#PTonICE Podcast

The podcast discusses the phases of rehabilitation for shoulder instability, including the importance of core stability and tailored functional exercises. The significance of incorporating speed work into the rehabilitation program is also highlighted. The chapters cover treatment options, exercises and progressions, and a systematic program for conservative care and physical therapy.

Dr. April Dominick // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick  continues with part 2 of her series on postpartum depression. In this episode, she discusses how rehab providers can screen for postpartum depression. She also offers tips for communicating with clients who we suspect have postpartum depression with scripted suggestions and responses to support a client in the moment. 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 - APRIL DOMINICK What's up PT on Ice Daily Show fam? My name is Dr. April Dominick, and today I'll discuss how to screen for postpartum depression and share tips and scripted phrases that you can practice saying to get comfortable supporting someone you suspect has postpartum depression. In the ice pelvic division, updates and course offerings are going to be that we are on the road October 13th and 14th in Milwaukee, Wisconsin. And your next opportunity after that will be with myself and Dr. Christina Previtt. We will be tackling all things pelvic health in the Pacific Northwest in Corvallis, Oregon, and that's gonna be October 21st and 22nd. So head over to PTOnIce.com and grab your seat. Our final courses for the fall are still listed, and you still have a few chances to catch us live. So in episode 1553, that was the last episode I did of this postpartum series, depression series, we talked about prevalence rates, we defined postpartum depression, and we talked about risk factors for postpartum depression. Since then, I ran across another systematic review from 2017 that cited worldwide greater than 10% of pregnant and immediate postpartum women are having depressive episodes, greater than 10%. That number is still astounding to me. While screening for PPD or postpartum depression is one thing, if someone is sharing that they're struggling and you sense they have some signs and symptoms of postpartum depression, we as providers may feel empathy for the person in front of us, but we may be at a loss of words for how to communicate that with another individual. So in the second half of today's episode, I'll go through a few key phrases that you can build off of in response to someone you suspect having postpartum depression, with the ultimate goal, of course, being referring them to the appropriate mental health provider and or medical provider. 00:00 - SCREENING FOR POSTPARTUM DEPRESSION But first, let's chat about how we can screen for postpartum depression. Just a quick definition of postpartum depression, it is going to be someone with moderate to severe depressive symptoms. That can arise around post childbirth whenever that occurs, all the way up to four weeks post childbirth. And then that can also last for up to a year or more postpartum. Postpartum depression, it affects daily functions. So someone has some struggles with chores or daily childcare tasks compared to the baby blues, which is a more mild form of depression. Postpartum depression does require medical intervention as well. So pregnancy and postpartum, as we all know, is a time of psychological vulnerability, especially in those first few weeks when there's so much transition happening after delivery, which is why early identification and screening for treatment is key. So we want to ask the questions, whether that's verbally or in a paper or outcome measure form. So ACOG recommends that patients be screened for postpartum depression at a few certain timeframes. At the first OB visit, at 24 to 28 weeks gestation, and there was a study in 2013 by Wisner et al that suggested for a majority, depression begins prior to delivery. So this is why we have those checkpoints during pregnancy. And then the other times that they suggest that we screen for postpartum depression is at the comprehensive postpartum visit, whether that's at six weeks, four weeks, eight weeks. And then also I loved this at pediatric visits well into the first postpartum year, because pretty much after that six week visit, um, most women are not seen by their OB until the next year for their annual. So those are some timeframes that we as PTs are likely seeing these individuals maybe during pregnancy, postpartum, so we can also help with this screening process. In terms of outcome measures, there are a number of outcome measures out there that are used to screen for postpartum depression. We are going to go over two of the most common evidence-based tools. The first is the Edinburgh Postpartum or Postnatal Depression Scale, and then the Patient Health Questionnaire. They're both two scales that are recommended by ACOG and by the Postpartum Support International Group, which is a really cool resource, and we'll talk about it more in my next episode, but it's going to be a resource available for those in that perinatal mental health space period kind of combines those two things. So the two outcome measures, the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire, we love them because they are available in many languages and they are quick to administer and they're free. Who doesn't love free stuff? They are validated also for the perinatal population. which I think is something important that while we can give someone a major outcome measure that's for general depression, it's even really more helpful to have someone go through an outcome measure that is specific to the time and space that they're in. And then scoring, the lower the score for both of the outcome measures is going to indicate lower or more mild depressive symptoms. The cutoff value of 11 or higher out of 30 for the Edinburgh scale is going to maximize the combined sensitivity and specificity. 07:21 - THE EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS) Let's go through a couple of differences, though, between what we'll call the EPDS for the Edinburgh Postnatal Depression Scale. So for the EPDS, it's got 10 questions. And not only does it address the depressive symptoms and suicidal thoughts, but it also has an anxiety component of perinatal mood disorders. And that anxiety piece is likely what contributes to it being the most widely used screening tool. The other interesting thing I came across is that the EPDS is actually reliable and a valid measure of mood in the supporting partner, whether it is a male or a female, which I think is great. Example of items from the EPDS. are as follows. The person is going to be answering whether or not they have been so unhappy that they have been crying, the thought of harming myself has occurred to me, or I have felt scared or panicky for no good reason. Moving to the patient health questionnaire, that's going to be nine questions that assess for the depression component. It does include an item about suicidal ideation, but it doesn't have an anxiety component that the EPDS does. Instead, it includes some of the somatic symptoms of major depressive disorders, such as fatigue, sleep disturbance, changes in weight, and these reflect what is also on the DSM categories. Here's an aside for all these outcome measures. So in my research, I ran across a study from 2017 by Ukatu et al, reviewing about 36 articles that used PPD screening tools, and they investigated the outcome measures and their ability to detect maternal depression. So two of the conclusions from this review that looked at a bunch of articles that use PPD were, one, is that they found no recommendation could be made about the most effective tool for detecting PPD, which is, I guess the good side of that is you can use, there are a lot of tools out there and they will likely be capturing the depression component. 10:28 - WHEN IS THE ONSET OF POSTPARTUM DEPRESSION? The other thing that they mentioned was there's no recommended time duration in which to screen patients, again, from all of those reviews that they studied. So one of the reasons they suggest that the timing can be difficult to recommend is that For certain outcome measures that are administered at the two-week mark, the outcome measure may not be able to differentiate symptoms of baby blues, which commonly ends after about two weeks post-birth, versus postpartum depression that can have a much later onset. And that can be anywhere from post-birth up to three to four weeks for onset. So I just thought that was an interesting find from the screening side of things. But the two that we talked about are the EPDS and the patient health questionnaire. So outside of administering those two outcome measures, when it comes to screening, you'll want to also use the power of your ears and your voice to catch anything that may have been missed in those outcome measures. Remember, some people won't necessarily be honest on the outcome measures. They may be less likely to share that they're struggling due to the feelings of shame, abandonment, maybe they have a lot of guilt about not being enough for their baby, or they may not even realize their current emotional state, even when asked right on the outcome measure. So be an active listener. Ask the person How are you doing? But don't stop there. If you get a general response that's like, I'm good or I'm okay, I think you should ask it again. Say, I'm going to ask you again, how are you doing? Then you should also be on the lookout for words or phrases that the person may use in their conversation, like dark, heavy, blue. And then we certainly also want to have screening out postpartum psychosis in the back of our minds. So hearing voices that tell me to drop my baby, if you hear that, that is very serious. It is a medical emergency. This postpartum psychosis is going to affect about one to 3% of moms. So that's how to screen postpartum depression. How do we have the difficult conversation? How do we navigate the intricacies? when we suspect the person in front of us may be suffering from some postpartum depression. A few general tips. You'll want to listen with compassion and empathy, particularly to the non-physical symptoms. As neuroscientist, Dr. Andrew Huberman said, says, use your body to shift the mind. An individual that's not functioning at their usual physical capacity, or is in pain, or I don't know, recovering from a human body coming out of their body, or they're lacking sleep, right? This does not only affect the physical body, but it's also going to affect the brain and the soul. So it is within our scope to chat about this as their mental status is linked to their physical healing and recovery and management of their condition. As a provider, ignoring their mental status is not an option. You'll also want to avoid being dismissive. So someone may have been very vulnerable with you and they shared that, you know, they're just struggling. They're struggling to find the energy. They're struggling to feed themselves. And then you as a provider, like, okay, moving on to range of motion of your leg, like absolutely not. That is not acceptable. So avoid being dismissive, hear them out. Then remind them that addressing their mental health now will be so much more beneficial than months or a year down the line. And then mentioning that you'd like to take an integrative approach and refer them to a medication provider or their OB or a PCP or a psychiatrist, right? We'll talk in the upcoming podcast, but medications like antidepressants are also a good treatment option for them. So what are some specific responses that you can practice or just have in the back of your head when you suspect someone may be experiencing postpartum depression? I don't know about you, but especially in the public health space, I tend to get, you know, we talk about intimate subjects and there are some times that someone will share something with me. And I mean, I am feeling so much for them, but I have a hard time putting into words the quote right thing to say. And I'm not saying that these things, these scripting phrases that I'm going to give you are the right thing, but it's something to go off of if you're just struggling in that way. 16:43 - HIGHLIGHT & CELEBRATE So the first phrase, and I think it's probably one of the most impactful, your feelings are validated. I'm in a group text with a few moms and one of them, they've all been recently pregnant and recently postpartum. Some of them have been going through some tough times when it comes to emotions. And one of them said, my OB put her hand on my arm and told me how brave I am for asking for help and really realizing that I need to be my best self for my family. And she told me I could call her office anytime to talk to her. And that meant so much. So just letting the person in front of you know your feelings are validated. Number two, early identification. So if you've got someone who is pregnant and you suspect that they're going through some tough times from an emotional standpoint, you can say, you don't have to feel this way for the next eight months of your pregnancy. There are resources available. Number three, highlight and celebrate the person's abilities. Say, look at what you're doing. All of this is very impressive given the circumstances and all the stress that you've been under. Bring it back to a potential or current bond with the baby. And you know, if the baby's in the room with you, even better, have a little side conversation before the appointment starts with the baby. When I point to you, look at your mother with loving eyes. I'm just kidding. But definitely show the person or show the mother, look at how you're learning what your baby needs, right? For comfort, for snuggles, for food, for diaper changes. So remind her of the role she's playing. And then number four, remind her your health is a priority just as much as the baby's is. So often, as soon as labor and delivery is over, maybe we have that six week, postpartum visit, the rest of the visits are not for the mother, they're for the child. So just reminding her that her health is definitely linked and just as important to her baby's health. And then number five, say this happens. There's a fine line though between normalizing that this happens a lot, but also it's not so normal that you don't need to address, that we can't have you not address it. So there was a resource that is, was in the deep dive realms of the ACOG website and the title, the title just gives me chills. It says, how do you talk about mental health conditions in a strength-based way? Love that. Here were their suggestions. Say mental health conditions are common. Mental health conditions are like medical conditions or like diabetes. They need to be treated. Medical conditions are, or mental health conditions are treatable. And that reminding the client that the aim is that every woman who is pregnant or postpartum or every person who's pregnant and postpartum is screened for mood disorders. They also recommended that their clinical support office staff needs to be skilled in talking to patients in a strength-based way, as they may be the first to encounter a postpartum person. And I wholeheartedly believe that because the face of the first person you encounter can really and truly change the trajectory of your care. So let's sum things up. If you're a healthcare provider, interacting with someone In the pregnant and postpartum period, you are in a unique position to be screening for postpartum depression. We covered using two outcome measures such as the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire. If we suspect PPD, we as rehab providers can be confident in having these early conversations early on and during the client's pregnancy and then again in the early postpartum period. Using tips and verbal responses, the scripting phrases that I mentioned, can help support and validate the client's concerns in a strength-based way. Reminding them that their health is equally as important as their baby's. Reminding them of what they've accomplished under these incredible circumstances. And telling them, hey, this condition is treatable, just like we would treat a shoulder injury. This awareness can decrease stigma, it can normalize screening and detection, and encourage women to discuss any mental health concerns with you. Join us next time for specific treatments, resources, and ways to support a person with postpartum depression. Cheers, 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.

Dr. Paul Killoren // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren emphasizes the importance of using e-stim in conjunction with dry needling. This combination provides validation and helps the practitioner determine if the needle is in the muscle. Furthermore, using e-stim with needles can reduce post-treatment soreness, making it more approachable for patients. Paul also highlights research supporting the use of e-stim in various treatment goals, such as pain modulation, neuromuscular changes, tissue nourishment, nervous system accommodation, and somatosensory reorganization. Paul always recommends using e-stim after inserting the needle, as it offers multiple benefits for both the practitioner and the patient. 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 PAUL KILLOREN Good morning. PT on Ice daily show streaming worldwide on Instagram and YouTube. I'm your host for the day, Paul Killoren, of the dry needling division for ice, and I'm hijacking the mic. Normally on Thursday for the PT on ICE Daily Show, we have practice management, we have leadership stuff, really inspiring messages from Jeff Moore, from Alan himself. I'm hijacking the mic and calling this Technique Thursday. We're talking needles on a Thursday. dry needling division. Before I dive in, some pretty exciting updates. Our very first advanced dry needling course is going down January 12th to 14th. And we actually have a registration page up and live that has a little work to do. But the course is going to be ready and the very first advanced dry needling course for ice will be in Washington in Bellingham in January. And then having the upper, lower, and advanced course that will form the ICE dry needling certification. So again, our division's not even a year old. We have had our upper and lower dry needling courses running across the country for almost 12 months. And this will be that final piece. So really exciting stuff coming out of the dry needling division. But I'm going to dive in, dive right in today. 01:58 - THE NEEDLE IS IN, NOW WHAT? And the title of today's episode is my needle is in, now what? And honestly, when I framed this topic, when I started to prep and form this discussion, in my mind, I pictured that novice clinician, I mean, you're on your first dry needling course, you're doing vastus medialis, vastus lateralis, glute medius multifidus, you learn the technique, the palpation, the anatomy, you're looking for a bony contact, you get super excited, just like, oh, sweet. There's the bone. That's what I was looking for. Now what? So really, this is a question I've answered consistently on level one or kind of first dry needling courses for the last decade. But again, when I started to prep for this episode, there's layers to this. And really, whether you're a novice, an intermediate, or even an experienced dry needler, Sometimes it's worth having this discussion of, our needle is in. Like first we learn how to do it safely, how to do it specifically, but our needle is in, now what? And to fully acknowledge, depending on who you listen to, how you were trained, the answer of, now what, will be very different. Because first of all, there's that technical spectrum of, well, now we piston the needle, or now we twist the needle. Now we use e-stim. But even there, let's say there's a dosage spectrum of, okay, if I piston how many times? If I twist it for how long? If I just leave it there, what duration? If I use e-stim, what parameters? So again, I thought this would be a pretty easy, a pretty short, quick-hitting topic, but there's layers to it. And first of all, let's say that there is significant value to my needle is in a very specific target. Again, safety always comes first when you learn dry needling, but I think we also can acknowledge one of the benefits, one of the advantages of the needle as a clinical tool is we can be sniper precise. We can put a needle in semi-membranosis, in multifidus. You know, this is not necessarily a technique of broad stroking manual therapy of like, we're doing the lateral hip, we're doing the low back, we're doing the SI region. To some degree, even a manipulation, we're saying, you know, we're not joint specific necessarily. We're kind of giving input neurophysiologically to joint receptors and there's more of a regional and global response to that. With a needle, I think we can just say, first of all, I have a needle in semimembranosus. 04:46 - THE BLESSING & THE CURSE OF NEEDLING I mean, The blessing and the curse of needling is it keeps us honest, especially if we use e-stim. When you get that motor response, the needle's telling you, it's like, you know what, Paul? You're not in semi-membranosis. You missed. You're either like, you drifted subcutaneously or you missed superficially in tendinosis, you missed deep in adductor magnus. So first of all, I don't wanna just like completely glaze over the fact that your needle is in a very specific target is a big part of the equation. I mean, for ice, for our dry needling, we teach safety for sure, but you as like highly educated, skilled clinicians, teaching you all how to be safe with a needle happens pretty quick. So our, our goals, our mantra with dry needling are be safe, be specific. Again, that's, that's a big part of using this needle as a tool and then be strategic. And that's what I want to go to today, because again, the topic here is, my needle is in, now what? And again, let's acknowledge that it depends, not just on how you're trained, it depends on that patient on the table, on what is your goal for that session, what is the acuteness or the chronicity of the condition. So by no means do I want to make this sound easy, but I am going to give a very specific answer to this question. And again, I have previous training, I know the narratives out there of the needle is in, now we twist it for two minutes. Or the needle is in, now we just let it sit there. Or we pissed in it. And again, there are narratives, there is research, and there is benefit to each of those approaches. But I'm telling you that those aren't the answers. Again, I have a pretty specific answer that I'm going to get to But I think I'll torture you just a little bit longer by setting the stage. And really, I'm going to flashback, not even talking needling, I'm going to flashback to my DPT education. I went to Regis University, graduated in 2010. So what attracted me to Regist was Dr. Tim Flynn, Julie Whitman, Jim Elliott. I mean, big manual therapy specialists, but researchers of our day. So we finally, you know, you're year one, year two, you finally get to that musculoskeletal management, you finally get to learn some manipulations from Tim Flynn and Julie Whitman. And you know, if you don't remember how you started with manipulations, it wasn't good. The hands were not skilled, like it wasn't crispy right out of the gate. So you spend a half day, you practice on your classmates at home, and finally you're like, man, I'm starting to feel like my hands have some skill. So imagine you are there, you're learning manipulations, your hands are feeling more skilled. Imagine how disheartening it was for me, and I remember this day, when Dr. Tim Flynn stands up and says, you know what, you can teach a monkey how to manip. And I mean, He's overgeneralizing, but the point is still true. He's like, you can teach a monkey how to manipulate. It's really how, like when to manipulate. Um, I guess how to apply it. There is skill there. We'll acknowledge that. But then it's what you do afterwards. So, I mean, that, that hit for me. And first of all, it's like, Oh man, there are manipulating chimps out there that are doing this better than I am. And again, that wasn't his point, but. But the point remains knowing when to use it, how to use it to some degree, but then the dosage and the follow through, the aftermath is really the true magic. That applies for dry needling as well. Again, can we teach a monkey how to put a needle randomly into tissue? For sure. Like there is not much needle skill to getting a needle interstitially, into muscle tissue. There is a skill to being more specific, and there is a skill to answering the dosage question, now what? And I'll tell you now, without further ado, we have our needle or needles in. The answer to now what is e-stim. And you know, I don't, you know, I kind of do the, you know, I was trained previously, I know the research, the narrative and the benefit to all the other approaches, but the answer today is eSTEM. And honestly, what makes me so confident in that is first of all, I have my own empirical anecdotal, like I was not using eSTEM, now I am. I have that sample size to make me confident. But what makes me more confident And it's not even just the research, I'll touch on that in a minute. But what makes me more confident is knowing or hearing that some of the other dry needling educators or other dry needling institutions in the US and worldwide that previously were saying there's no additional value to e-stim with dry needling, or we're essentially just doing tens through a needle, they're now starting to use e-stim. And whether they use it the same way we do with ice, whether they explain it the same way, what they're saying is there's value to e-stim. And here's what the research says, is our needles are in, now what? E-stim is the answer for almost any treatment intent. First of all, I mean, if you haven't taken one of our upper or lower courses, we teach e-stim right out of the gate. I mean, day one, we learn how to use the unit, we get muscles to pump, Again, there's high value when you first learn dry needling to using e-stim because it keeps you honest. Are you in that muscle? Are you not? But that immediately gives you some, I guess some validation, like I'm saying, but some grace. Because first of all, what we know is that if we use e-stim with our needles versus not, any sort of post-treatment, post-needle soreness will be much less. So there's a very, um, a very real like patient approachability aspect to using e-stim. And there's research to support that. 12:33 - E-STIM DOES IT BETTER But beyond that, what if our treatment goal is not pain modulation? What if it's neuromuscular changes? E-stim does it better. What if our goal is, tissue nourishment, blood flow, maybe venous return, lymphatic activation, edema evacuation. What if our goal is that? ESTIM does it better. What if our goal is nervous system accommodation? Or what if it's getting the biggest, baddest neuropeptide or enkephalin, endorphin, but our pain modulating up top cortical response. What if that's our goal? eSTIM does it better. What if we're talking pain science and there's some somatosensory reorganization, there's some homuncular smudging that we would like to remap. We'd like to give a very profound and precise input to that homunculus, to that somatosensory cortex. eSTIM does it better. So again, these are, these are research based answers. Very real research that says group A just got needles, whether that was pistoning or placing or what have you, and then group B got e-stim. What was the difference? At this point, e-stim does it better. And really, that is the long and short of this episode. And again, I think to not minimize the impact of you have to learn how to put a needle in safely, There is significant value, especially with the needle, to say, my needle is in, very precisely, fill in the blank. My needle is in peroneus brevis. My needle is in extensor hallucis longus. My needle's in glute minimus. There is significant value to the precision of that tool. But that's only half the battle. My needle is in, excellent. That took some training, that took some some skill honestly that took some three years of doctorate level like anatomical training and education and awareness that took a lot to say my needle just contacted I guess the external ileum like we are at the depth and the location of glute minimus that's awesome that you checked the box that is step one but if we don't fill in the then what you're leaving a lot on the table clinically And if you just logged on, the answer is eSTEM. So again, I know I see some of the names jumping on. Thanks for joining. I'm preaching to the choir, to some of you, because you've taken our upper or lower courses. We immediately talk about how to use eSTEM, the research behind eSTEM, and then we use it all weekend on the course. And it's a different experience. I think eSTEM makes dry needling a little bit classier. We can be a little bit more classy with our needles when we use E-Stim. We can also be a little bit more dialed, a little more tactical with our treatment intent. Again, is your goal pain modulation? Is it neuromuscular changes? Is it blood flow? Is it just fluid dynamics of moving fluid? Excuse me. So that's the answer for today. Again, jumping on on a Thursday for a Technique Thursday. We're talking dry needling. And the question was, needle is in, now what? And the answer was Easton. Excuse me. So if that prompts any questions, again, this is a big piece of our curriculum. Drop some comments in the thread. Hit us up on Instagram. This is on YouTube as well, so you can throw some comments there. Again, my name is Paul Killoren of the dry kneeling division for ice. If you hopped on late, We are launching our advanced dry needling course in January. That'll be the final piece of our upper dry needling, lower dry needling, and then advanced for the certification. If you're in Washington State, that'll be the third course of the series to allow us to dry needle as far as getting 75 hours. But if there's anyone out there who is trained in needling, who is uncertain about using eStim or the benefit of eStim, first of all, I'll just encourage you to try it. Like, there's value there to hearing your patients explain the difference of using eStim or not. Otherwise, we have an online course if you already have the needle skills, you know how to put your needle in, but then what? If you don't know how to use the eStim, there is an online course through ICE as well, eStim plus needles. That's all I've got for today. Thanks for logging on. I'm incredibly proud of myself. This is my most concise, my most brief podcast topic, but it's an easy one for me. So if you're out there saying, what do we do after we put the needle in? I'm not saying there's not value in twisting or pistoning or just static needling. There's blood flow changes. There's neuromuscular changes. There's tissue disruptive like inflammatory cascade responses to all of that but the answer is e-stim and With that I'm logging off folks. Thanks for joining PT on ice daily show. See 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 conducting obstacle courses in a specific, dynamic, objective, and progressive manner. It emphasizes creating exercises and challenges that replicate daily life movements and tasks, incorporating variability and unpredictability to improve adaptability, leveraging subjective and objective outcome measures, and setting clear goals and tracking variables in dynamic gait training.

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey explains that patients with frozen shoulder often struggle to manage their condition and experience fear of the unknown, which can significantly impact their cognitive and emotional well-being. Lindsey emphasizes the importance of understanding the patient perspective and their emotional stories. She highlights that patients may fear the future and the unfamiliar territory of living with a frozen shoulder, which can have a profound effect on their psychological well-being. Lindsey also emphasizes the need for healthcare professionals to appreciate the expectations and experiences of patients with frozen shoulder, acknowledging that their pain is not an exaggeration. She suggests providing controllable solutions and empowering patients to advocate for themselves in order to receive timely care and diagnosis. Lindsey underscores the challenges faced by patients with frozen shoulder in managing their condition and the significance of addressing their emotional and cognitive well-being. Lindsey reinforces the importance of healthcare professionals assisting patients with frozen shoulder in finding ways to continue engaging in activities they love. This involves helping them adapt their activities or modify their movements so that they can still experience joy and maintain a sense of autonomy and independence. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 LINDSEY HUGHEY Good morning PT on Ice Daily Show. How's it going? I am Dr. Lindsay Hughey. I will be your host today on Clinical Tuesday. It's so good to be with you all. It's been a little while. Today I am going to chat with you about frozen shoulder and helping your patients navigate no man's land. But before I unpack this episode, I'd love to tell you a little bit about courses that Mark, Cody, and I have coming up. Cody actually was just promoted to lead faculty. We are so excited. And he will be teaching his first class this weekend solo in Minnesota so Rochester and there are still tickets left if you want to join him he would love that and you're sure to have a blast with him this weekend so October 7th and 8th can you believe we're already in October so wild other courses coming up in November on November 11th 12th we'll be in Woodstock Georgia and then our final courses of the year are in December. So you have two opportunities on December 2nd, 3rd. Cody will be in California, Newark, California. And then December 9th, 10th, I will be at CrossFit Endure again. That's always a blast of a spot. So Fort Collins, Windsor, Colorado area would love you to join. Those are our last of 2023. And then we'll be in 2024, which is super wild. So please join us. Thanks for letting me share courses coming up. 03:37 LIVING WITH FROZEN SHOULDER So last week, if you tuned in to clinical Tuesday, Mark hopped on here and he chatted about frozen shoulder, just the challenges associated with treating folks with frozen shoulder. And he really highlighted not only best treatment as we know it, but the importance of coming alongside the patient. And we need to do that better because this is an area, and if you think about any patient you've ever seen with frozen shoulder, it's always challenging, right? Because they are suffering and there are just so many unknowns. But we do have more knowns in regards to the patient perspective that just came out this past May. William King and Claire Hebron out of the Physiotherapy Theory and Practice Journal published a qualitative review of frozen shoulder. So specifically giving us the vantage point from the patient. So this study involves six folks, two were females, four were males. Their age range between 35 and 66. So a varied mix of sexes and then age ranges. They all were British and there was a mix of right and left and even bilateral frozen shoulders. So these interviews were done with these six folks and the question that was asked of them was can you describe in as much detail as possible what was important and meaningful to you in your experience of living with frozen shoulder? They used hermeneutic feminology methodology for those research nerds that want to know and they found the following five themes And so today I'm going to tell you what those themes are, and then I want to unpack some of the participant details from each theme. And I'm sure you'll be able to relate with some of your patient care experiences. And then kind of end the show with suggesting a rewrite of the title, plus some key takeaways for us going forward in caring for these folks with frozen shoulder. So the five themes illuminated from this article, and again, that's title, and I'll drop the link, is Frozen Shoulder, Living with Uncertainty and Being in No Man's Land. The five themes that were found were, number one, patients felt an incredible pain experience that they described as dropping me to my knees. Two, a struggle for normality in life. Three, an emotional change of self four the challenges of traversing the health care journey and then five coping and adapting and learning how to do that. So I want to unpack each one of these just a couple examples to help you appreciate that patient perspective. So dropping me to my knees that incredible pain experience All of the patients that were interviewed described multiple experiences where if they move their shoulder quickly or hit up against an object unexpectedly or involuntarily kind of reached and forgot about their shoulder for a second, that this pain would literally drop them to their knees. That when they would go to like stretch in the morning, they would scream and writhe out of pain. And this not only affected their body and their discomfort but like their family. Some of the participants described kind of scaring their partner because of like sudden outbursts or yelled. So an experience that's not just personal but affecting those around them. 07:28 EMOTIONAL CHANGE OF SELF Number two, the struggle for normality. So a lot of the folks describe multiple daily activities just being very limited and I'm sure your patients have had the same right just getting dressed, just rolling over in bed, unable to sleep, just that constant ache that's with them always kind of being in their mind and then challenging just normal daily activities. Not just ADLs and IADLs, but starting to lose work function, missing work and or recreational function. So one participant actually had to sell their fishing boat or chose to because they said just transporting the boat became so cumbersome and a reminder of their shoulder limitation. One of the participants described being unable to throw the ball. They're at a family gathering and their kid is watching other people throw the ball with their parent and the parent that has frozen shoulders just sitting there thinking, oh I can't even like throw the ball with my kid so this normalcy doesn't only impact them personally again in their daily life but it's impacting their family relations around them their work right their ability to actually provide for their family and then the recreation like enjoyment in life people that love to fish that was my dad's like favorite pastime if there's an emotional psychological peace here that is huge then that is challenged when someone has frozen shoulder that they can't do that one activity that brings them peace or joy and they can't um help provide for their family because they're suffering Which leads us to that third theme found, an emotional change of self. So all of the participants described overall just low mood from being in constant pain, having low self-esteem and starting to feel less worth in their family unit. Just kind of feelings of uselessness because not being able to reach overhead or being limited in the ability to just help out with daily chores. this was a really challenging thing to read, but one of the patients described that emotional change as if you were an animal, you would be put down because you're miserable. So basically like lack of thriving and like that was heartbreaking to read, but like this is how low emotions get when you're in, when patients have that frozen shoulder state. And a lot of them said not just the emotional drain is challenging, but like you're physically drained because of that emotional taxation. So multiple participants reported poor sleep, which I already mentioned earlier from a normalcy perspective, but they linked that to how this led to fluctuating mood because you never know when you're gonna get a good night's sleep. And so overall mood was very cantankerous and unpredictable. which patients even again mention that they're not able to even sleep in the same bed as their partner because they're so disturbed and uncomfortable in their sleep. And so they're sleeping in a separate room, again, that's that intertwining like emotional change of self being affected. and when this happens right you start seeing sleep being affected it makes you want to prompt for health care help right and so this leads to that fourth theme where patients are traversing the challenge of the health care journey going to a health care professional hoping they can help them sleep better helping they can take away the pain. 09:28 IMPACT OF DELAYED DIAGNOSIS ON TREATMENT But what most of the participants really highlighted is that this delayed diagnosis happened consistently where they saw multiple healthcare professionals prior to actually getting a solid diagnosis that this is in fact frozen shoulder. And so there was this, there's this period of not knowing and switching back and forth, like what's wrong with my shoulder? And then you finally know. And, um, even the treatments they were getting were challenging because patients said they didn't actually see solid results. So they would ask for a pain medication and then some of the healthcare professionals would be afraid of addiction. So they wouldn't give them stronger medications to help. And so there was this balance of figuring out what's that pain medication that's right for the patient. A lot of the patients, said that injections were life-changing. So getting a corticosteroid injection was helpful, but it didn't always happen right away. And some of them had to really advocate for that to occur. And that some, even the patients that were finally recommended to get the injection mentioned they were afraid of the needle. So we have to understand it might be a delay to get to the treatment that's effective, And then they might even have a fear of actually using that treatment that's recommended from the healthcare provider. So they're dealing with a lot of challenges in the healthcare journal. And disappointingly enough, as for most of our audience that are PTs, a lot of the folks said that PT wasn't the greatest. They didn't have initial great experiences because the PT would give them stretches that were super painful and not working. And the patient would have to wait a whole week to tell the therapist that, and then the therapist would give them something new, and then the stretches would hurt and not really work, and they'd come back again. We can do better here, right? If you test, retest in that session, you'll know whether that's working. So some kind of disappointing healthcare journeys for most of these folks. But there was some hope along the journey. So the fifth theme found was coping and adapting. Once patients did finally get to the healthcare provider or the PT that started providing effective care, they did have hope. Once they saw it start working or when they got that injection and the pain started going away, they could move their shoulder a little bit more. So when pain's down and range is better, they were super jazzed about it and finally had some hope. Various participants did say that it requires that coping and adapting, it requires you to shift your mindset, that press on attitude in the face of adversity. So helping our patients get there quicker, I think is something that we have an opportunity for. Another part of that, some coping strategies was people just learning, some of the participants mentioning that learning to work around the disability, right? If they were right-handed, starting to use their left arm, to keep functioning in kind of a pushing through mentality. The final binding theme of all of these, so we've unpacked examples of dropping me to my knees, an incredible pain experience, the struggle for normality, three, an emotional change of self, four, the challenges of the healthcare journey, and then five, coping and adapting. That theme that they found binding them all together was uncertainty. Or as the authors of the study titled No Man's Land. One thing I said that I was going to unpack was a suggestion for a rewrite. So we are dealing with humans, not just men. So I'd love to suggest that we call this No Human's Land. But this does come from a phrase, right, that was used to describe unowned land or unoccupied land or land that's not officially owned or inhabited by someone. but we are dealing with multiple humans, right? Not just males. So that rewrite I think is important here. 13:58 FROZEN SHOULDER & THE FEAR OF THE UNKNOWN But ultimately the main thing I want you to appreciate is with the unknown of how this disease may progress or regress, we have to do better for our patients here. They will not be able to manage their present living with frozen shoulder if they're fearful of the future. They don't read it. Oh, hopefully you're all still there. Give me a wave or like a thumbs up. If you are a little alarm went off. Sorry about that. Um, but patients will not be able, um, to manage living with their frozen shoulder. If they don't know how to manage it in the present, if they're fearful of the future, sorry for the folks that had to hear this twice on YouTube, but That fear of the unknown, right, or no humans land territory, this affects cognitive and emotional well-being. So what can we do with these themes, knowing patient perspective a little bit more deeply here? And I know it was only from six folks, but I'm sure you can relate and think back and reflect on patients you've seen, and they've had similar tough experiences. There are powerful takeaways here. appreciate that expectations from your patient they're always tied to a real human with an emotional story and we have to know that and appreciate that. We have to know that this pain is not an exaggeration. We need to give stabilization to that human story. with some of the facts of the do's and don'ts about frozen shoulders. See Mark's podcast last clinical Tuesday because he dove into best treatment and about what we know, what we thought we knew, and where we are presently. We have to provide controllable solutions. Some solutions. Help your patients advocate for themselves early. and with tenacity with their specialist, right? Help them get to that corticosteroid injection. You don't usually hear us saying that, right? That medicalization, we try to avoid that here at ICE, but here's a condition where we see, especially in the United Kingdom, this being a helpful pathway in combination with physical therapy. So help them get to the proper care and diagnosis faster. Make it so they don't have to see three healthcare professionals before they start feeling better. USPTs test retest the value of your treatment in session. Don't send someone home in writhing pain that worsens their range. Send them home with something that is helpful, right? That's easing and know that before they leave so they don't have a whole week of time of ineffective self-care. Let's not forget the human behind the painful and stiff shoulder. Those with frozen shoulder, let's help them feel direction at a really destabilizing time in their life. Help them figure out a way to do what they love, to keep working, help them be autonomous, to navigate their pain, their setbacks, and then their interactions with the healthcare team. We have a really cool opportunity to make living with frozen shoulder a little bit more endurable and making the patient feel more known. Thank you for being with me this clinical Tuesday and sorry about that little blip in the middle. Happy Tuesday. Cheers. 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. Jess Gingerich // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich challenges the notion of associating the word "safe" with breath and movement, particularly during pregnancy. She questions why breath suddenly becomes a determining factor for safety in this context. While she acknowledges that the pelvic floor experiences increased demand as the fetus grows, she also affirms that it is a muscle that can strengthen with appropriate exercise. Jess encourages weightlifting as a means to strengthen the pelvic floor during pregnancy. She explains that stronger muscle fibers are more resilient, sharing this information with her clients in the clinic. She also highlights the fact that individuals are not instructed on how to manipulate their breath when coughing or sneezing, which exerts similar force on the pelvic floor as lifting 35 pounds. Since this natural phenomenon is beyond our control, it is unreasonable to expect individuals to exhale on exertion for every activity. Jess also address the misconception that breath holding is detrimental to the pelvic floor. She explains that breath holding actually increases spinal stiffness, enabling individuals to lift more weight and become stronger. However, She clarifies that breath holding with a bear down to the pelvic floor is not recommended. She differentiates between different positions of the pelvic floor, referring to the basement (during bathroom use or childbirth) and the first floor or attic for other tasks. Overall, the episode aims to alleviate fear and promote understanding of the pelvic floor. Jess emphasizes the importance of educating individuals about their pelvic floor and its functions, highlighting its potential for strength and dispelling myths and misconceptions surrounding breath and pelvic floor function. 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 JESSICA GINGERICH Good morning and welcome to PT on Ice daily show. My name is Dr. Jessica Gingerich. And I am on faculty here with the pelvic division here at ICE, which means it's the beginning of the week. So happy Monday. We are going to talk about breathing in the pelvic floor. This is a hot topic in the pelvic space. often referred to specific breathing strategies that are like safe or protective to the pelvic floor. And in reality, it's just not that simple. So let's start with a few housekeeping items. We are currently in our last cohort of the year for the online course. So if this is something that you've been wanting to get on, we're about to put the pedal down starting January 9th. So head over to the website to sign up for that online course. In the month of October, we will be in Brookfield, Wisconsin on the 14th and 15th in Corvallis, Oregon, October 21st and 22nd. So again, those courses are all on the website, so head over there and snag your spot. They are filling up fast. 01:50 BREATHING DURING EXERCISE Okay, let's talk about breathing during exercise and how it stresses the pelvic floor. How many of you, as moms, clinicians, or just someone with a pelvic floor, hint, all of you, have been told to exhale on a lift or exhale on exertion? My bet is behind your phone, you are silently raising your hand because you've heard that. Whether it's for yourself or for your clients, wherever you are in the exercise space, you've probably heard that. When we think about this, so there's a lot of information from fitness professionals or medical professionals in the exercise space saying a lot of different things and boy is it confusing. This is especially true in the pregnant and the postpartum population. These clients typically come in having some kind of, have done some kind of research around breathing and lifting, and they're worried about their pelvic floor. So how do we help them understand how to manipulate their breath with exercise? So firstly, let's take the word safe out of it. If I am a non-pregnant female versus I get pregnant, Why is my breath all of a sudden making something safe or unsafe with a particular movement? There is more demand placed on the pelvic floor, especially as the fetus grows. Sure, yeah, that happens. Is the pelvic floor a muscle? Yes, it is. Do muscles get stronger as we place appropriate demand on them? Also, yes. We need to encourage weightlifting to some capacity during pregnancy so the muscle gets stronger. Stronger muscle fibers are harder to break. I love telling clients this in the clinic. We don't ask someone to manipulate their breath when they cough or they sneeze. which by the way is the equivalent of lifting 35 pounds or putting 35 pounds of force through the pelvic floor because it is a natural phenomenon that we cannot control. We don't tell them how to manipulate their breath there. So having someone exhale on exertion for everything is unreasonable. There are times where that can be helpful, especially early postpartum or if there are symptoms. But have you tried to exhale an exertion with double unders or box jumps or lifting 80% of a one rep max? You can't control your breath, like during movements where your heart rate's up. It's virtually impossible because your heart rate's up, your respiration rate's up. And as for the 80%, your body is just going to do what it's going to do, which is probably gonna include a brief breath hold or maybe even one that's longer so you can get through that movement well. Secondly, breath manipulation should be initiated one of two ways. Are they symptomatic? No. Continue what you're doing. Are they symptomatic? Yes. Let's change a bracing strategy or breath manipulation to see if we can continue that volume and that weight without symptoms. From there, we continue to scale as needed. And lastly, Breath holding during exercise. And what I mean by this is someone is lifting a heavy barbell or let's say both of their wiggly children at once from the ground. And Oh, by the way, one is screaming their head off. They're going to brace their core, hold their breath and lift the weight or their babies. Have they just ruined their pelvic floor or has their body just done what it's going to do naturally? My answer is the latter. We cannot always manipulate the breath, especially in life, especially life as a mom. We need to stop scaring moms and over-medicalizing breathing when in reality, our bodies are going to just do what it needs to do to get through a task. We believe in this so heavily that we teach bracing mechanics in detail, in depth, in our live course. So I mentioned those live courses at the beginning. Get on that. Like you, whether you're treating this population or not, you're going to see it. So to recap, there are no safe and unsafe exercises. It's simply, are we ready for that particular demand, whether that's weight or volume. We modify due to symptoms. We aren't ruining the pelvic floor by holding our breath. Breath holding increases spinal stiffness, which allows us to lift more weight, which also allows us to get stronger. And that's huge. Now, I do wanna be clear. Breath holding with a bear down to the pelvic floor is not what we want to do. When our pelvic floor goes down, and what we like to refer to that as in the basement, that's when we're going to the bathroom, right? That's when we are actually having a baby. any other time our pelvic floor is likely going to be on that first floor or in the attic and somewhere in between depending on the task at hand. So let's start taking the fear out of this. Let's start encouraging moms, really anybody, to do what their body's meant to do, and let's help teach them. It's something that we can do, we can teach them. Your pelvic floor, we can't see it, right? We can see how our shoulders move and how our neck moves and head moves. We can see that. We can't see how our pelvic floor moves unless we're laying down with a mirror between our legs doing an active Kegel, and that's not realistic. Also, knees go over toes when squatting. I hope everyone has a great Monday. 08:13 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. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock takes a deep dive into the jerk, discussing the importance of learning a strong leg drive, improving shoulder mobility, and committing to a strong finish with the movement. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app.physicaltherapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. Good morning, everybody. Welcome to PT on ice Daily Show. I'm your host, Mitch Babcock from the Fitness Athlete Division. That means it's Fitness Athlete Friday, and I'm stoked to be back on the podcast, bringing to you another episode, this time going into some nuanced stuff around the jerk. So stay tuned for some more details around how to make your jerk a little bit better. Today's topic, don't be a jerk with your jerks. Before we get into that team, first of all, I'm wearing my Lions shirt. Did you watch the game last night? Of course you did. Thursday night football. Let's go Lions. It's been a long, hard existence being a Lions fan. So we're out here stoked that we got t01:27 MITCH BABCOCK hree wins already on the season. Other news, non-football related, is that the fitness athlete team is going to be around the country coming up real fast here next weekend. Joe and myself are going to be out in Linwood, Washington, and we're rocking a big course out there. So if there's still time, if you want to slide in just under the cap of that course out in Linwood, if you're in the Seattle or greater Seattle area, we'd love to have you out at that course. We also have some courses coming up in the southern region. We've got San Antonio, Texas. And we've got Anna Maria Island in Florida. So if you're looking at Florida or a Texas course, we've got two of those in store for you coming up in the month of November. So otherwise, welcoming in the fall season here today. 01:43 MAKING YOUR JERK BETTER And today's topic around don't be a jerk with your jerks. We just finished up a nice May cycle where we did a lot of snatching and clean and jerking for the last eight weeks. and giving my members of the gym as many helpful tools as I can as a coach and an athlete of what's helped me with my shoulder overhead, specifically the push jerk in this cycle, but all of these principles also apply for the split jerk as well. And I see this done wrong or at least thought about wrong a lot. I figured it was helpful to share with you guys, whether that's from a personal standpoint as an athlete, you're out there training in the gym yourself and you're like, hey, This is sweet. I hate jerks. I hate split jerks or push jerks. And I want to get better at those. Or if you want to be able to pass that on to your clients or members, hopefully this will be helpful. So the first thing I want to talk about is what not to do. Don't press your jerks. 03:37 THE JERK HAS LITTLE TO DO WITH ACTUAL PRESSING The push jerk and the split jerk is not about how much you can press vertically. It has little to anything to do with actually pressing the bar vertically over your head. Think about what your one rep max strict press is. Ladies is usually somewhere in the ballpark of 60 to 100 pounds. Men, somewhere in the ballpark of 100 to 200 pounds of a strict press. And yet people are able to do almost twice as much as that when it comes to a jerk movement. It is not about your strength to move the bar off of your shoulder and press. So stop thinking of it like you need to push the bar up. The jerk is about pushing yourself under. That requires a couple things. One, specifically the legs. You need to start thinking about your legs way more than your shoulders on your jerks. It is all about your legs' ability to launch the bar off of your shoulders enough that you can then press your way under the jerk. Again, goes for the push jerk or the split jerk. So when you're in setup position, you've stood up that heavy clean and you're ready to make the jerk. Hopefully make the jerk. You need to be thinking about how much leg drive can I create vertically on this bar right now to launch this thing as far off my shoulders as possible. That means I need strong legs. I need to be better at my front squat. Specifically, when I stand up out of a heavy front squat, I need to be powerful in the finish as I'm standing and finishing that lift. So that's something that you can be training on days that you're not jerking at all, but be thinking about that last little third of the squat. Standing it up with a little power, with a little speed, and learning how to create really rapid short triple extension. Power cleans, same thing. Rapid triple extension at the top, but all we're trying to create here is more powerful legs. You can work on just dip and drives. It's a very common drill for Olympic lifters to work on. Get a bar in the front rack position. You just dip, hold, and just create a slight little bit of triple extension coming out. Dip, hold, create triple extension coming out. The focus point on the jerk needs to be on a strong leg drive. Now, once you get that to occur, then the press is actually you pushing your body under. It's just pushing myself down to a supported arm position. The shoulder is strong if it can meet the load in its locked out position. It's significantly less strong when it has to do any sort of motion to try to press out that kind of weight. So the quicker you are to press yourself down and support, the heavier of a jerk you'll be able to have, because it's just about supporting the load, not about pressing the load. 07:01 SHOULDER MOBILITY & THE JERK That requires shoulder mobility. And this is the big downfall to your split jerk is likely either A, you've been thinking about trying to press it over your head this whole time instead of jumping over your head. And B, your shoulders are too dang tight to really get into that full 180 degrees of flexion lockout arm position. You're trying to press it out in front and that's killing you, right? So you gotta open up that shoulder mobility. And you guys are the experts at doing this. Mitch, what do you like to do to open up your shoulders right before I'm weightlifting. I'm not talking about a PT session. I'm talking about something members can do out in the gym, boom, in real time to open up that double arm overhead position. I want to use a green band, but I don't want to do a single arm. I want to do double arm. And so rather than looping the band and attaching it to the pull-up bar like we normally do, I want to drape the band around the bar in this fashion. This is a poor example, but you get what I'm trying to say. I just, I don't want to half hitch it at all. I want to just loop it over the bar and have the band hanging down. I'm going to put both my hands through the band and I'm going to spin around. If you're watching this, this is a great I hope you're having fun with this because I'm spinning right now. I'm going to do like three circles and what that's going to do is wind up that band. So I've got it looped over the bar and I wound it up by doing three circles in it. My hands are now held in this double overhead position and I'm going to kneel down on the ground from that position. I'm going to start to have the band pulling my shoulders, essentially both arms, right near my ears at this point. When I'm down there kneeling on the ground, hands overhead and hooked to the band, now I can start to add some side bending into this position, which really starts to peel on this lateral seam of my arm, coming down to thoracolumbar fascia, up into the tricep area. I can side bend left, side bend right, and even add in a little upper back T-spine extension to that drill. It is the best opener I have found recently to get my shoulders ready to push jerk. because I'm hanging out in the exact position, an exaggerated version of it, but the exact position I want to finish my jerk in, which is the head through, the T-spine up and extended, and the arms behind my ears. So when you're thinking about pushing yourself under the bar, make sure your shoulder mobility is opened up so that you can do that. Okay, so what do we got so far? Strong leg drive, Don't press your jerks. Instead, push yourself under your jerks and make sure your shoulder mobility is on board for you to do that really well. 10:47 IMPROVING JERK TECHNIQUE And the last thing you need to think about, the only really cue I'm thinking after I think jump is I think head through. I think jump and I think head through. Too many people are scared to put their head through on a heavy jerk. They're committing to failing it and therefore they're committing to self-preservation. And so what they do is they jerk and they leave their head back behind the bar and they're like, if it works, cool, then I'll bring my head through. But if it doesn't, I can bail quickly and easy. That is just committing to failing the rep right from the start. You have to know that if this goes bad and I'm still pushing my head through and I can quickly get out and underneath the bar if I fail it. You're, trust me, you're athletic enough to move out of the way of the bar. I've seen it a number of hundreds and hundreds of times of athletes trying to get the head through, fail the rep and are still getting out from underneath the bar. You've got to commit to that head coming under and through the window. Because if not, the bar is going to be out in front of your center of mass. And it's way too heavy for you to hang on to out there. My max jerk is 350. There's no way if I don't get my head through that, that I can hold that kind of load overhead. I've got to bring the head through and I've got to bring the arms behind my head. And that's when I close my eyes and say a little prayer. Oh, I hope this goes good. But the head is forward. I'm not looking at the bar. The head's got to be forward and through. So the only two cues, if you're thinking about anything, it's jump as hard as I can and push my head through that window and pray for the best. Shoulder mobility needs to be on board. It's all about the legs. It's not about the shoulders. And it's about getting your head through the bar. And if you do those three things, you go out in the gym today, right now, and you start practicing those three things, I promise your jerks are going to feel faster, snappier. You're going to reach lockout a lot quicker, and you'll be able to PR that push jerk or that split jerk, whatever you're doing. And hopefully add 10 pounds on it. Don't forget to tip your caddy when you do. All right. I'll open, I'll share my Venmo below. Don't worry. That's how to not be a jerk with your jerks. I hope that stuff helps you. I hope that gives you some things to think about maybe for your athletes you're working with or cues that can help them and restore that overhead position. I think I should probably film a video of that shoulder mobility opener. I got a feeling I'm going to get some comments or questions about, Hey Mitch, I had no idea what you were trying to explain. Can you drop a video? So I'll walk right out in the gym. I'll film that and I'll do my best to drop a link to that video in the best place possible. Maybe over on my Instagram. Head over to my Instagram, Dr. Mitch TPT, follow that. And then, uh, I'll drop that video there for you guys, man. So glad you guys are here. Happy Friday. Go lions three and one and one and O in the NFC North. It's a good time to be a lion's fan for the first time in about seven years. Team. I hope you have a great weekend. If you're taking a nice course, let us know if you're taking a nice course next weekend, we'll see you out there. And if you want us to head down South, come find us in San Antonio or find us in Florida. and we'll be hanging out down there in the month of November. Have a great weekend, everybody. 01:27 MITCH BABCOCK 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 Moore // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes emphasizes the importance of trusting a proven process for success, particularly in the later stages of a business or any endeavor when uncertainty arises. He cautions against blindly trusting any process and encourage listeners to thoroughly evaluate its merits before putting their trust in it. Jeff acknowledges the prevalence of outrageous claims and self-proclaimed experts in today's era. He cautions against falling into this trap and emphasizes the need to dig deep and evaluate a process before trusting it. He suggests spending ample time observing and studying someone who has achieved desired outcomes through their process before fully committing to it. This advice applies to various domains, including clinical practice. If someone is considering adopting a specific treatment approach or following a mentor's guidance, they should first spend a substantial amount of time observing the mentor's success with a wide range of patients. Only after extensive evaluation and proof of the process's effectiveness should one trust and implement it. Overall, Jeff emphasizes the importance of trusting a proven process but stresses the need for thorough evaluation and proof. Blindly trusting any process without proper evaluation may not lead to the desired outcomes. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 JEFF MOORE Okay team, what's up? Welcome to Thursday. Welcome to Leadership Thursday. And welcome back to the PT on Ice Daily Show. Thrilled to have you here. I am Dr. Jeff Moore, currently serving as a CEO of Ice, and always happy to be here on Leadership Thursday, which, as always, is Gut Check Thursday. Let's start off every Thursday how we always do. Let's talk about the workout of the week. Here's what we've got cooked up for you. We've got 21-15-9. Couldn't be a more classic rep scheme. We've got thrusters and bar-facing burpees. So hopefully the first thing you're thinking is it looks a lot like Fran, right? We've got two movements, we've got that classic rep scheme, but I'm going to argue it's going to be a bit worse. With Fran, we've got push-pull, right? So at least you're pushing that thruster and then you're pulling up on that rig. Now we've kind of got push-push, right? So we're going to go thruster and then hitting that push-up motion during that burpee. It's probably going to be a little more painful. Additionally, you're probably not going to be able to sprint through quite as fast, looking at how long a burpee takes compared to a pull-up. So in Fran, you might be able to out sprint the darkness, right? You might be able to get done with the workout before that darkness really catches up to you. Here, I think you might be living in it for a while. So just let us know how it goes. Make sure you tag us, Ice Physio, hashtag Ice Trained. Let's have some fun with the workout over the next couple of days. As far as upcoming courses, the thing I want to highlight this week, is that virtual ICE is open. So as you all know, our virtual mentorship, we only open it every quarter for a couple days, bring in a new group, add into the crew, and then launch, close those doors and launch for the next quarter. We are trying to hold that price steady. It's been 29 bucks a month forever. It's still 29 bucks a month. Yes, it's CEU eligible, but more importantly, it's a great way as you're going through ICE courses to be able to be in that group, hold you accountable. Every Tuesday we meet, going over case studies, new thoughts that aren't built into our courses. It's a way to deepen your knowledge and really make it more clinically implementable, if you will, by every week revisiting and expanding on some of our concepts. So if you want to jump in, go to Virtual Ice on the website. PTOnIce.com, as always, is where everything lives. 02:37 TRUSTING THE PROCESS Let's talk about trusting the process. So trust the process, absolutely, right? You should totally trust the process. But I wanna unpack a couple things around this conversation that aren't talked about enough. So number one, trust the process. Everyone speaks of this in the early stages. Okay, so kind of a classic conversation around this topic is, hey, when you're just getting started, you might not see gains right away, don't worry, trust the process, it'll show up in time. That's clearly very relevant. And certainly when you think about areas like fitness where we often talk about this, yes, you're not gonna stack on a ton of muscle in the first couple weeks of training. You've gotta trust the process and those gains do show up down the road. There are certain areas where that early phase This concept is the most important, but I'm going to argue today that in the world of business, it's really in the later phases where I think this concept becomes significantly more important. 05:29 LOSING CLARITY ON CAUSE & EFFECT So let me, let me build the argument. So early on in business. The connections are very, very clear, right? You don't need nearly as much trust that what you're doing is reaping a reward simply because cause and effect are much clearer early on. For example, If you're building a practice and you form a new relationship and you see an increase in customers, it's pretty obvious that those increased customers came from that relationship because you don't have a ton of relationships yet. And any increase in customers is really obvious because you don't have a ton of customers yet either. Additionally, it's really easy when you run an ad or something of that nature to see again that swell of business following that ad is quite noticeable and it's very clear where it came from. Following up with your customers is a lot easier. Number one, there aren't as many of them, so it's easier to dive in and figure out, hey, how did you wind up here? Where'd you come from? and there aren't as many people delivering your service. So you don't have to bring everyone together and try to kind of coagulate the data and see, hey, where's everybody coming from? The connections are simply clearer. There's not as much noise, little changes make very obvious results, and it's not as hard to collect or aggregate the data, because there aren't quite as many people delivering the service. Early on, you don't need as much trust. Five years down the road, it's much harder, right? It's much more challenging. You often find yourself saying things like, I have no idea where that person came from, right? There's so many more things going on. There's so much more noise that it's much, much harder to prove. Did this action result in a certain effect? Now we fight this valiantly, right? Everybody, and you should, is trying to track everything, right? Whether it's where a customer landed on your website, or if you're running an ad, you're putting a tag on there so you can see, hey, when that person came to the website, if we track them through to the commerce side, did they actually convert? You're doing your absolute best to track everything. But the larger you get, the more mature the organization, it becomes significantly more challenging to definitively prove that any individual action resulted in any significant outcome. There's simply too many variables. You don't know, did it come from word of mouth? You really can't track that all that well. There's so many things going on that it's tough to have that clarity that you had early on. The reality is growth results in necessarily losing some clarity on cause and effect. The more mature the business, the more true this is. So what's the answer? The answer is to very much embrace and trust the process. In the absence of proof, You're just gonna need to check the boxes of what's known to work. I would argue the earlier that you can do this, the earlier that you can stop wasting your time demanding proof of every single action that you did having a reward or a response, the more efficient you're gonna be and the faster you're gonna succeed. The earlier that you can say, I no longer need to see proof that this thing that I'm doing is reaping a reward, I'm just gonna do all of these things with absolutely ruthless consistency, and I'm going to trust that by doing so, the end result is going to be additional growth and more progress. The earlier you can trust the process, the more efficient and more successful you're gonna be. But there is a catch here. It's got to be a proven process. And this is what I want us to really think about this morning. 07:39 OUTRAGEOUS CLAIMS & TRUST Team, we are living in an era of outrageous claims, right? We are living in an area where A huge amount of people that can't do are claiming to be able to teach, right? They're claiming to be able to get you unbelievable outcomes, even though they themselves don't really have a track record of being able to do so. That is the era in which we live. Heavily marketed, thinly veiled, outrageous claims. That is really where we are. Because of that reality, you need to dig deeper. The passion behind this topic is coming from having seen so many people over the years come to me and say, here's where I'm at. And me thinking, dude, how did you fall for that? Like that person, there was no reason to believe that those claims were being backed up by any significant track record of proof. The person simply did not dig deep enough. And that's what I wanna say to you today. 12:50 SHOULD YOU TRUST THE PROCESS? Should you trust the process? Yes. after you have went through extensive lengths to prove that that process actually results in the real world, in the outcomes that you're seeking. This is across every domain. Clinically, if you're gonna choose a mentor, if you're gonna lock into somebody and say, I am going to treat the way that person treats, I'm gonna ask that person what the big rocks are, and darn it, I am gonna implement those in every patient that I see. If you're gonna do that, You better have spent a solid year around that person, watching them day in and day out succeed with patients. A wide variety of patients, a wide range of complexity of patients, until you get to a point where you're like, look, that person gets it done. Better than everybody else I've seen, almost regardless of who shows up in front of them, the methods that person's utilizing month after month after month after month consistently work. I buy it. That person can actually get it done. I am going to trust their process. In Con Ed, at ICE, I hope you never sign up for a certification until you've taken one of our courses and went back into the clinic and implemented and decided for yourself, do the tools that I learned in that weekend course or that online course when I went back in my clinic, was I demonstrably better? Was I more efficient? Was I having more fun? Did it actually work? Until we prove that to you, I don't want you to sign up for some long series of courses. I want you to test us, and I want you to go and see, does it actually work? That's the kind of level I want you digging in on everything. In business, you don't buy that someone can grow your business until you have talked to a bunch of people who aren't affiliated, who maybe have done some of their mentorship, but are not actively in their program, and you reach out in your private circle and say, hey, has anybody worked with so-and-so? I want to have some conversations. And you dive in and say, is it really as good as they say it is? Were the principles that they taught able to grow you? Anybody can put that on an Instagram ad. Did it actually work for you? Is your business three times bigger now than it was a year and a half ago like they said it would be? Dive deep and ask the hard questions. I love it when people reach out to me. And they're thinking about opening it onward, right? And they say, look, I want to talk to a couple other owners. I love it. They want to hear from the people. Did they actually deliver? I love when people who are getting coached up to become faculty at ICE, I hear them reaching out to other lead faculty. They're not offending division leaders by doing that. They're just going out and saying, hey, here's kind of what I'm being sold. Did it actually shake out like this? In looking for multiple sources. Business leaders, I hope you all are never offended by that. People are not second guessing you. Yeah, they are, but they're not disrespecting you. They're just doing the work. They're saying, look, I heard you, but now I'm gonna go see across multiple sources if what you're saying historically has added up. Are you actually able to get the job done? Have you proven that? Or are you just saying that because you want your business enterprise to grow? Do you have the goods? Team, in fitness, to me, with CrossFit, I had never heard of it before 2013, 14, but as I got into it, I looked around for proof. In the first thing I saw, in the second thing, in the third month, in the second year, is that everybody who just consistently did what was on the whiteboard and showed up five days a week had what I wanted, meaning tremendously well-rounded fitness. I was shocked by where they wound up. They had tremendous cardio engines. They were strong as all get-out. They had tremendous skills in gymnastics and mobility. The people who did the whiteboard, as written, five days a week, as hard as they could, and used that process, wound up exactly where I wanted to be. You can only watch that so many times until you're ready to say, okay, I believe it. I buy it and I'm all in. So yes, right, trust the process. And yes, put your head down and check the boxes. But after you've established certainty. Now I want to finish by saying here's why this is so critical. Here's why doing the legwork to prove to yourself to be fully committed that this person can actually get it done and that it should thus be transferable to your success. The reason it's so important is two things. Number one, once you do put your head down, and I am totally advocating for you to put your head down, right? Head down, stop looking for proof of every single thing, and just check the boxes with absolute rigor. I'm encouraging that. But once you do that, there aren't a lot of checkpoints. So once you've committed and you've said, I'm just gonna keep checking these boxes and I'm gonna trust the process, you're not really looking for proof, right? Because we've just established it gets harder and harder to gain any, so you've just simply gotta trust. The problem is if you're wrong, there aren't a lot of checkpoints to reveal to you that you're wrong. So you're gonna go a long ways down that trail. There is gonna be a tremendous investment until you realize, oh man, that system or that person or whatever didn't actually have the goods. I should have done more front-end homework. The second reason is because if you've done the work to truly prove it to yourself, if you've watched that clinician for a year and become absolutely certain their method works, if you've taken a couple courses and become absolutely certain that when you implement it, you're better for it, if you've done the work to be positive or as close to it as you can be, you're much less likely to quit. Once you put your head down and say, I'm just gonna check these boxes, I know what's gonna work, you are much more likely to go the distance to a point where you actually begin to reap very serious rewards because you won't be second guessing yourself because you've got certainty in your corner. But if you didn't do the work, you're gonna be saying much earlier than you should, am I sure this is the right path? And now you're gonna need proof and validation, which as we've just talked about, is hard to come by. So now you're gonna quit early, and if anything abbreviates success, it's early cessation of effort. Because there are a lot of checkboxes or checkpoints along the way to tell you whether or not you're on the right path, And because going the distance is so critical to success, you have to do the work to increase your certainty that that person's process or that system is gonna work for you. Do that work and then trust the process. Understand it's probably more important late in the game, at least in business, when things get cloudy and murky, than it is early on. I hope that spins the idea of trust the process, maybe a little bit different way in your brain, and certainly encourages you to go one step further on drilling down to be certain the process you're about to trust has actually proven merits historically. Have a wonderful Thursday, team. We'll see you next week. Enjoy that Gut Check Thursday workout. Cheers. 16:16 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. Dustin Jones // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses evidence based recommendations on shoe wear for older adults. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up, everybody? Welcome back to the PT on Ice Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app.physicaltherapy.com. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code IcePT1MO. When you sign up is that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:43 DUSTIN JONES Welcome folks to the PT on Ice daily show. My name is Dustin Jones and today is Wednesday where we're going to be talking about all things older adults in particular. shoe recommendations for the older adult population. Shoe wrecks, heel drop, doesn't matter, barefoot, minimal, conventional shoe, what the heck's the deal with the toe box, what in the world is a shoe last, we're gonna talk about all these things, what the evidence says, and then what we're kind of seeing out in the real world, right? Many of us are seeing in clinical practice or in the context of fitness. Before we get into the goods, just a few quick announcements. Our online MMOA Modern Management of the Older Adult courses are going to be striking up here within the next couple weeks. So Essential Foundations, that is our foundational online eight-week course, is going to be starting October 11th. And then our Advanced Concepts course is going to be starting on October 12th. That's just for folks that have taken Essential Foundations. We've got a bunch of live courses coming up through the fall across the country. The one that I really want to point your attention to is Falls Church, Virginia. That's going to be the weekend of October 7th. 02:51 SHOE RECOMMENDATIONS All right, shoe recs. This is a topic that I really enjoy digging into. I've got a decent amount of experience around shoes. I used to sell shoes right out the gate of PT school. I was working in outpatient PT clinic and then working in the first kind of barefoot style shoe store in the country. Two of his treads out of Shepherdstown, West Virginia, currently in Charlestown. And just had a lot of, made a lot of mistakes, learned a ton, met a lot of interesting folks that were in this space that were really challenging a lot of conceptions. around shoes and what is good for individuals. And I was very dogmatic at one point and I've kind of come to the middle a little bit in terms of what I perceive to be beneficial and the evidence is starting to show that as well. 03:55 THE OLDER ADULT FOOT So when we talk about recommending shoes for older adults, I think the first thing that we need to acknowledge is that the foot is different in an older adult than when you're younger, right? We see age-related changes typically in the older adult population that warrant us to really question the shoe that they're in, right? The reality with the footwear industry is that many of the shoe lasts, lasts being the shape of the foot where they basically create the shoe from. The shape of that shoe last largely mimics what you may see in a younger individual, not necessarily the common things that we will see in older adults. What do we see in older adults? Typically, you're going to see a larger circumference of their midfoot. larger circumference compared to when they were younger, you typically will see a lowering of that arch in many older adults. We often do see that the angle, the toe angles of that first and fifth toe typically do go in, which we're well aware of all the issues associated with that. And we see these changes yet 99% of the shoes out in the market are looking at a younger foot and creating the shoe around that as opposed to an older adult individual. So we need to acknowledge these changes because that is what's going to influence the current evidence-based recommendations. So what I'm going to go through is kind of what the current evidence says, the most recent systematic review looking at shoe recommendations for older adults, and then I want to dive into the whole minimal barefoot shoe versus conventional shoe debate, particularly for this population. So what do we know to be true in terms of some key characteristics of shoes that are gonna be helpful for older adults. One, and probably the biggest issue, is that it fits. I know it sounds super simple and silly, but if you check the fit of many of your patient's shoes or your client's shoes, you will see some very ill-fitting shoes. Whether it is the shoe is too big, there's a lot of wiggle room, their foot is moving a lot within that shoe, or it's the opposite, right? The shoe is way, way too tight for that individual, and that creates a whole host of issues related to skin breakdown related to performance breakdown as well. And so we want to be very aware that it fits well, all right? So that's the first thing. Next thing is that it has fixation. A shoelace system, for example, we could say Velcro as well, but laces are typically better, is that if that shoe is properly fit and it's fixated to that foot, that is going to allow them to do what they need to do when they need to do it, all right? The second thing, third thing is going to be a firm supportive heel counter. So I've got a shoe here. If you're listening on the podcast, you can come to YouTube or Instagram to see the video. So this is just a Reebok Nano. I can't remember the model of this one, but back here, you know, is a pretty solid heel counter. So it's this back portion of the shoe. And so you want this to be firm and supportive. and snug when people put this on so you don't want a ton of room around the heel with this heel counter you want to be nice and snug and that's why trying shoes on is super super important. Next thing is around a 10 millimeter heel drop and this is where some of y'all are going to say no Dustin it needs to be just a zero drop shoe Current evidence shows that 10 millimeters around that range that older adults do really well there. If you start to go above that, particularly above 15 millimeters, you see an objective change in their balance performance through different outcome measures and their postural stability as well. If you're not familiar with heel drop, it's the difference of the thickness of the heel to the forefoot. This information can be hard to find on most websites when you go to look up shoe specs. That's why you want to look up the reviews of that shoe. Typically, a running world, there's a bunch of running related sites that will do all kinds of shoe reviews and they will give you some of those specific specs. When we worked at Two Rivers Treads, we would literally get a demo product and then we would cut the shoe right down the middle and we would measure the heel drop because a lot of those numbers weren't being published. We found some really interesting things. What the trend in the heel drop realm You know, 20 years ago, it was very, very common to see heel drops north of 10. You know, you'd be going, you know, 14, 17, 18 range in a lot of running shoes in particular. And over the past 20 years, particularly the past 10 years, that that average has gone down and down and down to where it's pretty normal to see a four to five millimeter drop from the heel to the front. That was not the case 20 years ago. So that has changed tremendously in the footwear industry. So around 10, excuse me, around a 10 millimeter heel drop. Next is a firm midfoot. So when we're looking at kind of the sole that it is relatively firm, you will typically see firmness in the midfoot and the forefoot is going to, excuse me. All right now, the forefoot is going to be a little more flexible. That allows for, you know, terminal stance, that we have a lot of extension, big toe extension is a big one, but that midfoot, a kind of firm, medium thickness is a good thing for older adults. In terms of the traction, a slip resistant sole that's multi-directional and tread. There's not a lot of evidence to support, you know, super thick, aggressive tread like you would see in something like a trail shoe. but some tread that is going to allow them that slip resistance in several directions, not just anterior to posterior. The next thing that you are going to want to look at is the beveled heel and then a rocker angle. All right. So this is really important for older adults that you typically want to see around a 10 degree beveled heel. So towards the back of the shoe, when we're going towards the very back of the heel, there's kind of that upward curvature. So it's not completely flat, but there's a little upward tilt around 10 degrees is really great. This allows or decreases the amount of them kind of catching their heel, especially during that swing phase. On the other side of the shoe, the front of the shoe, we have our rocker angle. You also hear this referred to as a toe spring. Now, not the fact that there is a spring in the toe or the front of the shoe, it just references that upward slope that you will see towards the front of the shoe. around a 10 to 15 degree rocker angle or toe spring is really good for older adults. The reason being is that when you're going into that terminal stance, you need a good bit of big toe extension, right? Some more ankle dorsiflexion as well. Usually you need about 45 to 65 degrees of big toe extension. And if you don't have that or it is painful, then having that upward slope basically gives you some artificial big toe extension. It can be really helpful with walking, but particular activities that require a lot of big toe extension, think going uphill, think lunging or getting to and from the ground, that rocker angle is priceless. And then last but certainly not least, we want an anatomically shaped toe box and this has changed dramatically over the past 20 years as well that we typically saw the shoe last kind of curve inwards and now you're starting to see that wider toe box to where the widest part of the shoe is almost towards the very end of the shoe or the front of the shoe. Now don't mistake a wide toe box to be a loose fitting shoe, because you will have a little bit of room to wiggle your toes in a properly fitted toe box. But if you have good fixation, particularly around the waist or the middle of the shoe, it is not a problem to have some wiggle room in the toe box. So we're talking length, but we're also talking width as well. so that is really important so when you look at all these characteristics hopefully you're starting to say oh my gosh that's a lot to think about this is why it is so so important for two things one to have a good relationship with A local, particularly running stores are usually the best around town. If you have an awesome local running shop to where you can send your folks, they have a solid fit system and they have some solid recommendations that can meet some of these characteristics. you're going to refer your folks and they're going to be in good hands, right? But it's also important to encourage folks to not just go to Amazon, to not just go and buy the shoe online, but you need to try this on. These characteristics, but then also that shoe feeling comfortable is very, very important. All right, so those are kind of the current recommendations. That is based on a systematic review that was released in 2019. I'll drop the citation for that in particularly the Instagram post. I'll do that there. 12:39 MINIMALIST SHOES: PROS & CONS All right, now let's shift gears a little bit and let's talk about the whole minimal shoe, barefoot shoe versus conventional shoe debate. Once again, I will say I was so dogmatic about this. I was the guy that ran half of a marathon without any shoes whatsoever. And the first half I wore Vivo barefoot because we were running on gravel, right? Like I was that guy. I drank the Kool-Aid hard, um, and then learn some valuable lessons along the way. And I've changed my stance a little bit. I'd say a lot actually on this, but let's talk about some of the pros and cons of particularly older adults wearing a barefoot style shoe. The first one is, there is evidence that a barefoot style shoe, when I say a barefoot style shoe, some of the key characteristics, typically it is a zero drop shoe. What I'm holding now is a Merrell Vapor Glove. I've bought three pairs a year of these things ever since they came out back in the day. I love these shoes. So it's typically a zero drop, a very flexible sole. So if you're not watching the video, I can roll it up like so. and it typically has a wide toe box. So the widest part of the shoe is going to be towards the front. That's kind of the typical characteristics of kind of a minimal barefoot style shoe. It also has a very low stack height in terms of how high it is off of the ground. So there are a couple studies, particularly with older adults, looking at how that's influenced some different parameters. And what they found is that when they wear a barefoot style shoe compared to a conventional style shoe, is that it does improve their postural sway. How does it do this, right? So think about the somatosensory input. You get a lot more input from that system whenever there's less stuff between your foot and the ground. You also have a lower center of mass, which can be very helpful for balance. And also, without that heel slope or heel drop, it doesn't shift your center of mass anteriorly. And so based on a couple studies, postural sway was improved significantly compared to conventional shoes when wearing those minimal shoes. So less sway, less postural deviation when folks were in static and dynamic situations. 15:07 CHANGES IN WALKING GAIT The next thing is that when folks put on that barefoot style shoe, they adapt their walking gait, running gait as well, right? Like we'll have the endurance crew talk about that all day, but I'm mainly talking about older adults in particular with walking. Their ambulation parameters will typically change. What we typically see is that we see a shortened stride length, we see an increased cadence with their walking, and the big one is that they have a decreased stance time. So they're moving their feet a little bit quicker and their stance time is a little bit shorter. Now, this is really important because let's think of if you have some type of external perturbation, you lose your balance. You try that ankle strategy, that hip strategy, it ain't working. You got to do that step strategy. When you're taking short strides, you have that increased cadence. When you have a relatively lower stance time, you are much more agile and adaptive to be able to take whatever stepping strategy you want to take. That is a big one, so that is a big reason why these barefoot style shoes can be helpful for older adults. What are the cons to wearing these with these individuals? One is that there's hardly any rocker angle. If you look at the video, there's a slight upslope for these shoes, but if you wear Xero shoes, Vivo barefoots, for example, you don't see any upslope or rocker angle towards the toe. and very little support in that area. And if you have limited big toe extension, if you don't have at least 45 degrees, for example, terminal stance of your gait is gonna be pretty tough, especially if you're symptomatic at in-range big toe extension. So these rocker angles can be helpful for individuals, especially if they're on uneven terrain, going uphill, limited big toe extension, they want that rocker angle. It's helpful for them, get them in one, all right? Though also the cons are the zero drop for many individuals, that life requires some ankle dorsiflexion to navigate the world, especially if you are going uphill, stairs as well. If you don't have hardly any ankle dorsiflexion, zero drop shoes are very difficult and what ends up happening is you end up shortening your stride even more. increasing your cadence even more, and ambulation can become less efficient. What that also does, especially when you're going uphill, if you're wearing a zero-drop shoe and you have limited ankle dorsiflexion, when you're going uphill, you max out your dorsiflexion, you don't have anywhere to go, so you start to see different deviations, and you also start to see a lot of pressure on the forefoot and the ball of the foot. If you have skin breakdown issues, neuropathy for example, this could have a whole host of complications. So there's some drawbacks to having a zero drop shoe for particular individuals and we need to be very aware of that. Now with all that being said, I, this is me, Dustin, anecdotally speaking, I am definitely for most individuals to be in some type of minimal barefoot style shoe. I think by and large, for many of the things that we do throughout our lives, it's a really good thing, but there's a lot of times where you want a solid shoe, right? You want some stuff between your foot and the ground. You want some help with that big toe extension. You want some help with that ankle dorsiflexion. So when I'm thinking about recommending barefoot style shoes to older adults, I'm thinking about three main things. And this is kind of a checklist that I want you to think about. 18:28 PROTECTIVE SENSATION One, and maybe the most important one, and this is probably one of the bigger mistakes that I've made in this realm, is that they need to have protective sensation. They need to have protective sensation. You need to get your monofilament out, your Seams 1C monofilament out. Check that protective sensation because if they do not have that, I highly recommend not recommending a barefoot style shoe because you will have lots of bumps, lots of bruises, stepping on gravel, you can create some trauma, if you will, and if they don't have that protective sensation, they may not be aware, and most individuals are not regularly checking the bottom of their foot to see if they're having any issues. I learned this one the hard way. I was treating someone that had type 2 diabetes and recommended, at the time, Altra, A-L-T-R-A, made a lot of barefoot style shoes, and I recommend the Altra Atom. You can look that up. It's one of my favorite shoes and basically gave this person a foot ulcer from some of the trauma that they received over several, several days. So learn from that mistake. Number two, you want at least 45 degrees of big toe extension. That's kind of the minimum for most individuals through ambulation, particularly through that terminal stance. So 45 degrees of big toe extension and also kind of symptom-free big toe extension. A lot of folks will have painful in-range big toe extension. So you need to be aware of that. If they don't have that, then you want a shoe that has some bit of a rocker angle. And I'm not saying you go to some like maximal style shoe, but even a relatively, I wouldn't call it nano, a minimal shoe, but the stack height isn't anything crazy. The heel drops three to four millimeters from the back to the front. And it has somewhat of a rocker angle. Something like that could be helpful for individuals and not putting too much between their foot and the ground. And then last but not least, their ankle dorsiflexion. At least 10 degrees of ankle dorsiflexion. That's kind of the minimum that we're looking through throughout gait. They need more than that when they're navigating uphill, when they're trying to do squatting, for example. But that's kind of the minimum. And I'd be very clear of when they want to wear these. When they're doing activities that don't require a lot of dorsiflexion or big toe extension, rock those barefoot shoes. But if you know you're going to be getting to and from the ground a bunch, if you're going to be guarding and kneeling, if you're going to be doing a bunch of squatting and lunging, then you probably want a solid heel drop. You probably want a nice rocker angle to support some of those deficits. So, I know that's a lot. I'm going to drop all these studies that I'm referencing in the comments of the Instagram post, but I think we need to be clear that we have evidence-based recommendations for older adults. I went through them at the beginning of this. I would say they're rather somewhat outdated, especially as the evidence is starting to evolve of looking at some of these different styles of shoes. But we're starting to see some early evidence supporting a minimal or barefoot style shoe in older adults. But we can't just do a blanket recommendation. Everybody gets Vivo barefoot. Everybody gets Xero shoes. That's not the case. We need to have that checklist, protective sensation, 45 degrees of big toe extension, 10 degrees of ankle dorsiflexion, and you're probably going to put someone in a good position. All right. Thank y'all. Y'all have a lovely Wednesday. I'll talk to you soon. 21:41 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. 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The podcast discusses the complexities of frozen shoulder and challenges in its treatment, debunking outdated myths. They emphasize the importance of early intervention and introduce a clinical practice guideline. Different approaches to treating frozen shoulder are explored, debunking the myth of intense manipulation. The podcast advocates for a patient-centered, pain-focused treatment strategy.