. So it is okay to move on if this is a pain point that doesn't seem to be addressed. So money is the first part of our golden triangle. TIME The second part is time. Time is a finite resource that we're all running out of. I think every day now the moment I turn 37, I am statistically halfway dead. And statistically, every day beyond that point is that much time left I have on Earth. Time is interesting. Some folks don't feel the value at all. Some folks tend to place a great emphasis on it, maybe even more so than anything else. Humans are the only creatures that can perceive time, so I think it's unique that we're able to perceive the flow of time, and we're kind of aware of moments where we have maybe too much time that we might call boredom, and moments where we feel pressed for time. A lot of us, the majority of the human race, will spend most of our lives using our time to generate money and then trying to use some of that money to buy some of our time back. And that's the way it is, even if it is a little bit sad. But I think recognizing that that's how most of us are going to move through life is important. For some people, time will always be more valuable than money. It does not matter how much you offer someone, how much you may offer them for overtime, whatever, their time doing other stuff is important. There are those people, the clock strikes five, they're out of there and we need to understand and respect that that is one of their values and work around that in whatever way we can. Very few people though, even folks who maybe don't seem to value their time a lot, very few people do not like to have their time wasted for no reason. And this happens a lot in life. It happens a lot in day-to-day life. It happens a lot in the workplace. Think of every situation where you've shown up early or stayed late for a meeting or some other event that was canceled delayed or rescheduled even without notifying the people currently sitting and waiting there for that to happen. Every time someone schedules a meeting with me and doesn't show up, that's a strike in my mind against that person. Very few of us have the tolerance to have our time completely wasted in that manner. but it happens a lot and it happens a lot in the context of the physical therapy workforce. Think about how many times you've come to work and the first two patients on your schedule have canceled or rescheduled, right? And you're thinking, what the heck? Why didn't anybody text me or call me, right? I could have gone to the bank or I could have sat and had breakfast with my kids at home or any, literally anything else would have been a more valuable use of your time. We also, are often asked to work in situations where we know it's not a good use of our time, right? I think of every time I have been asked in the past to work on Christmas Eve, right? Especially in the context of patient care. I know as soon as I'm asked to work on Christmas Eve that no one is going to come to their appointment on Christmas Eve. I remember it's burned in my brain, I spent one Christmas Eve with a completely wiped-out schedule, laying on a treatment table, and I watched all six Rocky movies in a row, right? I watched like eight hours of Rocky movies and did not see a single patient. What a monstrous waste of my time, and the clinic's money, just a bad situation for everybody. The Japanese have a term for that. It's called "Isogaghii" is the act of pretending to be busy. Even when you have nothing to do, we hate that. That is not something that we should encourage. If you don't currently have something to do, don't be here. I live my life by that model. When I catch people sitting in the clinic and they're just kind of pushing buttons on a computer, I always ask, what are you doing here? Oh, you know, I'm, you know, final, I'm like, okay, go, go home, right? Go away. No "Isogashii". We do not need you to sit at your computer doing nothing until 9 pm just to appear busy. So that's money. That's time. AUTONOMY The last part of the triangle is autonomy and independence. It's important to know that we developed this very early, and we all have a strong sense of it, even if we don't voice that it's one of our values, right? I think of my son, he's about to be 11 months old. A couple of months ago, we were hand-feeding him, already he has that sense of autonomy. Now when I go to feed him, he slaps the food out of my hand, and then he grabs it and feeds himself, right? He's already expressing, hey, I'm not a baby. I don't need you to hand-feed me. I can feed myself, right? And that's already present in very, very small children, right? Those of you with toddlers, you know, that independent streak starts and doesn't stop. Those of you, especially with teenagers, you know, it gets more aggressive. And then obviously all of us as adults, have a very strong sense of autonomy. Again, even if we don't express it explicitly as one of our values. Just like time, autonomy is violated on a very regular basis in very unfortunate manners. This happens a lot in the workplace. A lot of you work for employers who control how you're allowed to dress. how you're allowed to speak and talk with your patients, how and when you're allowed to perform very basic physiological functions about when you can eat food. Some of you work for employers that don't let you eat or drink at work. You have to leave the building and eat outside by the dumpster like an animal because you're not allowed to eat in the building because the owner or the manager doesn't like the possibility of crumbs. That is a huge autonomy violation. We also see this in our workflow as well. A lot of us are performing unnecessary documentation so that someone can check our work, right? So that someone can audit our notes just for the purposes of having a checklist where they audit our notes, right? It serves no actual purpose as it relates to helping the patient by documenting what we did with the patient. And for those of us who take insurance, create a claim that goes to the insurance company. There is no point where it's required that all of these extra processes that we add to our workday are mandated. Nonetheless, many of us work for an employer who has all of this extra work, all of these extra checks on our autonomy just to have extra checks. That's very insulting and it creates a lot of redundant work that also simultaneously affects our time. So we are getting a one-two punch of time and autonomy when we're doing a bunch of busy work that doesn't respect our time. It doesn't respect that we're independent clinicians who have often been working a while with a bunch of advanced education. The final thing I'll say here is that what you'll unfortunately find is that leaders who micromanage more, and who place more limitations on autonomy are often the same leaders who have minimal or no restrictions on their own autonomy, right? The person who is a stickler about a dress code is often the person in the office in shorts and a t-shirt and sandals working on the computer, right? So be mindful of those things. As you are maybe seeking out a new position or evaluating your current position, there's no double standard on autonomy. THE GOLDEN TRIANGLE AS A ROBUST BASE FOR SATISFACTION So the golden triangle, the interdependence between these three things builds a very robust base personally and professionally. However, I think it's very important to note that if we take our comparative analysis engine in our brain and compare it to Maslow's hierarchy of needs, What some of us are doing is trying to aim for the very top of the pyramid, aiming for esteem, aiming for self-actualization, and trying to become the best physical therapist that can be when those other bases of the pyramid are not being met, right? We don't have our basic needs met because we don't have enough money coming in. We don't have control over our time. We don't have control over our autonomy. We talked last week about the pitfalls of social media, trying to make you think that the reason that you're unhappy is you're not buying enough stuff or consuming enough content. With that stuff in that content, mainly being focused on trying to push you to the top of the hierarchy of the needs when really what you need to do is address the base, meet those basic physiological needs, safety, security, love, Make sure that time, money, autonomy are on board before you consider purchasing that $10,000 self-help retreat or the mentorship program or the mindset program. I think a lot of our perceptions of concepts like burnout or imposter syndrome are really just the result of our comparative analysis engine and our skull recognizing differences and asymmetries between what we're doing every day and the results we're either achieving or not achieving compared to other people. And when we look and step back and look at this golden triangle, we see, okay, I am not making the money I think I should, especially compared to my peers. My time is not being respected. I'm working more than I think I should to make the money I'm making. And oh, by the way, I'm being treated Like an infant at work by having a dress code and having all of these extra redundant Processes at work that I need to do that consume more of my time and we are always again It is part of our survival. It's hardwired in our brains to make these comparisons. We're always consciously aware of the time and the work and the money and the autonomy compared especially to other people and kind of comparing again back to that hierarchy of needs. And that if we allow one or two or all sides of this triangle to be violated, that's where we find a lot of frustration, and trying to jump your way to the top is not going to get you there. You need to address that base. When folks reached out and they described their appointment situation, I used to be a lot more polite with my thoughts when people emailed us and said, what do you think? I'm seeing 20 patients a day. I'm making $62,000 a year. And every month that I see more than 250 patients, I get a $500 productivity bonus. What do you think? I used to be a lot more polite when answering those emails. I am not polite anymore, right? A lot of the dissatisfaction, a lot of the burnout, I hate that term, a lot of the burnout, though, can probably be addressed if we're a little bit more firm and reinforcing and adhering to our values of Again, money, time, autonomy, are all of those things in place? Okay, now we can begin to look more up that hierarchy, begin to pursue maybe specialization, become the best physical therapist we can be, or even if that's not something you value, the best whatever you see yourself becoming. But again, we can't get there if we don't address the base. Doing anything else is just addressing the symptoms. It's not addressing the root cause, right? We need to address the root cause first. We can't just keep treating the symptoms by buying stuff and taking vacations and that sort of thing to try to solve the unhappiness that we're perceiving. We need to know that it's all related and that we need to address it first before we can begin to kind of reach beyond the top of that pyramid. So I hope this was helpful. I would love to hear any feedback or comments you all have. I hope you have a wonderful Thanksgiving and we'll see you all tomorrow. We're gonna talk about rowing. 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.

Explore the delicate balance of instilling hope in older adult patients while managing their expectations. Learn about the importance of optimizing time and finding a balance between hope and facts in physical therapy. Discover how mindset impacts aging and physical health, and the power of positive words on exercise. Find out how to balance hope and reality in the recovery process, guiding patients and connecting them with resources.

Dr. Mark Gallant, an expert in patellofemoral pain syndrome, discusses debunked treatment paradigms (DUDs) and evidence-based approaches (STUDs). He emphasizes assessing work demands on the knee, addressing power, coordination and skill training, and ensuring equal load distribution. The podcast also explores a study on knee pain in young women, the importance of volume matching, and factors contributing to knee pain.

Dr. April Dominick // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the anatomy & physiology of phonation, the mechanics of breathing, and the relationship between the pelvic floor & the demands of speaking/singing. In addition, April covers unique considerations for professional singers & speakers and implications for physical therapy treatment. 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 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.APRIL DOMINICK What's up PT on Ice fam? This is Dr. April Dominick from the Ice Pelvic Faculty Division here today to talk about the pelvic floor and its role in breathing and voicing today. I have a feeling it'll take your breath away. But first, some updates from our pelvic division. First, we have our last live course offering of 2023. It is happening December 2nd and 3rd. with Christina Prevett, and that is gonna be in Halifax, Nova Scotia. And let's not forget about not one, but two of our online eight-week course offerings. Level one is going to kick off next year on January 9th, and the brand new level two advanced concepts are going to get rolling on April 30th. So head over to ptonice.com and secure your seat in one or all three of those offerings. So we wanted to hop on today to outline what we know about the pelvic floor and its essential tasks and things that you've probably already done today like breathing and talking. THE PELVIC FLOOR & PHONATION I'll discuss the essential anatomy and then the structures that are involved and then we'll unpack the complex physiology of breathing and voicing with a special focus on what the literature supports right now in terms of what the pelvic floor's role is in phonation. Spoiler alert, there's not a ton. And when I say phonation or voicing, all those terms mean talking. So we need to understand what normal function is in order to identify dysfunction during pelvic floor assessment, especially when it comes to an individual complaining of any bladder issues or bowel dysfunction, leakage, pelvic heaviness, or pain during tasks like breathing and talking, or yelling and singing, This can happen to anyone. Think about the last time you were in a really loud bar or at a concert and you're yelling at someone or trying to talk to people and your voice gets a little fatigued. Maybe there's some fatigue in the pelvic floor as well. This can also happen with other occupations that primarily use their voices. So I'm thinking about teachers, maybe chefs in a busy kitchen or coaches, professional singers even. Another point to bring up is breathing and more recently phonation have been used in the clinic by physical therapists to treat pelvic floor dysfunction. Yet we lack robust evidence to support these clinical practices. So when it comes to breathing and voicing, I want you right now to think of some body parts or structures that are involved. I'll give you three seconds or you can pause. THE ANATOMY OF PHONATION Most of us probably thought of the obvious structures like the nose, the mouth, the lungs, and maybe even the diaphragm. And those are great starts. And we're going to run through the other important players for breathing and voicing. Breathing and voicing work in a closed system, which involves the interplay of three regions. with different diaphragms. So the cervicothoracic diaphragm, the respiratory diaphragm, that's the diaphragm that you think of when we talk about the diaphragm, the dome shape, and then the pelvic diaphragm. So when it comes to the cervicothoracic diaphragm, the major surrounding structures of interest are the oral and nasal cavity, the larynx, which is also known as the voice box, and that houses the vocal folds, the trachea, and then there's supporting musculature. There's paralangeal musculature like the SEM and scalenes, as well as the intercostal muscles. From a nerve standpoint, we cannot talk about the pelvic floor or voicing or breathing even without talking about the vagus nerve, as well as the phrenic nerve that runs along this area. The vagus nerve innervates the vocal folds and the phrenic nerve innervates the diaphragm. So that's the cervicothoracic region and diaphragm. Then we've got the respiratory diaphragm. That's going to separate the thoracic cavity from the abdominal cavity. And the diaphragm at rest, it's that dome-shaped muscle And it's got many origins, the xiphoid process, some of the lower ribs, the lumbar spine. Indirectly, it also attaches to the psoas and QL or quadratus lumborum. And then in that same region, we have the abdominals and they aid in power production for respiration or phonation. We're talking the internal and the external obliques, the rectus, and then the transverse. Then we have the pelvic diaphragm, our third area. The pelvic floor muscles are actually the floor of this entire closed-core canister system. Its three layers involving the levator ani, the coccygeus, piriformis, optorenus, and ternus are all muscles that span from the pubic bone back to the coccyx, and then from the ischial tuberosity to the other ischial tuberosity. Functionally, the pelvic floor is involved in so many things, abdominal and pelvic support, modulation of intra-abdominal pressure, postural and respiratory support, bowel, bladder, sexual function and arousal, and reproductive function. When those pelvic floor muscles contract, they close off the urethral, vaginal and anal openings. When they relax, they open those openings so that if we need to, we can urinate or poop or do any of those things. So that's the anatomy piece. THE PHYSIOLOGY OF PHONATION Now I want to go into the relevant physiology when it comes to pressure generation and management. So breathing is the transmission of air into and out of the lungs. Sounds simple. Right? No, not so much. We're going to go through how each region that we just discussed supports respiration in two forms, inhalation and exhalation. For the cervicothoracic diaphragm, the vocal folds are there and they march their own drums. So during inhalation and exhalation, those vocal folds stay open, and that's to allow airflow in and out. In terms of the intercostals, during inhalation, the external intercostals are going to elevate the ribs and go upwards and outwards, which expands the thoracic cavity, and then they'll relax on exhalation. The SEM and scalenes are going to assist in the inhalation portion as well as provide some postural support for the head and neck. So that was a cervicothoracic diaphragm. THE MECHANICS OF BREATHING Now we're going to go into the respiratory diaphragm physiology and mechanics of breathing. So during inhalation, that dome-shaped muscle contracts and changes from dome-shaped and then flattens as it descends towards the abdominal cavity. This is going to create a vacuum that pulls air in. And then during exhalation, that flat diaphragm passively relaxes and returns back to its dome shape. Then we have the abdominal muscles. They are a little more straightforward. On inhale, they're going to relax and expand outward. On exhalation, they're going to contract and draw inward. Then we have the pelvic diaphragm. So during inhalation, the pelvic floor muscles relax and elongate. Then on exhalation, in the presence of now increased intra-abdominal pressure, the pelvic floor should contract and lift, which closes those openings, preventing any unwanted leakage or prolapse symptoms. And we have a few confirmations of this happening in the literature. In 2011, there was a group Telus et al, and they confirmed that these pelvic floor movements are happening with respiration during real-time dynamic MRI. We love some of that research. We also have other studies that show, hey, via EMG activity, there's actually some pelvic floor activity prior to resisted expiration. And this is cool because it demonstrates that maybe the pelvic floor has some sort of neural pre-planning during the expiration phase. So I know that was a lot of information, so I'm going to put it all together for you in terms of respiration, what's happening from head to floor. During inhalation, the vocal folds are open to allow the air to flow in. The external intercostals are going to elevate the ribs up and out. The SCM lifts the sternum. and clavicles, the diaphragm contracts and descends downward, the abdominals expand outwardly in response to the displaced organs, and then the pelvic floor elongates inferiorly. Whereas exhalation is more of a passive process of the muscles relaxing. But it can be a forced process as well, like during exercise or playing an instrument, or if we're under any stress, So now I'll run through the muscle responses during passive expiration, which is essentially inhalation in reverse. The respiratory diaphragm and inspiratory muscles relax, the pelvic floor and abdominals, synergistically contract, and there's this beautiful parallel lift of the pelvic diaphragm and the respiratory diaphragm upon exhalation. And then finally, those vocal folds, remember they stay open. so that air can exit the body. So that is respiration. It is the foundation and the power source when it comes to phonation or talking. As far as phonation goes, the entire body is a vocal organ. So the next time someone asks you at a party, hey, do you play any instruments? Be sure and tell them, heck yeah, I play this little thing, the voice. So next I'm going to detail the symptoms or systems involved in voice production. And I'll point out the differences in function of the two major muscles between respiration and phonation. As I said, the voice is a highly complex instrument involving many different body parts. THE FOUR SYSTEMS OF PHONATION And so we're gonna think of phonation as comprised of four major systems. And these systems are like a four-legged stool. When they're all working in sync, that stool or the voice is nice and stable. When one leg of the stool is a little off, then your whole stool is wobbly and your voice is a little wobbly. Another key thing to remember is that phonation occurs during the exhalation portion of respiration. So the first of the four systems is the air pressure system. It's going to manage pressure and flow. It sets vibration in motion. We can liken that air pressure system to a musician's breath as they are playing the saxophone. In the human body, the structures that are involved in the air pressure system are the trachea, the chest wall, the lungs, diaphragm. Then we move on to the second of the four systems, the vibratory system. It's made up of material that can vibrate when activated. So if we're thinking about the saxophone, we're thinking about the reed as the vibratory system. This creates pitch. In the human body, the vocal folds, are what create pitch. They open and close, and that lets short puffs of air come through the glottis at high speeds. And the number of vibrations per unit of time is what creates pitch. Low pitch is the result of the vocal folds shortening and vibrating more slowly. Whereas high pitch is created by lengthening the vocal folds and vibrating more quickly. Loudness is determined by the subglottal pressure which is generated by the abdominals and modulated by the pelvic floor. And then we have our third system, the resonators. They are going to amplify the vibrating sound. It's the actual physical saxophone itself. They affect the richness of the vocal tone. In the human body, that's going to be the throat, the oral and nasal cavities. This is what is going to create someone's recognizable voice. Then the final and fourth system is the articulators. They are unique to the human voice. So there is no analogy for an instrument here. Articulars add quality and timbre. They modify sound shapes as they leave the mouth, which creates recognizable words. And these are the tongue and the soft palate, the lips. So in summary, for phonation or voicing, the voice is produced via the interaction of those four systems. Subglottal pressure creates sound pressure and intensity, via rapid oscillations, the vocal folds produce sound pitch. Via the vocal tract, the glottal sound is articulated, adding in someone's unique voice timbre. And then intra-abdominal pressure is controlled and generated with the rest of the core canister. And that's going to be mostly the pelvic floor and abdominals helping out with that piece. So during phonation, the primary muscles and their actions involved in the inhalation portion remain the same. So prior to speaking, we usually inhale and then we talk, talk, talk. The exhalation portion of respiration is like I said, when we phonate. COMPARING EXHALATION TO ACTIVE SPEAKING So I'm going to talk about the two differences between quiet exhalation and actual phonation or speaking. One is that the vocal folds don't stay open like they do in quiet exhalation. During phonation, they are doing the vibration, opening, and closing through the different frequencies to produce pitch. Second, when it comes to the pelvic floor, there's very little research on what it's actually doing when we are phonating. Aliza Rudofsky is paving the way in these uncharted waters when it comes to research on the pelvic floor, phonation, and the voice, A study she published in 2020 looked at the glottis and the pelvic floor via bladder displacement. So they used 2D ultrasound imaging and folks without pelvic floor dysfunction. She had participants in a standing position. We love that because most singers stand or most people when we're talking, going about life, we're either sitting in an upright position or likely standing. And she had participants, she cued them to do a pelvic floor contraction, to do a pelvic floor strain, as if they had to go to the bathroom. And she also gave them some cued phonation tasks, like saying, ah, for three seconds at different pitches. She also had them take a note and go from low to high. And then she had them do some grunting. She found that during the pelvic floor contraction, the bladder moved cranially, or upwards, and during straining, the bladder moved caudally, or downwards. This is what we would expect. Interestingly, for the phonation tasks, she found that the bladder displacement was significantly different than that that she saw with the pelvic floor contraction. And remember, with pelvic floor contraction, we tend to see more of a cranial displacement, but with these glottal tasks, she found there was more of a caudal displacement towards the feet. And again, that's different from what we normally see with expiration. So this was some novel information about what's happening with the pelvic floor during phonation. She also recently did, and Aliza did an interview in August 2023, and she talked about some of the research she's currently conducting, still doing data collection, but she's having folks without pelvic floor dysfunction say on one exhale, one, two, three, four. And what she's finding is there again is a tendency towards pelvic floor lengthening that's happening and there's also this buoyant nature of the pelvic floor with a specific up and down response to each of those numbers. So again, that's early data collection, but really cool to hear about what could be happening that's a little different than what we would likely hypothesize with the pelvic floor and phonation. And to me, that buoyancy kind of likens to running. So in running, we know that with repeated impact, the pelvic floor is responding like a trampoline. It's going up and down. It's automatically doing this. And so this sounds to me very similar to that. Quiet respiration requires much lower subglottal pressure than phonation. So per Aliza's work, in those without pelvic floor dysfunction, as subglottal pressure demand increases, with the task of voicing, the pelvic floor has an overall tendency towards lengthening and then potentially going up and down with each voicing. Clinically, we can use these results to coach and educate patients, maybe those who are pre-abdominal or pelvic surgery or during pregnancy. We can talk to them about what may happen to the pelvic floor if it's unable to support those higher subglottal pressures that occur with certain phonation, like yelling or even singing. The pelvic floor system may give way in the form of urinary or fecal incontinence, pelvic pain, and feelings of heaviness. especially in that immediate phase, postpartum, vaginal delivery, or cesarean section because we just don't quite have those muscles or that muscular support to help with managing the intraabdominal pressure. And now I want to wrap everything up because that was a lot of information. So in terms of respiration and phonation, We can agree that those are both very complex systems of the body that use a number of body structures that start from the glottis and make their way down to the pelvic floor. Respiration is the process of inhalation and exhalation. During inhalation, the vocal folds, stay open, the SEM and external intercostals lift, the diaphragm contracts, and descends down, the abdominal slightly expands, pelvic floor elongates. Exhalation is either passive or forced, and generally the reverse process. When it comes to phonation, there are four main pressure systems in place. The air pressure system, the vibratory system, the resonators, and the articulators. They all work together to create unique vocalization. During the exhalation portion of phonation, everything stays the same with the exception of those vocal folds, moving back and forth, opening and closing, and then the pelvic floor showing a tendency towards lengthening with a potential buoyant response to each individual vocalization. The inability to support the intrabdominal pressure generated by these tasks with higher sub throttle pressure, such as phonation, may result in pelvic floor dysfunction. Clinicians can use this data as a preliminary sounding board for blending the intricacies of the vocal respiratory and pelvic floor systems, especially when they're treating someone who's coming in for pelvic floor and or vocal dysfunction, as we eagerly await even more research for these systems. Thank you so much for listening. And if you all celebrate Thanksgiving, have a 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 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. 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Explore the significance of the running off-season and the missed opportunities for recreational runners. Learn about the importance of physical and mental recovery, and effective strategies for the off-season including light cycling, swimming, and yoga. Discover how to optimize the running off-season by incorporating other activities, adjusting intensity, and prioritizing recovery and injury prevention.

Alan Fredendall // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Chief Operating Office Alan Fredendall discusses how and why behind more carefully curating the digital & social media content you consume on the internet.   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 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 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. ALAN FREDENDALL Team, what's up? Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day's off to a great start. Glad to have you here on the PT on ICE Daily Show. My name is Alan. I'm happy to be your host. Currently, I have the pleasure of serving as the Chief Operating Officer here at ICE and a lead faculty member in our Fitness Athlete Division. Leadership Thursdays, we talk all things practice management, small business ownership, and general leadership tips for all of you out there who are leaders in your own way. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday couldn't be more challenging but also simpler than getting out there and hitting a 5k run or if you can't run hit a 5k row. Great aerobic test. As I get more into endurance running, I would argue I've been learning to hate 5Ks the most if it's a really uncomfortable distance to settle into kind of a longer, slower pace of, you know, you're setting a good pace on the first mile. Dang, I'm almost a third of the way done. Second mile, third mile. can be quite an aggressive distance. It's the most commonly programmed CrossFit workout if that surprises you. I've posted some benchmark times as far as percentiles for both the 5k row and the 5k run to kind of compare yourself to where I stack up against the general population. So have fun with that one. It's good to test that at least once a year and see how your 5k has changed, especially if it's a goal for you to get your aerobic, your longer energy system a little bit more efficient, and specifically to get better at maybe 5k runs. Some courses coming your way. Before we talk about these courses coming up before the end of the year, I want to challenge you that if you are in the market for an ice course, and you're able to purchase a course before the end of this year, you should do that. Wink, wink, wink, right? There might be a change being announced soon that would make you regret not purchasing now. So you'll see that maybe an announcement coming soon. courses before the end of the year we're almost done we have some courses this weekend but that's probably too late for you we'll be off next weekend for Thanksgiving and then we have just three weekends left of live courses in 2023 December 1st through the 3rd that weekend you can catch Paul up in Bellingham Washington for dry needling upper body You can catch Zach down at his home base at Onward Tennessee for cervical management. Christina will be up in Halifax, Nova Scotia, A for Pelvic Live. Ellison will be down in Tampa, Florida for dry needling lower body. Cody will be on the road for extremity management out in California in the Bay Area in Newark, California. Brian Melrose will be in Helena, Montana for lumbar management. and Julie Brower will be on the road in Candler, North Carolina for Older Adult Live. That's right outside of Asheville. The weekend of December 9th and 10th, we have Fitness Athlete Live. That's your last chance to catch that course this year. That'll be with Mitch Babcock out in Colorado Springs, Colorado. You can catch Extremity on the road again, this time with Lindsey Huey in Fort Collins, Colorado. And Older Adult Live, your last chance this year will be in Portland, Maine with Alex Germano. And then our very last course of the year, of course, we expect nothing less than a person of Paul's caliber to be the last person working this year. He will be in Salt Lake City for dry needling his upper body. That'll be the weekend of December 15th, 16th and 17th. That's a three-day course. So if you're in a state that needs a lot of hours like Washington, or Maryland, that'll be a chance to catch a three-day version of that course. A course is coming your way from us here at ICE. YOUR TRIBE DICTATES YOUR VIBE Okay, let's talk about today's topic. Your tribe dictates your vibe. You've often maybe heard the other way around. Your vibe attracts your tribe. How you carry yourself, your personality, your values, kind of attract the people around you that are maybe in your friend group, your colleagues at work, that sort of thing. I want to talk about it from the other angle your tribe dictates your vibe, of the people you choose to follow, whether they're actual in-person people or specifically today's topic, of the people you follow on social media can really dictate not only how you feel about yourself, care yourself, but of what you might begin to spend your time and money on for the worse or for the better. So I really, really, really want to stress that social media, I think, is destroying our society for the worse. Certainly, it has value in things like this and sharing information and education. from one person to a large group of people. But I think overall, we can begin to follow people who appear really relevant to our lives. But actually, if we do a really deep dive, we understand they actually have very little in common with us. And then ultimately, at the end of the day, we're in charge of who we follow. Many of us are not on social media against our will. And so that the emails you subscribe to, the social media accounts you follow, all of this digital content that you consume can have positive or negative effects on you. And to really stress, if you take nothing else away from this episode, to be really diligent in the streams and feeds that you begin to curate as you begin to follow email newsletters, social media accounts, and the like. THE PITFALLS OF THE INTERNET: TALKING TOUGH & SOUNDING SMART The first point I want to make today is The pitfall of the internet, as it's always been since its inception of consumer-based communication, is that it's super easy to talk tough and sound smart on social media. We live in a very impatient, rapid-fire, fire-and-forget type of world now. You may not know, but certainly, if you work at all in customer service, you experience, that the average expected response time to an email or social media message is now 10 minutes or less by the average customer. That's a study from Forbes from this year in 2023. I could say a whole bunch of crazy stuff right now on this podcast. I could say it in a social media post and I would have almost no side effects come to me because our society now is so rapid-fire, so fast, so consumable that you would consume this. Maybe what I'd say you would resonate with, maybe it would make you upset. It doesn't matter because you will forget about it in three minutes when you scroll on to the next piece of content. on your social media feed or the next podcast episode that you queue up. The only regulation on what we say is from you all, from the consumers. What's noticeable on social media is that the people who tend to be the most aggressive and make the largest blanket statements are often those who do so without any sort of evidence or support. They're also not the people who tend to engage in the stuff that they create, right? They're very aggressive. They fire something out there. They know it might make you upset. You might actually make a comment. And that's kind of their goal, right? That drives their engagement up. That shows their post to more people. Maybe it further upsets people. It gets more comments. And what we need to realize is that cycle is kind of what fuels those people to have large follower bases, to be able to advertise different things to you. Hashtag, you know, ice barrel, try out your hashtag toe spacers, right? Those people are trying to strike a nerve on purpose to get more engagement, more followers, more followers, engagement equals I can make more money selling sponsored things to you. So we need to be aware of that trap that is out there for us on social media and be aware of the pitfall of the internet and social media itself of this very consumable temporary transient content and recognize if you're falling for that trap of if you are getting upset and making comment or if you're following people who make kind of outlandish, unsupported statements. If that makes you upset, again, the whole theme of this episode is why are you following accounts like that. YOU HAVE NOTHING IN COMMON WITH THE MAJORITY OF PEOPLE YOU FOLLOW The second point I want to make of why are you following accounts like that is that you have nothing in common with the majority of people that you follow and obtain content from. You're making less money than you want to. You're working more hours than you want to. You're not feeling as physically well or as fit as you want to. You're not happy with how your body looks. Maybe you're not happy with how your marriage is going how you're raising your kids how your sex life is going, and how your postpartum recovery is going. You name it, you're being told that whatever is wrong with you, X is Y with you. Y is the solution, right? You are not having a good life because you don't wake up at 4 a.m. and do a 6-hour morning routine. You're not having a good life because you don't wake up and do a gratitude journal, use toe spacers, do yoga, meditate, do a cold plunge, or a sauna, or any of these other things that you're told are the difference between this apparently very successful person and you. But often when you do your research, when you look behind who are these social media influencers, you're often being sold solutions by people that are usually millionaires and who are usually millionaires, not because of the stuff they're telling you that they do, but because they're convincing people like you to buy the stuff that they're selling. And that's how either they are making their money or they're maintaining the level of income that they already have, right? Or maybe they started out in life and mom and dad footed the bill for college and for grad school and for their first house and they don't have a lot of debt and so they have a lot of extra time, they don't need to work as much to become this social media influencer and begin to sell you supplements and Toast Facers and all this kind of stuff. And the more you listen to those folks about what's wrong with you is that you're not consuming this stuff, the more money they actually make and the bigger that asymmetry actually comes. What's not said is that a lot of those folks have made their money by living what they're doing right now, which is a very imbalanced life of working more than you want to in order to try to pull yourself up the socioeconomic ladder. You're told that you're burned out or whatever and really the cause of their success is doing what you're doing right now and eventually getting to the point where their success comes to a level where they no longer need to work as much and maybe now they have more time to show you a video of them working out on the beach in Bali. And by the way, use my promo code Stephen10 for 10% off, whatever. And again, the more you consume that, the richer that person becomes. But at the end of the day, you do not have a lot in common with that person, yet you are trying to model your life after them, even though that's not how they currently live their life. And maybe that's not how they ever lived your life. These people are happy, healthy, and fit because they don't have to go to work anymore. Or maybe they never had to go to work. They can wake up and do their morning routine and go surfing because they're able to afford a full-time nanny to take care of their kids. Or maybe they don't even have kids and they get 12 hours of sleep because they have a night nurse. Or again, maybe they don't even have kids. And you get my point that they are living a very different life than you and maybe they never lived the life that you did. So it doesn't make sense for you to spend a lot of your time consuming their content and buying the stuff they're selling to somehow try to fix your life. Follow people who represent you, who represent your values, who are honest about where they made their money or how they got to the level they are at. I tend to follow people who are very upfront about how they got where they're at by pulling themselves up from being very, very, very, very poor, working a ton, and pulling themselves up the socioeconomic ladder. Is that ideal? No, but sometimes that is life, as true as it can be. And I resonate a lot more with those people who say like, look like this was the way that worked for me. It may not work for you. And I appreciate those people who are honest that look, it was a lot of years of 100-hour work weeks, working multiple jobs to pay off my debt to afford a house, to raise kids, and kind of get to where I'm at now. And I really, really appreciate that transparency, especially more as life goes on. So, what can we do about this of recognizing that Social media is meant to be fire and forget, instantaneous, consumable? It's meant to sell you things. It's meant to show people who maybe have nothing in common with you that you want to see yourself become only if you buy these products. If that's the way it's designed, what is the solution? CUT THE CORD The solution is to cut that cord, right? Take a serious examination of the accounts you're following, of the newsletters you subscribe to, of in general the content you consume digitally via social media, email, whatever, and stop following stuff from people who make it seem like the only reason you're not obtaining the fulfillment you want is that you aren't buying enough of the stuff that they're selling. Stop following accounts that tend to speak on best practices, but speak so dogmatically. Manual therapy sucks, it has no value. On the other side of the continuum, manual therapy cures diabetes, right? Stop following that stuff if you don't actually believe that stuff. Some of us follow that stuff just to watch the comments and watch people argue, or maybe you're even that person, spending your time that could be spent better elsewhere, arguing with people on the internet. I'll be very honest, I used to be that person. If you knew me a decade ago, I was that person. I was that person yelling at people on Twitter. and Instagram and all the other social media platforms, and I've talked about this before, one of the biggest shifts in my life was meeting Jeff Moore, our CEO, who one day sent me a screenshot of all these comments I was making, all this time I was spending on the internet, on social media, and just said, is this the best use of your time to advance the field of physical therapy? And of course, if you really ask yourself that question, then the answer truly is no. So stop following that stuff. Stop following those accounts. Stop following people who tell you that the way you're treating patients is wrong. If they are people who maybe don't currently treat patients or have not treated patients in a long time, five years, 10 years, 20 years, or maybe people who have never treated a patient ever, right, that person who went from PT school, maybe right to a Ph.D., or a consulting job, or to work for an insurance company as an adjuster, and has no actual real-world experience. Why are you following content like that? Knock that off. Follow people who are in the clinic every day, who are trying to make it all happen, who are trying to blend manual therapy, patient expectations and beliefs, and fitness-forward lifestyle, getting people loaded, getting people addressing their sleep and diet. Follow people who put out content like that, not content that maybe just makes you upset at the end of the day. Follow accounts that make your life easier. Follow accounts that give you resources that you can provide your patients so you don't have to work as much making that stuff yourself, right? Follow, obviously, I'm biased. I can't not have any bias here. Follow us, right? Go to PTonICE.com, click the resources tab, and look at literally an endless list of ebooks, workshops, of patient resources already created for you to make your job in the clinic easier so that hopefully you don't have to spend as much time making the money that you're currently doing. You don't have to work as hard doing it. Follow people in a manner that sees you working less and making more and not just buying more gadgets and $10,000 mentorship programs. THERE'S NOTHING WRONG WITH YOU And I think finally, what I want you to resonate from today's episode is to recognize deep down that there's nothing wrong with you. If you work more than you want to and get paid less than you think you should, you are not damaged. You are a normal American, right? 77% of Americans live paycheck to paycheck. Half of all Americans work two or more jobs. It is totally common to work more than you want to, to try to get ahead. Again, some of us are trying to pull ourselves up a huge deficit, right? We're trying to close a large asymmetry. We're trying to go from the poor person who grew up in a trailer park to maybe the first person in your family to finish middle school or high school or undergrad and grad school and be the first person to own your own home and be the first person to maybe have a retirement account and actually be able to think about retiring. We're trying to pull ourselves up multiple rungs. And I think for most of us, we believe that working a bunch is not how we get there. And I think when, again, we follow people who are more transparent in how they have their success. You'll find that's how they also got there, right? They didn't toe space and cold plunge their way from the trailer park to owning their own home starting a family paying off their debt and being comfortable in retirement. So recognize that there's nothing wrong with you. CHALLENGE YOURSELF TO CURATE BETTER CONTENT Okay, challenge you. If you look at my social media account, if you look at my Instagram, you'll see I have tens of thousands of followers. I don't know who most of those people are or why they follow me. Yet, look at that ratio. When you look at the ratio of people who follow to followers, it is my belief that you should only follow people that you want to see content from. What you'll see when you look at my account is that I only follow a couple hundred people, right? I follow close friends and family members. and people that I want to see content from. Again, my goal with social media is to curate a feed that makes my life easier with different tips and tricks about physical therapy, coaching, leadership, business, about all the different spheres I'm involved in. That's how I curate my social media feed. I don't follow people back who follow me if I don't think they post any content, that's certainly possible, or content directly relevant to me. And I think it's okay if you have to unfollow those people. Some people may think that means they follow you. Well, hopefully, they follow me because they find value in what I post and I think it's okay to not reciprocate if you don't feel the same way. I'm sure the people who follow me that I don't follow are nice upstanding people who treat their spouses and their children well hold the door for people to pay their taxes on time and leave a nice tip at the restaurant for the waitstaff, right? Not saying there's anything wrong with them. It's just I don't believe that the content they create is beneficial to me, and otherwise, it just becomes an endless blob of noise that maybe as you start to follow and compare yourselves to, you start to feel bad about yourself. So take a step back. Why am I following these people? Is it beneficial to me? It's okay to unfollow people, I promise you. I'm giving you permission, I'm giving you the blessing to do so. Cut that cord, recognize that you don't have as much in common with most of the people that you follow, as you think you do, and recognize that a lot of those people are relying on showing you this grandiose awesome life in order to sell you stuff so that they can continue to live that awesome life of working out on the beach in the Caribbean and living in their mansion in Costa Rica and using dye-free detergent and eating organ meat and all the stuff you're told is the reason that you're not doing as well as you need to. Consider, that your tribe dictates your vibe. Who you follow can really make your day or ruin your day. It can make you feel bad about yourself. You could get caught comparing yourself. So just knock it off. Cut that cord. Hope you have a fantastic Thursday. Have fun with Gut Check Thursday. We're going to be at a live course this weekend. Enjoy yourselves. I'll be back here on Thanksgiving Day. So I'll see you all on Thanksgiving Day. If you won't be joining us, I hope you have a wonderful Thanksgiving. Have a great Thursday. Have a great weekend. Bye, everybody. 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. Julie Brauer // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer as she discusses that the problem with patient education lies in the tendency of healthcare professionals to overwhelm patients with excessive recommendations, mistakenly believing that this approach is effective. They often act like a "fire hose," bombarding patients with information without considering whether it is truly understood or has a positive impact. This ineffective method of simply talking at patients, providing detailed explanations, or presenting long to-do lists is often learned from clinical instructors and perpetuated without recognizing its limitations. To enhance patient education, healthcare professionals should adopt a three-step framework. This framework involves "show and tell" by combining education with action and intervention, clarifying and recapitulating information to ensure comprehension, and following up and following through with patients to establish mutual accountability. By implementing this framework, healthcare professionals can avoid overwhelming patients and ensure the effectiveness of their education. 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 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 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. JULIE BRAUER Welcome to the Geri on Ice segment of the PT on Ice Daily Show. My name is Julie Brauer. I am a member of the older adult division. Excited to be here with you all on Wednesday where we jam on all things older adults. Excited to be talking to you all this morning about patient education. Our topic specifically is patient education finish the drill. All right, so what we are going to talk about this morning is the problem with what many clinicians perceive to be effective patient education. And then I'm going to unpack a three-step framework that you all can use to level up your patient education interventions. And I'm going to then share a few really detailed examples of how you can implement this going forward using clinical scenarios that many of you all experience pretty frequently. The goal here is that we just walk into the rest of our week doing 1% better, okay? THE PROBLEM WITH PATIENT EDUCATION: THE FIRE HOSE All right, so what is the problem with patient education? The standard. Too often, we act like a fire hose. We flood our patients with too many recommendations, and we think that it's effective patient education. Team, we cannot fool ourselves. that simply talking at our patients, right? So explaining the very detailed pathophysiology of their condition or explaining their fall risk profile after running your outcome measures or giving them a 10 item to-do list of safety and lifestyle recommendations that they have never heard before and assume that we are making a positive impact. Many times I think this comes from the fact that we didn't really learn in school how to be effective at communicating to our patients and providing education. And then we just kind of followed what our CIs did, right? I am so guilty of this. I remember as a new grad going into a patient and you're so excited because you want to tell them everything in your brain that you know, you want to share your knowledge. And I remember I would just fire hose, fire hose for 10 to 15 minutes and I would walk out of that room and be like, man, I crushed it with Dolores. Like she just learned so much. I just did an awesome job. And then I would sit down and write literally a paragraph of all the things that I educated my patient on. And for some reason, because I wrote an entire paragraph of my educational interventions, that must make it good, right? Like I perceived that I did this awesome thing. So I think that's a scenario that we find a lot. The other scenario, which I've also been here, and many of you have probably been here too, is that you constantly have this productivity being shoved down your throat, or you are just so freaking burnout and so exhausted, you look at your clock and you're like, I gotta get this last patient in. I gotta get this last patient in. I'm exhausted. I don't have a ton of time. I don't know if I'm going to get a second set of hands to get them up to do any exercise interventions. So what am I going to do? I'm going to go into this room and I'm going to sit there and I'm going to educate. I don't even know if I can stand up to do it. So I'm going to just stay in my chair, educate and type as I'm there. I know a lot of us had been there, right? I know a lot of us have been there, but are we really helping our patient? Do we really think that just by sitting there and telling them a bunch of stuff, it's going to cause any positive impact? We have to really start to dig in there. So I want to offer you all a solution. I'm going to explain this three-step framework. So what does finish the drill mean? It means one, we're going to show and tell, Two, we are going to clarify and recap. And then three, we are going to follow up and follow through. So let me unpack each of those. SHOW AND TELL, CLARIFY & RECAP, AND FOLLOW-UP & FOLLOW-THROUGH Show and tell. Are we pairing our education with action on our part, an intervention, a demonstration? Are we facilitating action on our patient's part? Show and tell. Next, clarify and recap. Are we ensuring that the education that we are giving, the literal words, the process, the steps that are coming out of our mouths is actually being understood? Are we ensuring that the message we are sending is being received in the way that we intend? Are we asking the patient to recap what they heard? Are we asking questions to clarify misunderstandings or gaps in knowledge transfer? And then lastly, follow up and follow through. Are we following up with the patient after we make those recommendations? Are we following through with a caregiver or the next provider? Are we holding ourselves accountable and the patient accountable? That is what it means to finish the drill. Show and tell, clarify and recap, follow up and follow through. Okay, let's go through a few scenarios to give you guys a very detailed, clear example of how you can implement. I have a massive list of these, but I'm just gonna give you three here this morning, okay? All right, for you acute care clinicians, You have Dolores on your caseload. She has just had a lumbar fusion surgery, and you go in to evaluate her. Instead of just telling her, Dolores, you have movement restrictions. No bending, lifting, or twisting, right? We all know the BLT restrictions. What we know is that restrictions can cause a lot of fear. A lot of patients never discharge them and they walk around like they're in straitjackets for a really long time. So instead of just telling Dolores what she can't do, let's show and tell. Let's show Dolores how to hip hinge safely. and distinguish that from actually bending and flexing at the spine. So how do we do that? If many of all have been following ice for a long time, you know this awesome hack. You can take the toiletry bucket that is in Doris's room. You can go take some towels, roll them up, soak them in water and put them in the toiletry bucket. You can put that toiletry bucket on an elevated surface like the bed or the chair, and you can show Dolores how to safely hinge. Let's clarify and recap. Let's ask Dolores, hey, Dolores, do you have any questions about moving your back safely and rebuilding its strength? Let's have Dolores recap the points of performance of that hinge motion and demonstrate it for us. Lastly, let's follow up and let's follow through. If you are lucky enough in acute care to see your patient twice, let's say it's the very next day, or maybe it's later in the day, on the same day, you can ask, Dolores to set the environment up. Show me how to pick this up. We are checking for Dolores's ability to have those points of performance and be able to form that hinge movement. Let's follow through, which is very hard to do as an acute care clinician because many times you have no communication with the next provider. You don't ever get to see Dolores again. How can we do it to the best of our ability? We can follow through by talking to Dolores, maybe putting it on her phone or on a piece of paper. I need you to show this to your outpatient PT. And what does it say? Can you please teach me how to deadlift? Right? We are planting a seed, passing the baton, trying to make sure she stays in that fitness forward lane because we don't want her back on our caseload. Maybe we even take it a step further and we actually recommend to Dolores a specific fitness forward PT in the outpatient setting who we are going to want Dolores to go to. Finish the drill. Okay. Let's talk about a home health example here. So let's say you have Dolores in home health. We know that her visual acuity is impaired, right? Maybe you have done an acuity test. You know that her prescription on her glasses are really outdated. Let's not just tell Dolores about the importance of vision, helping her balance to prevent a fall. Let's not just tell her to make that eye appointment with her doctor and then walk out the door and hope that she does it. Let's show her how to send a message via MyChart. Guys, systems are starting to charge patients for MyChart messages. Let's start to show them how to send appropriate messages via MyChart, right? Let's make this actionable. What if we call the doctor, put them on speakerphone with Doris, guide Doris how to schedule her own appointment to increase her self-efficacy? Let's clarify with Dolores by asking, are there any barriers that you can perceive getting to this eye appointment? Let's follow through by contacting a caregiver to schedule with them. Hey, this appointment, Dolores has a eye appointment this day, this time. Are you going to be able to take her? Let's make sure it's on both of your all's calendars, right? Or maybe we plan ahead with a service like Go Go Grandparent so that we know that the transportation piece that was a barrier is now something that is facilitated and that we have taken care of that. Okay. Lastly, let's talk about an outpatient example. All right. You're working with Dolores, an outpatient. She lives with her partner at home. She's got some balance issues. She has had a fall. So you are treating her. Let's not just tell Dolores to take up her rugs and put nightlights around her house. How often do we give that cookie cutter recommendation of let's remove all your rugs, right? Instead, How about this? How about we make this actionable and we get Dolores or Dolores' partner or a caregiver to get a video walkthrough of the pathway from Dolores' from the edge of her bed into the hallway, into the bathroom, into the living room, out her front door, whatever her normal pathway is for the day. What if we get a video so that we can actually see what her home environment looks like? And then we can say, okay, Dolores, that rug, that one, the one with the tassels that you know she's probably gonna trip over or she has tripped over. Can we get rid of that rug, Dolores? Why don't we clarify by asking, Dolores, are you willing to get rid of that rug? She may, older adults, we know this guys, right? It's really hard to tell them to get rid of rugs. They may be really resistant to that. So Dolores, are you willing to get rid of that one rug? Because you have gone through and you've triaged out of all of the rugs, that's the one that's gonna cause us the most problem. What if we ask Dolores, what are your feelings surrounding getting rid of your rubs? And you dig a little deeper there. Let's follow through with talking about how we're going to actually get this done. Because maybe Dolores may not have the capability to get down on the ground and remove her rubs. So what if our follow through is calling nephew Johnny to ask him, Hey, will you, within this week, come over to Dolores's home and help her take up her rubs? Right? What if, We don't just tell Dolores to have those lights throughout the home. Now that we have the video, we say, Dolores, the lights would be most helpful if you put them here, here and there. Here is the Amazon link of some cheap but effective ones to buy. Let's put it in your cart right now. That is how we follow up and follow through and make this actionable, right? Then we can say, Dolores, here's your follow-up. Bring in a video in the next week and show me what your pathways look like now. So you are able to see that we have followed through with this recommendation. The nightlights are where they're supposed to be and the rugs are taken out. Guys, this is what it means to finish the drill with our educational interventions. Show and tell, clarify and recap, follow up and follow through. I would love to hear you all take this framework into the rest of the week. And while you're with your patients and you're starting to just fire hose and spew out those recommendations, I would love for you to pause take the pause and really think how you're going to finish the Drew. How are you going to show and tell, clarify and recap, follow up and follow through? All right, team, that's all I got for you today. Lastly, let's talk to you all about our courses that are coming up. We have some sold out courses, which is wild to have at the end of the year. November, we have a sold out course in Illinois. In December, we are sold out or we're very near sold out in Portland, Maine. And then we have another chance for you all to catch us on the road in Asheville, North Carolina. In January 1st of the year, we are going to have both of our online courses, our Level 1 and Level 2, formerly known as Central Foundations and Advanced Concepts, that are going to be starting up on January 10th and 11th. You know where all that info lives, ptinex.com, mmoa.online. Hit us up if you have any questions. Go out there and start to make those educational interventions. Just 1% better team. All right, y'all. 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.

Dr. Lindsey Hughey, Extremity Division Leader at PT on ICE, discusses approaches to promote system-wide healing. Education plays a key role by informing patients about their condition and recovery journey. Mindfulness techniques can reduce stress and aid in healing. Exercise, including walking programs, is crucial for recovery. The podcast explores rebuilding capacity and functional patterns after surgery or injury, the importance of training functional patterns, and exercises for post-op extremity care.

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore describes pelvic varicosities & varicoceles. Rachel breaks down the difference in how these present in both male and female pelvic physical therapy patients as well as how to conceptualize treatment in the clinic.  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 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. RACHEL MOORE All right, good morning PT on ICE Daily Show my name is Dr. Rachel Moore I am here this morning. It is Monday morning. That means it is our pelvic day here on this podcast So I'm here with the pelvic division and I am super excited to talk to you guys this morning We're gonna be kind of diving into varicoceles and varicosities, vulvar varicosities, and the way that those are actually incredibly similar in our treatment approach, whether we realize it or not. Before we dive into that though, if you missed it, we've officially rolled out all of our certifications here at ICE. So we have certifications, we've had them before in the clinical management of the fitness athlete division and an MMOA, but now we have new ones. So we have orthopedic, we've got dry needling, we've got an endurance athlete, and then what we are super excited about in the pelvic division is we have our pelvic cert as well. So this is three courses, two online, a level one and a level two, and then one live course. If you're looking to get in on that certification, our upcoming courses, we actually have one this weekend in Bear, Delaware. That's going to be with myself and Alexis Morgan. So super excited about that. Still, time to hop into that if you want to buy yourself a plane ticket and get out there. And then we also have one on December 2nd. If you are north of the US border in Canada and Halifax, Nova Scotia, Christina is bringing those live courses to Canada. So we're super excited about that. Our next L1 cohort kicks off January 9th, and then our L2 you can already sign up for. So if you want to be in that first cohort of that L2, it kicks off April 30th. So if you're interested in getting that cert, all of the options are out there. Hop into one of those courses. We're excited to see you in them. VARICOSITIES AND VARICOCELES Let's dive into our topic for the day. So a lot of times those of us in the pelvic space if we are maybe majority see women a lot of us tend to maybe start there and then maybe branch off into seeing men but if we are in this kind of blinders-on situation where we're like no no I only see women sometimes we may be uncomfortable or unsure if somebody gives you a call and asks about a certain diagnosis or maybe you have a friend or somebody that you know that is struggling with something and asks for advice on the pelvic space and you're trying to figure out how to get them into your clinic. And so I wanted to draw a parallel this morning between two diagnoses that we see as fairly common that actually are very similar in the way that we treat them. So that is going to be varicoceles and varicosities. So in utero, the reproductive tissues of males and females begin developing similarly. If you guys remember that from PT school, when we were learning about the brief amount that we cover these types of topics, once testosterone starts being released, that's when the reproductive organs shift and either develop into male organs or continue on the path of female organs. And so if the testosterone is there, then the tissue that is becoming the scrotum becomes the scrotum. But if the testosterone is not there, then that tissue continues on to turn into the labia. So when we think about our tissues and our anatomy, we often talk about how male and female anatomy really aren't that different. It is similar parts arranged differently and maybe to different sizes and proportions. But when we look back all the way in utero, we can see that developmentally these things start the same and there's a certain point where things branch, but we have these kind of analogous, um, uh, tissues within males and females. So, We know that the tissues are similar between the scrotum and between labia. When we're talking about varicosities, this is important for us to know because these are two diagnoses that we tend to see come up fairly frequently. VARICOSE VEINS IN THE PELVIS So before we dive into the specifics of varicose veins in the pelvic area, let's talk about what varicose veins are. Varicose veins, if you're not familiar with them, are enlarged twisted veins. So oftentimes this comes from damage to the valves in the veins. So our veins have one-way valves that help push blood up and prevent backflow back down. If there is damage to the inside of the vein and the valves are damaged somehow or maybe are not operating at the capacity that they need to be operating, we can see kind of a backlog of blood and that can lead to this kind of inflamed or swollen look to the veins and that blood just kind of pulls in there. The causes of the damage, quote-unquote, Inside of the vein can be known. So this can be something like high blood pressure or it can be unknown Things that increase your risk for developing varicosities are gonna be things like being female So that's always fun when gender is one of the top things can't control for that genetic predisposition so if you have a family history of varicosities then this might be something that you're really keeping an eye on and older age as we get older maybe those valves within the vein become a little bit less competent increased body mass and then in pregnancy we'll dive into that here in just a second and then also interestingly having a history of blood clot that's really important to kind of keep in mind on our radars not only in our post-surgical patients but we're starting to see blood clots kind of popping up more and more um and so if you have somebody who might be not hitting any of these other risk factors but has a history of blood clots it's still something that we want to kind of keep on our radar varicose veins aren't a medical emergency by any means but they can cause some like uncomfortable unpleasant symptoms like heaviness aching pain and then swelling. VARICOSITIES Let's dive a little bit deeper into varicosities of the pelvic region so in our biologically female counterparts we see vulvar varicosities this is varicosity that develops on the vulva so anywhere along the outside of the vagina so that tissue of the vulva It can happen on labia majora, labia minora. It can be going towards the inner thigh, more into that groin area. Really just kind of depends on the area that is affected. The risk factor for this specifically is pregnancy. So we see this come up in pregnancy for a few different reasons. One reason is that we have an increase in blood volume during pregnancy in order to support the baby. So that increase in blood volume means that our veins have to work harder to push more blood up. we also know that we see relaxin circulating and that does have an effect on all tissues and then we have an increase in pressure so we have increased pressure from both the weight coming down of baby placenta amniotic fluid and all the things but then if we also think about like the anatomy of a pregnant belly as people progress through pregnancy get into this maybe anterior pelvic tilt their belly maybe drops low it can cause some congestion or some backup within that system which then leads to less efficient drainage. This is something that we see pretty often in the clinic really and you might be familiar with this if you're in the pelvic space. but what we tend to not really think about is how this parallels varicose seals. So a lot of times we're pretty confident and comfortable with vulvar varicosities, but then somebody comes in with a little bit different anatomy, and we kind of get thrown for a loop. So a varicose seal is a varicose vein that's located within the scrotal sac. This can actually develop during puberty because blood flow to the genitals increases during puberty. As those tissues are maturing things can just get a little thrown off, but it can also happen as a result of surgeries So think about vasectomies even though those are like minor office procedures surgeries vasectomies or trauma to the scrotum They're surprisingly common, especially in the adolescent puberty side of things. And just because you have a varicocele doesn't necessarily mean you'll even know it, aside from feeling it, potentially. So the biggest way or hallmark of this is called the bag of worms. because within the skirt sack that varicocele feels like a thick ropey worm and so as people are feeling around checking testicles for different things then you might feel that bag of worms type sensation or that that feeling with your fingers and other than that you may not have any idea However if you have a varicose seal that is causing problems We can see swelling pain and heaviness as I talked about earlier and if this is left alone and becomes severe it can actually impact fertility in men because it can lead to decreased sperm in the ejaculate and so it can be something that if it happens in adolescence and somebody is trying to conceive later on in life with their partner and they're struggling, it's an area to look at. Just like vulvar varicosities, we see an increase in symptoms when we're standing for prolonged periods, but uniquely to this population, we can see potential pain with ejaculation. So with vulvar varicosities, we might see pain with intercourse because of the pressure on the outside of the vulva during intercourse. But with this population, it's going to be more so during ejaculation that there is pain. WHAT TO DO ABOUT VARICOSITIES AND VARICOCELES We have our person in front of us, male or female, who comes into your clinic, some varicosity of some sort going on. What are we supposed to do? Jess actually did a really fabulous episode on this topic. It's episode 1198, so if you want to go back and listen to that, she talks specifically about varicosities during pregnancy, and those same concepts can be applied to varicoceles in men. So I highly recommend giving that a listen. We're going to dive in just really briefly touch on some of those topics and then I'll let you guys really dive into justice. External support can be a game changer for these folks, especially those with varicose heels whose anatomy is already putting things in a gravity, um, disadvantageous position for drainage. So giving some type of support, whether that is like when you're getting up and moving using your hand to support or getting some type of support garment. There are specific support garments that are made both for males and females for varicosities. soft tissue massage and when we think about this we're really thinking like mimicking lymphatic drainage I talk about this all the time with breast tissue and engorgement but the same thing we're thinking about this like congestion within the pelvic region and so we want to think about clearing more proximally up Towards the iliac vein so that we can kind of promote that drainage and then work our way down Rather than coming down to the bottom and just shoving everything up and causing more congestion Superiorly, so we're starting closer to the midline Draining quote-unquote that area. So if you're watching on Instagram, we're saying we've got a guy in and he's got varicose heels maybe we're starting here and then we're working lower and then working lower and until we get to that most distal tissue. From an exercise intervention standpoint, the pelvic floor muscles, of their functions are a sump pump. So when they contract and relax, they push fluid out of areas. So teaching our patients how to do pelvic floor contractions, how to lift up and contract into the attic, relax down and go into the basement, get that pumping mechanism going, and then teaching them belly breathing on top of that to help facilitate that as well. Finally, from a positional standpoint, we can have our patients if at the end of the day, they're super symptomatic and they're feeling rough after being on their feet, laying on their back, propping their legs up on the couch, or on a wall to get some passive decrease in gravity pressure on the pelvic region, and we can even take that a step further, have them plant those feet on that surface and do some bridging where they're squeezing their glutes, maybe adding in that pelvic floor contraction, layering that in, so we've got gravity coming down, we've got our muscles contracting and relaxing, really everything helping to push that fluid up and out into the drainage system to go bring that blood back to the heart. So, if you have somebody come in your clinic tomorrow, and you are a pelvic floor PT who traditionally treats females, and a guy walks in and he's like, I have a varicose seal, I don't know what to do. I hope that you can put your cap on, thinking cap on, and realize like, you got this, you know what to do. At the end of the day, we have to remember that our males and our females, although the anatomy is arranged a little bit differently, and proportions are a little bit different, they are similar tissue. So keep that in mind. You guys are rocking it out there. Have a happy Monday. Thanks for having me. Bye. 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.

Dr. Megan Peach discusses the importance of cadence in running, variables that affect cadence, the relationship between cadence and speed, and the optimal running cadence. Learn how cadence can be used as a retraining tool for runners, how factors like running experience and BMI impact cadence, and how increasing cadence can improve running pace and speed without negative impacts on gate mechanics.