#PTonICE Podcast

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett Addresses the fear of exercising during pregnancy and how it can hinder the care provided to pregnant individuals. Christina shares that she has received messages from pregnant individuals expressing their concerns and uncertainties about exercising while pregnant. The fear of exercise causing harm is often the primary concern that arises when someone discovers they are pregnant. Christina emphasizes that this fear is not supported by scientific literature and believes that removing this barrier can lead to a significant shift in the way pregnant individuals are cared for. She argues that the medical system has contributed to this fear and stress the importance of reframing the conversation around exercise during pregnancy. Instead of focusing on the potential harm, Christina suggests highlighting the health-promoting aspects of exercise and removing any obstacles that may prevent pregnant individuals from engaging in physical activity. Christina also points out that society does not have a movement problem, but rather a lack of movement problem, which is often observed during pregnancy. She highlights that the fear of harm is one of the factors contributing to the decrease in exercise during pregnancy. Overall, Christina emphasizes the need to address and alleviate the fear of exercise during pregnancy in order to improve the care provided to pregnant individuals. By reframing the conversation and focusing on the health benefits of exercise, pregnant individuals can be empowered to continue exercising during pregnancy and set up for success. 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 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor, Jane. If you don't know about Jane, Jane is an all in one practice management software with features like online booking, scheduling, documentation, and a PCI compliant payment solution. The time that you spend with your patients and clients is very valuable and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms, that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app.com. Use the code icePT1MO at sign up to receive a one month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on Ice daily show. 01:26 CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the faculty within our pelvic health division. If you did not see, we had an absolutely packed house in Arizona for our two-day live course, and we have a couple of live courses coming up through the end of the year. Importantly, we're taking the move up to Canada and we are trying to see if we can take some of these courses up there. So I am going to be in Ontario this next weekend, the 31st first or 30th first. in Hamilton, Ontario, which is close to Toronto. And then in December, I'm going to be in Halifax, Nova Scotia, in the east side of the country. So if you are a Canadian who keeps saying, why aren't we bringing these ice courses up to the north into Canada, we are trying to do that. So I hope that I will see some of you in our Canadian courses towards the end of this year and this weekend. Okay, so this is kind of a little bit of a punchy topic where, and I've been thinking about this a lot. 02:40  ETHICAL RESISTANCE TRAINING RESTRICTIONS So to give context, so today we're going to be talking about, is it ethical to put resistance training restrictions on women that are pregnant? Where this comes from, so we are in this space of exercise, and to this day, very commonly, there is a restriction that can sometimes be placed on people that are pregnant that tell you that you should not lift more than 25 to 30 pounds during your pregnancy. And if you have seen me in the geriatric division, We've done a lot of pushback against putting restrictions on the amount of absolute load that is on an individual because of these preconceived notions that individuals of a certain age are not capable. I've had conversations before where people think that the two divisions that I'm a part of, the geriatric and the pelvic health division, are very different, but they both have one key concept that are kind of overlapping with them. that is under dosage of an under prescription of exercise. And so my PhD in geriatrics looked at high load resistance training for at risk older adults. I have since shifted some of my research into the pelvic health space looking at high load resistance training during pregnancy And that is where this conversation came up. So the motivation behind this episode was a conversation that I had with Margie Davenport, who I'm doing some postdoctoral research with, where we were talking about a systematic review that we are working on with Jess Gingrich, who's part of our pelvic team, on resistance training during pregnancy. And so part of the things that we are reporting on are things like what was the frequency, intensity, time, and type. exercise prescription principles for these randomized control trials or these exercise studies that were done in individuals who are pregnant. And I've talked about how understanding the context where these prescriptions come from, saying don't lift more than 20 or 25 pounds, have come from the fact that we do not have research in this area over a certain prescription, hence some of the cross-sectional data that we're doing, hence some of the follow-up studies that we are doing. So that's where this came from. But the reframe that really came into my mind over the last little bit was when Margie said, is it ethical to put restrictions on pregnant people for lifting? And so let's talk about that. So when it comes to these restrictions or when it comes to our recommendations, they come from the foundation of do no harm, right? no harm. We are trying to make sure that we are keeping our pregnant people safe and we are making our recommendations and they tend to be more conservative because this is a very protected time in a pregnant person's life. And so because we don't have any research in pregnant people, we say don't do it. But when it comes to the research, where we have to go is looking outside of the research, blending it with what we know in our current patient population, and then take the wants and desires of the person that is in front of us. We know that strength is protective at every single point in our life. We know that being stronger makes you more resilient. We know that it prevents chronic disease. that it keeps you with higher amounts of quality of life for longer. It helps protect you and give you reserve if you are sick. There are so many reasons why strength is protective. And it has been shown across almost every single patient population at every age. It is shown that strength is protective. When we have our pregnant population, we use these restrictions because we don't have anything above. But when we come down to the foundation of strength is protective, And we think about the lens of these restrictions, don't lift more than 25 pounds. We have to ask the question, are we going by do no harm? Because it's not that we have evidence that going above 25 pounds is harmful. It's that we don't have evidence at all. And so when we don't have evidence at all, we have to take a look at other areas or other amounts of the lifespan of the woman. And we have to think about, are there any harms that we can think of that are specific to pregnant physiology? And then kind of blend these two things together. 08:16 RESISTANCE TRAINING DURING PREGNANCY And from a pregnant physiology perspective, the theoretical constructs that are driving some of these recommendations are things like the change to fetal heart rate and placental blood flow as a consequence of lifting heavy weight, and the shunting of blood away from the uterus that happens when we resistance train towards the working muscle. And we don't have any evidence from our acute studies that have looked at hemodynamics in the cardiovascular response to resistance training at a variety of loads to show that there is any adverse event that happens to mom or baby hemodynamically that would insinuate that there is some type of harm to fetal inflows and outflows as a consequence of resistance training. When we look at high load resistance training across the lifespan, we also have to think of what happens if we start to make women afraid of resistance training. What happens when we say don't lift more than 25 pounds or don't lift this heavy weight because you're going to prolapse or don't lift this heavy weight because it's going to cause incontinence. We don't have to just think about this snapshot in time where we're trying to maybe circumvent some leakage. We have to think what is the internal dialogue that starts to happen in that woman's life that is going to impact her at 65. where we think that we shouldn't be that resilient or we shouldn't be doing that much resistance training, we shouldn't put that muscle on us anymore because we are going to cause pelvic floor issues or we are going to harm our baby. What does that internal dialogue do to exercise selection in the postpartum period, in the midlife period, in the perimenopausal period, in the older adult period? Is me saying that you shouldn't be resistance training going to impact what I'm working with older adults down the line? and this may seem like a bit of a stretch but when we don't have evidence around fetal hemodynamics we don't have any case reports that have shown that an individual who's lifting heavy weight goes into a hypertensive emergency or that there's any type of pre-eclampsia that happens acutely or that after going to the gym an individual has had a fetal death which would be a case report that would come out in the literature as a special kind of This is something that happened that we should keep our eyes on that's how we start developing levels of evidence to start investigating different phenomena Because we don't have any of those things This reframe I think can be super important of Not what is the what is the harm of resistance training? it's how are we setting our moms back if they don't resistance train during their pregnancies? And you know I've talked to moms who've been placed on activity restriction or bed rest and they say like I had a complication that caused me to have to be in bed and let me tell you being weaker going into that postpartum period was painful for me. It was a lot harder for me. It was not something that I would wish on anyone to have to feel so weak and vulnerable in a time where you already feel weak and vulnerable. So instead of saying what is the risk of us doing resistance training during pregnancy, It's what is the risk if we decondition our moms to be and have them, are we setting them up for success in the postpartum period by purposefully deconditioning them? And you may think that that is a strong statement of purposely deconditioning, but when you are making a recommendation that they are not allowed to lift their toddler up or that it is somehow dangerous to do that, We don't want to acknowledge that while we are removing a stimulus, that we are actually promoting deconditioning. We are promoting deconditioning of the musculoskeletal system. And when we look at return to exercise postpartum and we look at persistent issues in the postpartum period, for example, diastasis recti, we know that those with diastasis recti are weaker across their abdominal musculature than those that aren't. We know that one of the biggest issues to returning to exercise is pelvic floor dysfunction, but it is also lower extremity musculoskeletal pain where our body has not had that type of stimulus or impact. It hasn't remained as strong as it was before pregnancy. And now when we're trying to return to activity. we're having lower extremity pain. 12:22 MOM WRIST & MOM KNEE Why do we have so much mom wrist and mom knee, which we now have evidence are not actually physiological changes that occur within a female's body that are a consequence of the hormones of pregnancy. We see a weakness issue that comes into pregnancy, a certain amount of deconditioning that is expected as a consequence of pregnancy, but we do not promote, uh, blunting of some of that deconditioning by promoting resilience and resistance training. And so I feel like there is a paradigm shift that is happening, and it starts with reframing our questions. Instead of saying, what is the harm of resistance training? If we flip that and say, what is the risk of deconditioning a pregnant person? that changes the game. It changes the way that we frame exercise and what we consider to be bad. We don't have evidence at any levels of intensity in any modality of fitness that high intensity resistance training or aerobic training is bad for a developing fetus. or for a pregnant person. And in fact, it is creating a cardiovascular training effect to strengthen the fetal cardiac system when individuals are participating in aerobic training. And so how do we set moms up for success? Instead of saying, what is the fear? of exercising because that's the first … I literally had somebody message me yesterday saying, I'm four weeks pregnant and now I'm so scared. I have all these questions. I do all this strength training. I do all of this aerobic training and I don't know what I'm allowed to do. We have created that system where you get a positive pregnancy test and the first thing that you question and the first thing that you start to be fearful of is, is the exercise that I am currently doing going to cause harm? Our medical system has created that, and we need to work tirelessly to remove it, and instead say, what are the health-promoting factors, including exercise, that I enjoy, that I want to do, that I want to continue in order for me to feel strong, for me to feel healthy, for me to feel happy, for me to have strong mental health and resiliency, and that is going to trickle into the health of my baby. If we take that reframe, if we say instead of what is the things that are going to cause harm, it's how do we remove barriers to exercise, especially when we look at our society and we do not have a movement problem. We have a lack of movement problem. And dip in exercise occurs during pregnancy. And there is a lot of things that can contribute to that. But one of the things is fear that the exercise that they love to do, that they self-select to do is somehow harmful. And if we can remove that barrier, we are going to shift the way we take care of our pregnant people. And we are going to start to see our pregnant people be able to do all of these wonderful things without the fear that is unfounded in the literature of doing harm. All right, my rant for a Monday. I hope you all start to think about this. I have actually really been thinking about the do no harm piece of exercise and if it is founded and how to change the way that we frame exercise prescription. for our pregnant individuals. So I hope you found this helpful. If you have any thoughts around this, I would love to hear it. I'm definitely gonna be thinking about the way that I'm framing this up and seeing if there's any challenges that I can think of in my mind that would counter some of these arguments. So I would love to have these conversations with you all. If you wanna see some of the research coming out on exercise and pregnancy, I encourage you to sign up for our pelvic newsletter. It goes out every two weeks. We just had a letter go out last week. where any new research that's coming out, we try and stay on top of it. And this is where some of these podcasts come from. So if not, I hope to see you on the road. If you are Canadian, I hope to see you at one of our courses in Ontario or Nova Scotia. Otherwise, have a really wonderful beginning of your week, everyone, and we will talk to you all soon. 16:55 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. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko stresses the need to maximize preparation and recovery for a successful competition. He emphasizes the importance of preparing for the week before the competition, the competition day itself, and even the week after the competition. Joe encourages individuals to focus on their game plan, proper nutrition (including carbs, protein, and electrolytes), fluids, and electrolytes. Additionally, He highlights the importance of keeping the body moving between events to avoid stiffness and stagnation. The ability to warm up, maintain a good heart rate, and perform at a fast 100% effort is crucial for success. On the day of the competition, Joe advises sticking to one's game plan and not letting others dictate it. He mentions that CrossFit is about being able to adapt on the fly, but it's important to trust one's strategy and see where it takes them. Joe also emphasizes the importance of nutrition during competition day, stating that eating is necessary and what one eats matters. He provides the example of an elite athlete who consumed multiple Snickers bars for fast carb and glucose intake to replenish muscles, but notes that this strategy may not be applicable to everyone. After the competition, Joe discusses the importance of the follow-up week. He suggests focusing on recovery during this time and allowing the nervous system to recover and do what it needs to do. He highlights the significance of giving oneself time to recover, as it is an important part of the overall competition process. Overall, the episode emphasizes the importance of preparation, execution, and recovery in the context of a competition. It highlights the need to have a game plan, trust one's strategy, focus on proper nutrition, and prioritize recovery to maximize success. 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. 01:26 JOE HANISKO Good morning, everybody. It's PT on Ice, daily show live. It's Friday, I would say September 22nd, getting close to October already. It is Fitness Athlete Friday. I'm Joe Hanisko. I'll be your host today. One of the lead faculty of the clinical management of the Fitness Athlete crew. Today we want to chat about competition. So CrossFit competition prep 101. Just the basics. We get either personally ourselves or some of our clients who are signing up for local or online competitions and we want to make sure that we're preparing them and that they understand what their expectations are for getting into that competition. the week before, the actual date of, and then even that week after, like making sure they maximize their preparation and their recovery for a successful event, especially when really all that we typically have to see in comparison is these elite athletes who are going to be doing things similarly, but also different because of the amount of training they've put in and just the fortitude that they've built up in terms of an athlete and the resilience that they've earned in an athlete. We'll talk about that CrossFit Competition Prep 101. Before we get going, I want to make a couple of call outs to the CMFA Live agenda that's coming up for the rest of the year. Both of our Essentials and Advanced Concepts course took off online in the last week or so. So those are going to be going through until the end of the year and we'll get those going again at the beginning of 2024. But in terms of live courses, we have a handful coming up in the next few months to close out the year. So if you're looking to get into any Con Ed courses, we are going to be in California. Washington, Alabama, the state of Texas, down in Florida, New Orleans, and Colorado, all before Christmas. So from now until Christmas, we have six or seven CMFA Live courses that will be out there. So grab a seat if you're looking for that. Hop on to theptnis.com and you can find all of our courses there. All right, CrossFit Competition Prep 101. 03:45 PREPPING FOR COMPETITION WEEK  Let's talk about the week of. So you're going into this weekend of competition. What do we do that week before? I would say that at this point, We're not talking about the prior weeks and months of training. That's a whole other conversation. But at this point, whatever you've done to earn your right to sign up for this competition, you've done it, you've earned it. You can't really gain a whole lot more in one week of training, but you can lose a lot in that one week. So we want to make sure that we take that week leading into competition pretty seriously. If we're assuming maybe competition day is on Saturday, which is most common for a lot of local events, I would say that those first two to three days of that week, Monday, Tuesday, Wednesday, per se, I would focus on training as normal. Keep things consistent. If you guys have specialized programming through your gym and or you're using some sort of online platform like Mayhem, Days one, two, and three can stay pretty consistent. We don't have to change a whole lot about that. It allows us to stay moving, feel good, test some things out, and it's not until day four and day five that we really start to maybe change some things there. Day four, I would say, is a great opportunity to just take a complete rest day, figure out how the body is feeling, let things calm down. Maybe we focus on just a nice walk outside, maybe we do some mobility work and some soft tissue work to kind of prep the body but I'm cool with day four-ish in that time frame being a complete rest day if that works out into your calendar. It gives us time for the body recover for the nervous system to recover and then it gets us to day five the day before competition. I would suggest that the day before competition you don't do absolute rest. I think it's kind of nice to low level prime the body for movement especially when you're about to do something at a pretty high intensity the following day. So this could be super easy, like moderate EMOM style work, where you're doing a lot of body weight or simple movements. This could be just a zone two kind of monostructural day where we hop on the erg, sorry about that light there, hop on the erg, get some of our heart rate into that zone two level and just do a nice 20, 30, 40 minute cruise control type of workout. But I like the idea of the day before competition, moving the body and taking that rest day, maybe a day or two before competition. opposed to resting right up until that point there. So in terms of our basic agenda, days 1, 2, and 3, you can stay pretty consistent. Day 4-ish, probably 3 or 4-ish, we're going to take a complete rest day and let the body completely recover, maybe focus on soft tissue mobility. And then day 5, we want something smooth and easy, get the body feeling good. If you have any you know problem areas we're doing a little bit of accessory work to tune those up but we're not hitting a hardcore CrossFit style event the day before that competition. A couple other things that I would maybe not do in that week before is I would not go above 75 80 percent of your maximum volume in terms of load so if your programming calls for deadlifts, squats, whatever it might be, some heavy loaded exercise, no matter what, keep that in that moderate, upper moderate range there. I feel like being in that 60, 65, 70, maybe 75% range at the most gives you an opportunity to load those tissues, feel like you're getting something out of it, but also not blasting the nervous system. Our nervous system is probably one of the most undervalued parts of our recovery because it's hard to sometimes assess until you go and perform. But when the nervous system is down, our actual performance will be down as well too. And typically what drops the nervous system is high volume training and high loaded training because we only have so much of the tank to give before we need to recover. So I would avoid hitting heavy, heavy weightlifting the week of. Keep those 75-ish percent or lower. That being said, too, another thing I've seen a lot and had a lot of education on is if your event calls for some sort of weightlifting complex, like a hang snatch to overhead squat to hang snatch complex, I'm just making something up, don't go out and test that thing at max capacity over and over and over again. One of the biggest flaws that I see with our novice CrossFit athletes is that it's something new. It's like, oh, I haven't done this exact complex. I don't know exactly what it's going to feel like. Well, go and test it at that 50%, 60%, 70% maybe. but I see so many people the week or two prior doing it three or four times and what they're doing is depleting their nervous system and when it matters on that Saturday when competition is there, you may in fact lose some by having tested that so often before. So I would, I'm not saying don't trial it to see what it feels like, but I'm saying you should have a good understanding now with all the training you've done before to earn your right to be in that competition, roughly what your capabilities are, and then testing that complex at lower to moderate weights will give you a little bit of an insight to where you think you can be, but you are not going to get stronger by practicing that over and over again in a week or two before that event. So get familiar, but don't blast yourself with those complexes. Yeah, and then the other thing I was gonna say is just don't, in terms of testing, going a little farther, don't test all those workouts that you're about to do at max capacity multiple times either. I'm on board for learning, for strategizing with team, if you have a team event, I think that is great, but do those several weeks in advance. Don't go and blast your body the week of testing an event that you're probably gonna do because that's where we'll see decreased performance and potentially injury risk that will increase when we're doing that stuff there so recap of the week of the week of you're going to train as usual for the most part days one two and three Day three and or four, we're going to take a rest day and let that body completely recover. Just focus on mobility, recovery style stuff. Day five, we want to move a little bit. Lightweights, bodyweight style exercises, throw that into an EMOM format. Get yourself on a ERG machine and do some zone two monostructural work. We want to avoid max effort loads throughout the week to keep our nervous system healthy. We don't want to test everything over and over again. Save yourself for Saturday. You will not lose by not training, but you can lose by overtraining in that week before. All right, so now you're in the day of. Day of competition. This looks a little bit different to everybody, but a few little pointers that I have, some of them will be obvious, but just reminders, is that just stick to your game plan. Hopefully you've thought your process through and trust it. You know yourself as an athlete, your team hopefully has connected, or your training partners, and you know each other fairly well. Don't let other people dictate your plan. Stick to your plan. CrossFit's all about being able to adapt on the fly, which you will have to do sometimes, but don't go in constantly thinking that you have to change your strategy. Trust your strategy and see where things take you. 10:37 NUTRITION ON COMPETITION DAY  In terms of nutrition during competition day, I feel like we need to be eating. I think that's an obvious thing to say, but what we eat matters. We see people, Matt Frazier was a good example, who would just slam multiple Snickers bars in a day of competition because he was looking for fast carb glucose intake to replenish those muscles. It's actually not a terrible strategy, but we're not Matt Fraser either. There's got to be probably some moderation to that. I do believe having easily digestible carbohydrates, which may include some sugar and that's fine. A couple little gummy worms here or there, some fruit, maybe some of those protein bars or energy bars that have some carb in it, built in it. things that taste good and that are easy for you to digest are probably best. We need carbs to replenish our muscular glycogen system and just our overall metabolic system. I think getting some protein in is fair, but we don't need to heavily douse protein. We don't need to be eating like multiple burgers that will sluggishly kind of slow you down. So lean proteins, beef jerky, a little bit of pulled chicken, something like that can be a fairly easy type of protein to digest. And then I would say a third thing being fluids and electrolytes. So this is where getting salt waters of some kind, like a element for an example, or your own homemade version of that, getting that electrolyte balance into our body is crucial. You're going to be pumping fluids out, And you can get really scientific with this and weigh yourself before and after an event like some of these higher level athletes do. But I don't think that we have to be at that level. But do replenish your fluids. Be drinking water. Get some sort of electrolyte back into that system. And I think these are going to be two really crucial things in terms of adjusting fluids that are important there. Some of these sports drinks, just read the back. Get smart with these guys. Like read the back of some of these labels and you'll realize that you could make yourself a way better balanced electrolyte style drink than the marketed ones that have virtually nothing inside of them. So get online. figure out how you could dose in some table salt with some other electrolytes and just make something that is gonna help you retain fluids, especially if you're doing this in a hot, humid environment where you know you're gonna be sweating a lot. And then I think the other thing in between events is don't just sit and do absolutely nothing. Take some time, five, 10, 15, 20 minutes at the most to recover and chill, but as you're leading up into that hour before your next event, try to move. walk around, hop on a bike if they have one. This is where I will actually, in some circumstances, support things, simple things like massage guns. There is some anecdotal and potentially actual structural evidence that would say that the vibration and impulse is a good way to just kind of prep that nervous system and keep those tissues a little bit more aware of what they're about to be doing. I'm game for it. Whatever you gotta do to stay agile and feeling like you're at your best is what we need to be focusing on there. So day of, stick to your game plan, proper nutrition, including carbs and protein predominantly, and then electrolytes is big as well, fluids and electrolytes, and then find some way to keep that body moving in between events that you're not stiff, stagnant, going in. The ability to warm up, keep your heart rate at a good level, and then hit a fast 100% effort event is crucial to success. We don't wanna be going in cold. Even if you're feeling a little tired, you gotta find a way to keep that heart rate moving. 14:17 TAKING REST AFTER COMPETITION All right, final thing is our final prep, I should say follow-up week, the week after your event. So you've done your week before, you've completed your event, congratulations. Sunday, Monday, Tuesday, leading into the next week, what do we do? Be okay, I'm gonna say this again, be okay taking more than one day of rest. I have an event coming up this weekend that has for sure three main events that all are at least 18 to 20 plus minutes in domain plus five like mini events. And then if you are lucky and fortunate enough to earn your right into the championship event, that would be four main events. So four main events plus five mini events. I don't train for that. Nope, not many novice athletes do. Elite athletes, yes, they are prepping with four to six hours of training on average per day in a week. We don't do that. Not many of us are doing that. So if we are going to go out and sell our soul in this event on a weekend, be okay taking Sunday, Monday, and maybe Tuesday and doing little to no major physical activity. It doesn't mean you have to be a couch potato. Maybe you are again going for hikes, walks, little bike rides, whatever it might be. Find some enjoyable sport that you like, like golf to get out and just stay active. I'm not asking you to be lazy, but I'm asking you to respect the amount of volume that goes into some of these CrossFit events. I see a lot of people who go and smash it on Saturday and then are at the gym on Sunday working out or Monday doing a, you know, high level, uh, online programming that is consisting of two plus hours of training. to each their own at the end of the day, but it's okay, I'm giving you permission to let your body recover. At the end of the day, for me, I'm reminding myself that this is not about today and tomorrow, this is about 20, 30, and 40 years from now. I am building my fitness to be a better, older adult. So be okay taking some time off. Use the next week to just sort of assess the body. Did anything tweak? Are you sore? Are you stiff? Focus on those areas. This is where getting your clients maybe back into your clinic that following week and just prepare for that. Say, hey Johnny, I know you got an event coming up on Saturday. Why don't we make sure that we have a day to meet on that following week just so we can talk about how it went and be sure that we're doing some good recovery things and I can help you better game plan that following week as well if I can see you early on that week. So take time to assess the body. And I would suggest again, similar to the week before, keeping loads in that 75, 80% or lower before we get back on track with your normal training. Just allow again that nervous system to recover and do what it needs to do, so. Hopefully that was helpful, guys. Again, either for yourself or for clients that you're having, but I love the fact that people are dedicating themselves to fitness and that they're willing to put their body, their soul, their personalities, their mentalities, their identities on the line and go sell it on a weekend or online competition. We are training for a purpose. We have short-term goals. We can go test those out. We have long-term goals. All this is leading to that direction. So preparing yourself for that competition is really important. Executing on the day of is really important and making sure you give yourself time to recover afterwards is also important. Hopefully it's helpful. If you have any questions, comment on the videos. Otherwise, take a look online and see if you have any interest in getting into our CMFA live courses coming up across the country. They are filling up. So let's get on those and enjoy the end of our year together. I will talk to you later. Have a great weekend. 17:46 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall delves into various lease terms, including flat rate leases, triple net leases, and percentage-based leases. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ALAN FREDENDALL Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day is off to a great start. Thanks for being here today on Thursdays. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as the Chief Operating Officer here at ICE and a lead faculty over in our fitness athlete division. Today, Thursdays, Leadership Thursdays, we talk all things business management, clinic, and practice leadership. Thursdays means it's Gut Check Thursday, so let's talk about this week's workout. We have a little couplet of power cleans and push jerks with a low to moderate weight barbell and some running. So we have 20, 15, 10, 5 power cleans at 95-65 and push jerks at 95-65. After each round you're going to run 200 meters. 20 power cleans, 20 push jerks, go for a run, 15-15 run, so on and so forth. When I sent this to our CEO, Jeff Moore, last night, he said, wow, that seems like a heavy, high-volume barbell workout. And I don't agree at all. This should feel about a 10-minute workout as usual on Gut Check Thursdays. You should be able to pick a weight on that barbell where you can really cycle big sets of power cleans. Maybe for some of you, even hang on to all of the power cleans and go right into your push jerks and really get a high intensity stimulus out of that workout and hit some quick 200 meter runs in between. So goal time, 10 minutes, scale to do big sets on that barbell. I love workouts like this because they're really easy to modify. This is the type of workout that I'll probably give to a patient in the clinic, right? If we can ditch the barbell entirely, we can do some dumbbell cleans and jerks, we can do some kettlebell swings and some landmine press, we can run, row, bike in between. It's a workout where you can take kind of the stimulus and manipulate it a number of different ways to achieve the same result based on the equipment you have and what your patient or athlete can do in front of you. So have fun with Gut Check Thursday. Course is coming your way. I want to highlight our pregnancy and postpartum division as we're rebranding to Ice Pelvic Health. So we have one live course and one online course with a second online course launching in 2024, a level two course, an advanced course. So you can catch that Level 1 course. The next chance to catch that will be January 9th. And then that Level 2 course, which will require the Level 1 course as a prereq, will be launching in 2024. And then some live courses are coming your way between now and the end of the year. This weekend, this weekend coming up, Alexis and Rachel will be down in Scottsdale, Arizona. The weekend, next weekend, September 30th and October 1st, Christina will be up in Hamilton, Ontario, up in Canada. The weekend of October 14th and 15th, Alexis will be in Milwaukee, Wisconsin at Onward  Milwaukee. Out in Bozeman, the weekend of November 4th and 5th, again, Alexis. The weekend of November 18th and 19th, again, Alexis will be on the road, this time in Bear, Delaware. That'll be out at CrossFit Bear. That's actually ICE faculty member Lindsey Huey's gym. And then your last chance to catch the ICE public live course this year will be the weekend of December 2nd and 3rd. Again, I'm in Canada with Christina. That'll be in Halifax, Nova Scotia. So check out that course. Our goal with that course, bringing on the second online course, is to have a three-course series that results in a certification and management of the pregnant and postpartum athletes. So that's what's coming your way from the Ice Pelvic Division. 04:31 IMPORTANCE OF LEASE NEGOTIATION Today on Leadership Thursday, we're going to talk about negotiating your lease. And maybe for some of you, this is a thought you have in your mind as maybe you're thinking about beginning your practice of what does it look like cost-wise, what does it look like in practical application to buy or rent a space such as a clinic space where you can set up your practice. And maybe for some of you who are working for somebody else, or maybe already working for yourself, and you are maybe going through lease renegotiation, you're thinking about moving locations, of what are the essentials to look for in a good lease, what are the different options available to set up a lease, and what are some things that we look out for. So let's talk first about what and why this is so important. Of all the expenses that a business can have, your lease or your mortgage, the money you pay for your physical space, is going to be one of your highest expenses, but it's also probably the one that is the only one of all your fixed expenses that actually has room for manipulation. When we think about paying for internet or paying for maybe a fax service or something. Those are fixed costs, but they're unlikely to budge, right? You can't really call up the cable company. You can't call up Comcast and say, Hey, you know what? I think I paid too much for this. I'd like to pay half as much, right? They're just, they're going to hang up on you, right? They'll probably talk to you about bundling or try to give you a 5% discount for six more months or something, but you're really not going to be able to move the needle on that expense. Likewise, payroll, paying our folks is another big expense that's fixed. And that's also not an area where we can really budge the needle on expenses. If you don't believe me, go ask the folks that work for you if they would work for you for half as much money. Again, you're probably going to be met with maybe some laughter or maybe anger if they think you're serious. but that's an expense that we're unlikely to be able to significantly manipulate. It's very different with something like a lease. Based on the current commercial market for commercial real estate, based on even zip code, it may only be a five minute trip down the road to a new location, but based on zip code, based on a number of different factors, there tends to be more room here to hopefully reduce that expense a little bit. So I want to talk about ways to do that. and ways to set up your lease terms and maybe terms you have not even heard of yet. So let's start with there. Let's start our first point. Let's talk about what are the typical terms of a lease. So the most common, the one we're all probably very familiar with, even if you've never leased commercial real estate, you're familiar with this because you've probably done this with an apartment. It is a flat rate lease. This is paying X amount of dollars per month based on the lease terms. We're very familiar with renting apartments, maybe renting townhomes or condos of hey, it's $900 a month and it's a one year lease, right? And usually at the end of that lease, the price probably goes up a little bit and if you're still gonna live there, you renew that lease and you're kind of in that fixed rate lease cycle. 07:36 GRADUATED LEASES The next is really kind of unheard of and very uncommon and falls on you, the person looking for a space to really inquire about it as if it can be an option for you. And that's a graduated lease, where you're eventually going to arrive at a fixed price per month that does not change, but you're not going to start out there. So an example might be you pay $500 a month for the first three months of your lease, Maybe the second three months of your lease, you pay $750, and maybe the last six months of your lease are built up to maybe $1,000 a month, as a quick example. So we're slowly graduating to the full terms of that lease. Why is this helpful? Obviously, it's less money over the 12 months. That's the number one reason. The other way is this is really helpful when you're first beginning your business. When you first hand your shingle, you probably don't have a full clinical caseload, which means the revenue coming into your business is probably not where you would want it to be to maybe even pay the full amount of that fixed rate lease. So negotiating for a graduation of the understanding of, hey, I'm not making 100% of the revenue I believe I can make currently. Can we kind of step up to that amount over time? This is a great idea, a great model to pitch, especially if you're not renting your own building or space. If you're thinking about starting up a side hustle in the corner of a gym, and you're literally just getting a portable treatment table in the corner, you're not getting a lot for your money, so the idea of spending maybe $1,000 a month to have 20 square feet in a corner is less than ideal, especially when you're first starting, of hey, can we just see where this goes? Can we do $200 a month for the first three months? Can we do 400 for months four to six? can we do 600 months six through nine and then maybe months nine through 12 we're at 800 a month and then we can revisit at the end of the year what changing to a fixed rate amount might look like. So this gives you some breathing room that you don't have to rush out and think about stressing and worrying about maximizing your revenue from day one. It gives you that kind of room and time to go out and market your clinic and not just thinking about maybe I need to be working in home health or something to even pay for this lease and I don't actually even have time. to see patients at my own clinic because my lease is so high. So graduated lease is a really great option that's often not really thought about, not really offered, something you may have to ask about, but something that a lot of business owners, especially if you're subleasing a space, might be very open to because for most of those folks, that space is empty anyways and they'd rather have you paying more and more and more over time than paying nothing at all for that space. 11:01 TRIPLE NET LEASES The next type of lease is something that almost no one is familiar with unless you live in a really big city or you deal with really serious commercial real estate, and that's called a triple net lease. How a triple net lease works is you pay a little bit of money for the actual principal on your lease, but a lot of the cost of your monthly payment is a shared split of usually the insurance for the building, the maintenance costs for the building, and the taxes for the building. So this is very common in bigger cities where you have multiple businesses inside of the same building, where you have a shared entryway. When I think of a triple net lease, I think of the flagship Onward and Onward Charlotte, where there are, I think, 12 businesses in a three story building, a couple businesses per each floor. That is usually where you will see a triple net lease of the taxes, the insurance, the maintenance costs for that building, are all kind of added together and then divided among the number of leases inside of the property. So this can be a great way to get a cheaper lease, especially the bigger the building. Yes, more maintenance costs, more taxes, more insurance, but more people to spread the cost across. So overall, a pro to this approach is we tend to see cheaper rent and overall a cheaper lease payment because those costs are shared. Now there are some downsides here that we need to be aware of. If you're the first tenant in a brand new building, you have no one else to share your costs with, right? So asking if that does happen to be you and the lease is a triple net term of how does that work with the sharing of this cost? Am I expected to pay 100% of it because I'm the only business in this building currently? That's not ideal. Or is the landlord going to assume the majority of that as more and more businesses open up inside of the common building? The other concern there is that overall physical therapy is really low maintenance. When we look at actual property wear and tear, maintenance, that sort of thing, we don't tend to damage a lot of the buildings we're in. We might have some scuff marks on the door frame from maybe folks coming in and out with with walkers and wheelchairs and things like that. But you don't tend to see a lot of big property wear and tear in a physical therapy clinic, which means in a triple net lease, you could make the argument that we're probably paying more than we need to because we use such a small amount of the shared spaces, especially in something like the bathroom as well. physical therapy clinics are not nearly as business busy as a business like a gym or a restaurant where maybe hundreds of people per hour are coming and going and if they're using maybe shared bathroom spaces they're really causing the majority of the maintenance costs for that compared to your clinic. So just being aware of how many tenants are in the building and also what are their business types. Is there a lot of foot traffic? If so, that's going to jack up the overall maintenance cost of the building, which is then gonna be passed on to you as one of the tenants in the building. So be aware of those factors if you're thinking about a triple net lease or you're being offered a triple net lease. The last type of lease type available is something we should never do, which is a percentage-based lease. We should never do this, first of all, because it's illegal for us to do this as healthcare providers. Getting into a negotiation where you pay 10% of your monthly revenue as your lease, what that looks like, how that functions, is essentially kickbacks. We are not allowed to be involved in any sort of kickback system as healthcare providers. Does it happen? Yes, but part of being a business owner is managing risk and one of the biggest things you get in trouble for. is something like that. So knowing that you should not do this, this also just becomes weird of now if your rent is based on a percent of your revenue. First of all, the payment is different every month. It's not going to be exactly the same. It's going to fluctuate up and down. So that's always a little bit awkward. The other awkward part is now you have to sit down. You either have to give complete access to your landlord, to your financials so that they can look and say, I will be the one that calculates how much you owe me. Or you need to sit down monthly and give that information to your landlord. And that just doesn't feel good for one business owner to just be laying open how they do their operations and financials to another business owner. The issue with this, aside from it being illegal, why it's not good for business, is that in general, a physical therapy clinic can expect linear growth. As my caseload gets more full, I see more patients, my revenue increases. When I reach the point at which I have no more time, in my week to see patients, I hire another therapist. And the process just keeps repeating. Their caseload gets full, their revenue increases in a linear fashion, so on and so forth over time. That does not happen in other businesses. For example, with a gym, especially a gym that maybe has an unlimited membership model, they're going to reach the point at which they can have no more members, and there's no more way for them to increase their revenue at all. So as your Revenue at the clinic continues to increase as you hire a second, a third, a fourth, maybe a fifth therapist. Your revenue grows and grows and grows. In a percentage model, your rent is going up, up, up, up, up, up, up in a way that it starts to become unfair for you as the PT clinic owner to be expected to always pay 5%, 10%, 20% of your revenue of your monthly lease payment is going to increase linear alongside your revenue as a clinic. And it's going to become very quickly an out of control expense. So that's never something we want to get involved in. The last thing we never want to do is not a type of lease that is official is any sort of quid pro quo, any sort of this for that arrangement of if you treat me 10 times a month for physical therapy, you can rent the back room of my gym or my spin studio or my yoga studio or whatever. That's just not really good business for a number of reasons. First of all, we have, I would argue, a lot more to offer as physical therapists. At any given time, 87% of the American population has some sort of pain, which means When you give up time on your schedule in exchange for something, you can expect those times to be almost always booked, right? Imagine that same situation with a massage therapist. Hey, you can have this back room if you give me two massages a week. Guess who's never missing those two massages that week, right? The landlord, right? They're always gonna be using those in a manner where, again, very similar to a percentage lease, you're gonna find yourself having the feeling that you're giving more than you're getting. The other main reason to never do this is that if you trade lease payments or really any other sort of expense in exchange for physical therapy treatment or programming or something like that, that is now an expense you cannot show on your taxes. Part of being a business owner is yes, making money, but also being able to justify all the expenses related to running your business that you possibly can to reduce your tax liability so that you pay less taxes over time and overall the clinic has more profit. If you are exchanging your lease and it has a $2,000 value a year, you cannot write off that $24,000 as rent payments on your taxes to reduce the tax liability of the income that the clinic generates. And the more you do quid pro quo stuff, the less expenses you show, and to the government that looks like more revenue with less expenses, it looks like more profit, it looks like more taxable income. We never want to be in a situation where we're paying Anywhere close to the amount of taxes is actual profit that the clinic makes. It doesn't feel good to go to work and run a business and then pay almost all of your money in taxes at the end of the year and not have a lot left to show for it. So that's really why we want to avoid quid pro quo type arrangements, trading expenses in exchange for physical therapy treatment or other physical therapy services that you may offer at your clinic. So I hope this was helpful. We talked about different lease terms, about why leases are maybe the one area of running a business where we have a lot of room, wiggle room. to hopefully reduce the price, or at least keep the price as capped as we can. We talked about different types of lease terms, a typical flat rate lease, a graduated flat rate lease, a triple net lease, quid pro quo, and percentage based leases. So, I hope this was helpful. I hope you have a fantastic Thursday. Have fun with Gut Check Thursday. I'm literally getting ready to go next door and do it right now. If you're gonna be at a live course this weekend, I hope you have a fantastic time with our instructors. Have a great Thursday. Have a great weekend. Bye everybody. 18:37 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. Christina Prevett, Modern Management of the Older Adult division leader, discusses masters athletes as role models for positive aging. It explores the impact of psychosocial factors, relationships, and connectedness on healthy aging. The episode emphasizes the importance of physical function and highlights the positive physiological and psychosocial effects of being a master's athlete.

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses a mobilization technique specifically designed for patients with unilateral symptoms. These patients experience tightness primarily on one side of their body and often feel the need to be stretched out, especially in the morning. To address these issues, Zac introduces the concept of mobilization with movement. This technique involves actively moving the affected area while applying a mobilization force, with the goal of improving symptoms and increasing range of motion. Zac then demonstrates a mobilization technique using cups. He explains that the cups will be placed on the region of the patient's back that is most tight or painful. The patient is then instructed to keep the cups on for about a minute, allowing them to acclimate to the sensation. It is important to note that this mobilization technique may not be suitable for all cases of back pain. Back pain can manifest in various ways, and it is crucial to have the right patient in front of you for this technique to be effective. However, if the patient experiences improvement when they forward bend and their symptoms feel better during this movement, the mobilization with movement technique can be beneficial. Zac  suggests starting with easy active range of motion exercises and gradually adding more stimulus, such as overpressure or the use of weights. He highlights the versatility of this technique and mention that he frequently uses it in the clinic for patients with similar presentations. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine 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 INTRO Good morning PT on Ice Daily Show. Zac Morgan here. I'm a division lead with the spine division, so you can find me on the road teaching either the cervical spine management course or the lumbar spine management course alongside of Jordan Berry and now Brian Melrose. Speaking on that spine topic before we jump into this morning's Technique Tuesday, I wanted to just point out the next handful of courses that we have. So we actually have three different lumbar course offerings this weekend. So last minute you want to jump in, we'll be in Richmond, Virginia. Baton Rouge, Louisiana, and then Denver, Colorado. So if you're looking for a last second seat there for lumbar spine, jump into those. If none of those work, we have a few more offerings this year. So in October, the 21st and 22nd will be Frederick, Maryland. So right outside of the DC area there at Onward Frederick. Also have Fort Worth, Texas, the November 4th, 5th weekend, and then December 2nd and 3rd at Onward Charlotte. I have a lumbar course as well. Quickly, just pointing out the cervical ones, and then we'll jump into the content. Greenville, South Carolina, October 14th and 15th. Bridgewater, Massachusetts, that's November 11th and 12th. And then here in Hendersonville, December 2nd and 3rd. So those are the cervical and lumbar offerings left this year. But without further ado, let's kind of jump into the topic this morning. 01:21 TECHNIQUE TUESDAY So this morning I want to kind of bring back Technique Tuesday in the Spine Division. If you've been around forever, like myself, you remember those days way back in the day where Jeff was in his clinic there in Upper Michigan showing some different techniques each Tuesday morning. And those were always really fun to consume because it just gave you some new ideas and things to play with. in the clinic and this morning I wanted to cover a technique that doesn't live in our lumbar course but it is one that I find myself using from time to time. But before we actually jump in and do the technique I'd like to kind of describe who I would do this to because in particular this is a technique that you want to have the right patient selection for. If you've been to the lumbar course, you've heard the stories of derangement and dysfunction. If you're McKenzie trained, you may be really familiar with those terms as well. If you're not familiar, go back a few months to where I did a PT on ice kind of covering these topics about the lumbar spine needs to flex, and that'll kind of refresh you or jump in the live course if it's all completely blank to you. But essentially, technique selection for the right patient is huge here. So what we're looking for is the patient who does have their symptom onset when they flex forward or when they bend forward, they feel their symptoms, but the response to that flexion is the important part. So we're looking for that dysfunction patient or soft tissue extensibility dysfunction, however you like to think of that. McKenzie coined that term dysfunction and essentially the idea being that the soft tissues living on the backside of the spine are not extensible enough and then when the person bends forward and they reach the limit of that extensibility they receive their symptoms. So the real key in diagnosing this person is their response to the flexion. Because if you've been around for a while, if you've seen patients presenting with low back pain, you know that for some folks, when they move into their symptoms, they get tremendously worse. If that is your person in front of you, each time you have them flex, they feel worse, or they lose range of motion, or perhaps even peripheralize symptoms down their limb, that is not who you would do this technique to. Rather, the inverse should be true. So on your active range of motion exam, this patient's gonna come in, and they're gonna present with back pain, Sometimes they might have some leg symptoms, but more commonly back, buttock pain. And you're gonna have them bend forward, and when they bend forward, they'll say, oh Zach, that's my symptoms, I can feel it right there. And often if you observe their lumbar curve while they're forward bending, you'll notice this person does not have that nice reversal of the lumbar lordosis. As a matter of fact, they'll often hold their lumbar spine very rigid as they move forward. So their back will stay completely flat, and they'll just move into hip flexion. Now the key is that you have to have them do that multiple times. So if you have them go ahead and follow up with another rep, what you should see if the patient's a dysfunction patient would be definitely no worsening, but probably more often a bit of improvement. Whereas the derangement patient worsens every time they flex. This person feels a bit better each time you move them into the provocative motion. So for that, we want to treat that with repetitive flexion. So this person needs to restore their lumbar flexion and we're here to help them. So homework often is going to be simple flexion, like just get in a position, flex your back regularly. You can go with a typical McKenzie dosage of 10 reps an hour. You know here at ICE we make those decisions based off of that person's irritability, both psychological and physical. And so dosage is going to play a lot into their irritability. But one technique that I love for this patient is a mobilization with movement into lumbar flexion. Now we see this patient a ton at our clinic because this, you'll see this presentation show up quite a bit with weightlifters. So weightlifters will often have some sort of a flexion injury at some point and then they'll quit flexing their back. So they'll maintain neutral and often they'll even hyperextend a bit to maintain neutral in their back. But one thing's for sure, they will not allow their back to flex. And as with anything in the body, if you don't use it, you lose it. And so over time, this person develops a lot of stiffness and tightness in their back. They have a lot of complaints like that, and they have a really hard time forward bending. The odd part is the solution again is to forward bend. So in homework, I'm going to have them do that in life. Whether that looks like a cannonball position, repetitive standing flexion, it doesn't really matter so much. But one thing I love doing in the clinic is this mobilization with movement. So shout out to Brian Mulligan who kind of conceptualized mobilizations with movements, snags, nags, huge kind of founder in the manual therapy world and really responsible for kind of giving us some of these techniques. But this is one in particular that I find myself using quite a bit. And I actually have a really good patient here in front of you. So I'm gonna have Alexis step in. If you don't know Alexis, she's my wife, better half, and then also faculty in our pregnancy and postpartum course. So Alexis has this problem. She has a really hard time flexing her back. It's typically pretty bad here in the morning, so now is a pretty good time for us to be doing this. 06:06 MOBILIZATION WITH MOVEMENT But essentially what you want to do for this mobilization with movement, confirm it's on the right patient, then have them sit on a table. In general, I would probably bring up the table up a little bit, but this will work. It really doesn't matter if you have a massage table or a high-low. This one's super easy to do. The only item you need is a mobilization belt. and it doesn't really matter so much which one, but I kind of like this blue one for a couple reasons. It's cheap. Um, so this is the Mulligan belt and then it doesn't have that big leather piece that sort of gets in the way for this mobilization and it costs extra that you don't need. So what you're going to do is form a big loop with that mobilization band. So make sure it's in a big loop and it's going to go around you and the patient. So put it around your back first. And then you're going to reach around the patient, clip, make sure that buckle's not contacting them. And then the belt should live right at their ASIS. So you want that belt to be essentially where like the waist part of a seat belt would be on an airplane or in the car, right at the ASIS. Then I'm going to tighten that up to where I've, right now I've got way too much slack in the belt. So I'm going to put, this to where we now have it taut, so it is nice and firm. And essentially what I'm thinking about with the belt is fixing her pelvis to this table. So you can see it's at a little bit of a downward angle. not completely parallel. If I was completely parallel, I'd be pulling Alexis back towards me. I want this downward angle with the belt to kind of fix the pelvis down to the table. From here, the mobilization is super easy and simple. Sometimes I'll start out without even mobilizing, but just fix the pelvis and then have the patient move through some active range of motion and deflection. So what Alexis is doing is she's just reaching her fingertips towards her toe here, trying to allow this part of her low back to really relax. and just move forward. So typically this is how I would start someone out here. Rather than cranking on them immediately, I'll just allow them to access whatever flexion they feel comfortable with and just move forward. And you know at ICE we like to pump. So we're usually going pressure on, pressure off. We're hitting that in range position and then coming out. Let's say 10 or so reps have gone by and she's continuing to improve each time we do this. She likes the feeling of the stretch. That's where I'm going to add my pressure or my mobilization force. Now I've seen this technique taught segmentally specific where you find the exact segment that you feel is reproducing the patient's symptoms and drive on that. But I'll be honest with you all. I'm typically not the guy that's in there with my thumbs on a specific segment. Rather, I use my whole hand to give nice broad force. If the problem's in their thoracolumbar junction, my hands are typically right here around the bottom of the ribcage, pushing forward. But, go ahead and come on up. If the problem's a little bit lower in the lumbar spine, my hands are just gonna live a little bit lower. So I'm not putting any segmental pressure here. What I am doing is just essentially pushing into flexion in the region of the back that I feel is provoking the symptoms. So don't overthink your mobilization force. Just very gently add pressure all the way to in range and then come off. Super, super simple. I find just as much success being very regional as I do being very segmentally specific. So don't overthink this one. This is just repetitive motions with overpressure. Very nice way to loosen up the lumbar spine. typically this patient loves it. 10:08 LOOSENING UP THE LUMBAR SPINE Now a couple little nuances here with this technique before we finish up. Sometimes you're going to have a patient who is more of a unilateral restriction. So they're going to mostly complain of right-sided back pain and it's going to be mostly tight on their right side but not so much on their left side. For that person, you want them to forward bend and reach to the left. You want all of these tissues to open up. So Alexis is now forward bending and grabbing her left ankle, and you can see that that would open up this side, and it gives you the really nice ability to just kind of push and open up kind of that QL, all of the lumbar extensors, everything sort of living on this side of the back. So for those more unilateral restrictions, come on out, She's liking that position, that's why she's hanging out there so long. For that unilateral presentation, sometimes I'll do this mobilization a bit unilaterally as well, but just some nuances that you can play with. 13:33 MOVEMENT WITH CUPPING The last piece that I wanted to show you all is just a way to increase the vigor a little bit, and kind of give the patient that perceived stretch, because often this person is gonna tell you, when they wake up in the morning, I feel really tight, and I feel like I need to be stretched out. And so we want to kind of match that feeling So for that I want to expose their back a little bit and I'm going to add some cupping. So what I'll do with cupping is I'll kind of take my cups, find the region that seems the most tight or painful to the patient, and then I'll fix these cups on them, have them hang out with the cups on. I'm not gonna do that on the video, but for a minute or so, just to sort of acclimate to having these on their back. And then after a minute or so goes by, they're gonna move through those same flexions with the cups on. So I'll show you real briefly just a couple of those. Always use a little cream when you're using cups. It's much friendlier. to your patient. But essentially what we're going to do is fix that cup on her back. That already gives her a bit of a sensation of stretch. These are over the lumbar extensors and they're in the region that's been provoking her symptoms, the region she feels the most tight. Now again, a minute or so would go by. We would make sure she felt relatively comfortable here. with the cups on before we moved, but let's say that minute has passed and I'm ready to go ahead and move through some more range of motion. The cups are still on. Now my belt is in the exact same position and Alexis is doing the very same thing. So she's just forward bending. I can even add some more pressure if I like, or I could slide these cups around and see if I could isolate the exact area that feels the most stiff. appreciate that this is definitely a higher vigor than where we started with. So you want that person to have lower irritability at this point. You want to have seen some good symptom response prior to progressing to this much vigor. But if you're seeing good success and you want to up the vigor here, cups are a really nice way to increase the stretch to that region. So in summary, No one technique is good for all back pain. Back pain presents a bunch of different ways, and you've got to have the right person in front of you if you expect it to work. So for this technique, if the person improves each time they forward bend, their symptoms feel a bit better when they move into them. you want to move into those symptoms with your treatment, and that's where this mobilization with movement is really helpful. You can start out really easy with just active range of motion. You can then add some overpressure. If you want even more stimulus, you could add some cups, or better yet, even have them hold a weight in front of them and have that weight drag them down. Lots of creative options here with this mobilization with movement, and just one that I find myself using quite a bit as we see an awful lot of folks who have this dysfunction presentation. Team, hope to see you on the road at some point. We are out and about a bunch throughout the rest of this year. Jump on ptonice.com and jump into any of the live courses that are in your area or ones that are on your list. Keep your eyes peeled for future announcements with ICE. Lots of cool things on the docket coming out here in October. So I will see you again here soon in a month. Until next time, hit that mobilization with movement. 14:29 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. Alexis Morgan // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan emphasizes emphasizes the significance of comprehending your own body and the process involved in utilizing the pelvic floor. Without this understanding, it can be challenging to educate and support others in this area. To better understand and utilize your pelvic floor, Alexis suggests a five-step process. The first step is to "tell" the actions of the pelvic floor, which involves becoming familiar with its location and functions. Alexis uses the analogy of an A-frame house to explain the contraction and relaxation of the pelvic floor. The second step is to "demo" the actions of the pelvic floor. This can be done through videos or using a pelvic model to visually demonstrate the movements. The purpose of this step is to help individuals visualize and better comprehend what was explained in the first step. The third step is to "practice" contracting and relaxing the pelvic floor. Alexis encourages listeners to pay attention to any sensations they feel when they contract their pelvic floor. During virtual sessions, she advises being mindful of any additional body movements that may occur during the contraction. The fourth step is to "ensure" that the individual is correctly performing the pelvic floor movements. This step involves confirming if the person felt the intended movements and if they understood the instructions. If there is any uncertainty or confusion, Alexis emphasizes the importance of not progressing to the next phases until both the individual and the instructor are confident in their understanding. Lastly, the fifth step is to "progress" in using the pelvic floor. Alexis mentions that this five-step process may not occur in one session and that it may take time before individuals can confidently progress. However, by understanding their own body and going through these steps, individuals can develop the knowledge and skills necessary to effectively assist others in utilizing their pelvic floor. Overall, the episode highlights the significance of understanding one's own body and the steps involved in using the pelvic floor in order to effectively educate and assist others in this area, as well as provide meaningful care virtually. 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 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor, Jane. If you don't know about Jane, Jane is an all in one practice management software with features like online booking, scheduling, documentation, and a PCI compliant payment solution. The time that you spend with your patients and clients is very valuable and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms, that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code IcePT1MO at sign up to receive a one month grace period on your new account. Thanks, everyone. Enjoy today's episode of the PT on Ice daily show. 01:26 ALEXIS MORGAN Good morning, PT on Ice daily show. My name is Dr. Alexis Morgan, and I am here today representing the pelvic division. Happy Monday. I hope you all had a wonderful weekend. Let's discuss a huge topic that is virtual care this morning. Virtual care is something that really grew a lot during COVID. and we all kind of had to pivot, right, and try to figure out, okay, how exactly is this done? One of the areas that I feel like is potentially the most surprising about doing virtual care in is pelvic floor health, pelvic floor assessment, pelvic floor physical therapy. A few weeks ago, I did a PT on ice, about the virtual care and the subjective exam. And did a whole entire podcast on that, did not have time to discuss the objective assessment. So today I'm hopping back on to discuss how we do the virtual objective assessment. If you missed last time's podcast, go ahead and rewind back about a month and look for that. that virtual subjective care, because that's gonna be important and of course it's gonna lay the foundation for this pelvic floor assessment in the objective category. So, let's go ahead and just dive right in to exactly what we teach and what we do for that objective exam. We talked last time, and we talk all the time in pelvic health, that we are educators, that we really teach people how their body works and we teach them the truth about their bodies when in fact they've read unfortunately online and in magazines and on YouTube and in various forms they've heard lies. They've heard myths and they've heard misconceptions. It's very confusing. It's a confusing area of our body. And we get the opportunity to be educators. Part of this objective exam, when we are virtual, is education. So here's how it goes. It's really a five-step process. Number one, tell. Number two, demo. Three, practice, four, ensure, and five is progress. So let's dive into each of those categories. 04:47 ACTIONS OF THE PELVIC FLOOR So with tell, number one, first you're gonna tell them the actions of the pelvic floor. You're gonna essentially get them oriented with where the pelvic floor is and what it does. You're teaching, you're telling. So you're gonna tell them the actions of the pelvic floor, right? So when it contracts, it goes up. We use the analogy attic, first floor, and basement of the A-frame house here at ICE. So tell them that. So when it squeezes, it goes up into the attic. When you're just chilling, you're hanging out at first floor. We're just at rest at that first floor. That's where life is. happens when we're just chilling. Then we go into the basement. And that basement is the downward movement towards the feet. The holes expand, they enlarge. That analogy is helpful for someone to understand, helpful for them to kind of visualize that. But generally, that analogy isn't quite enough. And because in this objective exam, you know you're not gonna get to give them direct feedback, direct visual or tactile feedback, you've gotta go that extra step. So step number two, so step one was tell. Step two is demo. So you're gonna demo with maybe a video or your pelvic model that you have. Help them visualize what it is that you just said with that analogy. So looking at the pelvic floor, when it squeezes, it goes up towards your head. When it relaxes or an effortful relaxation, it opens up and goes away from your body. That's demo. So they can actually see. So tell and demo these two work hand in hand together. Step number three is practice. So you're gonna ask the client, okay, I want you to practice that. Go ahead and contract your pelvic floor. Do you feel anything? When they are contracting, you're looking for on this virtual call, you're looking for any kind of extra little body movements that they may have. If they're holding their breath, if their entire musculoskeletal system rises, they're doing too much. They're putting way too much into that. And so you can cue them and have them, okay, can you, can you do a similar thing? Can you still raise your pelvic floor? But can you do it with your entire body? relaxed. Just move your pelvic floor, even if it's a little bit less of a muscular engagement practice. You also want to have them do the opposite. So you had them go into that attic. Now you want to have them go into that basement. If they had trouble going into the attic, we definitely want to just move on and go to the basement because maybe they'll feel that a little bit better. So we go into the basement and we say, okay, I want you to bear down. I want you to push towards your feet. I want you to open up those holes, whatever language they need, and you wait for them to feel that. So we're talking them through this practice, but that's not really all. We've got to go on to step number four, which is ensure. So, you've got to ensure that they're doing what you both think that they are doing, what you both want them to be doing. You've got to ensure. So you're gonna ask them some questions, like, okay, so we talked about how it contracts, it closes up, and it goes, your pelvic floor, when you squeeze, raises up, like towards your head. Did you feel any of that movement? Are you sure that you felt it go up? Can you feel the difference between up and down, between that attic and that basement? Can you feel a distinct difference? If they can, I'm still reading their answers, and if they're saying, yeah, yeah, I think I felt that, I'm not convinced with that. I'm not convinced with a little question mark sounding. Yeah, I think I felt that. What we want to hear is, yes. Yes, I felt it. It wasn't strong. I didn't feel much, but I definitely felt a difference in that direction. We want to hear that. Because from that, we can then progress them. Number five. progress them to teaching what the pelvic floor should be doing in their problematic movements. Whether that is double unders, squatting heavy, catching a clean, whatever that might be. We want to teach them what their pelvic floor should be doing. That's again beyond the scope of this of this podcast this morning and please come on to our courses where we can really dive into that. But realize that that five-step process does not always occur in one session. So tell, demo, practice, and ensure absolutely will go hand-in-hand together. But it might be a while before you can progress. because if that person who's like, I think so, I think I felt that, or maybe they're saying like, I didn't feel it at all. I really don't know what you're talking about, Alexis. I didn't feel that. If neither one of you are sure that they felt those movements, you can't go on. You can't go on to the next phases because they have no idea. This little area of their pelvis is like a black box. They can't feel it. They can't move it. How are we supposed to rehab it? We've got to give them homework. We've got to give them projects to work on to be able to feel that. Some examples that I use is I'll send them with a mirror. to look at their pelvic floor to see if they see that movement. Or they can use their finger. They can use a finger and insert it vaginally and feel those differences. They can feel that pelvic floor move. Just getting to the point where they can feel that mobility is a really big improvement and can get them to where they can feel that elevation and that depression of the pelvic floor. So a visual tool for them or maybe a tactile tool for them with their finger. That's kind of a double tactile cue, right? They can feel it with their finger. They can also feel it in their pelvic floor. You might go with just a third option, a single tactile cue. So rolling up a washcloth and sitting on top of that. or straddling over the top of a bouncy ball to be able to feel a little bit of the difference. One of my most commonly used ones for the single tactile is actually tell them to sit in a bathtub where it's super, super still and work on feeling those movements. 13:15 USING WATER AS A TACTILE CUE Because of the pressure of the water, and the stillness of the water, they can actually feel any slight movement, particularly if it's still and if it's quiet in there. So that's one of my favorite ways to send them home with Homework, to try to get to where they can feel that movement, they can actually engage their pelvic floor, and they can discern the difference between a contraction and that effortful relaxation, or the attic and the basement. You send them home, you repeat all of this on the next visit in about a week or 10 days. Give them that practice to do and follow up with them soon on this, and you're gonna go through that same thing. tell, demo, practice, ensure, see how their confidence is, and then potentially at that point, then we progress. Then we move on to their positions that challenge them or their movements that challenge them, and we educate accordingly. I hope that was helpful for you all to utilize in your own practice and realize that It is challenging to do this if you don't understand your own body and if you don't understand all of these steps. So if you're listening to me today and you're like, I don't really understand how to use my pelvic floor, then you go through these steps. And I guarantee you that when you flip to the other side and you're talking others through this, you being able to relate to them is really going to be able to help. and you can understand that client so much better. Thank you all so much for joining today. I hope this was helpful. I hope you all have a wonderful week. This weekend, I'm gonna be in Scottsdale, Arizona with a whole lot of you all. We are so excited to join you all for the two-day live course. We're gonna have a blast down in Arizona. We've got several upcoming courses. So be sure to take a look on ptonice.com and be sure to register for our newsletter. Everyone always asks us, how do I find out more information? How do I stay up to date on the research? How, how, how in this fitness forward pelvic health world that is ice pelvic, The way to do it is to register for the newsletter. It comes out every other week, every other Thursday, and we give you all the goods there. So be sure to sign up for that, it's absolutely free. And of course, come on over to our courses, our live courses, and we're rolling out our last online course of the year right now, and we're gonna start fresh in the new year. So we are really looking forward to seeing you all out on the road or online. Thanks for being here. 16:42 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. Megan Peach // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses the importance (or not!) of ground reaction force as it relates to running related injuries. Megan discusses research evaluating the association between ground reaction forces & running related injuries, noting that these forces do not seem to be directly linked to the onset of injuries. Furthermore, Megan shares that footwear that decreases ground reaction forces does not also seem to have an effect on the development of running related injuries. Megan cautions listeners to not worry too much about the manipulation of ground reaction forces in training or in rehab as the link to injury prediction seems to be poor. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 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. 01:26 MEGAN PEACH So what I want to talk about today is ground reaction force and how it relates to running related injuries. And we need to be a little bit cautious, I think, when we're talking about ground reaction force and how it relates to those injuries, because I think the popular opinion is that ground reaction force really is kind of the cause of running related injuries, or we need to address ground reaction forces when we're addressing running related injuries, or we need to reduce it And what the literature actually says is that it's not really the case. And so I'm going to give you a couple of examples from current literature that may tell a different story from popular opinion. So we'll start with a 2016 article. And this was actually a systematic review meta-analysis. So it pooled a lot of different studies. And what it looked at was the association of a ground reaction force with running-related injuries. What they found was that when they pooled all of the injuries together, loading metrics, so loading variables like ground reaction force or loading rate, were not necessarily related to running-related injuries when all of the injuries were pooled together. It was a bit of a different story when they individually looked at separate injuries. where they took out patellofemoral pain, they took out bone source injuries, they took out Achilles tendinopathy, for example. And what they found was that the vertical loading rate was associated with subjects or was related to the injury in subjects with tibial stress fractures. And so different outcomes there when we pool the running related injuries versus when we look at them individually. Another more recent study, so 2020 now. looked at about 125 injured runners, and they compared these runners to healthy controls. And what they found in this study was, contrary to the previous study, was that when they assessed the whole entire group of injured runners as a whole, so all of the injured running injuries together, what they found was that the impact variables, so vertical loading rate, ground reaction force. They were associated with running-related injuries when all of the subjects were pooled together. Different results when then they separated out the running injuries and looked at them individually. 03:59 IMPACT VARIABLES And so when they took groups of running-related injuries, groups of patellofemoral pain, groups of IT band syndrome, groups of Achilles tendinopathy, et cetera, what they found was that some injuries were associated with impact variables and some were not. And so the injuries associated with impact variables were our patellofemoral pain, our plantar fasciitis, And the injuries that were not associated with impact variables were tibial bone stress injuries, Achilles tendinopathy, and iliotibial band syndrome. So when we take a step back out of that space and think about our injured runner on the treadmill looking at their gait mechanics, when we have a injured runner with patellofemoral pain or plantar fasciitis, and they're on the treadmill, what we would expect to see in terms of faulty gait mechanics are faulty gait mechanics in the sagittal plane. So looking at that runner from the side, very typically or commonly we'll see clinical patterns of an overstride, we'll see a lack of knee flexion at initial contact, and we'll see an increased angle of inclination, so increased dorsiflexion at all at initial contact. in the runners with patella femoral pain and plantar fasciitis. So very common, not always. And it's not like that clinical pattern can't be seen in other injuries as well. It's just very common in those two injuries. And that makes a lot of sense because that clinical pattern is very much associated with increased ground reaction forces as well. So it would make sense that within this study, when we separate out all of the injuries and pull them as separate injuries and look at them, that those two specific injuries would be related to ground reaction force. When we also look at the other injuries, so IT band syndrome and Achilles tendinopathy, and we get those runners on the treadmill, we see different clinical patterns. So more likely in those runners, are we going to see movement faults from a different angle? We're likely to see um, faulty movement in more of the frontal plane and, and maybe kind of surrogate transverse plane movement faults as well. So we would likely see, um, increased femoral adduction, maybe internal rotation of the lower extremity, uh, potentially this crossover sign or a narrow, um, foot to center a mass, maybe over pronation. Those are very, very common mechanical faults that we might see with, um, your IT band syndrome and your Achilles tendinopathies. And so when we think about those movement patterns, those are much more associated with range of motion deficits. Maybe they have too much, maybe they have too little. Neuromotor control of that range of motion, maybe strength deficits in that frontal plane, but much less associated with the impact variables like ground reaction force and loading rate. So it makes sense from this study that those specific injuries, the IT band syndrome and the Achilles tendinopathy from like a clinical standpoint would be less related to ground reaction force than the other already previously mentioned injuries. So then when we take tibial bone stress injuries and we look at that, it's kind of in a group all of its own because when we look at bone stress injuries, and I'm talking more specifically to tibial because we just don't have enough information on the other common bone stress injuries like metatarsal or femoral. Most of the research right now is on tibial bone stress injuries in terms of biomechanics. And so when we consider a tibial bone stress injury and whether or not it's related to ground reaction forces. We have to look at the forces on that bone. And so ground reaction force is just one component of the force, the total force on that bone. And it's the external load. When we look at the internal load, it comes from muscles. And so when we're talking about the tibia specifically, we're generally talking about the soleus because it's directly attached to that tibia. And when the soleus contracts, it imparts this internal load directly onto that bone. So it's considered an internal load. When we look at the differences between the external load and the internal load, the external load during running activity or the ground reaction force is generally about two and a half to three times body weight of that runner. But when we look at the internal load, it's upwards of eight times body weight for that specific runner compared to the two and a half times for external load. So you can see how the internal load in a tibial bone stress injury is going to play a much greater role in the development of that bone stress injury than the actual external load coming from that ground reaction force. So again, the results from this study suggest that ground reaction force doesn't really play a big role in, um, tibial bone stress injuries. And that is consistent with the rest of the literature as well. Um, there was a systematic review about a decade ago, looking at ground reaction forces in, um, bone stress injuries, tibial and metatarsal and their conclusions were, um, supportive of this result as well, where they found that ground reaction force is really not related to the development of, um, bone stress injuries in runners, as well as more recent literature has basically corroborated that and their results are very, very similar. Now, a more recent study, so one published just last year actually, looked at 800 runners Um, now that's, that's insane for our running study that those are huge, huge numbers. And so initially I was thinking, okay, this was a survey study. Like they sent out a survey to a bunch of runners and they got it back and they figured out some results from the study, but no. they actually got 800 runners and put them on a treadmill, did their motion capture, and then evaluated it all for ground reaction force and biomechanics. And so that's a tremendous amount of work, a tremendous amount of data, and really interesting results as well. And so really, the big purpose of this more recent study was to look at um, risk factors, uh, for running related injuries in two different shot conditions. And so one shoe was a, uh, like a hard cushions shoe and one shoe was a softer cushion shoe. And so they're looking at the differences in risk factors between those two different shoes and, um, interesting results. So while they did find, uh, different risk factors based on the different shoe condition, what they didn't find was any of the loading variables, so there were numerous in this study, but the big ones are ground reaction force and loading rates. And they did not find any association with the loading variables and in either of the shoe conditions and risk for injury. So basically, what they're saying here is that regardless of the type of shoe that that runner is wearing, or those 800 runners are wearing, 10:41 GROUND REACTION FORCE & RUNNING RELATED INJURIES Ground reaction force did not play a role in the development of that injury, which is super, super interesting because I think often we associate different shoes with different ground reaction forces as well, but that's not necessarily the case. And that's not what the literature is telling us. And so. all of this literature combined. And certainly this is not all the literature. It's not all encompassing. And these are, these are just four different studies. Um, so take that with a grain of salt, but I think there's, there's this popular belief out there that, um, ground reaction force is very closely related to the development of bone stress or not, sorry, not bone stress, but running related injuries, regardless of the type of running related injury. And I think we can look at studies two different ways. And so In one way, we can look at the study as a whole and take all of the running-related injuries and pool them together, and then look at the results from there. But those results tend to be very, very different from when we separate out running-related injuries and say, okay, what do the patellofemoral pain injuries look like, and what are the mechanics for Achilles tendinopathy, and how are they different from IT band syndrome? And when we do that, we actually get very different results, not only for the biomechanics, but for the ground reaction force as well. And so, you know, contrary to popular belief, I don't think impact variables like ground reaction force are a very good predictor for running related injury, nor may they be. And again, this is different per injury. So they may be something to address in injuries that are definitely related to ground reaction forces like patellofemoral pain, plantar fasciitis, plantar fasciosis. But ground reaction force may not be the best thing to try to address with other types of injuries like bone stress injuries or Achilles tendinopathy or IT band syndrome. And I think the main goal here is just to get the point across that it's not the only metric, and quite often we don't actually have access to that information anyways in a clinical setting. It's more in a lab based setting, but we need to look at that whole runner. So we need to not only address if we are addressing ground reaction force, but address the range of motion, address other running biomechanics, address the strength, address the neuromotor control, so that we can basically address that runner as a whole. Okay, that's all I have for you today. I hope that was helpful. I hope you have a wonderful Friday and a wonderful weekend. Don't forget, if you want to sign up for Rehab of the Injured Runner online, our last cohort of 2023, make sure you get in there. Go ahead and sign up today. All right, have a good one. Until next time. 14:39 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com   In today’s episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the concept of excessive humility and being overly open-minded, discussing how it can hinder individuals from taking action and being useful. While acknowledging the importance and benefits of open-mindedness in considering different perspectives and possibilities, Jeff also points out that excessive open-mindedness can render one unable to take stances or make decisions, rendering it useless. Jeff emphasizes the need to strike a balance between open-mindedness and the ability to take a stance. He cautions against being so open-minded that one loses their ability to make decisions and take action. Excessive open-mindedness, according to Jeff, can lead to a lack of direction and clarity, making it difficult to make progress or contribute effectively. Similarly, Jeff addresses the issue of excessive humility, particularly in relation to feeling inadequate to take action due to a lack of knowledge. While it is important to acknowledge and respect the limits of one’s knowledge, Jeff argues that excessive humility can be detrimental. Constantly waiting for more information or certainty before taking action, they assert, can result in paralysis by analysis and prevent individuals from being useful in their professional careers. Jeff encourages individuals to have a level of humility that allows them to act even in the presence of uncertainty. Jeff highlights the importance of being willing to make choices and decisions, even if they may not always be perfect. By embracing the imperfection of action and remaining focused, individuals can gather data and fill the gaps in their knowledge. This approach allows for continuous improvement and growth while avoiding the pitfall of doing nothing. 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 back to the PT on Ice Daily Show. I am Dr. Jeff Moore, currently serving as a CEO of Ice, and always thrilled to be here on Leadership Thursday. I cannot wait to jump into this topic about choice and the need to make one. Before we do, it’s Gut Check Thursday. Let’s not ignore the workout. Let’s talk about it. Let’s take it on head on. It’s a doozy. We’ve got five rounds for time, okay? We’ve got 12 handstand pushups, nine toes-to-bar in six squat cleans. Okay, it’s gonna be at 155, 105, so a little bit heavier than we usually encounter our cleans in Gut Check Thursday, but the volume’s a little bit lower there on that set. Five rounds of that for time, bang that out, you’re probably gonna have some rest on the handstand push-ups and the heavier squat cleans. Try to keep moving steady, make sure you tag Ice Physio, hashtag Ice Train, we love tracking those videos. Get it in, it’s Thursday, get the work done. All right, upcoming courses, I want to highlight CMFA Live this week. We’ve got Newark, California coming up. I think there’s only two spots left in that course. That’s with Zach Long and crew. It’s going to be September 30th, October 1st, so in a couple of weeks over in California. We’ve got Linwood, Washington coming up October 7th, 8th, and then down in Hoover, Alabama, November 4th, 5th. So if you want to get out on the road, learn all things barbell movements, get into some basic gymnastics, talk about programming, demystify a lot of things around resistance training. That is the course you need to be in. It is, of course, part of our CMFA certification, which includes Essential Foundations, Advanced Concepts, also known as Level 1 and Level 2 on the fitness athlete side. And, of course, during that live course, you get testing in person if you want to obtain that certification. So hit that up. PTonICE.com is where all that good stuff lives. 02:16 YOU HAVE TO CHOOSE Let’s talk about the topic. You have to choose. Team, it has always driven me nuts. From the very, very first entrance into my professional career, this comment or idea of more research is needed has always driven me crazy. Now, I don’t mean from the actual research side. Like, I get the idea of why that statement is made, at the end of papers, like, hey, to get to a certain level of statistical significance or confidence, we have to have more data, right? Totally understand where that comes from in the research world. But the ridiculous incorporation or discussion of that into patient care has always blown my mind, right? So you see so many folks saying that, we don’t know, we don’t know, we don’t know, as though we can’t do anything. This is absurd from a patient care perspective. Like, I always imagine these people, like, are you really sitting in front of your 8 a.m. and saying, hey Lynn, I know your shoulder’s really bugging you. Problem is, the jury’s still a little bit out on the best rehab for this until we know, we’re gonna pause here, I’m gonna have you come back. Like, are you really doing this all day, every day, every 30 minutes with a new patient? Of course not, it’s absurd. To be of any use, we must decide and act in the presence of uncertainty. This is true literally everywhere in our lives. It is obviously true in patient care, right? We’ve got to do something for Lynn, right? We know it’s not gonna be perfect, but we’ve gotta act with the knowledge we have and do our best. We have got to decide and act in the presence of uncertainty. And this goes so far beyond patient care. This is true in every aspect of our professional journeys and lives. We’ve gotta be willing to say, we’ve gotta be willing to choose to say, From what I’ve learned and experienced thus far, I currently believe X. I don’t care what domain you’re talking about. I don’t care if you’re talking about business, sports, hobbies, patient care, nothing moves forward with waiting. I was thinking about this last weekend. So for those of you who haven’t followed my recent journey, I’m getting into enduro motorcycling, right? So I’m signing up for some races next year and I’m terrible at it. So this weekend I’m up in the mountains and I’m flying down this trail, moderately out of control per usual, and having to choose lines in real time, right? So you’re coming up on obstacles, going relatively fast, thinking I’ve got to do something in real time in this moment. I have to choose. Now, knowing full well in that moment that if I was to go back to that same trail two years from now, I have no doubt that I would choose a different and by different I mean better line because I’ll be better at the activity. But that does not mean right now I don’t have to choose. I just have to choose, thinking with the experience that I have, what is the best way to move forward, knowing full well it isn’t going to be perfect. In a couple years when I come back, I’ll choose something different. This is the process. Just because you know down the road, you will know more and do better, doesn’t mean right now you do nothing. not in patient care, not in business, not in sport. Yet, people are always trying to remain neutral and I want to discuss a few of the reasons why they do this and I want to challenge them a little bit. So, number one, people are often proud of themselves for being open-minded. What I would say is excessively open-minded. Being open-minded is great. Always remaining vigilant that better options are out there and keeping an eye open that you’re not missing them because you’re so tunnel-visioned, that’s great. But being excessively open-minded to the point where You say, yeah, I’m open to that, I’m open to that, I’m open to that, I’m open to that, I’m open to everything. 06:23 “AT SOME POINT, BEING SO OPEN-MINDED IS HAVING NO MIND AT ALL” Well, at some point, being that open-minded is having no mind at all. And having no mind at all isn’t useful to anybody. Being open-minded is great. Being excessively open-minded to the point where you can’t take any stances is useless. And you’ve gotta be careful of which side of that line you’re on. Number two is excessive humility about what we don’t know yet. People love to say, yeah, but we aren’t sure yet. We will never be sure. That’s the nature of the game. So while, again, some of that humility is useful, so you’re not excessively betting on something that you truly don’t have the requisite data for yet, understanding that we are never gonna hit a point where we say, we are absolutely certain about this, Knowing that and owning that will allow you to act even in the presence of some level of uncertainty. So this excessive humility of, we never know enough to do anything, again, simply isn’t useful. Number three. People don’t wanna be seen as falling into a guru camp, and there’s some good reasons for that. Looking back historically, and again, speaking to physical therapy, it’s the area I know the best, there have certainly been plenty of extremists in guru camps that have led the collective astray, no doubt, but don’t be one of those. You don’t have to be an extremist in a camp to go in and say, hey, I think most of what’s going on here is pretty useful. There’s no reason you can’t go into it with that frame of mind. But people are so afraid of being labeled, of being in this camp, or that camp, or that camp, that they stay, again, doing nothing. And unfortunately, doing nothing doesn’t serve anybody. Number four, they don’t want to step on toes. Once you say, hey, I believe this, you are naturally going to rub some people the wrong way because now you’ve committed a bit. You’ve said, I kind of looked at everything that I could and I’m going to go this direction. I think this makes the most sense. Well, other people that made other commitments are going to be rubbed the wrong way by that. If that is not happening, you are not doing anything of merit. If you are never rubbing anybody the wrong way, I can promise you, you aren’t moving anything forward in a relevant fashion. So reflection point number one of this episode is are you doing that? In the past couple years, have you rubbed some folks the wrong way? I mean, give this some serious thought. Like really think, have your stances, have your actions bothered some folks? If that answer is no, you’re not standing for anything. And if you’re not standing for anything, you’re not being useful. So just give yourself a little pause today and really think, like, am I committing enough that people who have made contrary decisions are a bit bothered by that? That should be a constant in your life. As you’re working through decisions and emerging and making choices, some people aren’t gonna love those, and if you aren’t feeling some of that pushback, I think you’re holding yourself back and trusting yourself and making commitments that actually allow you to decide and move things forward. But the number one reason is I look at folks who are forever trying to stay in this kind of neutral ground that I really feel this static posture doesn’t get anybody anywhere is because they don’t want to be wrong. They don’t want to be wrong. They don’t want to look back in two years and know the line they took on that motorcycle trail was the worst one they could have chosen. They don’t want to be wrong. They’re perfectionists. Team action is always imperfect. Action is always imperfect, especially in hindsight. There is not a single action you are ever gonna take that you’re gonna look back with five more years of data and say that was perfect across every domain. That’s never going to happen. So if you can’t embrace that you’re gonna be wrong, at least in some percentage, every single time you make a choice, You are forever going to be paralyzed. It will be paralysis by analysis for the rest of your professional, business, patient care career. You’ve got to get over that. You’ve got to embrace that every single action will always be looked back as imperfect, and that is a beautiful part of the process. That’s what allows you, as you recognize that, to alter it, shape it, and make it better. This is the process. 10:55 “IF YOU CAN’T CHOOSE IMPERFECT ACTION, YOU CAN’T CHOOSE ACTION. PERIOD.” But if you can’t choose imperfect action, you can’t choose action, period. And that’s a problem if you’re trying to be useful as you’re moving forward. Bottom line is this, the people that I’ve observed who have been the most useful, and of course, the most useful meaning the most successful, because these two things tend to go together. You provide a lot of value, you’re useful, success follows, are always those who took really deep dives. They said, I think this makes a bunch of sense, I’m going all in. Like I’m gonna learn as much about this as I can, I’m gonna try to replicate it, I’m gonna try to leverage it, I’m gonna try to use it. But as they’re doing that, they’re aware and okay with acknowledging the shortcomings of that model. So that they can in real time be seeking out solutions to fill those gaps. They’re learning through action, which necessarily followed decisions, choosing. You have to do anything besides nothing. You have to do anything besides nothing, because if you don’t get out there and go, you can’t evaluate the shortcomings, because you aren’t doing anything. The people that I see that act with the most, again, it’s not arrogance, it’s not even confidence, it’s out of necessity to act. They know they have to say, I know this isn’t perfect, but I have to go anyways. Those people that are willing to be in that space, first of all, provide the most value, and absolutely learn and refine at the highest rate of speed, simply because the data’s now coming back at them because they’re out there. And because they’re out there, it’s a bit vulnerable and emotional, and you tend to learn a ton in those phases. Now, all of that being said, Your decisions should always change. This is a critical part of this conversation, right? Your decisions should always change with emerging data. If they aren’t, you’re just being arrogant. And now you’re falling into the other side of the problem, which is not having one eye open. If your decisions aren’t changing consistently, if that’s not just a part of your growth and process, where you look back and say, ooh, shoot, should’ve done, now that I know better, I’m definitely gonna do better because that was imperfect. If you are not regularly doing that, you are also going about this process wrong, but on the other side, right? Remaining blind and over-trusting your actions. So reflection point number two of the episode is have they? In the past couple years, Have you reversed course on a couple of key philosophies, beliefs, decisions, directions? If not, I think you’re erring on the other side, where you’re not keeping one eye open. You think your action’s perfect. You aren’t aware of the imperfection and looking for the gaps. You’re going in blind. This is every bit as errant, maybe even more dangerously, than the former. In this case, not only are you probably not being as useful as possible, but you’re probably leading folks excessively astray by not being aware of what’s emerging. So reflection point number two is are you every couple years realizing something you believe strongly had some pretty significant flaws and are you willing to incorporate emerging data to change them? Team. If you aren’t willing to embrace that action’s always imperfect, you’re never gonna choose, decide, and move forward. If you don’t do that, you can never get the data that fills the gaps of what we don’t know that you’re so concerned about, it’s holding you back from action to begin with. Trust that your intentions are good. Remain focused. Humble in the face of everything emerging, so you’re not totally just tunnel visioned in one direction. Allow that to shape your actions, but make sure that you’re actually playing the game. So when you get information, you can modulate in real time, forever become better, but always stay away from the pitfall of doing nothing. 14:49 “PARALYSIS BY ANALYSIS IS THE ONLY WAY TO ENSURE YOU’RE USELESS YOUR ENTIRE PROFESSIONAL CAREER.” Paralysis by analysis is the only way to ensure you’re useless your entire professional career. Do anything besides nothing, stay humble, be ever evolving, but be willing to choose. You’ll be wrong. I guarantee it. Me too. Let’s be wrong bravely and let’s adapt in real time. You have to choose. I hope it makes sense. Hit me up with questions, comments. Thanks for being here on Leadership Thursday. PTOnIce.com where everything lives. We’ll see you next week. Cheers, team. 15:28 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the book "Radical Candor" by Kim Scott as a valuable resource for improving patient care and leadership skills. Jeff highlights the book's teachings on radical candor, including its definition, common pitfalls, and practical application in patient care. Jeff emphasizes the significance of caring personally for patients and challenging them directly. Caring personally entails demonstrating genuine concern for the patient's life and goals, while challenging directly involves establishing and upholding standards and expectations that contribute to the patient's success. Jeff believes that this book is relevant to patient care and can assist clinicians in becoming better leaders for their patients. 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 wait list, 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 JEFF MUSGRAVE Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave. I'm one of the faculty with the Institute of Clinical Excellence in the Geriatrics Division. We call modern management of the older adult. Super excited to talk to you about a book that I recently read called Radical Candor, written by Kim Scott. This is a great leadership book, but it has some direct correlation to ways that you can improve your patient care, okay? So super excited to talk about radically candid patient care with you this morning. But before we get into that, just a couple things going on in the MMOA division. If you're looking to continue on to get your MMOA cert, Our next cohort of Essential Foundations is going to be on October 4th. If you've already had Essential Foundations, you're looking to get into Advanced Concepts, you're going to want to hop in the cohort October 10th, and if you want to see us on the road, there's still some spots in Oklahoma City for this weekend. 02:55 RADICAL CANDOR IN PATIENT CARE So, this book, Radical Candor by Kim Scott, what does it have to teach us? The things we're going to cover is what is radical candor. We're going to talk about some of the ways we sometimes miss a mark. This is going to hit home for me because one of these downfalls is something that I have succumbed to time over time and have been working to improve. And then how to apply this well in patient care and some things to consider. So, what is being radically candid? What does that mean? So, Kim Scott defines this in the book as two factors. Two factors to being radically candid. You've got to care personally. You've got to care personally. I think oftentimes, if you're listening to this podcast, you're someone who cares personally, because you're trying to get better. You're trying to level up. The second piece of this, where I think oftentimes we miss a mark as clinicians, is to challenge directly. to challenge directly. And for me personally, this was something really difficult to learn is how to challenge our patients directly to hold the line. We've got to hold the standard. We've got to say, this is what it takes. and we're going to hold the line until we get there. Or we're gonna make referrals to other people, we're gonna bring in whatever parts of the medical team it takes to get you to this standard, because this is what it takes to reach your actual meaningful goal, the thing that you really want to do. So that's what radical candor is. You've got to care personally and challenge directly. Some of the ways we see this go wrong, the first bucket is the one I fell into over and over and over again, and that was ruinous empathy. So ruinous empathy is defined as you care personally, but you don't challenge directly. You care about your patients, they know you care about them, but you don't challenge them directly. They may give you a really bad rep or any effort and you just say, that's so great, that's amazing, that's exactly what I wanted. And you know in your heart of hearts, that wasn't it. You didn't hit the mark. That's not anything like what I told you to do, and we did not coach them up. We want to be really effective coaches, really effective coaches, set people up for success, and we challenge them directly. We give some room for them to struggle. So ruinous empathy is the first bucket if you miss being radically candid. That is, you care personally, but you don't challenge directly. We're congratulating every attempt, whether it's actually a progression or not. Now that being said, I will tell you one of the factors that we use, one of the principles we use when we're working with older adults is we do intentionally underdose. We do make things a little bit easier so we can hit success. So we make the challenge a little bit easier so that we can get some successful reps early on, and that is important. But over time, we ramp up that challenge pretty quickly because we don't have time to waste, particularly with older adults. If we're not getting them strong, we're going to see them decline very quickly. 04:05 RADICAL CANDOR & FEEDBACK So to circumvent that, to make sure that they can be successful and we can be honest when we're giving them that feedback, we make sure the challenge is appropriate. And sometimes we'll make it just a little bit easy at the beginning, but we very quickly ramp up so that we are directly challenging our patients because that is where they're gonna get better. So maybe you're not being ruinously empathetic, Maybe you've fallen into this other category that Kim references as obnoxious aggression. And that could represent the burned out clinician here. I've had periods in my career before I found my passion where I was doing work, too much work, not saying no, and found myself completely overwhelmed with work. where you don't care personally about this patient, you've not connected on a deep level to be empathetic to what their experience has been, but you do challenge directly. So that could look like you being obnoxiously aggressive in your feedback. Like, nope, that's not it. Nope, nope, nope, nope. Instead of just being quiet, letting those improper reps happen, we like to have people start some of these new movements that we're teaching in such a way that they're not gonna get hurt if some ugly reps happen. We can let those ugly reps happen, and then once we see a good one, we'll be like, yes, that's it. that can help you circumvent if you tend to be obnoxiously aggressive in your feedback. So that is when you don't care personally, but you do challenge directly, and there's a mismatch there. And that can do a lot of damage when we're trying to build a relationship with our patients so that they trust us. If they don't think we care about them, then they're probably not going to come very long, they're not going to take our instruction well, probably not going to be very beneficial of a therapeutic relationship with that client. So that's the basics of radical candor and how we can miss a mark by being ruinously empathetic or obnoxiously aggressive. What I want to do now is just lean into what it looks like to truly care personally for our patients. So I truly believe that you cannot give world-class care, you cannot give the best care if you don't care about your patient. If you don't know enough about your patient to know how their problem is impacting their life, you just can't do it. If you don't know how it's impacting their life, you're never gonna dig deep enough to even get a good goal. And if you don't get a good goal, you don't really know what movement to work on. To give you an example of this, say someone is having knee pain. You've got an older adult coming to you for knee pain, and you just take that at surface level. Okay, I'm just gonna figure out why your knee hurts, and I'm gonna give you exercises for your knee. But maybe you've not dug deep enough to find out why the knee hurting, why that even matters. Why does that matter to this patient in their world? What impact is this having? If that knee pain is keeping them from taking care of maybe their favorite pet. We like to talk about Fluffy a lot. A lot of our older adults have pets. And we say, okay, why does it matter that you have to get in the ground, get on the ground to take care of Fluffy? Or maybe they need to kneel down to clean the kitty litter. It's like, well, I live alone. I have no help whatsoever. And Fluffy is my only emotional connection. Fluffy's the only person in my world. I'm completely socially isolated, and if I can't take care of Fluffy, I'm gonna have to get Fluffy away. And my fear is that my only social connection, my only being that I can connect with is going to leave me, just like maybe family members that have passed away. 10:53 CARING PERSONALLY FOR PATIENTS Man, if we have dug that deep into our patient's goals to know why it's important that they get their knee better, First of all, we're going to set a better goal because their knee may feel good and they may have better manual muscle testing. But if we don't ever bridge the gap back to them being able to get in the floor or take care of Fluffy, we've not really done our job. We've not dug deep enough to even get a good goal to care for them. And if they don't know how important this is, they're not going to trust us. like they would if we dig deep enough to know that we really genuinely care. And that trust is going to allow us to do the second part very well, which is to challenge them directly. We've got to challenge them directly. So what we've got to do is set very clear expectations of what success, what it's going to take to get to success. This client may have been dealing with this problem for decades. And if we tell them, oh yeah, I can get you better, in three weeks, even though we know this problem has been coming on for decades and decades and decades. When the reality may be that we are in more of an acute setting, someone just had a fall, they're in an acute or subacute setting, and the reality is to get back to getting into and out of the floor or getting their own groceries, it may be a year-long process. And if we just tell them, oh yeah, you know, I'm gonna give you a few exercises to do and if you do those for a week or two, you're probably gonna be better. That's not it. That's not truly challenging directly. That's being ruinously empathetic. 12:01 SETTING REALISTIC EXPECTATIONS We care, but we're not setting realistic expectations. We're not challenging directly. That patient needs to know this journey is gonna take you a long time, but you can get there. The tools, the resources are out there. I'm gonna get you started on your journey. I'm gonna plant the seeds of the fitness that you actually need. to hit these big goals and I'm going to make a referral to someone who can take care of you. So if you're in a more acute setting your job is going to be planting some seeds and you're going to send them to a fitness forward clinician on the next step down the line so they can hit those big goals after you've uncovered them. So This may take one referral, maybe you're an outpatient, it may take several referrals. Maybe their medications are off, maybe they need different shoe wear, maybe they need to go to a podiatrist or an optometrist. If we dig deep enough, we do a really good job on the front end and get this information, we need to set realistic expectations of all the people that may be involved and how long it's really gonna take. Our older adults know when we're not shooting them straight. They know. When you hear, I've not been active for 40 years, and I've got a goal that requires a lot of activity and strength I've not had for 40 years, they know immediately if the goal is not realistic, and they've already lost trust with you. They may show up and get what they can, but they're not going to open themselves up to the challenge that they're really gonna need to reach their goals. So that's what I've got for you team. I think that this book by Kim Scott was very beneficial. It is a leadership book, but is very relevant in our ability to be leaders to our patients. And the two main goals here is we have got to care personally for our patients. It's got to be clear to them that we actually care about their life, that we've dug deep enough on that first visit to find out what their true meaningful goal is. And then our second job is to challenge them directly. We've got to set and maintain the standard. We've got to set realistic expectations that's actually going to lead to their success. If you've read this book, if you've got questions, comments, concerns about what I outlaid out here, I would love to discuss it. Leave me some comments. Otherwise team, have a wonderful Wednesday. We'll catch you soon. 14:29 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. Mark Gallant // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses treatment progressions for lateral knee pain/"IT band" pain. Mark encouraged beginning with open chain exercises as a starting point for individuals with high irritability. These exercises can help decrease force on tissues while still providing a stimulus for the body to adapt. Additionally, open chain exercises stimulate the release of endorphins, which can have a positive effect on pain and mood. Mark mentions several open chain exercises that are beneficial for individuals with high irritability, including hip abduction, hip extension, and hip rotation. These exercises can be performed in different positions, such as bent over hip extension against a table or in a quadruped position with significant bracing of the anterior trunk. It is important to note that the intensity and volume of open chain exercises should be adjusted based on the individual's irritability level. For individuals with high irritability, the podcast recommends starting with a high volume of open chain exercises, such as two to three sets of 20 repetitions with a low load intensity. The goal is to challenge the individual and provide a stimulus to the nervous system. Overall, open chain exercises can be a beneficial starting point for individuals with high irritability as they help decrease force on tissues while still providing a stimulus for adaptation. It is important to adjust the intensity and volume of these exercises based on the individual's irritability level. As symptoms decrease and heavy, slow resistance training is introduced, closed chain exercises such as the hip thruster and Bulgarian split squat are recommended. These exercises effectively strengthen the hip and quad muscles while improving stability and control in the lower extremities. The hip thruster involves thrusting the hips upward while keeping the feet planted on the ground, targeting the glutes and hamstrings. On the other hand, the Bulgarian split squat is a single-leg exercise that requires the back foot to be elevated on a bench or step, improving balance, stability, and leg strength. In addition to closed chain exercises, proprioceptive training or reactive neuromuscular training can be incorporated. This involves using loop bands around the knees to provide feedback and improve body awareness. Proprioceptive training enhances control and stability during movements, reducing the risk of injury. Once individuals can handle both heavy slow resistance training and reactive neuromuscular training, they can progress to plyometric training. Plyometric exercises involve explosive movements like jumping and hopping to develop power and improve muscular endurance. The recommended goal is three sets of 20 repetitions or three sets lasting a minute for endurance, and 10 sets of three to six repetitions for power. Plyometric training enhances both endurance and power, important for athletic performance and overall functional fitness. Mark finishes this episode by offering a number of different options to reintroduce running, if it's part of that patient's goals. 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 INTRO All right, what's up PT on Ice daily crew. Dr. Mark Gallant here, lead faculty with the extremity management division alongside Lindsey Hughey and Eric Chaconas. Coming at you here Tuesday morning, Clinical Tuesday. Before we dive in, a few upcoming courses that we want to announce. I'm going to be in Cincinnati, Ohio this weekend with Onward Cincinnati. So if you've all been looking to check the extremity management course and haven't had that opportunity yet, definitely sign up today. Get on the list for Onward Cincinnati. There's still seats left. If that's not available, Cody will be in Rochester, Minnesota first weekend of October. So that'll be your next opportunity to check the extremity management crew out. 1:01 LATERAL KNEE PAIN So I was on here a few weeks ago and we talked about the myths of iliotibial band pain, where we came from, from the research in the 70s, and now how we've adapted with newer research and things we now know. Mainly being that this is no longer believed to be a friction mechanism of the lateral knee because we know the IT band is firmly attached to the lateral femoral condyle, the patella, the tibia, and that this is more of a magnitude or a volume of load with a potential lack of frontal plane control or simply too much volume to the lateral knee. So what are we gonna do if that person comes in? Tim's been running on the treadmill for most of the year, he decides that he wants to get out and do some trail runs, start working some downhill in. Brittany has been relatively unfit for most of her life and decides, you know what, this fall, it's the time that I'm gonna run that half marathon. And then they start to develop some lateral knee pain. Well, how are we gonna treat those folks out? And what we're really gonna look at, that's gonna depend on where their irritability is. So we have four or five steps that we're gonna go through and that individual can jump onto that highway wherever they're at on this progression. So if that person comes in and they're highly irritable, they tell you that they've got eight out of 10 lateral knee pain, it hurts when they're going downstairs, when it's the trail leg that's walking, they begin to have some discomfort, they're certainly having trouble getting out and doing any of their runs, and it's really a quite uncomfortable pain for them. Well, when that person comes in, like we talked about last time, we'll do the dry needling, the myofascial decompression, the soft tissue to help modulate their pain. How do we work the exercises in and how do we specifically dose those exercises? So if the person has that 8 out of 10 or above or even 7 out of 10 irritability, oftentimes a good place to start with our exercises is open chain exercises. they're really going to decrease the amount or magnitude of force going into those tissues while giving them a nice stimulus so that the body knows it has to adapt, we get some good endorphins going. We specifically like open chain abduction of the hip, open chain extension of the hip, and if you want to get some open chain rotation of the hip, that works as well. So we like either a bent over hip extension so that person is leaning against the table so they can really contract their abs so that we know they're not getting any back arching there. Or if they go into a quadruped position, really brace the anterior trunk significantly, and then do their hip extensions. For the open chain abduction, we'd like to get them against a wall, starting them so where their hip is in neutral, so their hip is either, their leg's propped up on a ball or a bench, heels against the wall, slightly internally rotated so we know we're really hitting those glutes and working our hip abduction that way. 04:01 OPEN CHAIN CLAMSHELL MODIFICATIONS For our hip rotation in open chain, the traditional clamshell has come under fire quite a bit in the last handful of years. What we like to do is a pseudo open chain clamshell where their feet, their bare feet are gonna be against the wall. So they have to keep that flat foot against the wall and then go into their clamshell. How are we going to dose this? Well, if you've been to the course, you know, we talk about the rehab dose, eight to 20 repetitions, 30 to 80% of their one rep max basing that that volume and intensity on their irritability. Well, these folks are higher on the irritability, so we're going to go higher volume. We're going to hit two to three sets of 20 repetitions with a really low load intensity. It's hard to get a high intensity load an open chain without volume anyway. So that's really going to lend itself to this to begin with. So our hip extension, our abduction, our pseudo clamshell, we're going to hit those two to three sets of 20 reps where they feel challenged when they approach that 20. It's getting a lot of stimulus to that nervous system. It's letting the tissues know that we want you to be active, but it's not giving them a magnitude of load that's going to be threatening to the tissue. Once the person says, you know what, I went downstairs last night and my pain was only a 3 out of 10 or my symptoms were only a 3 out of 10 or less, or that person comes in and says, you know what, now when I'm walking, when that leg's the trail leg, really doesn't seem to bother me that much. Maybe a 2 out of 10 at best. That's when we really want to make sure we're progressing to a more closed chain activity. What we love for our closed chain exercises, again, working into that hip extension, getting the quad stronger. We like a hip thrust, so a barbell hip thrust that we can really load up a lot of weight. If we see a big side-to-side discrepancy in strength, we can go single leg landmine hip thruster to make sure we can load that up. We also like a Bulgarian split squat. For our IT band folks, we're gonna modify this split squat a bit Instead of having all the weight on the front leg, you're gonna have a majority of your weight on the leg that's slightly elevated so that we can get a big eccentric load into that posterior leg. How do we like to dose this one? Three sets of eight to 12 repetitions at a weight where they feel like they've only got two or three left in the tank by the time they get to that eight out of 12. You'll notice that three sets of 10 fits beautifully into that eight to 12 repetitions. A lot of clinicians out there like to bash the three sets of 10 calling other clinicians lazy. Three sets of 10 is a wonderful stimulus as long as you're dosing it out appropriately, as long as they're approaching failure. We're not saying they have to get to failure, but can they get in the ballpark of that failure? So again, three sets, of eight to 12 reps. We really love three sets of 10. It's easy for us, it's easy for the patient, and making sure they've only got two to three reps left in the tank, specifically with the barbell hip thruster, the Bulgarian split squat with the weight shifted posteriorly. You can also add, if you want to continue to work on those hip abductors, we really like a kettlebell-weighted hip hike to get a closed-chain version of that hip abduction. At the same time you're doing your heavy, slow resistance training with your Bulgarian split squats, your hip thrusters, with your hip hikes, we also want to get that person to start being able to feel where they can control that lower extremity in space. So we really like reactive neuromuscular training, often used the acronym RNT for short, where they're going to have a band around their knees, so a small loop band that's going to pull their knees into valgus. with a flat foot, they're going to drive their knees outward. We're going to do this at a high volume. So either two to three sets of 20 or setting a timer and saying, I'm going to have you rock this three sets for a minute each. Again, we're really trying to get that nervous system to feel where that limb is and is in space to gain more control. So we want that volume to be a bit higher. You can also do this single leg where you have a meter loop band attached to a rig or a door frame. It's going to pull them into that, that valgus force with a flat foot. They have to drive that out again, high volume, three sets, 20 reps, three sets for a minute. You can progress this into having them do step downs, lunges or squats with that band on. So they have to feel their lower extremity limb where it's at in space while going through a movement. So, Just to rehash where we're at right now, high irritability, we're going open chain exercises at a high volume, lower intensity. Once they can tolerate that with mild pain, we're going to go into our closed chain exercises, increasing the intensity, making it really challenging for that three sets of eight to 12. At the same time, doing our closed chain proprioceptive work or our reactive neuromuscular training. 09:28 PLYOMETRIC TRAINING From there, when they say they're starting to tolerate that really well, then we wanna start working into our plyometric training. We talked about last week, we know that iliotibial band has a lot of similar properties to tendons. We wanna make sure that it has the ability to transfer force and absorb force quite well. We need to do this from both an endurance perspective and a power perspective. So can that tendon or that iliotibial band Absorb a lot of force and generate a lot of force and can it absorb and generate a high volume of force? So we like to do Lateral skater hops for a high volume to really get that endurance. So they're gonna be jumping side to side To get that that that volume for the endurance piece of three sets of 20 or three sets of a minute We also like pogo hops, where they're having to hop on one leg. Again, three sets of 20 or three sets of a minute. And then we really want to work on the power component. How high can they jump? How long can they jump? And can they go laterally against resistance? A couple of exercises that we really like for this, box jumps are great. Our long jump, just the traditional long jump. And then again, strapping either a band around the hips or a strap that's attached to an anchor cable column, and then we have them go three sets of three to six repetitions. So we're gonna have them go relatively low. If you've got the time in clinic, what we really prefer is 10 sets of three to six repetitions, because it's really gonna train that power very specific to how like our Olympic lifters would train. So again, if time is short in clinic, get the job done, get it in. What we really like is that 10 sets of three to six repetitions for our power. Another thing you can do for power is your rebound jumping. So they come off of a small step and they immediately have to jump to a higher box. That's going to train that lower extremity to both absorb force and immediately generate force overall. 12:01 RUNNING PROGRESSIONS FOR IT BAND PAIN As they're tolerating those plyometrics better, both from an endurance perspective and from a power output perspective, then we're going to really look at how we're able to get them running more effectively. So what this is going to look like is early on for running to get them out of symptoms, we're often going to have them run on a treadmill with a fairly steep incline. This typically will reduce symptoms for a lot of our iliotibial band folks. Then we're going to lower the treadmill. have them make sure that they can run with relatively low symptoms at a normal treadmill where it's a very controlled environment. Once they can run on a regular treadmill at that very controlled environment, then we're going to have them outdoor run. Once they can outdoor run on something like a track, a blacktop, or a sidewalk where it's relatively controlled, then we'll progress them to their trail running when they can handle a relatively flat trail then we'll progress them back to their downhills and then get them back out there on the circuit, hitting their runs. So again, these folks can enter this anywhere along that progression, depending on their irritability. If they're highly irritable, start them out open chain, high volume exercise. As their symptoms decrease, get them into that heavy, slow resistance with closed chain exercises. We like the hip thruster and the Bulgarian split squat. As you're doing the heavy slow resistance, also getting them into some proprioceptive training or reactive neuromuscular training with loop bands around the knees so that they can feel where those knees are in space. Once they can handle both the heavy slow resistance and the reactive neuromuscular training, we're gonna get them into their plyometric training. We want them to have both endurance and a lot of power. So three sets of 20 or three sets of a minute for the endurance piece. 10 sets of three to six reps for their power piece. And then, of course, whatever their functional activity is that was initially their aggravator, the thing that they love to do that they wanna get back to, making sure we're incorporating that. Starting out incline treadmill, go to a neutral treadmill, get them on the outdoor, on a blacktop, pavement, or a track, then progress them to a trail, and then progress them to the downhill running. Hope this helped as far as the plan for IT band pain goes. Hope to see you all out on the road next week in Cincinnati. If not, catch Cody in Rochester. Hope you all have a great Tuesday in clinic. Thanks for your time. Have a great day. 14:14 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.