#PTonICE Podcast

Dr. April Dominick // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick  kicks off part 1 of a series on postpartum depression. In this episode, she discusses the differences between postpartum depression and other PP mood disorders. She then highlights the prevalence of and risk factors for developing postpartum depression. In her next episode, she will focus on screening for and how to communicate with folks who may have postpartum depression. 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 APRIL DOMINICK Good morning, everyone. Dr. April Dominick here from the Ice Pelvic Division, and today we're gonna talk about postpartum depression. This is a series, so in part one, we will define it, we'll talk about its prevalence, and we'll go through some risk factors for developing this condition. But before we dive in, we have some exciting updates from our division. Drum roll, please, or Harp glissando. So if you didn't catch our big news that dropped on Thursday of last week in our pelvic newsletter, we now have an eight week online level two course that will drop in spring 2024. We are so excited for this course. It is loaded with fun material. So we'll talk about pelvic pain syndromes. We'll go through post-op rehab for the pelvic and abdominal surgery that someone may get. We'll go through some birth prep and talk about all things fertility and infertility. So hop into that course when it becomes available. If the virtual option is not for you or your cup of tea, then I invite you to join us on the road live where we teach all things pelvic health rehab, bridging the gap between the fitness athlete and pelvic health. We're doing internal exams, external exams. We are talking about core rehab, going through labs that go over diastasis recti, return to the barbell, hopping on the rig, endurance, impact. It is so much fun as well. So when can you catch us live? We have some courses coming up September 23rd and 24th in Scottsdale, Arizona, and October 13th and 14th in Milwaukee, Wisconsin. Those classes will be with Dr. Alexis Morgan and Dr. Rachel Moore. Or you can find Dr. Christina Previtt. That's right, I said doctor. She just earned her PhD and we couldn't be more proud of her. So Christina and I will be out in the Pacific Northwest in Corvallis, Oregon on October 21st and 22nd. Tons of opportunities for you all to learn with us head over to PTOnIce.com and check out more. 06:34 POSTPARTUM DEPRESSION All right, postpartum depression, the topic of the day. Let's just cut to the chase. We'll call a spade a spade, pregnancy and parenthood. That is a transformative time. It's filled to the brim with new challenges when it comes to emotional, physical, mental, and lifestyle changes. We'll talk about pregnancy, I mean, that's approximately nine months of physical body alterations that support and nurture the baby. Then we have labor and delivery. That's an incredible feat. It's remarkable in the mental and physical strength that is required to get the baby to come out into the world. And then we have postpartum. Voila, the baby has arrived. Now what? So even though the baby may be all that the birthing person has ever dreamed of, it's gonna come with a lot of emotions, anticipation, joy, maybe even fear. Not to mention the added responsibility of caring for a baby while the birthing individual is functioning on minimal sleep, who knows what's happening with nutrition, and then there's an emotional rollercoaster going on. What up, hormones? and all the while that person is trying to heal and recover themselves. All of that can put a person at risk for postpartum mood disorders. We'll focus on postpartum depression or PPD, but I am going to share other conditions that may look like PPD. There's a side note here. A lot of the research that I did is on the postpartum parent who identifies as pronouns she, her, hers, or mother. So I'll be using that terminology for this podcast just based off of the research that I found. So here are three different postpartum mood disorders to include in a differential diagnosis if someone is coming to you postpartum. Number one, we have baby blues. This is gonna be the mild, most mild form of a depressive mood disorder. Then we have postpartum depression. And then our third type is postpartum psychosis, and that's gonna be the most severe form of depression for postpartum. So let's unpack baby blues. Due to the hormonal changes that happen immediately postpartum, About 50% of new mothers get the baby blues. That's a lot. By definition, the baby blues are mood changes that are mild, transient, and self-limited. And that means it'll resolve on its own and there is minimal medical retreatment required. Someone experiencing baby blues may exhibit signs of tearfulness, sadness, exhaustion, They may be irritable, they may have decreased concentration, mooniness, and decreased sleep. But all of those changes don't affect the person's ability to care for the baby or their own daily function. So from a time standpoint for baby blues, the onset and conclusion is like a bell curve. The symptoms come on within two to five days after childbirth, they peak, and then they generally resolve within two weeks of onset. One of the most common complications though of baby blues is the development of postpartum depression. So what is postpartum depression defined as? The DSM-5 defines it as a moderate to severe depressive episode that starts around four weeks post delivery. And this is typically going to require medical intervention. Compared to the baby blues, The big difference is that with postpartum depression, or PPD, symptoms persist for a longer period of time, so they aren't transient. 09:06 EFFECTS OF POSTPARTUM DEPRESSION If we zoom out, a person with postpartum depression can have changes in feelings, changes in everyday life, and they may even change how they think about their baby. Common symptoms for someone who is experiencing PPD They may have chronic feelings of guilt, feelings of failure as a mother, loss of interest in activities that used to bring them joy, feelings of despair that do interfere with their ADLs, and self-care. They'll also have unreasonable worries about the child's health and possibly infanticide or suicidal thoughts. So I wanted to talk about the effects of postpartum depression on the members in the family. So it's going to put the mother at greater risk for developing depressive episodes in the future. It can also affect the mother and infant bonding, and this has some potential implications if, say, the person is wanting to breastfeed, that may interrupt the success with that just due to the bonding issue. Beyond that, it's gonna affect the co-parent or the spouse and overall family dynamics. And there is some research showing the effects of postpartum depression and how that may negatively affect the behavioral and emotional development of the child. All right, so we went over baby blues, we went over postpartum depression, I can't leave this conversation without talking about postpartum psychosis. This is a psychiatric medical emergency. It's associated with increased suicide and infanticidal risk. It's rare. The global prevalence of it is about one to two and a half in every 1,000 women. It's going to emerge during the first few days or weeks of childbirth. And folks with postpartum psychosis will demonstrate rapid shifts in mood swings that are similar to bipolar tendencies. They'll have a loss of sense of reality. They may experience hallucinations, lack of sleep for several nights, agitation, delusions, and attempts to hurt themselves or the baby. So when you're meeting with a client, two keys for differentiating between baby blues and postpartum depression is the time since childbirth and severity of symptoms. So with baby blues, symptoms are usually present and gone within the first two weeks. Whereas those symptoms that persist beyond the first few weeks are more in the PPD camp. And then with baby blues, the symptoms are more mild and they don't affect the daily function of the individual. Whereas with PPD, it is more moderate in symptom nature and it will affect their daily life. So what is the prevalence of postpartum depression? It is one of the most common complications for someone after they give birth. PPD occurs in 15% or one in seven postpartum women. One in seven. These numbers are just representative of those who actually report it. So according to a study done in 2006 by Beck and colleagues, as many as half of PPD in new mothers goes undiagnosed because the individual is not wanting to share this with their family members or to share it with a research study. They wanna protect their own privacy. There are some effects of race as well in terms of prevalence, at least in when postpartum depression hits folks. So African-American and Hispanic mothers reported the onset of PPD within two weeks of delivery versus white mothers who tended to report the onset of PPD later. Region also matters. So geographical region. The prevalence of PPD varies by country. And what we know is that folks from developing countries have a higher prevalence of postpartum depression. Okay, what are the risk factors for postpartum depression? Y'all, there are so many. There were so many that I'm only gonna highlight the ones that came up over and over again that had the greatest impact in the research. So a 2022 literature review of risk factors of PPD identified the following as those that had the most powerful impact on development of PPD. Previous history of depression or psychiatric illness, depressive symptoms during pregnancy, and decreased social and spousal support. So there has been some research done that suggests, hey, if someone has healthy and supportive relationships, that is going to act as a protective mechanism during the prenatal period, specifically for the development of depression as well. There were some other factors, risk factors for PPD. Low socioeconomic status, stressful life events, and obstetrical specific factors like gestational diabetes, negative birth experiences, preterm deliveries, and low birth weight infants. All of these have a profound effect on the development of PPD. There was another systematic review from 2021 that they identified six major risk factors, which some of those we've gone over. But there were two in their list that I thought were interesting. One was that a risk factor if you were a pregnant woman who gave birth to boys, and then if you had an epidural anesthesia during childbirth. So I felt like those two were interesting, just side effects or side notes, and they were from a systemic review as well. 15:06 THE ROLE OF THE HPA AXIS Another area of emerging evidence looks at the role of the hypothalamus pituitary adrenal axis, or HPA. So we're about to get a little nerdy, but I love the brain, I love neuroscience, and I'm a psychology major, so let's talk about the brain and the endocrine system. So the HPA, or that hypothalamic pituitary adrenal axis, is a known responder during stress because it regulates physiologic processes such as the immune system and the autonomic nervous system. The HPA releases cortisol in trauma and stress. So if the HPA is not functioning correctly, there's a poor stress response. I think we can all agree that pregnancy itself and labor and delivery are some pretty extreme stressful and sometimes traumatic events. So during pregnancy, there are higher levels of estrogen and progesterone. Then during the delivery of the placenta, there's a dramatic fluctuation and drop of estrogen and progesterone. This rapid drop in hormone levels during that immediate postpartum period is a potential stressor and thought to contribute to the onset of depression. There was a 2017 systematic review that found seven out of 21 studies evaluating postpartum blues, and then 15 out of 28 studies evaluating PPD found abnormalities in the HBA axis. And from previous literature, we know that the dysregulation of the HBA axis is present in those with mental illness. So from all that, this is what I want us to think about. A healthy management of stress during pregnancy and postpartum should be a priority. We as rehab providers and medical professionals can have a tremendous impact in offering solutions for stress management like exercise, nutrition, sleep, proper medications. All right, let's recap. 18:39 IDENTIFYING POSTPARTUM DEPRESSION When working with the postpartum population, one of the most common complications is postpartum depression. It affects 15% of women giving birth. It's imperative that we're aware of the different mood disorders that can happen postpartum and the differences between them. We have postpartum blues, very common, affects about 50% of new mothers. It's mild, it's transient, doesn't usually need medical intervention, but we do need to provide some validation and compassion for those individuals. It's usually resolved by week two from childbirth. Then we have postpartum depression. It's moderate and severe in symptom nature. It can arise around four weeks post childbirth. It is going to affect daily functions and be present for up to a year postpartum. It will usually require medical intervention. Then we have postpartum psychosis. This is going to be a medical emergency. It's rare. but the person will present with rapid shifts in emotions, maybe have hallucinations, and the lives of the birthing person and infant are at risk. We as PTs play a tremendous role in identifying postpartum depression and other mood disorders. We can refer them to their physician, their mental health providers, and this can be helpful for someone if we think it's a medical emergency and we're suspecting postpartum psychosis. Understanding risk factors for PBD can be impactful when it comes to managing and treating it. Some of those major risk factors we can ID during pregnancy as well. So, hey, we're treating someone who is pregnant and we notice, oh, they have a lack of social or spousal support. They've told you they have a previous history or are having some depressive episodes during pregnancy. They have a lower SES or increased stressful life events besides pregnancy and delivery. Or they may say, hey, I was diagnosed with gestational diabetes. What I want to point out, these risk factors are modifiable. So in my upcoming podcast in this postpartum depression series, we'll discuss screening for PPD in the clinic, ways to communicate with a client who may be suffering from PPD, Then our final episode will cover resources, support, and the effects of exercise in treating PPD. Cheers, y'all. 19:53 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 // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the role of carbohydrates, the relationship between carbohydrates & performance, carbohydrate loading, and carbohydrate consumption timing. 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 slash 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 slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 02:14 ALAN FREDENDALL Good morning everybody. Welcome to the PT on ICE Daily Show. Glad to be back again. Hope your day is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and elite faculty in our fitness athlete division. It is fitness athlete Friday. We would say it's the best darn day of the week here on Friday, live on Instagram, live up here on YouTube, and wherever you get your podcasts. Thank you for joining us. Some announcements really quick. If you're looking to join us in the fitness athlete division, we have a couple chances online and about a dozen chances live before the end of the year to catch us out on the road. Our online courses, fitness athlete essential foundations, that's our eight week entry level online course. All things relevant to treating the recreational athlete, the cross fitter, the Olympic weight lifter, the power lifter, the orange theory athlete, the boot camper, so on and so forth. That is the course for you. That starts this coming Monday, September 11th. We still have room in that class. And our advanced concepts course, also eight weeks online. Pre-requisite for that class is essential foundations, our entry level course. Advanced concepts is only taught twice per year. It is taught spring and fall. So this is your last chance to catch it this year. That will kick off the week after September 17th. That class has just two seats remaining. So if you're looking to round out your fitness athlete certification, make sure that you get into fitness athlete advanced concepts this fall. Live courses coming your way between now and the end of the year. Your next chance will be September 30th on October 1st. That will be out on the West Coast in the Bay Area with Zach Long. Also on the West Coast, October 7th and 8th, you can catch Mitch up in Linwood, Washington. That's outside of the Seattle area. Also on the West Coast, October 21st and 22nd, Zach will be on the road again, this time up in Vancouver, British Columbia. You have two chances the weekend of November 4th and 5th. You can either catch Mitch down in San Antonio, Texas, or Zach will be down in Birmingham, Alabama. Mitch will again be on the road in November, November 18th and 19th. He'll be in Holmes Beach, Florida. That's right outside of the Tampa area on Anna Maria Island. You can catch Joe Hanisco in New Orleans. That'll be December 9th and 10th. And then our last course of the year will be December 9th and 10th as well. That'll be out in Colorado Springs with Mitch. So that's your chance to catch us on the road in the fitness athlete division. Today's topic, let's talk about carbohydrates. Let's take a deep dive into what a carbohydrate is, how it's relevant to us here in the fitness athlete division as far as exercise, energy and performance goes. And then let's talk a little bit about when and how to kind of dose out your carbohydrates, who needs to be eating them, who maybe needs to think about eating more. And let's talk about timing of getting those in to best suits whenever we're going to be exercising to maximize and optimize our performance. 04:18 WHAT IS A CARBOHYDRATE? So starting very basic, if you know nothing, what is a carbohydrate? It is a sugar, a starch or cellulose plant material. So commonly we know carbs traditionally are things made out of maybe table sugar, candy, soda, that sort of thing, potato chips, things that are maybe less than optimal carbohydrate choices but are overwhelmingly what is often consumed when people eat carbohydrates. We also think of fruit being fructose. We think of the sugar that's in milk, lactose. We also think of carbs as vegetables that we eat when we're primarily eating the cellulose in a vegetable, we're eating that plant matter, we're eating things like green leafy vegetables, broccoli, kale, asparagus, that sort of thing. So different ways we can consume carbohydrates. They're not all equal as far as content goes, but those are all kind of classified as carbohydrates. Why do we care about them? Well, we really care about carbohydrates because eventually they become glucose in our body, which is an energy currency, a way that we metabolize energy reactions and chemical reactions in our body, but we also store glucose as glycogen. We store glucose as glycogen both in our liver and in our muscles. At any given time, we only have about four grams of circulating glucose in our system. So we have a relatively small amount. Our body does not really like to have glucose moving around in our blood system. So when we tend to get beyond that four grams circulating throughout our body, that's when insulin is released, insulin is released, and at the end of the day converts that glucose into glycogen, either stored within our muscles or stored in our liver, or if we do have an incredible excess of glucose in our system, it can be also stored as body fat. 09:13 MUSCLE GLYCOGEN  Aside from the four grams circulating in our body, we have about 400 grams stored inside of our muscles, and we have about another hundred grams stored in our liver. For most people, a total of about 500 grams of muscle glycogen or about 2,000 calories worth of energy. And that's kind of where, if you ever wonder where is the recommendation that I should eat 2,000 calories a day to maintain a healthy weight, where does that recommendation come from? It comes from estimations of how much muscle glycogen we are storing and throughout the day using for regular physical activity, but also for exercise. And that if we deplete that glycogen throughout the day, we will need to eat 2,000 calories of food to replenish that glycogen back into our muscles and back into our liver. We can make glucose and then store muscle glycogen on demand. This is that process you may remember back from middle school or high school biology and chemistry called gluconeogenesis, gluconeogenesis, make new glucose. This is a very, very slow energy intensive process. We can only make about 30 grams of glucose per hour. Now this typically comes from our body fat. It's synthesized, made into glucose, and then is either stored as glycogen or pushed into circulation for energy. So this is kind of where the all day energy you have of being at work, maybe working around the yard, relatively low intensity activity. The energy, the glucose that supports that energy, those metabolic reactions comes from that process of taking body fat, turning into glucose in the liver, about 30 grams per hour. 11:17 GLYCOGEN DEPLETION DURING EXERCISE Now when intensity increases is really our concern in the relationship between carbohydrates, glucose, glycogen, and exercise. That when we start to exceed about 65% of our VO2 max, we start to use more glucose, use more glycogen than our body can produce per hour. So we start to dig into the reserves that are inside of our skeletal muscle and our liver. Now at very high intensities and very long durations, especially if heat, if temperature, is a factor as well, humans can use up to 150 grams or more per hour of that glycogen, which means at any given time, there are only about a couple hours of energy stored in our body for higher intensity activity. So above 65% of that VO2 max, what we call a low oxygen environment, we can no longer make enough glucose and glycogen to replenish what we are burning with that high intensity exercise. We are in a high oxygen environment, relatively low intensity activities. Our body can again make those carbohydrates, make those sugars from the fatty acids from our body fat, but as intensity increases, we start to dig into our reserves. Now that typically happens around the 90 to 120 minute mark. That is going to be a little bit different for every person. Bigger people, people with more muscle can store more muscle glycogen. Those who are better trained, who exercise at all, but especially those who are used to doing long endurance training, can store a little bit more muscle glycogen. And then certainly you've heard of the concept of carb loading, where if we taper our activity for two to three days and we increase our carbohydrate consumption accordingly, we can supersaturate our muscles with glycogen as well. And overall, we may have about 50% more glycogen reserves than the average person. We might have maybe 600 to 700 grams available. So maybe we can kind of flirt with having two hours of energy total for high intensity activity before we need to start thinking about eating, eating food, eating it to not only continue exercise, but feel better after, which is part of what we're going to talk about today. The relationship between carbohydrates and performance, especially if you want to be training multiple times a day or otherwise just not feel terrible the rest of the day after you finish exercise. Now it's not an all or nothing concept. It's not, I have a hundred percent of my muscle glycogen or I've used it all and I need to stop exercising and eat. We certainly know that we can consume food during long endurance activities, but also that as those reserves deplete, we feel a performance shift as we're doing different activities of we can feel maybe speed slow down on a run, maybe power slow down if we're out and we're on the assault bike or something like that. And we know we can run out. That's a concept that's called bonking of where we have depleted almost all of our muscle glycogen and our body is going to take us from that high intensity, low oxygen environment and say, Hey, you need to cool it. We need time to recover some of this energy and your body's going to stop you for you. And that's the concept of bonking of shifting you to a high oxygen environment by lowering your intensity in an uncomfortable manner, maybe even possibly losing consciousness, but definitely not feeling like exercising anymore. It's really important that we never hit that point. If we can avoid it, we've all we've all done it. I have a story of hiking in the smoky mountains of bonking at the top of a mountain, mainly because my wife ate all of our food on the way up and I had nothing to eat. So I had no choice and bonked at the top. But it's important to know that we don't want to get to that point. We never want to use all of our glycogen and hit that wall because there is a compensatory recovery point afterwards where for one to three days after we're going to feel really low energy as our body slowly recuperates and restores all of that glycogen in our body. We're not going to feel like pushing the pace. We may not feel like exercising at all. It's going to impact our training. And what you don't want to get into is kind of this weekend warrior phenomenon. Where maybe you go you go for a really hard run for two to three hours. You hit the wall and then you don't feel like exercising maybe for another week, right? Where you don't feel like you can work out again for a couple of days. That's not very productive training. So we want to avoid that. 13:58 CARBOHYDRATE CONSUMPTION And we'll talk about that now as we talk about when should I eat my carbohydrates. So it's really cool that technically a human being does not need to eat any carbohydrates at all. You may have heard of the keto diet of being low carb, maybe no carb, under 50 grams of carbohydrates, being in a state of ketoacidosis of only utilizing your own body fat as an energy source and the fat and protein that you consume. But it's cool that we don't technically need to eat carbohydrates. Yet almost all of the metabolic and chemical reactions in our body are fueled by carbohydrates. It's very, very interesting how our body operates. So you can go without eating carbs. So again, your body can make carbs about 30 grams per hour, but we need to understand that that takes time as we talked about. And especially if we are doing longer, harder events, we're thinking about maybe training twice a day, something like that. Then we need to understand that that process is slow and we need to give the body either a lot of time or we do need to consume carbohydrates. We also need to recognize at some point that eating carbohydrates is like consuming jet fuel for a mechanical engine. Of it's a very caustic chemical reaction to our body, a lot like burning gas inside of a gasoline engine, that it does create some low grade, low grade inflammation that's kind of always present as we're eating carbs and fueling our chemical reactions with the carbs. And so kind of the longevity side of the research would say, if you want to live as long as possible, avoid that. However, that's in direct conflict with the performance research, especially if you want to be a more competitive athlete. You want to do longer, more intense activities. You want to maybe train multiple times a day. You need to understand that those are two kind of diverging thoughts of longevity versus performance. At some point, those tend to dissect and not reconverge of needing to eat carbs to fuel your activity, especially multiple activities in a day or a busy workday after you exercise or avoiding carbs. Maybe even you may have a longevity physician who recommends you take metformin prophylactically to keep as much glucose out of your system as possible because of the inflammation that's present. But nonetheless, we need to talk about that relationship between eating carbs and performance. So it's that that longevity versus performance question that we have a need to eat carbohydrates if we are a long duration endurance athlete, that when you start to run 10 miles, 15 miles marathon, ultra marathon, when you start to do long trail runs, long bike rides, long hikes, that sort of thing. Again, you are using your reserves faster than your body can make more. And you either need to know that at some point you're going to hit that wall that we talked about or you're going to need to start consuming carbohydrates as you exercise. Higher level elite endurance athletes may eat 90 grams of carbohydrates per hour in the forms of liquid carbohydrates, gels, chews, that sort of thing. Folks who maybe are doing half marathon or marathon training may be eating less, maybe about 30 grams per hour. Our fitness athletes don't necessarily need to eat carbohydrates during exercise. We think about a typical one hour CrossFit class. We're not really at the level of intensity and duration long enough to need to eat carbs during that hour. We can get away with doing that hour of fitness and then worrying about carbohydrates after. But there's also a want, a need versus want. The want for carbohydrates is understanding that performance trade off, but also understanding that your body can only make about 30 grams per hour. So what does that mean? That means if you do go to that one hour CrossFit class, you don't technically need to eat carbohydrates before or during, but that you might want to front load your consumption afterwards, especially depending on the time of day in which you do your exercise. If you're like me and you like to get up and exercise first thing in the morning and then you might be looking at, hey, I have 8, 10, 12, 14, 16 hour day ahead of me. Those subjective feelings that you may feel your patients, your athletes may feel of, I feel tired all day after exercise. I feel like I just need to go home and go to bed. I feel weak. I feel like I can't do my work tasks. I can't take care of my kids. Maybe even feeling lightheaded or some sort of impaired cognitive function. Like my mind just feels cloudy. All of those are good subjective reports to tell you that you should probably eat some more carbohydrates after that exercise session or to recommend that to your patient or athlete. And then we get in now to how to do that of our long duration endurance athletes. We've already talked about they're probably going to be or hopefully should be consuming those carbohydrates as they're exercising, especially once they cross maybe that one hour mark of again, it's not an all or nothing equation of go until I can't anymore of as those reserves of muscle glycogen get depleted, I'm going to feel worse and worse and worse than my performance. And how I get ahead of that is eating, eating those carbohydrates while I'm exercising. So the combination of me eating them and my body making some more keeps them relatively high, keeps my performance, my output higher, keeps me away from feeling kind of that onset of losing power, losing speed, losing energy throughout my workout. 22:08 CARBOHYDRATE CONSUMPTION & TIMING How to eat those? Well, I'm still trying to figure that out. As I get more into long endurance training, I have tried chews and gels and my body doesn't really sit with those. I tend to do better with liquid nutrition like Gatorade. Every person is going to be different, but definitely those people who are going out for longer workouts, especially crossing an hour need to find a way to start to consume that as they're exercising. This is also relevant to our fitness athletes who may be doing a multi event day. Maybe they're doing a local CrossFit competition. Maybe they're a quarterfinals or a semi finals athlete where they have multiple events per day, multiple days in a row. I always laugh now when I go to a CrossFit competition and I see that person after workout eating chicken and salad, right? Just not enough carbohydrates in that meal to replenish what was used in that CrossFit workout in order to have those reserves restored and ready for the next workout, which might be two to three hours after the first one. They might have a third one two to three hours after that, right? Those are athletes who they don't necessarily need to eat carbs during the workout because it's a relatively short event, maybe 10, 20, 30 minutes. But if they have to workout again in three hours, they're definitely somebody who's going to want to eat higher carbohydrate food. That's the case. You see CrossFit Games athletes eating gummy bears and Snickers bars, just getting as much carbohydrates as they can. Again, they're trying to maybe replenish 200, 300, 400, 500 grams of carbohydrates within a two to three hour window to be ready to work out again. So understanding it's important to get those carbs back in if you're wanting to train or you have to exercise again in a relatively short amount of time. I hiked the Grand Canyon last year with Dustin Jones and Jeff Musgrave and we did it. It was about a 12 hour hike up and down about 20 miles and we did it almost exclusively on water, Gatorade and gummy bears, right? Just high carb food that's going to keep our reserves up because we're basically hiking and walking in a hot environment at moderate to high intensity for a very long period of time. I'm thinking I just ran 10, 800s this morning. I have a 12 hour day ahead of me. The first thing I did was eat three bananas, right? The first thing I did was house 100 grams of carbs to give my body that jump start on replenishing that glycogen, which was not entirely gone, but definitely mostly gone at the end of that running workout. And that's really going to determine how you recommend carbohydrate intake to that patient athlete in front of you of what does the rest of your day look like? When do you train and what does the rest of your day look like? If you work out at 5 a.m. and then you have to go to work all day and you're maybe a physical therapist, right? You have a relatively physically active job. You're getting your steps in. You have an eight to maybe 10 hour day in front of you. You'll probably feel a lot better if you eat the majority of your carbs earlier in the day to replenish those reserves. You will find yourself feeling subjectively better. If you work out early in the morning, maybe you run and you want to lift weights at lunch or go to CrossFit after work. How can we fuel our body to be able to do double sessions in a day, two a days, right? The same thing, we need to front load that carbohydrate consumption in the morning, at lunch, in the early afternoon so that by the time we are going to work out again, most of those reserves are back. They're probably not going to be 100% back where I can PR my 5K in the morning and go PR a CrossFit benchmark in the afternoon. It's probably not going to work out that way to be 100% ready to go for a second session in the same day. But you will feel better during the day subjectively and you will definitely perform better objectively in that second session if you eat a lot more carbohydrates in between. Now who is that person that maybe works out in the afternoon or evening and that's their only session of the day and then they go home and they basically watch some TV, get ready for bed and go to bed? That is maybe a person who can get away with maybe a lower carbohydrate or could maybe play with a keto diet, right? Of hey, I work out at 6 p.m. when I'm done with work, I get home around 7.30, take a shower, eat some dinner, go to bed. That is a person that they do not necessarily need to replenish as much of their glycogen as possible because of their schedule, right? They deplete their glycogen in the evening, they are going home consuming some with maybe a dinner meal and then they're going to bed. They're giving their body maybe 8 to 10 hours to replenish hundreds and hundreds and hundreds of grams of muscle glycogen overnight while they're asleep. So that is a person who maybe could get away with lower carbohydrate or no carbohydrate consumption between when they work out and when they wake up again. That's a person who's going to work out, have dinner, sleep, have breakfast and have lunch again before they work out again 24 hours later and they're in a really good position where maybe they don't need to worry about it as much. So carbohydrates, what, when and how? Understanding they're very important for performance, especially for longer duration exercisers, for long endurance athletes. They're definitely linked to performance, especially if you are wanting to train multiple times a day. You are in a competitive environment where maybe you're doing multiple events in a day and then we need to understand timing of when should I eat them. For most people, if they're working out in the morning, they're maybe doing multiple sessions in a day. They're going to work and they want to feel like they have high energy. They should probably eat a good portion of their carbohydrates earlier in the day, but there is that person who maybe trains later in the day who doesn't have a lot going on between when they train and when they're going to train again, who maybe can get away with not eating as much carbohydrates as somebody else. So understanding that food is our friend, food is fuel and understanding how your body creates, consumes and utilizes carbohydrates for energy can be a really big game changer for performance during and after exercise. We all probably have that patient who seems really active, really fit, but complains all the time of being tired, of feeling weak, of not hitting PRs. And that can be a good person, yes, to evaluate their protein consumption, to make sure that their muscles, their musculoskeletal system is recovering appropriately, but also to have a conversation of what their carbohydrate consumption looks like. If we can up our carbohydrate consumption a little bit, we'll often find that that subjective fatigue, weakness that comes after a training session, especially if we're going to train again later or we have a long day of work or whatever ahead of us, we can alleviate a lot of that just by tweaking our diet a little bit. So I hope this was helpful. If you're going to be on an ice course this weekend, I hope you have a fantastic weekend. Have a great Friday. Have a great weekend. Bye, everybody.  24:46 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 CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

This episode of the PT on ICE Daily Show covers topics such as evaluating resumes when hiring, adding new practitioners to a practice, the importance of written employment agreements, and the significance of getting job agreements in writing to avoid misunderstandings.

The podcast discusses the importance of setting expectations with patients in the home health setting and emphasizes the role of effective communication. It explores the significance of assessing patient suitability for therapy services and the benefits of ending a relationship early if it is not a good match. The chapter highlights the importance of punctuality, accountability, and active listening in building a strong patient-provider relationship. It also delves into setting expectations in the patient-client relationship, including discussing fitness approaches, setting boundaries, holding patients accountable, and goal-setting based on commitment level.

Debunking the myth that weightlifting stunts growth, the podcast discusses the benefits of proper coaching and safety precautions in youth development. It also highlights the importance of weightlifting in developing well-rounded athletes and addresses concerns about potential growth plate injuries. Additionally, the podcast emphasizes the value and importance of weightlifting for kids, highlighting its benefits in terms of progression, mental health, and confidence.

Dr. Jess Gingerich // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich  emphasizes the importance of capturing and recording ideas when creating content. She stresses the need to write down ideas because they may be forgotten later during the content creation process. Jess suggests using a notes tab on your phone to jot down thoughts and ideas. Additionally, she encourages taking inspiration from what you see and not worrying about the possibility of stealing ideas or duplicating existing content. Jess emphasizes the importance of sharing your unique perspective and ideas, as someone who follows them may not be following you. Overall, the episode highlights the significance of documenting ideas to utilize them effectively when creating content. 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 signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show.  01:22 JESS GINGERICH Good morning PT on ICE Daily Show. My name is Dr. Jessica Gingrich and I am on faculty with the pelvic division here at ICE. As always, we have some wonderful opportunities for learning coming your way. If you go check out ptonice.com to see when we are going to be close to you. We have a two-day live course that's going to bridge the internal pelvic floor assessment with return to strength training, endurance training, gymnastics, and so much more. We also have an eight-week online course that is a wonderful starting place in treating the female athlete. If this is something that's been on your list, head over there and snag your spot. I'm going to actually take a turn and instead of talking about pelvic things, I'm going to talk about social media. Social media kind of from the lens of someone who has been doing it for two and a half years, so not all that long. I don't have a degree in it, so I would consider myself somewhat of an amateur with this, but also kind of talking about it in the space of pelvic health and how scary that can be because there are already a lot of really negative things around pelvic health and putting that on social media can be really difficult. 02:17 SOCIAL MEDIA & PELVIC HEALTH So again, I've been active on social media posting things about pelvic health, pregnancy, postpartum, and other various PT related things for about two and a half years. I was encouraged by the ICE faculty to just kind of do it, just do it, show up, post, don't think too much about it. And I remember feeling all of the things around this. I was nervous, I was scared, I was excited. I've felt things like, I just want to quit. I've also felt the things where I just want to push the gas pedal down and keep going. I've felt all of the feelings. So my nerves tend to get exacerbated when I think about, you know, what are people going to think about what I'm posting? What do I do when someone comments something mean or negative? What if I, when I share something, it's not enough? It is a topic, but there's a lot of different kind of things that you could post about it. Really the list kind of goes on. So what I want to do is I want to share some of the things that I've learned along the ways along the way, as well as breaking down some of those fears. 04:08 BREAKING DOWN CONTENT CREATION So first, if you have an idea, write it down, because you will not remember when you come back to it and you are thinking about the time that you're, you're creating content, filming stuff, you're not going to remember. So write it down, have something in your notes tab on your phone where you can write down and jot down kind of what you were thinking. If you see something that inspires you, just do it. You can take an idea and turn it around and make it where it's going to resonate with the people following you. Does not mean you're stealing an idea or that that's already out there. Post it because someone who's following me may not be following you. If you are feeling overwhelmed, take time off, turn your app off and go on a walk, do something different. That idea that post will still be there when your mental health is better. So let's break down some of the feelings. So what will people think of the post that you're posting? First of all, everyone's going to have an opinion. Everyone has an opinion. And what if they think instead of it being negative, what if they think it's helpful? What if it drives this person who needs you to view? Obviously you will have other opinions that trickle in and when they do, just think it will increase your engagement, meaning it will reach more people. The wonderful thing about having this kind of thought is that if you are an ICE trained physical therapist, you know the importance of positive messaging around anything. So if you are posting something and it's not negative, it's not going to encourage someone to not work out to stop what they're doing. Post it. What about all the negative comments that you see on so many other reels and posts? You will inevitably get those. They will come in, but sometimes it's really hard to read the context behind text. So when you first read a comment and you aren't filled with those butterflies and unicorns, like, oh, they really love this. This is awesome. Close the app, take a breath and think about the response you want to give. This is a great time to educate someone who doesn't know. Remember you are the expert and even like validating them can be very helpful. So this kind of leads me to my next point. What about not sharing enough? So for example, what if you get a comment from what like SoccerMom87 and she says something along the lines of you didn't address this? Well, that's a perfect time to come and say that's actually something that I was going to address on my next reel. Thank you for bringing that up. So now you have something that you can create another reel on and you didn't even have to think about it. I think sometimes people forget that you have a 12 second reel that you're trying to get some kind of educational piece around. And so you can break up your reels and that way you have content over the course of however many weeks. There are so many feelings around social media and the trolls will be there, but so will the people that are in desperate need to find the right person. So if you are sitting on your post, you've got several drafts in your Instagram drafts reels, post it, just post it, reread it, make sure there's no typos. And even if there are, that's okay. Just post it. I want to encourage all of you to go to my last reel. It is about running and peeing in your pants or maybe it's my second to last reel. I was totally off beat with the music that I found or that I use for it. I even made a funny face on the reel because I realized I was off beat, but I had a patient coming in. I wanted to get that content filmed and I wanted to get it posted. 08:00 JUST POST IT So I kind of said screw it and posted it anyways. And I've gotten a lot of love, a lot of like, hey, I love that you just kind of posted that and you recognized it. But I also have gotten some comments about the what ifs, like what you didn't post about this or what about that. And that's all I care about is that that's driving more traffic to this. I want people to know that they can run without peeing in their pants. And so the comment that was left, I just said, hey, that's a great point. I love it when this when that person can come into that visit. So if you are nervous, I want to encourage you all today's Labor Day. So I know most of you are off, but just post the reel or the carousel, whatever you have waiting in your drafts. And if you do have something that you post today and specifically one that you didn't want to post, I want you to tag me and I will love to share it and hope that it brings more people to you. So I hope you guys have a happy Monday and a wonderful Labor Day and we will see you next time. 09:33 OUTRO Hey, thanks for tuning into 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 CU's from home, check out our virtual ice online mentorship program at PT on ice dot 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 PT on ice dot com and scroll to the bottom of the page to sign up.

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the evolution of cycling pedals, including clipped in riding, and changes in the safety & efficiency of clipless pedals.  Take a listen to the episode or read the episode transcription below. If you're looking to learn professional bike fitting from our Endurance Athlete division, check out our live 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 slash 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 slash physical therapy. Thanks everybody. Enjoy today's episode of the P10i's Daily Show. 01:26 MATT KOESTER Alright guys, welcome to another episode of the PT on ICE Daily Show. I'm Matt Koester, lead faculty in the endurance athlete division with a specific specialty in bike fit. The title of today's episode, clipped in, clipless and clueless. I want to spend a little time today diving into a topic that I think is really fun. It's also really, really confusing, especially for people who don't understand the cycling industry, the cycling world. It's a very, very basic part of terminology that I think will help you to get a little bit more credibility having conversations with cyclists when you're discussing the pain that they're experiencing. Before we dive fully in on the topics for today though, I do want to take a moment and just give a quick shout out to our last bike fit host, bike fit course of the year. That's going to be down in Knoxville, Tennessee, September 23rd and 24th. Sadly a sad thing to say, our last one of the year, but we are super pumped for it. And if you're unable to make it and join us this year, have a good look into next year. We are currently ramping up probably what's going to be the biggest year for this course we've ever had. We'll be coast to coast and all over the place in between. So we're really, really excited for that. But if you like what you hear what we're talking about today, you want to learn more, you want to dive in, you're definitely going to have an opportunity to jump in in about a month. You can also learn from us on virtual ice where I'm going to be doing some podcast, some lectures on this content in a little while as well. So those are the things that are coming up down the road. 04:07 EVOLUTION OF PEDAL TECHNOLOGY As we shift into today's topic, as I mentioned clipped in or clipless those are some of the things that you're going to hear people talk about all the time and they can be relatively confusing and what we really mean is how is the foot interacting with the pedal? So the big part to talk about here right away is just terminology. I just want you to be able to hear somebody talk about this or bring it up yourself and actually know what the heck it is because otherwise it's really confusing. So in general, I brought some props today that I think will be helpful. If you're watching this on Instagram, it'll be really easy to keep up watching on YouTube. Same deal. If you're on the podcast, I certainly recommend you jump back onto one of these platforms so you can see if you're a visual learner because it'll help out in that sense. We're all pretty used to this style of pedal. It is just a flat pedal. Both sides look the same. Basically this is just going to go right into the crank. If you put your foot on it, they're going to go forward. That's as simple as it gets. At some point during the evolution of the sport of cycling, the idea was our feet are jumping around and we want to be more efficient on the bike. So how can we try to improve that sensation, be more connected to the bike? Well, the idea for the clipped in version of this, the original idea behind that was actually a cage or a strap that went over the foot and it had a little clip on the side that allows you to snap that thing down and it would lock your foot to the pedal. Some of them had plastic, some of them were really truly just more of a fabric cage, some of them were like a strap. Now, I don't have one of those with me today, but it is funny. My Nordstick rig mount actually is a perfect example of this. I'm going to use this for the purposes of this. Foot would slide into this space. It would be set down and then you would basically cinch and pull down on the strap on the side. What that would do for it was essentially lock the foot to the pedal. We were seeing cyclists get more efficient. The feet were mousing up the pedals. They were quicker, all kinds of good things there. 07:31 THE CLIPLESS PEDAL The next evolution of that was the clipless pedal. Now the clipless pedal or clipless pedal shoe interface, the idea was to get rid of this strap. I'll talk more about why you really want to get rid of that in a second. Just to explain that piece, if we talk about we went from flat pedal to one that had a cage over it or a strap to now this thing that we're used to seeing all the time, which has just these little pincers on it, these little things that grab onto what's at the bottom of the shoe. What that does is it operates kind of like den settings on ski boots and the way that they interact with your skis. When you step in, they click in, you're in a spot where now you can move around and do what you need to do, but if enough force is applied to it in a sketchy situation, whether beyond the mountain or on the road, they will come out. And in fact, on the bike, they come out pretty darn easy and it's usually modifiable to do so. The reason they're called clipless pedals, even though you are clipping in, is because they don't have that toe cage on them. And the main reason to get rid of that toe cage in many ways was actually a safety thing, as well as just an improvement upon the actual interaction between the foot and the pedal. The safety side of this is if I'm falling down and I'm going to the ground and I have an option to save myself by getting my foot off the pedal, if I'm running a clipless shoe or a clipless pedal interface right now, if I twist my foot a little bit or pull, it's going to come right off and I can put that thing on the ground and I'm going to be in a really good spot to save myself or at least not be attached to the bike when it goes down. Now the other side of that is if my foot is in this cage and I have strapped my foot down and it is nice and snug, when I go to tip over, my foot's not coming out of that. That's going to be really hard to get out. You're going to see those cyclists go with the bike, get slammed down to the ground. It's safer. That's the first part of it. That's kind of nice. It does seem a little bit scary to some folks to attach their feet to the pedals, especially when they're used to going from this to what now is this shoe that feels clunky and hard to walk in but snaps in just the same. Now that right there is just the general gist of it. So flat pedals, the original clip pedals just had a cage, went over the top. We go to clipless pedals. Those things are basically the shoe attaching to the pedal itself, easy to twist and pull in case of an emergency or kind of a sketchy situation. Now why does this matter to our patients? Why would they make that shift? I'm going to be honest with you that the first one that most people are going to actually say, it just looks more professional. It looks more legit. They've been riding with a couple of friends. Everybody's been riding clipped in and they're like, dude, why are you still riding flats? Well at that point, they're ready to make that jump. They've been doing this for a while. They're thinking to themselves, everybody else is doing it. They're thinking it's going to be more stable. They're thinking it's going to make me look better. You know, that's an important piece in this whole thing. You want to fill in with your peers when you're out for your rides. On our end though, and more importantly, it's going to give that person a reference point, a starting point, especially in the bike fit world. What we are trying to do is essentially get rid of as many variables as we can or at least control the variables that we can control. That way, when we talk about making modifications to some of these bike, we're actually going to know where we started from. In the bike fit process, it starts from the floor and it works its way up. We start at the feet, we go to the seat, and then we go to the hands or back to the feet if needed. In that scenario, there's a good chance we could spend two thirds of a 90 minute appointment doing just things with the feet, getting this all set up. In the case of somebody who has, let's say knee pain, I want to kind of pose this for why this nomenclature, why this stuff matters. Someone who's in a case where they have active knee pain while riding their bike. Let's liken this to somebody who comes in and says, I have knee pain with squatting. If I say, what type of bike are you riding? And they say something about their pedals and they're like, yeah, I've been riding flat pedals. What that tells me is that they have no idea where their feet are the majority of the time. Imagine somebody coming in who has knee pain with squats and you're like, hey, show me your squat. And they step back and they spread their feet out and they do one and then they kind of bring them in and they do another one and they're like, I don't really know where I want to be at and this is actually kind of what I do every time I'm at the gym. I don't know where I want my feet to be at. It'd be pretty hard to get good information from that, to not know where you're starting from. So in the case of somebody who's dealing with a specific pain complaint, it's nice to be able to at least educate them on, hey, I'm going to make sure that you have a reference on your flat pedal for where your foot should go. 09:45 SOLID FOOT POSITION WITH FLAT PEDALS But more importantly, if you're serious about this and you're doing it long term, we should get you a set of clipless pedals and a shoe that interacts with it appropriately. That way we can find the position that you're comfortable riding in. Because as soon as we know that we have a fixed position at the foot, we can then go adjust the seat and just other factors that are going to improve that person's knee pain. But if you don't know where their foot is relative to the pedal or relative to the crank arm and you go to adjust things on the seat, it's very unlikely you're going to get to where you want to be. If they move their foot even a half centimeter forward or back, all the angles that you used as a reference are going to be totally off. That can be a really frustrating place to start from. Now this isn't to say you can't do bike fits with somebody who is using flat pedals. We are going to talk about references. In the course a lot of times we talk about just saying that first MTP, that first knuckle, trying to get that in line with the pedal spindle, so this center piece as it attaches into the crank arm, is going to be a good reference for that person. But at the end of the day, if that person is A, riding on rough terrain like a mountain bike, every bump is going to shift their feet a little bit. Even with some of the best pedals out there where things stick well to the pins or the more pointy parts of the pedal. Shifting that person over to clipless pedals is going to allow them to stay in one spot the whole time. They may know the reference, but at least they're not going to get out of that reference position, so that's going to be really, really important for this person. Or that person, maybe they ride really consistent terrain, but they're getting better at the idea of improving their cadence. They're talking about trying to run 90 RPM for an extended period of time, which is the recommended RPM in most cases, especially on a road bike, for being the most efficient in any given gear for any given scenario, whether it's going up or down or in a good position. When you try to carry that much RPM on a road bike out in the street, it is actually pretty darn hard to keep your feet fixed in one position and staying still. That is actually a pretty big challenge. So for that individual, when they attach their foot to the pedal, all of a sudden now they can push the pace go faster because their feet aren't trying to slide off. There's less clunkiness in that pedal stroke. They're going to move a lot better at higher RPMs and be less frustrated trying to do so. More power down in those scenarios. Now the last thing for that person who is jumping into this or is curious about jumping into it, is what it does is it's going to, as I mentioned, smooth out the pedal stroke. So as somebody starts pedaling, in general we are putting the most of our power down. That is where we are most efficient. Our quads, our glutes, everything that drives down on the pedal, working with gravity, is what's going to propel us forward. However, that's not to say that it's not valuable to be able to pull through and pull up and over with the other foot. Now it's not your main power, it's not a big driver of the motion, but it does allow you to create a much more smooth and cyclical cycle stroke. 14:43 SAFETY & EFFICIENCY OF CLIPLESS PEDALS So the idea here is if you could have your feet attached to the pedals, you could have more influence over that pedal stroke. You can pull through, you can pull that foot up and over, you can counter what's happening on the other side so that things get much smoother and much more efficient. Athletes that go to a clipless pedal, that go to being clicked into the pedal, are going to have way better engagement when they're trying to run higher RPMs, pedal smoother, and be more efficient in the long run. Now the last thing I want to talk about is that safety piece, again, just because this is one of the things that always ends up being the determining factor for somebody jumping in or not. In general, people know that it's probably a more professional thing to do, but they're kind of like, ah, I don't know if it's for me. The truth is, there is a bit of a hurdle. There's a bit of a hurdle in terms of safety. Somebody gets on, they're nervous about getting on and off the bike, they think they're going to get to a stop sign and fall over, and in all reality, it does happen. I mean, it happens like the very first time everybody rides, you get one situation where you clip your right foot out because you're going to put your right foot down, but you end up leaning left and now your left foot's stuck in and you go over. It happens. You want to try to avoid it, but this is how you actually would do that, try to avoid it. The idea would be if you're on your bike trainer or with a friend holding it still, the idea is you click in, get your foot set, maybe you stand up, sit back down, take your foot out, put it back in. The idea is just get exposure to that mechanism and how that interacts so that you can get your foot in and out easily. As I mentioned really early on, we also have this little setting on the pedal that allows us to change, I kind of like the DIN settings on your skis, but you can change how easy it is for someone to get in or out of those pedals. For the beginner, getting out really easily might feel great. They might really, really like the idea that, okay, this is super easy to get in and out, but as soon as they go to put power down, they might be a little bit irritated by the fact that their foot keeps clicking out. They may want to crank that thing up because now they understand how to get in and out, they're more confident, they want to put the power down and pedal hard. Same way, an aggressive skier, he doesn't want those DIN settings super light. In fact, some people get to that point where they'd rather die than have them come off. People want those things firm so they can do what they need to do. So a couple of things just to wrap this whole piece up. The clipless pedal is a really interesting misnomer. The idea is it gets rid of the clip that used to be on the toe cage. It gets rid of that idea that now when I go to dismount the bike, my foot is locked in so I can't get off. So clipless pedals get rid of that locked in position and give you more of a temporary lockable position so that you can be more efficient while you're pedaling on the bike. To our patients, a lot of times it's just like the next evolution in their cycling journey. They end up wanting to go that route because everybody else is doing it. They know that it's a more professional look, it's a more professional feel, they know that it's a more efficient ride. For us, we love that because if we can get that person into that type of a shoe, into that type of pedal interface, we know that when we go to fit their bike, talk about the pain they're experiencing, we have a reference point that's going to be consistent and fixed the whole time. If we don't know where we're starting, it's hard to fix the issues that pop up. If you're going to come to a bike fit course, you're going to learn that we spent a lot of our time on the pedal and this is a big reason why. Understanding where somebody starts, understanding what you can modify and understanding how that can affect somebody's symptoms are paramount in this space. Alright, that's all I got for you. Have a great Friday, y'all. Appreciate your time. Thanks for jumping on. 16:23 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 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 highlights the key principles behind growing & scaling your practice, using McDonald's as an unlikely but successful example. 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 Good morning, PT on ICE Daily Show. Happy Thursday morning. Hope your day is off to a great start so far. My name is Alan. Happy to be your host today. Currently, I have the pleasure of serving as Chief Operating Officer. I'm a faculty member in our fitness athlete division. We're here on Leadership Thursday. We talk all things practice, management, ownership, small business, leadership, that sort of thing. Leadership Thursday means it is also Gut Check Thursday. Gut Check Thursday this week is a workout I actually did this past Monday. It is 9, 15, 21 calories on a rowing machine, power snatches with a barbell, 75 pounds for gentlemen, 55 pounds for ladies, and pull ups. Ascending reps game automatically. You should proceed with caution as you get more tired. The reps go up, something we don't like to see too often. Also very redundant in this workout on pulling and grip, right? Pulling on the rower, you have grip on the barbell, and then you have grip and pulling up on the pull-up bar. So it gets redundant, gets really grippy, even with that light barbell. That barbell should be so light you could do all of those rounds unbroken if you really needed to. Maybe one break in the round of 15, maybe one or two breaks in the round of 21. Definitely should be aiming to get that workout done under or around the 10-minute mark. I did that, rested three minutes, and then did 9, 12, 15, rested three minutes, and did 6, 9, 12. I don't recommend doing the extra two rounds. Just stick with the 9, 15, 21. That's plenty of fitness for the day. Courses coming your way from us here at IEFCE. I want to highlight our Extremity Management division led by Lindsay Huey, Mark Gallant, and Cody Gingrich, the newest lead faculty to join the Extremity Management team. You can catch those three out on the road this fall. A couple of different courses coming your way. September 9th and 10th, Mark will be down in Amarillo, Texas. Lindsay will be out in Torrington, Wyoming. The next weekend, September 16th and 17th, Mark will be on the road in Cincinnati, Ohio. The weekend after that, Lindsay will be on the road September 23rd and 24th in Twin Falls, Idaho. The first weekend in October, the 7th and 8th, Lindsay will be up in Ridgefield, Connecticut, and Mark will be in Rochester, Minnesota. November 11th and 12th, Mark will be down in Woodstock, Georgia, which is north of Atlanta, kind of out in the suburbs. The weekend of November 18th and 19th, Mark will again be on the road, this time in Murfreesboro, Tennessee. That's a little bit southeast of Nashville. Cody's first weekend as a lead faculty in the division will be the weekend of December 2nd and 3rd. That'll be out in Newark, California. That's the Bay Area, the Fremont area. And then December 9th and 10th, the last chance to catch extremity management for the year will be in Fort Collins, Colorado with Lindsay. So that's what's coming your way from the extremity division. 03:21 GROWING & SCALING YOUR PRACTICE Today we're going to be talking about hiring from the viewpoint of growing and scaling your practice. And I want to highlight the McDonald's story. So I want to talk about kind of what's always in our mind when we're thinking about growing our team, which is that little voice in the back of our head that says, geez, I hope the person that I hire is mostly like me, right? When we think about growing our team, we're often thinking about how to basically mirror or replicate ourselves. And while that's not 100% possible, that is the goal as we grow and scale. That what we're really talking about when we're bringing new people on the team, we're growing our current practice. We're thinking about maybe even a second location. We're thinking about maintaining our standards of how we run our business, of how we practice physical therapy and preserving our company's culture. So we're going to talk about the who, the what and the how. The who today is going to be McDonald's. Yes, McDonald's, the Golden Arches, the fast food company. The what is going to be talking about how they grow and scale their businesses. And the how is going to be the foundational training that every member of the team has, how that relates to your team as a physical therapist growing your practice and how shared belief systems are really important. So as a company grows, those things tend to get diluted over time. Over multiple generations of leaders and employees, teammates, whatever you want to call the folks who work with you. As we tend to get many generations deep, we noticed a subtle decline in quality and culture of when you first went to the business, when it was a single owner operator, you knew the owner. You knew how things went. You had a relationship with that person. And maybe when you come back to that business, our business in this case being physical therapy, maybe you can't see that provider before. Maybe their schedule is full and they offer to have you see another provider. As the customer is the end user, how do we know that that person is good as the first person? And how do we know that the 10th person is as good as the third person? And so on and so forth. And unfortunately, what we see happen is companies tend to grow, especially as they tend to grow to new locations and maybe even start to franchise. We see that that stuff just gets diluted over and over again until the current business that we are going to no longer resembles the initial encounter with that business. Maybe even to the point that as the customer is the end user, we decide not to give that business our money anymore. So how do we avoid that? How do we avoid the customer coming to that conclusion? 07:26 THE WHO: MCDONALD'S Well, we need to start with the who. We need to start with McDonald's. If you're not familiar with McDonald's, we'll talk about that and we'll talk about how they grew and really the foundations that allow them to grow there. So love or hate them. Everybody has their thought immediately in their mind, their knee-jerk reaction about McDonald's, but they certainly know how to run a business. They know how to deliver a consistent product. That product, at least in my personal opinion, may be quite mediocre. But dang, when you go to McDonald's in Texas or McDonald's in Michigan or McDonald's in Seattle, it doesn't matter. McDonald's in Hong Kong, it is maybe mediocre, but it's consistently mediocre, right? A McDonald's hamburger in Texas tastes the same way as a McDonald's hamburger in New York and the fries are the same and the experience of purchasing from McDonald's is largely the same as well. So they know how to deliver a consistent product and we want to figure out how they do that. They also certainly know how to grow. McDonald's has been in business for 83 years, almost 100 years of continuous business. We've talked here on Leadership Thursday before about how many businesses don't make it to the one-year mark, to the five-year mark, that about the 10-year mark, 75% of all businesses are gone. They have gone out of business before they reach the 10-year mark. So to have been in business almost 100 years continuously is quite impressive. They are the largest restaurant business in human history. They have $24 billion a year in gross revenue. Now that is an amount of money that can be hard to conceptualize. Let me break it down for you. If you haven't heard of ATI Physical Therapy, they are the largest chain of physical therapy clinics in the world. They only grow $600 million a year in annual gross revenue. So any town that is big enough to have a McDonald's, a Walmart, probably also has an ATI Physical Therapy for reference. Nonetheless, McDonald's is almost 40 times larger. They are present in 120 of the 195 countries on the planet, and they are the fourth largest employer in human history. Of the largest employer on the planet currently is Walmart. The second is the Chinese Government Railroad. The third is the Chinese Government Police Service, and the fourth is McDonald's. So of the jobs that you could currently get, you can't go work for the Chinese Government Railroad or police service. You can't just go drop an application and start. We're talking about the second largest American-based employer on the planet. Now if you haven't seen the movie The Founder, I highly recommend you watch that movie. It's one of my most favorite movies. Every time I watch it, I take something away from it. Came out in 2016, and it's really kind of the tale of the start of McDonald's and the growth of McDonald's across the country and eventually the world. 11:27 THE WHAT: SUCCESSFUL GROWTH So that's the what we're going to talk about today. We're going to talk about the franchising of the McDonald's Corporation. Amazing movie. Nick Offerman and John Carroll Lynch play the McDonald's brothers who formed the first McDonald's out in California many, many, many, many years ago. And Michael Keaton does a great job playing Ray Kroc, the guy who finds the McDonald's brothers and becomes the person that franchises McDonald's into the business that it is today. So the original McDonald's started out in San Bernardino, California. It was a one-location restaurant run by the McDonald's brothers. They had a very systematic way of approaching a business. They practiced and trained and redesigned the restaurant again and again and again to optimize efficiency, to basically make burgers and fries and shakes as fast as possible in the almost pre-drive-through era of you had to drive to McDonald's and walk up to the window and order your food. And they created a wonderful, flourishing business that Ray Kroc stumbled upon. He actually was selling a machine that could make six milkshakes at once. And he was hand delivering it to the McDonald's brothers out in California when he watched just how busy their restaurant was all day long and decided this, these guys are onto something. If we could take this business and multiply it, we could really make a lot of money. So those brothers practiced. They had their employees practice work, right? They trained almost military style of running and operating their business. And they did so with a systematic approach, a fundamental approach to how to cook and serve food in a high quality, yes, but also a consistent and efficient manner. And it was built upon a common foundation of training and also of shared values of we want to deliver a high quality product, but we want to do it efficiently. People don't want to sit and wait 30 minutes for a hamburger. They want to be able to walk up to this window and a couple of minutes, get their food, pay and be on their way. Right. The person that's on lunch break or grabbing a bite to eat after work or before work or whatever, walk up, grab your food, go again in the pre drive through area, definitely the pre door dash era of delivering a high quality product. Very, very fast. So Ray Kroc stumbled upon these guys and started to franchise it. Initially did not go the right way. And I think it's important to know that it did not start off in an amazing way that immediately started cheapening ingredients, started using premixed milkshakes instead of actual milk in the milkshakes and initially started with a model that had really minimal control over new locations and leaders. And early on, and you'll see this if you watch the movie, McDonald's all over the country was completely random and different as far as what you might expect. You might find a McDonald's in Illinois that sold hamburgers and french fries and milkshakes, but you might go to a McDonald's in Wisconsin and find barbecue food. You might go to a McDonald's in St. Louis and find them selling tacos. So they kind of had a rocky start that they got away from their foundations. They no longer kept that regimented training, that regimented shared value systems. But I'll tell you the tale of how they turned it around. One of the cooks that worked at one of the original McDonald's, his name was Fred Turner In 1961, he created a training system called what is now known as Hamburg University of saying, hey, this is getting crazy. Every location that the customer goes to, they might be serving completely different food. There may be a completely different experience. They might be dirty at one location, unbelievably clean at the next, a different food just all over the place with consistency and quality. We have to fix this. And that kind of evolved with Fred Turner working alongside Ray Kroc into forming now what is known as the present day McDonald's, which again, the food may not be the highest quality, it might not taste the best, but darn it, it is consistent. And that is really the values that McDonald's presents today. Consistency and simplicity and uniformity with a goal and a shared belief system of quality, service and cleanliness. So they formed this university back in the 60s, Hamburg University. They now have locations in eight countries. They started in 1961. That guy, Fred Turner, who was just a cook, worked his way up and eventually became the CEO of McDonald's for 20 years and really kind of led the global expansion of McDonald's across the planet onto every street corner in America, into 120 countries across the planet. Down to really specific stuff. He was really insistent that fries had to be cut 0.28 inches thick, that one pound of beef should make exactly 10 1.6 ounce patties, so on and so forth. Consistency, the ability to replicate that business across not only shifts at the same location, but at every location across the town, across the state, across the country and eventually across the planet. So that is the who, that is the what. 13:59 THE HOW: SHARED TRAINING & BELIEFS Now we need to talk about how, how did they get there? Again, they had a rocky start, but how they arrived at where they're at now, again, one of the largest, most successful businesses in the history of our species. How did they get there? They get there these days by being very, very selective that each addition to their team is of similar quality to the rest of the team, that they have a shared belief system and that they all go through the same foundational training of when you are maybe a line cook or fry cook or you work the drive through McDonald's. Yes, you are just an hourly wage employee, but once you are maybe going to get promoted when the regional manager, when the owner decides your management material, you go to Hamburger University. If you are thinking about starting a McDonald's franchise, you also go to Hamburger University. They are very selective in who goes to Hamburger University. Only 1% of the people who apply get accepted. And the goal of Hamburger University is to teach managers and owners how to run a McDonald's to the McDonald's standard. Again, we have that common shared training foundation. We are hiring people with a shared common belief system. We are allowing the business to grow and scale without the end user, the customer being really able to notice any change in quality. McDonald's is doing it right. If you leave your house at 6 a.m. and you have a 12 hour road trip and you grab a coffee from McDonald's and a McMuffin at the start of your journey, if you stop at McDonald's four states away for lunch or dinner, it should feel almost exactly like the McDonald's that you stopped at at the start of your journey right by your house. It should really be no different. And even you have probably done this and if you haven't done this, you are a liar. You have gotten a drink at McDonald's in the morning on a long road trip and you have stopped maybe at multiple McDonald's along your route to get a refill of your drink. And again, if you haven't done that, you are probably lying. A lot of us have done that. So that replicated experience location over location over location. And I think we have a lot to learn from that model. And that model does not start with putting money first. It does not start with putting numbers first. It starts with making sure that we are incredibly selective of who we let join our team. And so that brings me to the how. How do we do that? We do that by being extraordinarily picky with who we let join our team. A lot of people will see your clinic, your business, whatever you are doing, being very successful and they want to invite themselves to come on board the ship. They are happy to stop by and drop off their resume and let you know that they are ready to start a position whenever you are ready to start paying them. And oftentimes we find ourselves as our business, our clinic, our practice is growing. We need people more than we care about exactly who that person is. And we have the mindset of we can train that person later. We can mentor that person later. All that matters is that I have more patients on my schedule than I can see. I have a month long wait list. I have a three month wait list. I have a six month wait list. And that's money I'm not capturing now. So I'm just going to hire that person who walked in the door and threw their resume on my desk. And we can't do that. Not if we want to replicate a really high quality experience, a consistent quality experience for our patients and our clients. Not enough businesses are picky enough at this process of making sure that person has the same beliefs that we do, making sure that we have a common shared foundation of training. Us here, we now only hire students who do a long rotation here or folks who have passed the ICE certification exam. That's where our standard is at now. That tells us that person either we have trained them in our training, our foundation as well, and we find out if they have our common belief systems or not, or we know that is on board already because they have passed such a rigorous certification as the ICE cert. But not enough of us are that picky. 17:23 WHEN GROWTH GOES WRONG And what happens if we don't do that? What happens when growth goes wrong? I want to just share a hypothetical example, speaking of the extremity management division today. Imagine that folks just have maybe even a little bit of a difference in what they believe and what they have been trained to do as physical therapists. And we say, you know what? They're only like 20% different. It doesn't matter. It doesn't really matter at the end of the day. Let's just hire this person anyways, even if they are maybe 20% different than the rest of the folks already on the team. Let's take an example of Lindsay and Mark from our extremity management team. Let's say that Mark believes that the foot, the ankle and foot, has no orthopedic value whatsoever. When he teaches his course, he just kind of glosses over that material and maybe even ends his class early. He ends faster than he planned to, right? Maybe he just kind of flips through the slides, shows a couple techniques, maybe an exercise, and he says, you know what? The ankle is really not that important to the body. Have a great weekend. Thanks for being here. Bye. And we're done at 3.30. Now, as we take that person who is now going to train more people underneath of them, the next person Mark trains is likely going to give even less attention to the ankle and foot. They're going to pass over even more of the fine details. And you can imagine if we take that now several generations deep, three, four, five generations deep, that that next person teaching extremity management may not even teach the ankle and foot, right? They may delete it from their slides entirely. Hey, we don't teach that in this course. Which is not true at all, right? Now we have a consistency problem in the product. What about the other end of the continuum? What if Lindsay believes the opposite? What if she believes the foot is the most important structure in the human body? What if she believes that great toe extension is linked to developing Alzheimer's disease? What if she spends so much time on the ankle and foot when she teaches extremity management that now her classes run until 7 p.m. on Sunday? Again, we have for a different reason, a consistency product, a consistency problem with the product we're delivering. Now again, that same example, as we get multiple generations deep, you could imagine the next person Lindsay trains underneath her maybe believes the foot is even more important and spends even more time on the ankle and foot. And maybe three, four, five generations deep, that person spends all of Sunday talking about the ankle and foot. We don't even talk about the hip and the knee anymore. Everything's about the ankle and the foot. And eventually what we come upon is a divergent offering of the same product. That the consistency of the product is diminished or absent entirely. And we have an entirely splinter product being offered. We're now offering two separate products from the same company, even though up many layers above in the leadership position, we're trying to figure out why the inconsistency is there. And it comes from not having that shared common training foundation and that shared belief system. So who is McDonald's? What is how they have franchised across the planet into one of the most successful businesses And the how is being really particular in who you let on your team and making sure that they already arrive with similar belief systems about how to practice physical therapy in a common training foundation. So many people arrive, new students, new grads with a wide variety of beliefs depending on where they went to school, what continued education courses they may have taken after it really can lead to that divergent offering of product that really creates a consistency and a quality product for your business over time. And again, in our mind is the original owner, the leader of the business. That's something we're trying to avoid at all costs. When we think about hiring new people, we're thinking about how can I essentially copy myself as much as possible so that when people come to see this new person I've hired or this eighth new person I've hired or my new location, how can I be sure that they get the same consistent product that I initially delivered when I started the business and it comes down to that shared common training foundation and that belief system. So that's the first part of this series. I want to take you all through the who, the what and the how. Next time I want to talk about once you have actually found that person, where do we go from there into the nitty gritty of things like operating agreements, things of making sure that our training foundation stays the same as we move through our practice, as we move through time together with these members on our team. I hope this was helpful. I hope you have fun with Gut Check Thursday. I hope you have a wonderful, fantastic Thursday and a great Labor Day weekend. We'll actually see you next week for a little bit of talk on carbohydrates on Fitness Athlete Friday. Have a great Thursday. Have a great weekend. Bye everybody! 21:52 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. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

In this episode, Dr. Lindsey Hughey talks about the importance of encouragement and support in helping patients overcome challenges and develop resilience. She emphasizes the significance of reframing setbacks as part of the process and highlights the power of choices for improving well-being. The episode also explores the mental and physical struggles faced by individuals with hip and knee osteoarthritis, and how they can break the pattern of suffering through regular exercise, physical activity, and seeking support from others.

Dr. Rachel Moore discusses modifying workouts for postpartum athletes, including factors to consider and specific exercise suggestions. The importance of maintaining mental health and reintroducing impact training is emphasized. Various stages of postpartum are addressed, providing modifications and a workout plan. Advice on modifying movements and empowering athletes is also provided.