#PTonICE Podcast

This podcast episode discusses the importance of muscle mass and estrogen in aging women. It covers topics such as optimizing muscle mass and estrogen levels for functional aging, understanding vasomotor symptoms and genital urinary syndrome of menopause, the impacts of estrogen deficiency in aging women, and the importance of health promotion during menopause.

In this podcast, Dr. Mark Gallant discusses the importance of individualized care in physical therapy and the need for a standardized plan of exercises. He emphasizes the significance of having clear targets and allowing interventions time to take effect. Having a consistent plan reduces ego interference and ensures efficiency in treatment. Developing a game plan for patient care, including defining goals and criteria for progress, is also explored.

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic lead faculty Alexis Morgan discusses the research & practical approach to helping runners return to running beginning at 4 weeks postpartum. She references research that about 50% of postpartum patients begin reintroducing running at approximately 4 weeks postpartum, with varying degrees of symptoms. Alexis emphasizes utilizing the symptom behavior model to monitor symptoms, educating & encouraging patients that about 85% of all individuals have some sort of symptom(s) with running, and that volume is an important variable to have a successful return to running. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 - ALEXIS MORGAN Good morning, Instagram. Good morning, fellow ice people. Welcome to the PT on Ice Daily Show. Welcome to Monday. It is the start of another week. And we are so excited to be here. Really as we're wrapping up the end of this year, we still have a lot going on at the end of the year that I want to tell you all about this morning. And then we are really getting already very excited about 2024. And just want to talk to you all about some of the things that are going on. If you are in the ICE Students Facebook group, you've been to an ICE course or you were just recently added in because you just finished a course this weekend, welcome. You've seen some announcements in there as well a while back. And I just want to highlight a couple of things. So let's get started on that before we discuss four weeks returning to running, four weeks postpartum. So number one, we've still got three more chances for a live course, or you've got three more chances to hit us in the pelvic division at a live course. So this, not this weekend, but next weekend, if you're listening live, November 4th and 5th, we will be in Bozeman, Montana, and then a few weeks after that in Bexar, Delaware. And a few weeks after that in Halifax, Nova Scotia, Canada. That is the first weekend in December, December 2nd and 3rd. So those are your three chances to get into seeing this Pelvic Live course, experiencing it, having fun with us, learning so much about pelvic floor health. not just for pregnancy and postpartum, but in general, across the lifespan, men and women, pregnancy, yes, but also all things pelvic health. So those are your three chances, Bozeman, Bexar, Delaware, and Halifax, Nova Scotia, Canada. So if you're on the fence, go ahead and pop onto those. Second, thing that we i want to share with you all is about the pelvic level one course so our name is changing as you all have heard us talking about and we're actually going to be taking a little break through the next few months and our new level one cohort is going to start in january so Be sure, we've already got people signed up for that, gearing up, ready to experience the new content. Very regularly, we are always reading the research on a weekly basis. And once enough of it stacks up, we've got to reframe the way that we're teaching, particularly in the space, because it changes so incredibly rapidly. And so with that, we are updating that material. So that is coming up on, that will be on the website soon. Actually, that is actually already on the website. So that is on there. So a lot of things coming up at the end of this year, the beginning of next year. We've got even more announcements, so stay tuned. And we're gonna be announcing a couple more exciting things in our ice pelvic newsletter. So if you're not already signed up for the pelvic newsletter, go ahead and sign up for that because we've got even more things to discuss and share with you all. 04:31 - RETURNING TO RUNNING 4 WEEKS POSTPARTUM  So all of that aside, let's go ahead and discuss this four week return to running. This is a topic that a handful of years ago really was not discussed. No way are we going to be facilitating someone running one month after giving birth. That's what we thought a handful of years ago. But fast forward, we've got several examples of elite level athletes which then trickles down to our recreational level athletes, we've got several examples of people returning to running. And it's actually even showing up in our literature. And when we are starting to see this, it's kind of interesting in the pelvic world, like we have all of these thoughts and beliefs and oftentimes you're you're gonna run into some strong opinions surrounding those, and a deep connection here. We've gotta have that connection with our beliefs, but also be willing to let that go once the evidence and once the, even the anecdotal evidence that your clients show up to you with, once that narrative begins, and it's maybe opposite of yours, we need to be able to let that go and to explore and ask questions and be curious about, well, what are some other possibilities? And that's exactly what we're seeing in this four-week return to running. So what we've seen is people aren't running. Runners will run, as we always say, in pregnancy and then early postpartum. And what we know is that the longer someone runs in their pregnancy, the sooner they're going to run in that postpartum phase. And in Shefali Christopher's study looking at returning to running and risk factors associated with musculoskeletal pain, she actually saw that it was close to half of those individuals, 46%, reported returning to running at four weeks. And so we've got some information to kind of digest, right, as therapists. And what we know, and again, in her research, what we know is that when runners return to running, we're seeing that musculoskeletal injuries or musculoskeletal pain does occur. And so that's the number one thing that we want to be educating our runners on and we want to be looking out for. But rather than waiting until they've hit certain guidelines, what we are proposing and what we are doing, what I am doing clinically, what a lot of our faculty is doing clinically is we're educating our patients. And we urge you to educate your patients as well. Based on this evidence, this is what we're seeing. We're seeing that when we're returning to running, we're actually, many people are experiencing musculoskeletal pain, about 85% of people. Not just those that are returning at four weeks. The median time returning at 12 weeks. So that's significantly before and significantly afterwards. We educate them. So we can, Educate them. They know that okay. There's a risk of injury. There's a risk of musculoskeletal pain Of course, just like with everything and what we tell them is when you feel something You need to let me know That visit is so much easier to discuss that if it's already been planned. So you schedule your person a couple weeks out. Go ahead and return to running and see how that feels. We're gonna control for the volume. We're not gonna go out and run five miles for the first time in eight weeks. We're gonna control that volume. Build up slowly and see how they feel. If you're experiencing some mild knee pain or some hip pain, we are gonna address that. All the while, absolutely, we're doing our basic hip strengthening, right? I say basic, not just talking about a basic squat, but also your accessory movements like clamshells to work on that rotation. Or better yet, some single leg standing you know, the standing variation of the clamshell or the hip abduction with your foot on the wall. That way you're working both sides. We love that accessory work to decrease the risk of pain. But even while they're working on that strength, they're still, everyone is still at a risk. And so the best thing they can do is talk to you about it as soon as they experience that. And tell them, okay, let's back down on that volume right when they're when they experience that let's say they bumped it up to a two mile total volume of running maybe they were doing one minute of running 30 seconds of walking and they had just bumped all of that volume and those intervals up experience that bit of lateral knee pain let's bump that back down. What were they doing last week? Let's repeat last week's volume. Let's repeat last week's running workouts and let's calm that system down. That's how we'll address it from that pain aspect. And then of course, we're going to be continuing to build that accessory strength training and coaching their running, looking at their running form. We're not afraid of them experiencing that pain. In fact, we know more than likely they're going to experience that. Again, 85% of runners are experiencing some level of pain, typically in the lower extremities, not necessarily their pelvis or pelvic floor. So we know we're gonna bump into that. So we educate them on the factors, and then we schedule a visit to where we're gonna follow back up on that. That's already in their calendar, they already know. That way we can discuss those itty bitty issues that they have, and we can address them before they get bigger. That's exactly the same thing that we want to do with pelvic heaviness, symptoms of heaviness, really fatigue, we've talked a lot about that on the podcast here and of course in our courses, but pelvic floor heaviness or fatigue is another symptom that we're going to address in the exact same way. We're gonna decrease their volume. We're gonna educate them about it first and talk with them when they experience it, but they are going to decrease their volume when that occurs. We're gonna continue to be building that hip accessory work. All the while we're working pelvic floor strength, but pelvic floor and hip accessory movement, that's what builds up strength and endurance for the run. Just like how we expect them to experience pain, what we're realizing is that we expect them to bump into some symptoms of heaviness as well. We, as the rehab providers, are not scared of that. Just like we're not scared of them experiencing pain. We know they bump into that and we get them to back off immediately. We know they're not gonna have an issue there. We know they're gonna meet all of their goals and continue to run. We know this with the symptoms of pelvic floor heaviness as well. Heaviness, in most cases, many cases can come on with a lot of emotional concern. And honestly, in some cases, pain can do that as well. You've all experienced that with your patients. Very similar with pelvic floor heaviness. I see it very, we all see it very heightened in that emotional response. But if we can educate them on this first, if we can tell them, Hey, You're gonna bump into this. This is a symptom of fatigue. What you're gonna do when you bump into it is you're gonna back down. You're gonna back down in that volume. You're gonna wait to return to your next running workout until those symptoms have died down, because your body is telling you that that's too much. But you're gonna return, and we're gonna talk about it on our next visit, and you are absolutely gonna run that 5K at Thanksgiving. or you're absolutely gonna run that New Year's Day 5K, whatever that may be for them. So, educating them about symptoms, whether it's pain, whether it's heaviness, of course, leaking. I feel like we as pelvic floor PTs have educated people so, so much on leaking, but similar conversation here. you're probably going to have leaking with some point of return to running. Again, it's muscle fatigue that often precedes that return or that leaking. So we're going to probably experience it. If that athlete is running to a fatigue level, that's okay. We've gotta understand where their capacity is and where that lies and where that threshold is for leaking or for heaviness or for pain. We figure out where that threshold is, we go down from that. We build capacity and we bump that threshold up. That's the name of the game in all things that we do. That is the name of the game in pelvic floor health, in returning to running, even when they're returning early, like at four weeks. Realize runners are gonna run. Many of them are already going to run at four weeks. So go ahead and have that conversation at your two-week follow-up. Better yet, go ahead and have that conversation in their late pregnancy. Prepare them for what they're going to experience in that return to run. Prepare them for it to decrease fear and to improve education and awareness. Education goes such a long way in this area, but we've also gotta have that follow-up. We've gotta have that action item, okay? When they experience the pain or the heaviness, what you're going to do is X, Y, Z. Decrease that volume, right? Maybe return to some, diaphragmatic breathing and regulate your nervous system if it's someone who's has a heightened level of concern, right? We're going to repeat last week's workouts after symptoms have resolved. Give them several action items that way they feel empowered to make those decisions for themselves. All of that and then have that follow-up appointment with them already scheduled a couple weeks out. And that way, you can address all of these issues that are small, and we ensure that it does not continue to grow. So that's a very different way of guiding someone in this return to running, where someone is starting to run early, we don't have the time to go through all these strength and all of these assessments, but we just say, hey, let's use our symptoms as our guide. Let's start small, 15 seconds of running, 30 seconds of walking. Let's start small and add that in and let's see how you do. That is an example of us coming alongside someone who's already going to be running. This is how we stay in their corner as opposed to, Hey, you're not ready to run. Person's like, I know I'm ready to run. I mentally am so ready to run. I'm not gonna go back to that person. I'm gonna go run. We lose people when we have this black and white yes and no and I am the boss. We gain people, we gain people's trust and confidence and their willingness to work with us if we come alongside them. So that's what we're advocating for this return to run. Absolutely, you're gonna work on strength, overall building capacity, calf. We're gonna work on coaching them and how do they look with running and running form and their cadence. And we're going to be addressing all of these factors. Let's do it by letting them run and coming alongside them. That's a bit different than what you might be doing. That's different than what we used to do several years ago. What do you think? Do you want to try it? Have you recently tried it? Or are you concerned? Think we might be missing something? I'd love to hear your thoughts on this. Have a wonderful Monday. Hope to see you on the road at one of our three courses at the end of this year. And we will talk soon. Thanks for being here, 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 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.

The podcast discusses the debate on the importance of form in mechanics, emphasizing the need for evidence-based medicine, physics, clinical experience, and patient input. It also explores the challenges of applying research to real-world scenarios and the significance of mechanics in performance and healthcare.

Dr. Ellison Melrose // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses an alternate technique to dry needle the lumbar multifidus. Take a listen to the podcast episode, watch the video, or read the full transcription below. If you're looking to learn more about dry needling, especially dry needling with e-stim using the ITO ES-160 stim unit, take a look at our Upper Body Dry Needling course, our Lower Body Dry Needling course, or check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ELLISON MELROSE Good morning YouTube and good morning Instagram. This is PT on ice daily show. I am Dr. Ellison Melrose and I am currently lead faculty with the dry needling division of ICE. So we are going to go over a alternative approach for dry needling the lumbar multifidus today. Um, before we get into that, I want to go over our upcoming courses. So this, the remainder of 2023, we have, um, a handful of courses. This weekend, Paul's going to be out in Anchorage, Alaska, and I believe that is capped. After that, he will be down in Seattle, Washington on November 3rd through the 5th for the upper quarter. I will be out in Rochester, Minnesota for upper quarter dry needling on November 18th through the 19th. We will both be teaching the first weekend in December. So December 1st through the 3rd, Paul will be in Bellingham, Washington, and he will be hitting upper quarter then, and I will be out in Clearwater, Florida, so opposite sides of the states, doing lower quarter. So if you guys have a chance to find us out on the road, or want to join us for the remainder of 2023, those are the courses. We have one other one also in Fayetteville, Arkansas, the second weekend in December, where we'll be doing lower quarter. out there. So if you guys have any questions about those courses coming up, feel free to message us here or yeah, stay tuned for those courses. And then 2024 we'll be starting out pretty hot with some more courses and our advanced course as well. It will be, will be coming, um, in 2024. 02:10 - COMMON APPROACH TO DRY NEEDLING THE LUMBAR MULTIFIDUS So what I wanted to do today was to go over an alternative approach for, uh, dry needling the lumbar multifidus. So there, We are not gonna go over clinical reasons for needling the lumbar multifidus, but for those who have been taught how to needle the multifidus, there is one technique that is used fairly widespread across all educators, and that is the wrap-over technique. For demonstration purposes, I am going to be using my knuckle as the spinous process, and then we will be demonstrating it on a human body as well. For that wrap-over technique, so we have our spinous process here, Wrap over technique, we use two fingers to compress within a one centimeter gutter, just lateral to the spinous process. And we create a target window with our fingers and treating within that zone. In order to treat bilaterally, so both sides, you have to walk around the table to treat the contralateral side, which is fine, But when we're talking about clinical efficiency, it may be conducive to be able to treat or to needle staying on the same side of the patient. So we have an alternative approach for needling the multifidus where you are able to stay on the same side of the patient, and that will be your dominant side. So I am right-handed, so I'm going to be treating from the right side of the table treating the lumbar multifidus. I'll demonstrate first the wrap over technique and the alternative technique. 04:02 - ALTERNATIVE APPROACH TO DRY NEEDLING THE LUMBAR MULTIFIDUS For that alternative technique, so instead of using that spinous process, our palpation hand, two finger, stepping over that spinous process and compressing into the gutter, what we are going to be doing is we are going to be using our palpation hand, index and middle finger to orient us to where that lateral border of the spinous process is. In the lumbar spine, we have about a one centimeter gutter where we can feel fairly confident that we're going to be directing our needle towards the lamina with a directly posterior to anterior approach. From there, if we go outside that one centimeter gutter, we need to angle the needle medially to ensure that we have contact with the lamina as we need that laminal contact to ensure that we are at the depth of the multifidus. We are going to stay within that one centimeter gutter for today's demonstration, but we will start with that wrap over technique and then the alternative approach. The alternative approach, instead of using that two finger digital compression, we are going to be using the spinous process and either our middle or index finger to find that lateral border. So, first we want to find the spinous process and take the mid pad of our palpation finger and palpate that lateral border of the spinous process. From there, we're going to take our middle finger or our index finger, depending on which side we are treating, and compress tissue down within that one centimeter guide. From there, we're going to create a treatment window between our two fingers and treating directly posterior to anterior. towards laminal contact. 07:19 - ALTERNATIVE TECHNIQUE DEMONSTRATED So it'll make more sense when we're demonstrating it on the patient. So let's go ahead and do that. I'm just going to angle this camera down towards my patient. So here we have an exposed lumbar spine. I'm going to just orient myself to where we are. I am standing on my dominant hand side. From there, We'll just go over palpation. So spine is processed, we can palpate the lateral borders with our thumbs here. For that wrap over technique, we're going to take our pads of our palpation hand, stepping off, compressing tissue down, treating within that one centimeter gutter, okay? So let's start with that technique and then I'll show you the alternative approach after. So, palpating that lateral border of the spinous process, two fingers stepping off, compressing down into that gutter, keeping that needle angle directly posterior to anterior, so vertically, tapping, advancing the needle towards laminal contact. So in order to treat the ipsilateral side now, I would have to walk around the table and straddle that needle to do the same compression and same technique that we did on this side. So what I will demonstrate is the alternative approach and then we'll do another segment down below of the alternative approach just to show you how efficient this tool can be. So, instead of using those two fingers to hug the lateral border, I'm going to be using my middle finger on my palpation hand to palpate the posterior aspect of that spinous process. From there, I'm going to take the middle aspect of my pad and hug that lateral border of the spinous process. My index finger is then compressing into that gutter creating a nice treatment window. Again, we want to be aware of where that one centimeter gutter is and treating within that zone, directly posterior to anterior. So vertical, vertical needle approach here. So compressing down towards laminal contact. So there we have the alternative approach on that ipsilateral side. From there, thinking clinical efficiency, if we were going to set up multiple different segments in the lumbar spine, if we started proximally or superiorly and worked inferiorly, kind of like you're reading a book, that is going to be the easiest way to avoid some awkward hand positions with the needles. So we will needle the segment just distal to the ones that have needles in. So from there, Instead of using my middle finger to contact that lateral border, I'm gonna be using my index finger. We are treating the contralateral side from where I am standing. So again, we can appreciate the lateral borders of the spinous process. Take the pad of our index finger and hug that lateral border of the spinous process. Compress my middle finger now and create a treatment zone between my two fingers. Again, appreciate that we have a one centimeter gutter. Now we want to be treating directly posterior anterior to contact lamina. From there, I'm going to do a firm guide to compression, firm tap, advance the needle to laminal contact. And then we can do the same thing on the ipsilateral side. so middle finger palpating the posterior aspect of the spinous process wrapping to that lateral kind of hugging that lateral where it starts to curve creating a one centimeter gutter with my index and middle finger treating within that zone directly posterior to anterior towards laminal contact. So there we have, we went over the wrap-over technique and the alternative approach and just looking at the clinical efficiency that being able to stay on that ipsilateral side of the patient can do. I have a very small treatment room, so it allows me to not have to kind of wiggle my treatment table back and forth, and allows us to get a handful of segments within a couple minutes, which I think when we're thinking about using dry needling in the clinic, we want to save as much time as we have for using our electrical stimulation, as the new research is showing how beneficial that can be for treating pain, neuromuscular priming, also, um, recovery or hemodynamics, improving hemodynamics. So we want to get the needles in as efficient as possible as to allow for some optimal treatment time with the Eastern. So we, again, just to review with this technique, we are going to be using our index and middle finger. And instead of hugging the lateral border of that spinous process, we are going to be treating, um, with those fingers just off the lateral border, creating a one centimeter gutter between those two fingers, treating directly posterior to anterior and maintaining laminal contact to ensure we are at the depth of the multifidus. Thank you guys so much for joining me this morning, going over the alternative approach for dry needling the multifidus. And I hope to see you out on the road sometime this year or next year. 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. Jeff Musgrave // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the significant issue regarding the lack of individualization and care for older adults with cognitive impairments. Jeff points out that many older adults on their caseloads are at different stages of cognitive impairment, but this often goes unnoticed until it progresses to advanced dementia. The problem lies in the one-size-fits-all approach to treating cognitive impairments, where individuals with mild impairments are grouped together with those with severe impairments, or they are treated the same as the general population without screening for cognitive impairments. This lack of individualization and care for older adults with cognitive impairments is also evident in nursing homes. Jeff mentions a study from Germany that examined a population of nursing home residents. The residents were grouped based on their cognitive and physical impairments. However, the study found that there was a lack of personalized care, as a more diverse group was randomly assembled with varying levels of cognitive and physical function, and they all received the same basic intervention. Jeff emphasizes the need to tailor care to the individual's cognitive capacity, just as their physical capacity is considered. He uses the analogy of coaching a peewee football league, where practice would not be taken to the local NFL team if the capacity is not appropriate. Similarly, individuals with cognitive impairments should not receive interventions that are beyond their cognitive abilities. However, in the current state of rehabilitation for those with cognitive impairments, interventions are often not matched to their cognitive abilities. This lack of individualization and care for older adults with cognitive impairments is a significant problem that needs to be addressed. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - JEFF MUSGRAVE Welcome to the PT on Ice Daily Show. Good morning, my name is Dr. Jeff Musgrave. Super excited to be with you this morning, talking about a topic that's really important to me, but also reviewing a research article eight days off the press, a new technique called clustering to give better care to those with dementia on our caseloads. But before we get into that, if you're looking to up your Geri game, we are available. We've got some extra seats in our New Jersey course in Matawan, New Jersey this weekend. If you want to hop on that train, we'd love to have you. We've got space for just a few more. Next weekend, if you want to join us for live, we'll be in Annapolis, Maryland or in Central South Carolina. Last cohort of Essential Foundations just kicked off. We've got our first live meetup, so sorry if you missed it. We will be up in full force in January 2024. There is still time to catch advanced concepts if you want to sign up for that. The last cohort is about to begin, so grab those seats. 02:42 - JEFF MUSGRAVE So team, man, I'm so excited to get to talk to you about this topic. There are so many older adults on our caseloads in various stages of cognitive impairment. And this oftentimes goes unrecognized until it becomes advanced dementia. when things are a bit harder to turn the tide, but also there's a severe lack of individualization and care for those that have cognitive impairments. A big problem in general practice is this one size fits all. In geriatrics in general, whether we're talking about physical impairments, but unfortunately we see the same problem when it comes to cognitive impairments. We see those with cognitive impairments get treated the same regardless of how advanced those symptoms are. So we see one of two big problems here. We either see those with very mild cognitive impairments grouped with those with very severe impairments, Or we just see them treated the same because no one's screened or picked up on the fact that there's a cognitive impairment on board and they're treated just like the general population which is also not appropriate. So neither of those are a good look. So this study out of Germany was looking at a population of residents in nursing homes and what they did is they clustered them based on their cognitive as well as their physical impairment. So they used a clustering approach to try to get homogeneous groups of people based on not only their physical function but their cognitive function. So all these residents were 65 and up. They had mild to moderate dementia and were living in a skilled nursing facility. The physical measures that they used were the six minute walk test, the timed up and go, 30 seconds sit to stand. But the biggest place where they saw variation that dictated their function was on their mini mental state exam. So their cognitive impairment did a lot to dictate their function. So what they found at the end of this was that those that had more advanced cognitive impairments were not able, even if they had the physical function, to participate in as high level balance training as those that had more severe cognitive impairments. So those with more mild cognitive impairment were not able to participate at the same level, in particular when it came to balance challenges. 04:56 - COGNITIVE IMPAIRMENTS & TRAINING The interventions for this study unfortunately the link did not go through that I could see all the details but what they what they were doing was some form of strength training either seated if there was lower physical function versus standing or dynamic movement in standing if they had higher physical function. So lower to higher physical function and then they gave also a cognitive layer to their interventions while they were doing balance or strength training. So that allowed them to scale the intervention to those who, to make it more appropriate. So they had a higher and lower physical function, higher and lower cognitive function group, and they scaled the cognitive load as well as the instructions So one big thing that's missing is the environment and the type of cues that we give typically in clinical practice for those with cognitive impairments also need to be scaled. They can't be as complex of cues with multiple sentences in the same duration of time. We've got to really scale that to the person in front of us and individualize that care based on their cognitive capacity, just like we would their physical capacity. The way I kind of think about this is if you were coaching a peewee football league and practice is going really well, you would not march them over to the local NFL team for practice. Their capacity is not appropriate. But we do the same thing with cognitive impairments where we've got someone who has more advanced cognitive impairments, getting a much higher level of training than what they should be and it's no surprise when the results aren't as good and that's also what was found in this study was the experimental group had the matched physical and cognitive and then there was a more heterogeneous group that was just kind of randomly put together with higher and lower cognitive and physical function, and they all got this lowest common denominator intervention, which we commonly see, especially because this was looking at group training in skilled nursing facilities. What typically happens is we've got this big group of people, and we find the person with the lowest cognitive and physical function, and we give everyone that. So the person that has the lowest physical and cognitive function gets an appropriate challenge. Everyone else has lots more ability that is not tapped into and is not being challenged. So it's no surprise once you hear that's what's happening, which unfortunately is the state of rehab for those that have cognitive impairments in general, is it's not being matched to their cognitive ability. So those that were not matched based on their cognitive and physical function showed decline in their mental function by the time the study was complete. So those with matched physical and cognitive challenge to their actual, their functional level, They did great. They were able to maintain their cognitive level in this skilled setting. And those that were not matched showed cognitive decline in even a short period of time. This is pretty wild. 08:09 - SCREENING FOR COGNITIVE IMPAIRMENTS So some big takeaways here. Are we screening? Are we screening cognition in our older adults? The research says that the sooner we can screen people, the better chance we have to change their life and help them maintain their cognitive function and sometimes actually improve their cognitive function. There is a mountain of research that shows exercise is beneficial for cognition, especially if we're pushing into the fitness realm. and we're pushing people at high intensity and we're asking them to lift heavy things, we're asking them to learn new novel tasks. So we want to make sure we're doing that with older adults, not only for their physical function, but for their cognitive function. But we need to get a baseline of where they are to make sure that we're scaling these things appropriately. The tool that was used in this study was a mini mental state exam, which unfortunately is not great at screening for mild cognitive impairment, which is kind of that first phase before there is problems with activities of daily living, like once we get into more advanced forms of dementia. Tools like the MOCA, the Montreal Cognitive assessment may be more appropriate for catching signs of mild cognitive impairment. Also the SLUMS, the St. Louis University Mental State Exam. However, with that one, it's good to be aware that that can trigger automatically a local referral once it is complete. So you want to make sure that your patient, if there's any family members involved with care, that they're all aware that that will happen. And if this is like, man, I am not comfortable with this cognition stuff, this feels like way out of my depth, that's fine. You don't have to be the expert on everything, but you do need to be accountable to having resources in your area. Who is the SLPs, maybe outpatient, Or on your team if you are in a skilled environment that you can send for a cog referral. Or OTs, we have lots of OTs that are great at screening and intervening cognition and giving you an idea how many step commands, what type of environment, what type of cues are appropriate for this patient. but we have got to meet them where they are for cognition, just like we do for our physical interventions. So if you're not screening, start there. We've got to do more than alert and oriented times three. We've got to be getting these screening tools in use, or we've got to start making those referrals to people that are able to help get a baseline and make sure that our interventions are appropriate. So if you are screening, awesome, you are ahead of the curve. So now your job is to make sure that these interventions are appropriate, just like we're outlined in this study. 14:09 - SCALING UP OR DOWN BASED ON COGNITIVE PROCESSING DELAYS So what we want to make sure that we're doing is we want to know that there are things like cognitive processing delays, where it may take someone with more advanced dementia symptoms two minutes to process our commands. That was just five seconds of silence from me. If you can imagine two minutes of silence after your cues made this mistake so many times with this population. In two minutes, we've said a thousand things. and they're still processing the first thing that we said. So want to be mindful as we pick up on these symptoms. Cognitive processing delays can be up to two minutes. More mild forms, it could be five, 10, 15 seconds. It may feel a little more natural. Likely your skin's going to crawl, but it may be a very appropriate communication. It's going to look way different in this population. We want to make sure that the more advanced the cognitive impairment is, the more familiar the tools and the exercise interventions that we're using. We can't give a 40 point intervention and biomechanical explanation on a beautiful trap bar deadlift with an older adult. who has advanced dementia, we may be better off to use their purse and add some stuff to it, or add just grocery bags with food in it, and just ask them, pick this up. Once they do that, let's walk, walk 20 feet, or walk over to this area of the gym. No more cues, no more instruction, set it down. That may be a very skilled, very appropriate set of cues for an older adult with advanced dementia. So we want to keep in mind the tools. We also want to keep in mind the scenario. Can we control the environment? That is a skilled scaling tool. How loud is it? How busy is the environment? Is there lots of interaction? Are we at prime time in the clinic, out in a busy clinic where there's people throwing balls on a rebounder or the music's blaring? There's lots of laughter and fun. That may be a completely overstimulating environment for someone who has more advanced dementia. So the complexity… of the environment, the amount of noise, background noise, all those things are scaling options. So if we start in that quiet environment, we may eventually scale in to more advanced and complex environments where there are more distractions, where it is more like real life. But that's gotta be an intentional choice. That doesn't need to be an accident. We need to be very skilled with our interventions and that is part of it. How we choose to practice is also very important. Are we going to do random practice where we're jumping between tasks to task? That's going to be way less on the ability for someone with more advanced cognitive impairments. We may need to do block practice where we spend a big chunk of time, maybe 15 minutes, working just on a sit to stand. We may never get to a squat with a bar. That's fine. But if we can make it practical, we can meet people where we are, that may be where we need to stay. 15 minutes here, 15 minutes on the next thing, that may be our whole session. Or maybe it's something like a simple obstacle course. Pick this up, carry this, and follow me. That could be it. So I wanna keep these things in mind. If we are screening, we are getting a sense of what the cognitive ability level is of our clients, then our job is to scale it appropriately, and then you guessed it, then progress it as we're able. So we wanna use all those leveraging tools. So my advice to you, we're gonna switch gears, so that should be relevant to everyone. Now, if you are training in a group setting, kind of like this study outlines, where you're in a skilled facility, and you're doing group training, you can start with this lowest common denominator approach, but what you have to add in are easy scaling options. You've got to think about, we've kept everyone safe, but then for those that have the cognitive ability to do more advanced balance, or they're safe to do more advanced strength training, What can we do to scale it up for those individuals? So we've got everyone moving, everyone's safe. Now, how do we scale it up? Go heavier. Have heavier weight options available. Maybe instead of sitting, those people that have more advanced functional and cognitive impairments, they're going to be standing. Or maybe they're doing a dynamic movement. Maybe we're going to add some type of vestibular component where we're going to ask them to fixate and move their head side to side or up and down with the fixation point or maybe without a fixation point. Maybe we're having them close their eyes and head turn side to side or up and down. We can add that vestibular layer. We can add a cognitive component as well where we can ask preference questions like everyone, someone shout out, you can think to yourself or shout out loud some of your favorite foods. or name as many states as you can, or name things that are green. We can go very simple up to more complex counting tasks where maybe we're subtracting by 7 from 300 for someone that has a very mild cognitive impairment. Those things may still be on the docket. Those still may be very appropriate. But if we're doing group training, we can start with that lowest common denominator and then just offer scale up options. Another easy one that was even outlined in this study that they found to be beneficial was even just having a little piece of compliant foam for those that were already doing standing. Everyone in the group was mostly doing standing. They added the compliant foam in and that was a great option to scale up balance training. Everyone's getting instruction on the same movement, but there's not really a whole lot of extra instruction to change the surface. All right team, I got super fired up about this. Treated lots of people with cognitive impairments. If you're treating this population, I would love to hear any tips and tricks. Drop those in the comments. Thoughts? I will be dropping the article citation for you. The study was a new approach to individualized physical activity interventions for individuals with dementia. Cluster analysis based on physical and cognitive performance. I hope you enjoyed it. I hope you have a wonderful rest of your day and we will catch you next time. 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.

The podcast discusses the importance of dispelling negative beliefs and fear surrounding movement aggravating symptoms. It emphasizes educating patients about the risks of not moving after surgery or while in pain. It highlights the misconceptions about resting as the best solution for back pain and explores the negative effects of rest in rehabilitation. The importance of keeping older adult clients moving is emphasized to prevent long-term issues.

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore takes a deep dive into the Valsalva Maneuver from 3 different lenses: the scholarly research, the pregnancy & postpartum patient, and the strength & conditioning world. 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 TRANSCRIPTION00:00 - RACHEL MOORE Good morning PT on ice daily show. My name is dr. Rachel Moore. I am here with Representing the ice pelvic division. I'm on faculty with ice pelvic division. Whoo. Sorry. I need to drink my coffee um i just got back in last night super late night flying from a course this weekend our pelvic live course in um wisconsin it was so much fun we got to see some leaves change which is exciting for me because in houston we don't really have that happen um so really awesome super great weekend awesome and engaged group that we had. If you are looking to join us on the road to catch our live course, our live pelvic course, there are still so many opportunities this year. In that course, we are doing so many things. We are talking about pelvic floor considerations. We're talking about the internal assessment and actually going over and practicing it on your back and in standing. We're talking about pelvic girdle pain which is such a huge topic in the pregnancy and postpartum and just pelvic world in general and then day two we're diving into the actual fitness side of things where we're doing squats and we're learning how to brace and we're using weightlifting belts and we're getting up on the rig and doing gymnastics moves it is a blast every time I come home from a course I'm hyped and there are four more chances of in 2023 to catch this course on the road. So October 21st, we've got a course in Corvallis, Oregon. November 4th, we've got one coming up in Bozeman, Montana. November 18th, we've got one coming up in Bear, Delaware. And then December 2nd, we've got one in Nova Scotia, Canada. So tons of opportunities to catch this course live on the road. Our online course will pick up again in January. So if you're interested in joining us in the ice pelvic division, that's what we got coming up. 02:08 - THE HISTORY OF VALSALVA This morning we are here to talk about Valsalva. So the word Valsalva is kind of a term that nobody really knows what it means or everybody thinks they know what it means and they all have their own separate camps of what it could mean because it's described so many different ways in the literature. So what we're going to do this morning is clarify what the different definitions of this one word are, talk about the history of it a little bit more, where this term really even came from in the first place. So this topic is really near and dear to my heart. Recently, Christina Prevett and I recently just wrote a clinical commentary on Valsalva and on the nuances of Valsalva. and how as clinicians we can take this term and how we need to take this term and understand the lens, especially when we're looking at research, but when we're talking to patients about what this term even means and what we're actually looking for in our strength training fitness world when we say the word Valsalva. So let's kick it off with the history of Valsalva. The term Valsalva is actually named after a physician from the 18th century. So he was an otolaryngologist. Anyway, he worked in ears and throat, ear, nose and throat doctor. And he created this maneuver essentially as a way to push infection out of the ears. So, the maneuver that Dr. Valsalva described actually doesn't even look like the Valsalva that a lot of people talk about today. His maneuver was plugging your nose and blowing out, but not against a closed glottis. And when he created this maneuver, the purpose of it was to flush infection out of the ear by having that tympanic membrane push outwards to, in theory, push pus out of the ear. That is where this term was created. So when we look at Valsalva in the research lens, when we talk about diving into the specifics of research on this topic, if we're looking in the ENT world, autolaryngological world, we're thinking about this maneuver as a plugged nose, closed glottis, now push out in order to push that tympanic membrane out. When we're looking at this word in the urogynecologic world, it has a very different emphasis or purpose. So when we think about pelvic organ prolapse and the diagnosis of pelvic organ prolapse, that's where we see the Valsalva, quote unquote, being useful, I would say. So the Valsalva in a urogynecologic world is an intentional bear down and strain with a closed glottis. in order to measure the descent of the pelvic organs, particularly during that POPQ or that assessment for pelvic organ prolapse. So on the ENT side, we have the focus of plugging nose, blowing out, pushing tympanic membranes out. In the urogynecologic world, we've got this strain down through the pelvic floor in order to descend the pelvic organs and measure what that descent is. 06:04 - VALSALVA IN STRENGTH TRAINING In the strength and conditioning world, the term Valsalva means something completely different. In the strength and conditioning world, the Valsalva is a maneuver that is advantageous, particularly if you're a competing athlete in the strength training world, where we need a little bit extra spinal stiffness in order to hit a lift to PR. so in the strength training world this is an inhale into the belly and then a brace of those core muscles that anterior abdominal wall and all of those muscles within the core in general in order to increase that intra-abdominal pressure and spinal stiffness to be able to lift heavier. So when we do the Valsalva, we have a 10% increase in that spinal stiffness and that carries over or translates into pounds on the barbell. So when we're again thinking about our competitive athletes who are maybe trying to like edge somebody out, the Valsalva is an incredibly useful and productive maneuver. Even if we're not a competing athlete, if we're talking about just getting stronger and we're pushing ourselves to the capacity that we want to push ourselves to in order to make those strength gains, the Valsalva is likely utilized in order to increase that capacity to lift heavier. The confusion here comes from that one word having many different definitions. And when we look at the urogynecologic world versus the strength training world, they really are truly opposite. When we're thinking about straining and bearing down, we're pushing down with our abdominal wall muscles, we're pushing down with our pelvic floor, and we expect to see that descent. I 100% agree that we shouldn't put a heavy barbell on our back and then strain and push down through our pelvic floor. That is not beneficial and it is going to put a lot of strain through the pelvic floor. Absolutely. However, when we talk about Valsalva in a strength training capacity, that's not what the Valsalva is. The Valsalva in a strength and conditioning world is that intentional inhale into the belly and brace of that anterior abdominal wall muscles. When we do that brace of those anterior abdominal wall muscles, we don't want to see a descent of the pelvic floor. That would be an improper brace that would need training to improve that coordination. What we expect to see with a valsalva in the pelvic floor world is a matched degree of contraction for the demand that's placed on that system. So if we're thinking about somebody who's lifting a heavy lift, a one rep max, We expect that pelvic floor to kick on, but we're not necessarily volitionally thinking about lifting pelvic floor and doing that pelvic floor contraction. As that core canister is engaged and we engage that proper brace, the entire core canister should kick on to a relatively equal degree. So in the strength and conditioning world, that Valsalva is advantageous. In the urogynecologic world, if we're taking that concept and applying it to lifting, it is the opposite of advantageous. So when we're looking at recommendations for our strength training athletes and our patients, we need to understand the language that is being used and what the definition of that language is. So from the standpoint of our OBs who are telling our patients, don't ever do a Valsalva, in their mind, they're saying, don't ever strain and push your pelvic floor down when you're lifting. Totally. We agree. 100%. Don't do that. It's not going to be great. But the disconnect is that this one word has so many different definitions. So we really have to dive in and break down what was that recommendation specifically. So when we're with our patients, that looks like breaking down the definition for them. 09:01 - VALSALVA MANUVEUR IN THE LITERATURE But if we're looking in the research world and we're trying to read literature, read the newest evidence about what recommendations are for our pregnant and postpartum athletes, we need to go into the article itself and look at how they define Valsalva. Because we can easily read the abstract and the conclusion of an article that says Valsalva is not recommended, but if we're, looking at this article and it's actually meaning the bearing down, then we're not getting, we're not able to extrapolate that to the strength and conditioning side. So really with this term, it's one word named after a man who the original maneuver isn't even what we're talking about anymore anyway. Across the board, we have to either figure out different words or different ways to describe this, or it really falls on us as providers to break down what it is we're talking about. So rather than just telling your patients, do a Valsalva, maybe we don't use that language at all, and we just talk about bracing. When we do a brace, we can manipulate breath. If we're gonna take that intentional inhale and then brace, that is a Valsalva, But in order to eliminate the confusion across the board, we can just call it a brace. This makes a lot more sense to patients than being told by one person to never valsalva and then by another person to valsalva. And when we lay it all out and explain what all of these differences are and how it's all one term, but it has different meanings, and none of these meanings necessarily are the same. And in fact, in the urogynecologic world, in the strength and conditioning world, they're literally the opposite. It starts to click with patients, why it's okay that my physician told me not to do this Valsalva, but you're telling me that I can, because I understand that these are two very different physiologic mechanisms. Our clinical commentary over this that dives into all of this and so much more comes out in the spring. So keep an eye out. We'll be sending it out in the ice pelvic newsletter. So if you are not signed up for that newsletter, head to PT on ice.com, go to the resources tab, sign up for that newsletter, not only for our clinical commentary in the spring, but for all kinds of resources. in the pelvic floor world. Stay up to date on the newest evidence and also just check out some cool stuff that we find along the way. I hope you guys have an awesome Monday and I hope we see you on the road soon. 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.

In this episode, Dr. Zach Long discusses hip shifting in the squat. He emphasizes the importance of assessing if pain is the cause and if the shift occurs under increasing loads. If the squat is pain-free, he suggests that hip or ankle mobility may be the issue. The podcast also includes discussions on addressing hip shifting through strength, mobility, and corrective exercises, as well as drills like the sit squat and tempo box squat.

Alan Fredendall // #LeadershipThursday // www.ptonice.com  In today’s episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the three pillars of evidence-based medicine: clinical expertise, current best peer-reviewed evidence, and patient input. He gives suggestions on how clinicians can better incorporate all 3 pillars to improve practice. Take a listen to the podcast episode or read the full transcription below. If you’re looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don’t forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 – ALAN FREDENDALL Team, good morning. Welcome to the PT  on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete Division. We’re here on YouTube, Instagram, the podcast on Thursday. It’s Leadership Thursday, that also means it is Gut Check Thursday. Gut Check Thursday this week, four rounds for time, some interval work. Four rounds, 10 handstand pushups. Those can be strict or kipping. Read the caption on Instagram for some help with modifications if you’re still working on those. 10 handstand pushups right into a 50 foot double kettlebell front rack walking lunge. Kettlebells in front of the body, working the thoracic spine, working the legs, 50 feet of a front rack lunge, and then out the door for a 200 meter run on the treadmill, whatever. The goal there is one to one work to rest. That means we’re looking to finish that round in about two minutes. Work two minutes, rest two minutes, complete for four rounds. you’ll be done in ideally about 16 minutes. So read the caption, check for modifications, scaling is needed to try to get your round time as close to two minutes as possible, modify the handstand pushups as needed, reduce the load on the lunge as needed, and then sub out the run for a row or bike as needed. So hope you have fun with that one. That’s a great one that really facilitates intensity. You’ve got some upper body with the handstand pushups, some lower body with the running and some monostructural, with the lunging, sorry, and then some monostructural with the running. So a great workout to really drop the hammer, rest, repeat a couple times, really working on that anaerobic glycolysis system. Before we get started, just some quick courses coming your way. Today I want to highlight our cervical and lumbar spine courses. A couple chances left towards the end of the year as we get near the holidays to catch cervical spine management. This weekend you can join Zach Morgan up in Waterford, Connecticut. The weekend of November 11th and 12th, you can join Jordan Berry up in Bridgewater, Massachusetts. That’s kind of the greater Boston area. And then December 2nd and 3rd, you can join Zach Morgan at his home base at Onward Tennessee in Hendersonville, Tennessee. Lumbar management, also a couple chances left before the end of the year. Next weekend, October 21st and 22nd, Jordan will be in Frederick, Maryland. That’s kind of west of the Baltimore area. He will also be in Fort Worth, Texas the weekend of November 4th and 5th. And then you have two chances the weekend of December 2nd and 3rd. You can catch our newest spine faculty member, Brian Melrose. He’ll be up in Helena, Montana. And then you can catch Jordan Berry at his home base in Onward, Charlotte, also the weekend of December 2nd and 3rd. 02:55 – EVIDENCE-BASED MEDICINE Today’s topic, evidence-based medicine. A couple different ways to frame this. Are you doing it right? Are you doing it wrong? Or it takes a village of really drilling down and better understanding what comprises evidence-based practice. For many folks, they think it’s the research. For others, they think it’s many, many, many years of clinical expertise, pattern recognition, and others believe none of that matters. What matters the most is actually what the patient believes is happening, what they believe will help them, and matching our treatments, our interventions, our education as best as possible to essentially the patient input side of the equation. And if you’re on the podcast, I’m gonna show a Venn diagram. You’re not missing much, if I’m being honest. I’ve got it right here on the whiteboard. What we know with evidence-based medicine is that it’s actually all of that stuff, right? It is three different spheres, three stools, whatever analogy or metaphor you’ve heard to refer to these before is correct. When we look at evidence-based medicine, is it an overlapping of, yes, scholarly evidence, peer-reviewed research, Yes, clinician experience, practice and pattern recognition. And yes, also patient expectations and beliefs, and that the point at which these three areas overlap is the middle where we have evidence-based medicine, evidence-based practice. But what you’ll find is because of this overlap, none of these areas can be evidence-based on their own. So our goal today is not to show you this Venn diagram, but to show you when evidence-based medicine goes wrong, how it goes wrong, and how we can all get a little bit sharper at evidence-based practice in our clinic with our patients. So, let’s tackle these points one by one. The first, the one we’re all most comfortable with as clinicians is our own clinical expertise. Probably more important than anything else with expertise and experience is the pattern recognition, the dose response relationship that begins to form in our brain The more patience we see, the longer we’ve been seeing patience. This is, you could call this the 10,000 hour rule, whatever you want to call it, but the belief that the more work, the more time you put in, the more you will maybe, theoretically, begin to master your craft. And there’s some truth to that and there’s some non-truth to that as well. 05:06 – AVOIDING DOGMA IN PRACTICE The biggest issue, as I have it written out here on the whiteboard, is that just focusing on this area in your practice, the bias here is that you become really prone to dogmas, becoming a dogmatic person, becoming almost a guru. We see this, of course, and we’re going to mention it a lot on social media, of the approach on one side of the continuum or other. It doesn’t really matter if manual therapy sucks. physical therapy doesn’t do anything to the far end of that same continuum of, I believe that I’m putting people’s bones back into place with things like spinal mobilization manipulation. So it doesn’t really matter where people fall in the continuum, they fall somewhere on some sort of dogmatic continuum line, which is not great because it tends to the further they get into their own dogma and guru like behavior, the less they tend to incorporate research evidence from peer-reviewed sources and also the patient input. These people over time you may have heard phrases of I use what works with most people and the key there is that it works with most people not all people of the true person practicing evidence-based medicine the true clinical expert is the person that gets all almost every single person better. It’s not enough to get 50% of your patients better, or 60, or 70. You should, or we hope you would be pursuing excellence in such a manner that you’re thinking, how can I help 99.99% of people? And again, just focusing so much on one of the three aspects of evidence-based medicine with your clinical expertise is not gonna cut it. I often think of how much pattern recognition informs practice, but that doesn’t mean that that’s what we do with every person. I often think of when people come into the clinic, they present with anterior shoulder pain, what we might call instability, the feeling of looseness in the joint or otherwise just pain or maybe even stiffness on the front of the shoulder. I look at it as something wrong with the relationship between the deltoid and the lat. I understand the need to treat the rotator cuff, load the rotator cuff, but I also understand that the rotator cuff is ultimately paying the price for what the deltoid and the lat are not doing for the shoulder complex itself. That when these folks present with limited range of motion overhead, that getting in and treating, particularly the internal rotators, subscapularis can have a lot of value in restoring that range of motion and increasing tolerance to load long-term. However, that pattern recognition in my head is yes, where I’m going to go to first, but again, I can’t get caught up too much in thinking this is what works with most people, this is what I’m gonna do no matter what. I have to be aware, I have to be humble that if it’s not working for that patient in front of me, I need to go back and say what does the evidence say, what other treatments could I pursue, and also what input does the patient have into the equation of Are we maybe, yes, identifying the right cause, using the right treatment, but the patient expectation is that they can continue to do three to five hours a day of elite level CrossFit training on top of trying to move through the rehab of their shoulder. Those two things are always going to be at odds, and until I can start to incorporate more of the other arms of evidence-based medicine, I’m going to have a limited effect of how many people I can potentially help rather than most, I’m thinking again, how can I help that 99% of people? 10:40 – CURRENT BEST EVIDENCE That moves really nice into making sure that we understand that yes, evidence-based medicine does include evidence. It includes what we would call and what’s labeled as current best evidence. That’s the second aspect of evidence-based medicine. I think we can be really hard on ourselves and social media here can make you feel like you’re not doing a good job at keeping up with the research. Because the truth here, if we’re being really intellectually honest, is no one can keep up with the research. There are 1.8 million scientific journal articles published every year. There are 35,000 articles being published every single week. It is impossible for any individual practitioner to read all of those. Ever. It doesn’t matter if that was your full-time job. You would not be able to keep up with it. So what we tend to see is that we tend to focus on specialty areas in practice. And I think that’s okay. I think that helps narrow our lens. And as long as we are finding a source bias here is I think we do a good job with hump day hustling. There are other great sources as well that do a good job of taking a bunch of research and condensing it in a way that can be absorbed, especially that is then kind of classified by specialty area. But understanding, it’s really impossible here to always be up to date on the current best evidence. And just being up to date and reading new articles doesn’t mean that that evidence necessarily has any value. We need to be mindful of that fact as well, that just because something new has been published doesn’t mean it has value. This is a great example. This is an article. You may have seen this make the rounds on social media. The title is, One and Done, The Effectiveness of a Single Session of Physiotherapy Compared to Multiple Sessions to Reduce Pain and Improve Function in Patients with Musculoskeletal Disorders, a Systematic Review and Med Analysis. This paper was published just a couple days ago, so brand new off the press, right? We tend to associate newer with better in research, which is not always the case. And we tend to try to immediately incorporate articles like this into practice and make giant conclusions that often the paper does not support. Already there are people on social media posting this article and saying, look, physical therapy doesn’t work. You should not go to physical therapy. There are folks posting this and saying, see, I told you manual therapy does suck. In some of these studies, in a systematic review, they did manual therapy. I told you it was worthless. Dry dealing does nothing. Spinal manipulation does nothing. Cupping does nothing. People who practice that are committing malpractice. They should be fined or lose their license or be in prison for doing dry needling. And all of those giant conclusions are being made from just this one article. They’re being made in such a manner too that tells a lot of us who read a lot of research that they probably haven’t actually read the full paper, right? They probably have just read the abstract. Because if we read the full paper, what this paper is really saying is that more physical therapy doesn’t seem to help as long as all we care about measuring is pain. No information was given about any other outcome measure, strength, changes in vital signs, did people’s blood pressure get better, did stuff like depression, anxiety get better, kinesiophobia, all these other different things that we can measure about a patient that we would expect to change with physical therapy intervention were not measured in any of these studies. And probably the most important thing that’s missing from this study all the studies that it analyzes and pretty much every piece of physical therapy research is there’s absolutely no information on what was actually done to these people in a way not only that the study could be replicated in the future and possibly validated, or that we have any idea of what was done. It’s entirely possible that folks in some of these studies only got manual therapy, that some folks maybe, yes, got exercise, but how was it dosed? Did they test the sub-max lift? Did they train at or above 60% of that sub-max number to ensure that strength was actually happening? And the answer to all those questions usually is no. So it’s really important we don’t get deep down the evidence-based hole, knowing that for the most part, a lot of the research that comes out, even though there’s a high volume of it, it’s all quite weak and doesn’t necessarily get incorporated into practice because it doesn’t really help change and inform practice pretty significantly. Also from this study, Most of these patients had a spinal fracture, they had diagnosed osteoarthritis of the knee, or they had some sort of whiplash disorder of the neck. So kind of specialty populations that can’t just really be extrapolated to the general population to say that physical therapy doesn’t work. Nonetheless, people grab this article and they cite it. That kind of shows us an overlap between the sphere of clinical expertise and pattern recognition and evidence. I’ve written it right here on the whiteboard. That person, we would call that person a cherry picker. That person has a very shallow knowledge of the research and they’re basically using the research to better inform their own dogma, right? That is not evidence-based medicine. That is just cherry picking research that supports your bias and ignoring the rest and not really taking a deep dive in the research. We have to remember as well that it is evidence based not evidence only that we have to act in the absence of evidence we actually have to do something with people and that we don’t always have the best research to inform what we’re currently doing in the practice that if we are treating a patient we’re doing certain interventions they are making progress both according to their own input, their own goals, their subjective input, and also what we’re measuring objectively, then by every way we can measure it to both us and to the patient, the patient is making satisfactory progress. And sometimes we don’t always have research to support that. And that’s okay. We need to also be intellectually honest, that some of the research we would like to see happen can’t happen. A lot of research is either done on folks who are already healthy or it’s done in a manner that whatever intervention is given can’t potentially make that person either less healthy or more injured. We often see people in low back pain get some sort of treatment and then another group gets some sort of what we call usual care. Either way, somebody is getting some sort of intervention that is designed to improve their symptoms, not maybe theoretically worsen their symptoms. I would love to see research of folks lifting near or at their maximal one rep max potential with a deadlift, and I would love to see the outcomes of what happens with a group of people who lift with a focus on a brace neutral spine, what happens to people who intentionally flex their spine throughout the deadlift, what happens to people who intentionally extend their spine without a deadlift. Is that research ever likely to happen? No. Why? Because it would be really unethical to take a group of people who have nothing wrong with them and potentially cause them maybe a lifetime of debilitating injury just to try to prove a point from the research, and that is not the point of research. We have to be mindful that we’re conducting research on human beings who have lives, who have families, who have jobs, and as much as we would like to see some specific lines of research come to fruition, we’ll probably never see some of that because of the interventions the risk is simply too high, it probably won’t pass review from something like an institutional review board at a university. So we need to be mindful as well of, yes, we’re always trying to keep up with the current best evidence, but that doesn’t mean it’s actually the best, even if it is current, and it doesn’t actually mean that it’s research we would actually like to see happen, because it can be limited, again, by the ethical nature of actually conducting that research on living human beings. The bias here is being prone to being so far in this camp, and I’ve written here on the Venn diagram of being up in the ivory tower, of only doing things that has a lot of evidence to support it. Again, in the absence of evidence, we still need to do something with that patient. We still need to understand their condition. We still need to at least try some other evidence-based interventions to help that patient out. What many of you can’t do is have a patient come in for evaluation and say, I don’t have the current best evidence way to treat you, you’ll need to leave now. That usually doesn’t go very well. And we need to recognize as well, that patient is probably just gonna go see another provider anyways. Even if you were being very, very intellectually honest with them, that there was no evidence on treatment for their current condition, they’re probably just gonna go somewhere else and get less evidence informed care there anyways. So for the best, it’s probably that they stick with you for the long term. 19:14 – MATCHING PATIENT EXPECTATIONS & BELIEFS Our final aspect is including patient expectations, values, input. I think this is the weakest area for all of us, of the thing we probably consider last, when maybe it should be what we consider first. This is forgotten far too often that the patient, again, is a living human being with thoughts, feelings, beliefs in front of us, and doing our best to match our interventions to their expectations, beliefs, values, is really, really important, and kind of tying in to the current best evidence, we have really good evidence to show that as well. If that patient comes in and says, hey, you know what, you may not remember, but you saw my husband about six months ago for some really bad low back pain. he was in so much pain, he was off work, and you did something with some needles and electricity or something, and anyways, he felt so much better, he was able to go back to work, he’s back, he has no issues anymore, that’s fantastic, and I was hoping, with my back pain, that we could try something like that. Now, of course, what that patient did not get from their husband is all the other stuff you probably, hopefully, did with that patient. But what they took away from it was that dry needling appeared to cure that person. And so, it’s really helpful, I think, if you can match that expectation as much as possible. Yes, you could give that patient a 45 minute lecture on how dry needling for low back pain doesn’t have as much evidence to support it as strengthening the spine and increasing cardiorespiratory fitness and reducing inflammatory diet and getting more sleep and managing your stress and you can go all the way down that pain neuroscience rabbit hole to the point at which maybe that patient doesn’t come back to see you anymore Or if your long-term goal is to help that person and you know what is the most evidence-based way to help that person is to have their back get stronger, to help them with their current lifestyle habits, then probably the shortest point there, the shortest line between two points is a straight line between points A and B. It means that if you can just offer the dry needling, that’s probably going to be the most beneficial thing, right? You’re matching that patient expectation, belief, and value. Does it take time? Yes. It doesn’t take a lot of time. Does it take a lot of resources? No, it doesn’t. It costs a couple cents for the needles, right? And it lets us get to what we ultimately want to get to that person which is addressing their lifestyle, getting them loading, getting them moving if they’re not currently moving, and overall changing their life for the better from both a physical fitness but also overall health and lifestyle perspective. And I think far too often We have an agenda, we have a bias with certain treatments where it doesn’t matter who comes in the door. We can be on either side of the dogmatic perspective of everybody gets spinal manipulation, everybody gets dry needling without actually consulting the patient, do they want this or not? Are they open to another treatment? And what will ultimately get us to what we know works the best for most people, which is to get them moving more, get them stronger, get their heart rate up, address their lifestyle. So you can have many sessions of education only. You would think you’re practicing in the most current evidence-based way, but we know we can’t talk patients better. We actually need to do some stuff. And at the end of the day, I would challenge you that it’s probably better if they do that stuff with you versus leaving your care and going to see another healthcare provider. That’s another thing that articles like this do not address, of how much follow-up care did patients receive after they leave the study. Overwhelmingly, that is something that is not addressed. of if you do not provide the treatments that the patient wants, whether they want manual therapy, whether they want strengthening and you don’t have the time or equipment to provide that, whatever they want, if you do not match those expectations and values, they’re probably gonna go somewhere else. They’re gonna spend healthcare dollars somewhere else. And that might be with a healthcare provider that’s not as evidence-based as you are. So challenge yourself. Are you actually practicing within all of these three different spheres? Are you trying your best to keep up on the scholarly research, at least as it relates to the areas of practice that you’re passionate about? Are you honest with yourself that you do have clinical pattern recognition that has value, but knowing that it does have its limitations and you’re willing to adjust your treatment when things don’t work? And are you combining your practice expertise and the current best evidence with patient expectations and values to ensure that the treatment you’re offering is actually the treatment that the patient wants. So check yourself. Evidence-based medicine, are you actually doing it? I hope this was helpful. I hope you all have a fantastic weekend. Have fun with Gut Check Thursday. If you’re gonna be at a live course, I hope you have a fantastic time. We’ll see you next week. 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. 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