#PTonICE Podcast

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses that the decision to innovate or imitate is a career-defining choice with long-term implications. The host emphasizes that while collaboration and sharing of ideas are common in any field, blatant imitation is detrimental to one's career. The host distinguishes between collaboration and imitation, stating that imitation involves repeatedly hijacking other people's logos, sayings, or content. The episode provides three reasons why being an imitator ensures a mediocre and short-lived career. Firstly, the process of creation, coming up with something new and contributing in a unique way, is described as the most invigorating aspect of any career. The host emphasizes the satisfaction and impact that comes from thinking differently and having others benefit from one's novel ideas or techniques. Secondly, the episode highlights the importance of authenticity in career success. The host suggests that imitators may experience imposter syndrome because their success levels do not match their actual contribution. They are described as grabbing ideas from others, recognizing what will resonate with their audience, and building their business without truly creating or going through the challenges that lead to breakthroughs. The more their success grows without a true contribution, the greater the asymmetry and imposter syndrome. Lastly, the episode emphasizes the value of continuous creation and innovation for a long-lived and energetic career. The host encourages listeners to keep creating and strive for novelty and harmony in their careers. It is emphasized that the decision to innovate or imitate is a defining one, and individuals should aim to put forth their authentic selves rather than copying someone else's. Overall, the episode argues that choosing to imitate instead of innovate can lead to a mediocre and short-lived career. On the other hand, embracing innovation and creating something new is described as invigorating, authentic, and essential for long-term success and fulfillment. Take a listen to today's episode. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 JEFF MOORE Alright team, what's up? Happy Thursday, welcome to the PT on ICE Daily Show. I am Dr. Jeff Moore, thrilled to be your host, currently serving in the role of CEO here at ICE. It is Thursday, which means it's Leadership Thursday, but it also means it's Gut Check Thursday. Let's talk about the workout. This is going to be familiar to a bunch of you. So this is the workout from the CMFA Essential Foundations Course 21-15-9 Deadlifts Bar Facing Burpees. Quick, painful. Go get some of that. Post your time, post ICE Physio, hashtag ICE Train, hashtag Gut Check Thursday. It's a classic workout, we've done it a lot. It's a really nice benchmark one to challenge yourself in that kind of middle distance, high intensity space to keep coming back to every year and see how your fitness is evolving. So give that a shot. 21-15-9 Deadlifts and Bar Facing Burpees. Upcoming courses, I want to highlight Modern Management of the Older Adult Live because we've got a ton of options. So if you're trying to become the fitness for provider for your older adults in your community, you've got to hit the MMOA Live course. This weekend, they are in Watertown, Connecticut. Next weekend, July 29th, 30th, they are in both, Waukonson's, Georgia and Meridian, Idaho. That'll be the first, that's in Boise. That'll be the first course, I believe, at Onward Boise. So go get some of that. And then August 5th, 6th, they are at Onward Physio in Frederick, Maryland. Important to note, August 12th, 13th, they are in Lexington, Kentucky, and that is at Stronger Life, and that is the MMOA Summit. So if you want to meet all the MMOA faculty, they're going to be at that one course, August 12th, 13th, and that's at Stronger Life. So if you want to see the Stronger Life operation that Dustin and Jeff and the crew have been building out in Lexington, that is a really, really cool opportunity to kind of see behind the curtain and meet a ton of faculty. So go check out those courses. That's Older Adult Live on the road everywhere. So go get some of that action. Innovation or imitation, the career-defining decision. That's what I'm calling this episode. And I am not saying that lightly. I think if you really zoom out, and if we're talking leadership here on Thursday and thinking about looking long, long term at your career, if you decide to innovate or if you decide to imitate is probably the great decider. I mean, let me tell you the three biggest reasons why. But let me first note that we're not talking about sharing ideas, building off of each other, sharing techniques. There is a very reasonable amount of collaboration that is not copying an imitation. We're talking about blatant imitation, right? Where you know who you are, that you're hijacking other people's logos or sayings or content on the regular, right? Over and over again. I mean, if you scroll your feed, it's like you're obviously doing this. You've probably been reached out to. And then on the other hand, many of you probably have your own imitators, right? Where you look and you're like, gosh, that person's always taking my stuff and trying to put a very lame or benign twist on it. But it's pretty obvious what's going on. That's what we're talking about. Being that person, being in a position where you've got that person tailing you, we're going to unpack both sides of it. There's only one line on being imitated, many lines on being the imitator. So three reasons why being an imitator ensures a mediocre and short lived career. Number one, creation. Coming up with something new. Feeling like you really contributed because you saw something a different way or said something a different way and other people legitimately benefited that would not have if you didn't create that process is the single most invigorating thing in any career. That process of thinking differently, of contributing something novel, of having somebody come up to you and say, Hey, because you said it that way, things have really gotten better for me. I hadn't heard it like that. I hadn't thought about it like that. I have not used that technique. And now because you did that, things are better off in my sphere. That process of creation is the single most rejuvenating thing in any area of business. When you look at entrepreneurs, you look at people who are constantly high energy, are constantly seem to be thriving. It is largely because they're tapping into that creation energy on the regular and it gives back three times what you give it. That process of doing things novel and useful is what extends careers. It's what makes careers exciting. It would make it so it makes you get up in the morning and be absolutely beside yourself to dive into that next project. It's what builds anticipation for the next year of business. It is all of the things that constantly give you energy back that make burnout sound like a ridiculous idea because you couldn't imagine ever wanting to stop riding that train of creation. Creation is invigorating. And if you're copying, you're not creating. So you're never getting that energy back. And there is simply a timeline for how long you can go without it. Number two, this is the one that people don't see when they feel like taking other people's ideas is a viable way to continue their business. It's not. And this is why you can't build on a foundation you didn't pour. I'm not saying you can't go take the idea and put it on your platform and get a few likes. You can do that. You can get a short term bump in your business. There'll be plenty of people who didn't know you did it. Like you can do that, but you can't build on it. One breakthrough and by breakthrough, I mean the process of the breakthrough. When you were thinking about a certain idea and you realize in the moment, hold on, there's a better way to do this. There's a better way to say this. There's a better way to build this. That process, that breakthrough, having that moment changes you. Like it really changes you because not only will everybody that you told think a little bit differently or be able to use it novelty, but you changed because your mind saw a different pathway. That change is what's required to make you different, to see the next thing. When you're going through the hard work of trying to make something better and having that breakthrough, that process of when it happens is what allows you to see the next one because you're now different for having had that breakthrough. If you're just hijacking ideas all the time that sound good or look good or think might get you some business, you're not actually changing. You're not developing. You're not going through those breakthroughs. So you're not going to have the next one or the next one. So pretty soon your only option is imitation because you're not doing the work of creation. You can't build on a foundation you didn't pour. Other people's ideas being on your platform does not make them yours from the sense of you are not different for having come to them. So there is no way now that you're going to be able to go from there because you didn't even really get there. So think about how hijacking that process prevents your ability to look even further. The final one, and I don't speak all that much on this topic because it kind of annoys me, but it's important to acknowledge this is where imposter syndrome I think actually comes from. The worst cases of what you would call imposter syndrome, a complete lack of authenticity in an individual in a certain position that maybe didn't earn it, you can kind of feel that, that case of imposter syndrome, the worst cases are when somebody's, and I'm those listening on the podcast, when somebody's success levels don't match their actual contribution, and this is the case of the imitator, right? So somebody who's grabbing ideas from other people and they're catchy ideas, right? They're good at recognizing what's going to resonate with their audience, grabbing ideas from other people, putting them out on their platform, never really creating, never really never going through kind of the trough of challenge that leads up to a breakthrough, never experiencing that, just hijacking ideas and quote unquote building their business. The more their success grows in the absence of a true contribution, the greater that asymmetry, the greater the imposter syndrome. And the problem is the momentum only goes in one direction because like I said, once you start imitating, you're no longer changing, so you can't make the next step forward, so you're never going to. So all you're going to wind up doing is put yourself in a position where people think that you know a lot of stuff or have done a lot of the work when you know you haven't. And the more quote unquote successful you get, a lot of people knowing of your work and maybe even financially benefiting from it, but the more deep down you know you haven't really done any of it, the greater that asymmetry, the more fragile your steadiness in that space because of the absence of authenticity. You know deep down you haven't earned that success and the more that asymmetry grows, the more other people can feel it. The phonier it feels, the more it lacks authenticity. And team, as we talked about over and over again on Leadership Thursday, authenticity realness is at the end of the day, what people really resonate with long term. And you will have less and less and less of that every year, the asymmetry of what it looks like, you know, and what you've actually contributed grows. That is an exhausting place to be. Nobody likes that feeling of I'm going to be exposed. Nobody likes that feeling when it's getting worse and worse and worse and worse every year. It will eventually overwhelm that person. And that's what brings me to the last point of this podcast. For those of you out there who are doing the hard work of creation, who feel like you're often being imitated by that person in town, by that person online, whatever, right? You feel like gosh, I really thought that, you know, I put a lot of effort into that and it kind of got hijacked, right? And you're feeling that chronically. You're not. Because those individuals always succumb to the above. They can't have longevity because creation isn't filling their cup. They can't jump from a foundation they haven't built. And every time they do that to you, their imposter syndrome grows. They know it was your work. They know they didn't and couldn't have thought of it. But they also know other people think they did. And the more that asymmetry grows, it has a breaking point. They never have longevity in the space. So stay in your lane and drive fast. We know how frustrating it can be, right? We know how exhausting it can seem at times. But understand that because of the above, every single one of those people's careers will be short lived and fizzled because all of the above are fixed equations. There's no getting out of that stuff. It's the wellspring of what a long lived energetic career can be. In the absence of those things, it simply can't be. So for those of you who feel like your work is being ripped off, let that be kind of a statement of confidence that I promise you because of all of the statements above, that will be a temporary discomfort for you. Keep creating. Team, innovation or imitation, it is the career defining decision. Do the work to try to come up with novel things that excite you, that excite others, that bring harmony into your career because you're actually putting forth your authentic self, not somebody else's authentic self. Do it right. You only get one shot at it. Cheers, team. I hope that helps on Leadership Thursday. I will see you over here next week. PT on ICE.com. It's where all the goods live. Have an awesome Thursday. 13:18 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 PT on ICE.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.com and scroll to the bottom of the page to sign up.

Christina Prevett // #GeriOnICE // www.ptonice.com  In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Christina Prevett discusses the significance of research in the field of physical therapy is along with the importance of translating that research into evidence-informed practice. She acknowledges the substantial nature of their research and highlights the necessity for clinicians on the front line to have access to this valuable information. Staying up to date with available evidence and combining it with clinical expertise and patients’ experiences and desires is emphasized as crucial for clinicians. The episode also addresses several gaps in research that need attention, including the need for rehab research for individuals in sitting positions, outcome measures for wheelchair users, and managing conditions in neurological populations. The host expresses frustration at the lack of clinically relevant outcome measures for wheelchair users and emphasizes the need for research to support the role of rehab in enhancing quality of life and managing various conditions. Overall, the episode underscores the importance of research in informing and improving physical therapy practice. Take a listen to learn how to better serve this population of patients & athletes. If you’re looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don’t forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What’s up everybody, welcome back to the PT omn ICE Daily Show. Before we jump into today’s episode, let’s chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they’ve made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can’t miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you’re sure to use the code ICEPT1MO when you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody.Enjoy today’s show. 01:33 CHRISTINA PREVETT Hello everyone and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty in our geriatrics curriculum. So in our geriatrics curriculum, we have three courses in CertMMOA. We have our online eight-week essential foundations course, our online eight-week advanced concepts course and then we have our live course. We are on the road in the summer and into the end of 2023. So our books are closed for 2023. So we have all of the courses that are going to be on the 2023 calendar on the calendar. And so if you are looking to get into one of our courses, know that there isn’t going to be an option for something closer until we’re kind of booking for 2024. So this weekend, Julie is going to be in Watertown, Connecticut. And then the next weekend, 29th, I guess it will be two weekends, 29th, 30th, I’m in Watkinsville, Georgia. There’s still some room in those courses. And so if you guys are interested, just let us know and come hang out with us for all of our geriatric research and all of our geriatric course material. Okay. In today’s content, on Monday, I talked about gaps in pelvic health research. So I’m on our pelvic faculty as well. And so today I’m going to take the exact same approach and talk about gaps we see in the geriatric research. I am obviously in full blown research prep mode. I am defending my PhD on resistance training in older adults, at risk older adults at the end of July. So you’re going to see me full blown in the research space. And so hence the topic of these podcast episodes. When we are comparing different areas of literature, and we’re talking about geriatric rehab in particular, one of the things that I want to start out with is that the state of our research in geriatrics is actually pretty good. You know, we are pretty far ahead when it comes to comparing to other areas. Like when I compare to pelvic health research, there is no comparison. I can off the top of my head bring out 10 studies that have never actually even been done before in our pelvic health research, but I cannot say the same thing in geriatrics. I had to really, pardon me, I had to really think about where I thought our gaps were. And obviously I’m thinking about this around my contribution to the literature with respect to my PhD. So the first thing that I wanted to talk about is the fact that our research is pretty good. You know, we have a lot more in this space and now we’re kind of going into the nuance of our rehab and how to translate the research that we do have so that clinicians who are on the front line have access to that research and can really truly embrace evidence informed practice where they are up to date with the evidence that is available. They’re taking their clinical expertise, they’re taking their patients experience and desires and kind of combining them together. So that’s the first thing. So I’m going to be talking about four, three or four different gaps in the research that we have so far and what this means when we are making recommendations or we are thinking about them with respect to our plan of care for our older adults. So the first thing, and I’m on, this is my bias because this is where my PhD was, was we have very few studies that have looked at high load, low repetition weight schemas for resistance training with older adults. We have one that I can think of maybe two studies and the second study is kind of an ish because it had a descending rep scheme where they use less than five repetitions and higher loads. My PhD tried to change that. I did two pilot studies that looked at the safety and feasibility of a three sets of three to five repetition schema at an intensity of seven to eight out of 10. So that high vigorous intensity, high load, low repetition resistance training. And so it’s important for us to know this, right? We don’t have this research. And when it comes to the way that we work in geriatric literature is that we see what works in our younger or middle aged individuals. Then we push into our healthy older adults and then we push into pathology. Right. This is the story that we saw with high intensity interval training, for example. Right. We saw that it worked in athletic populations. We started pushing the intensity into HIIT training in middle age, healthy older adults. And now the state of the literature, we cannot even deny it because we have evidence for HIIT training in a variety of different pathologies, multimorbidity, obesity, different age groups, et cetera, which is great. We don’t have that yet when it comes to geriatric literature in this high load schema. What we see from a muscle physiology perspective is that the magnitude of strength increase tends to bias heavily towards heavier weights. See the one that I did there versus lower weights, higher repetitions. When it comes to individuals who are doing nothing and they start doing something, of course, we’re going to see improvements in strength at any set reps. But the magnitude of those differences tends to bias when our loads are heavier. Because we don’t have anything in the under five repetition schema, we see this reflected in our exercise guidelines. Right. Why are our exercise guidelines the way they are? Right. Two to three sets, eight to twelve repetitions, 60. Now we’re kind of pushing into that 70 to 79 percent of a person’s one repetition maximum is the standard exercise prescription that we’re seeing out of the American College of Sports Medicine. We saw it in the International Conference for Frality and Sarcopenia Research consensus statement. And this is because that is where the vast majority of the literature goes. And this is where this momentum can build around two to three sets of 10. Right. Because we’ve always done it this way. There’s a good chunk of literature that’s there and we don’t have anything on the flanks. Right. We don’t have anything in under five. We don’t have a ton in the 20 plus. And when we get into the higher repetition ranges, now we have this interference that can happen between cardiovascular fitness and neuromuscular fatigue. And which one is the one that’s breaking down first or is the limiting factor? All of this to say. When we don’t have those discrepancies, we have to be mindful, one, about the strength of our recommendations, but number two, we have to be pushing towards trying to get studies that evaluate this type of loading schema so that we can take a big picture view and then really start to look at dose response data. So that’s number one is that we don’t really have a ton of studies that look at repetitions less than five and kind of my one B is that this influences things like our exercise guidelines and not in a good or bad way, just a we have to use what’s available. And that’s why things are the way that they are. The second one is going to kind of be a blend of pelvic health because we in advanced concepts, we go through in week five urinary incontinence and pelvic health issues and geriatrics. And I’ve talked about this a bunch on the podcast before. But we have very little evidence that’s looking at conservative management of pelvic floor dysfunction for individuals over the age of 65. And we have almost nothing when we look at individuals over 75 or 80. Urinary incontinence is one of the leading causes of institutionalization. So where individuals need a higher level of care, end up in assisted living, end up in institutionalized setting is because of issues with urinary incontinence. That should be justification enough that that we need studies in this area and kind of this one B or two B to C type of step down is we don’t really have a ton on pelvic floor muscle training in older adults. We have some. It’s not a ton. Oftentimes, our older adults are giving are given medications that influence their urine flow rate, whether that’s directly with medications being given to work towards helping with kidney function or things that are given as a consequence of having urinary incontinence that change urinary flow and urinary output. A big example that has nothing to do with either of those things, but is actually a side effect because this is the second classification is individuals are given a medication for one issue and side effects relate to urinary incontinence or other pelvic floor dysfunctions is Lasix or diuretics. Individuals who are on diuretics can have horrible, horrible problems with urinary urgency and urinary incontinence or both. And it has a huge impact on their quality of life. And right now, the only research we have is that it negatively impacts their quality of life. And the next step is to try and figure out what to do about it or what can we do about it conservatively? Can we change medication timing? Can we work on different things? Can we work on urge suppression techniques? Is that going to be relevant because urine outflow is higher because of the water pill? There are so many questions, but we have nothing like we have zero studies that have looked at how to help our clients with urinary urgency or urinary incontinence as a consequence of their medication regimens. This is important because the thing that happens is that people stop taking their meds because they literally cannot go out of their house or cannot be too far from a bathroom without not taking their pill. Because if they’re on their pill, they’re going to the bathroom all of the time for the five to six hours post taking their medication. And so this can essentially make a person homebound. That is important, right? In PT, that’s a super big thing. In OT, it’s a super big thing. In rehab in general, we are trying to discharge homebound status. And this is a big influence of that. Kind of in this urinary incontinence vein for the elderly, for our older adults, you know, we have conservative management in general. We have men management in combination with conservative management when there is a medical side effect because of the medication a person is on. And then the third one is some of the issues that we see post catheterization. So individuals who are placed with an indwelling catheter and then are removed from that get into this situation where they are in bed, they go to the bathroom whenever they need to because the catheter is there. And then once the catheter has been removed, sometimes there can be a disruption of pelvic floor musculature. There can potentially be damage to the urethral structures. And then you also have to try and work on those urge suppression techniques so that now you’re not just going to the bathroom whenever you get the slightest urge to go to the bathroom, but you’re holding it in order to go to the bathroom when it’s convenient for your schedule or when you have the block of time within your day that you can go to the bathroom. We are now also seeing different types of catheters like periwicks, which are external catheters. And what do those do? All of these things that we’re seeing hugely in acute care, we’re seeing it in, you know, individuals going into home health. This kind of goes into neurological populations who may be doing self catheterization. All of these things and the role of rehab in managing these conditions to improve a person’s function and quality of life really has been understudied and a big low hanging fruit that we could potentially be having huge impacts and potentially preventing transitions to institutionalized care is by being able to tackle some of these problems. But we need the research to back us up first. So that’s number two and two A and two B. And then the third one that we’re going to talk about, and I think this one is a frustration point for a lot of our clinicians, is clinically relevant outcome measures for our wheelchair users. So we have a ton of outcome measures in the geriatric space. One of the things that I think is actually really cool is that in our rehab space, our geriatric outcome measures are very strong. We have we have several options. We have good cutoff scores. We have reliability and validity data. We have minimally clinically important differences. All of these things. We have standardized protocols. We have different MCIDs, different reliability and validity data across different settings, which makes sense because our older adult population is extremely heterogeneous. All of that is good. You know, that is great. We touch on that a lot in MMOA about how we want to be leveraging our outcome measures and not just for the sake of doing outcome measures, but in order to guide our clinical reasoning and create risk stratification, which is what they’re intended for. The problem becomes when we have a client who spends a good portion of their day in sitting. When it comes to our outcome measures, we have this Goldilocks type of scenario that we need to be mindful of. We are going to have a cohort of individuals who are going to experience a floor effect and a person who is a wheelchair user on a 30 second sit to stand test is a very good example of that. They are going to get zero and they are probably always going to get zero. And therefore using a 30 second sit to stand test for a person who spends the majority of their day in a wheelchair is not helpful. We also see that we’re going to have some older adults who are going to have this ceiling effect where they are going to knock it out of the park and we’re not getting any information. When I was working predominantly in outpatient, one of the first things that I would ask my older adults who walked in independently into my clinic was can you stand on one leg? I was not going to be wasting 15 minutes of my time doing a Berg on those individuals because it’s a waste of their time. It’s a waste of my time and it doesn’t tell me anything. And so we have to kind of figure out we want this composite, we want these tools in our toolbox that we can pull and leverage based on our clinical impression after a person’s subjective. But when we have individuals who are sitting, we have very, very few outcome measures. We have the function in sitting test, we have stuff like the FIM. We can maybe start using the Berg and look at some of their transfers, but our pool to try and fit this Goldilocks scenario is quite limited. And so we really do need to think about clinically relevant outcome measures for things like transfers or bed mobility or things that are relevant for them. And these things are starting to come out. We have some pilot research on different outcome measures. But what we try and leverage now with an MMOA is trying to get objective data for things like transfers. And what that can look like is instead of giving MinMondax assist, which is important, we’re going to do that based on our clinical judgment, but also put a timer on it. And so if we can put a timer on it, then we can see the first time we did this sitting at the edge of the bed transfer, it took us five minutes from start to finish. And now it’s taking you 30 seconds. Like that’s a huge improvement or it’s taking three minutes. That changes the flow of a person’s day. It helps the caregiver a ton. It makes individuals feel more capable who are trying to help their caregivers with their care. And so we also need the research to back us up with that. And we need help to try and figure out how we can justify our rehab for individuals in sitting. If we can’t use the outcome measures that are so commonly prescribed in different settings to try and see improvements over time. And we can make huge improvements in a person’s function and a person’s capacity who may not have the potential to get into standing and do more standing tasks, but still has an infinite amount of potential to improve their quality of life and the things that they’re doing throughout their day. So those are kind of my big three areas in geriatric practice that I think we need to be focusing on that rep dose response data in resistance training, where we’re looking at load under five repetitions and seeing, does that have any improvements or the magnitude of that improvement in strength with, with a direct influence on a person’s physical function? When it comes to pelvic floor in the older adult space, we have a lot of work to do when it comes to just conservative management in general in our individuals over 75, anything with response to medication management, symptoms, side effect profiles of medications and their influence on the pelvic floor. And then post catheterization work, whether that’s indwelling or external catheterization and what that does to things like urgent continents. And then our third is helping our individuals who are spending most of their day in sitting. How do we help our wheelchair users so that we can justify our care, have normative data and reliability and validity data of outcome measures to be able to speak to our insurance providers who are, you know, a lot of times we’re trying to justify our treatment interventions and then make sure that we know when we’re making clinically relevant changes in their quality of life, when the goal of getting them in standing is not the one that we’re looking at. All right. I hope you found that helpful. If you have any other questions, just let me know. I’m going to be in the research space a lot in the next couple of weeks. I might be sick of it by the time I get to the end of the month with my defense. But let me know what your thoughts are. If you have any other questions, if you are not signed up for MMOA digest, that is our every two week newsletter where we bring all of that research to your inbox. So if we see any studies that are coming out that are filling in some of the gaps that we were talking about, you’re going to know about it first. If you’re signed up for MMOA digest, just head to ptnice.com slash resources. If you’re looking for research in general, make sure you are following hump day hustling. All right. Have a great day everyone. And we’ll talk soon. 20:07 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 CUs from home, check out our virtual ice online mentorship program at pt on ice.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.com and scroll to the bottom of the page to sign up.

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the importance of including lumbar flexion in a robust rehabilitation program. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ZAC MORGAN, PT Good morning PT on Ice. I am Dr. Zac Morgan. I am with our spine faculty, so I lead the spine division teaching lumbar and cervical spine courses. And this morning's episode is going to be a little bit on that topic of spine pain and specifically why low backs must flex. So we'll get to that, but before we do, let me just point you in the direction of a few courses that we have coming across the country over the next few months for both lumbar and cervical. So over in Richmond area, lumbar, the next offering will be September 23rd. We actually have several courses going, lumbar that weekend. So if you're anywhere in the country and you want to catch lumbar spine, September 23rd is a good one to have marked down. So it will be outside of Richmond, in Baton Rouge, and over in Parker, Colorado, right outside of Denver. So several good offerings spread all around the country. If you're looking for cervical management, we've got a few coming up as well. We've got Brookfield, Wisconsin, that's July 22nd, that weekend. And then August 26th and 27th will be over in Charlotte, North Carolina, and then September 9th over near Atlanta in Roswell, Georgia. So several good open offerings. If you're looking for one of those spine management courses, we'd love to see you out on the road. We'll have a bunch more throughout the year. So watch the website, watch the podcast, and you will know when we're going to be in your area. This idea for this episode came into my head this morning about, or not this morning, this idea came into my head over the last few weeks as I've seen more and more posts from, we'll just say Instagram influencers, people that are in this space of Instagram and perhaps are physical therapists and treating a lot. And I see a lot of vilifying of lumbar flexion, specifically a lot of pointing towards anatomy and the reasons why people shouldn't flex based on their anatomy. And the most common reason that you're going to see people vilify flexion in the low back is due to concerns of disc herniation. And we all know that there's some older studies that have pointed towards lumbar flexion, putting an increased pressure on the posterior annulus of the disc, and thereby making a lot of therapists for a long time very concerned about having their patients move into flexion because of the fear of every flexion weakens the posterior annulus of the disc. And with each flexion, you're actually weakening that tissue, eventually causing a problem. But I want to push back on that narrative a little bit. Now understand that at ICE, we think of back and neck pain in patterns. So there are some patterns of back pain where I will withhold flexion on my clients. I'll tell my client, hey, please, I need you to stop flexing. Sometimes I'll even utilize tape so that that way they're able to feel when their low back is moving into flexion. But that pattern is fairly obvious. And that one is what you classically think of as more of your lumbar radiculopathy or derangement presentation. And typically in that client's objective exam, when you ask that person to move into flexion, they're going to worsen. So each time you have them flex, they'll either lose range of motion in deflection, meaning their fingertips won't slide as far down their thighs as they did prior, and or they'll peripheralize. Their symptoms will exit the low back or maybe intensify in the low back and start to spread down the limb if they have some sort of sciatic related complaints as well. So if you're seeing a loss of forward flexion and or peripheralization of symptoms, that is the client where I would withhold flexion and not forever. I would tell that client on day one, Bill, right now, when you've been forward, your symptoms are getting worse. For the next couple of weeks, I need us to be really judicious and careful with forward bending. But understand that is a normal, healthy movement for your low back to make. And one day we're going to get back to it. So make sure you always prep them with that because we want that client to know we're coming back to flexion no matter what. Flexion is a normal part of the range of motion of the lumbar spine. It's really challenging to move through the world without flexing your low back. If you don't believe me, go ahead and throw some tape or have one of your coworkers throw some tape on your back and see how often you're pulling that tape top. Every time you put your shoes and socks on, when you sit on the toilet, putting your pants on, loads of things make your back into reflection. People recognize this when they hurt their back and they're flexion sensitive. All of a sudden they're like, wow, I didn't realize how much I use my back. What they're usually complaining about is that flexion. I didn't realize how often I flex my back. So let's get into it. There's a time and a place to withhold flexion, but it's certainly not everybody because for most people they need to be able to move. So one pattern in particular that pops into my head of people that really need to flex is the dysfunction patient. And if you're McKinsey trained, you've probably thought of this in terms of like, if a derangement doesn't clear up their end range flexion, they will become a dysfunction. But I like to think of that pattern as more all encompassing. Essentially a dysfunction patient is someone with soft tissue extensibility dysfunction across the posterior side of their spine. Meaning they don't have the elasticity in their muscles, in their paraspinals, and all the structures on the posterior side of their spine. They don't have the elasticity to move into flexion. And you'll hear this person say things in the subjective exam like, Zach, it's so tight. It feels very tight. It feels like I need to stretch. My back is always tight. When I wake up in the morning, my back is tight. If I've been standing for a long time, my back will get tight. If I have to sit for a while, my back will get tight. You'll hear them complain of things like tightness. And one thing that always stands out in this person's objective exam is you'll ask them to forward bend and they'll turn to the side and go to forward bend. And you'll see that they only access hip flexion. They actually don't reverse their lumbar curve at all. So you'll see that low back just stay flat as they move their fingertips down their thighs and their hip flexion will eat up all that motion. Often this person will have adapted pretty decent hip flexion. And sometimes I'll even see them put their palms on the floor. But if you look at their lumbar spine, there's no motion coming from them. So when we see that pattern, often flexion is part of the solution. Getting that person's low back to accept load and deflection can be part of what helps them solve this problem. So I always want to be really careful when it comes to vilifying any motion, because for some people that motion's the solution. While for other people that motion may really bother their symptoms. And this is the big overarching point is one solution is never going to work for all of back pain. If there was one solution, if the solution was to not flex, or if the solution was to only extend or spinal manipulation or dry needling or anything, we wouldn't see back and neck pain be this multi tens of billions of dollar problem year over year. If we had it figured out that well, this problem would be much easier to solve. So it seems clear that some people need it and other people's don't. And that's how back pain works. That's why you listening to this episode as the provider need to be confident in this space and understand that not one prescription works for all of back pain. So let's talk about why flection works a bit. And some of the things to think about moving forward, just to help push back again on that narrative of vilifying flection. First things first, with a lot of these people, they feel very tight and they feel very compressed. I don't have perfect proof for this, but if you think about the attachment site of the pair of spinals, I mean, from the base of the skull all the way down to sacrum, those big ropey muscles run parallel to one another on either side of the spine. If that person's tense, if they truly are tight, if their nervous system is just really heightened in the region, often that tone in those pair of spinals goes up. And what you see is a compressive type feel when they have it in the neck, they'll feel like somebody's got their hands on their head, just pushing down in the low back. They just hate sitting or hate compressive load. And one person that tends to do really well with flection based exercise is this one. So often, if you have that person start to put some length into that system by repetitively challenging flection, those muscles will relax a bit and the tone will drop some. And as that tone drops, the person will report a better feeling in their back. Hey, it feels like it's stretched out. That really feels like a good stretch, Zach. I love moving in that direction. Yeah. Now that I've done that, I feel better. Reminder the derangement patient who doesn't need to flex. They're going to feel worse each time that they do this. The dysfunction patient may feel bad while they're flexing, but they feel better after. So that's one of the key differences. And part of that is cause I think we're reducing some of the compressive load. That's just sort of statically sitting on this person's spine by getting them to move those muscles. So one thing that's nice is we get a reduction in that compressive load. This kind of goes hand in hand, but that subjective report that your patients give you of, man, my, my back feels so tight. It's so tight. I need a stretch. This addresses that feeling for whatever reason, their nervous system feels as if they're tight in that region. Sometimes people are, they truly have muscle extensibility dysfunction. Other times people are just tense and they have a hard time relaxing those muscles. Either way, repetitive flexion in my practice has been a really good way to sort of give those muscles some input or give them some actual stretch that allows them to lengthen out and allows that person to move with more, uh, fearless, thoughtless movement that allows them to kind of move about their day without feeling like a robot quite so much. So often getting rid of some of that tightness feel involves doing some stretching. And I realize I'm kind of going counterculture here because I feel like the pendulum is swung very far away from sweat stretching. But the most common question I get asked in the clinic is, can you show me a stretch for this? And I know a few of you are laughing and thinking, gosh, yes, people always think that's all we do is show stretches, but people see value in stretching. And if we believe in, in, um, patient expectations, then we should match those expectations to some degree. I'm not saying we're not going to load as well. We're off. We're going to do that. If the patient's impartial, my preference is certainly eccentric exercise because you get the added benefit of tissue durability alongside lengthening. But if we're just trying to get the person to buy in, I'm all for stretching and often stretching those pair of spinal makes this person's back feel way, way better. The next piece is just motion is lotion, right? Like our, our body is built to move. It is not built to be static. It has been adapted over years and years for movement, not for desk sitting, not for being really still. And so part of this is just motion is lotion, right? Like when we get a fluid exchange through those structures of the spine, through those muscles, the person's back feels significantly better. And there's no reason to run from that. We want that fluid exchange. We want that person moving around. And then the last piece team that I want to emphasize is why we should flex is that function is huge here. So if we were unable to flex our back, things like putting on our socks are completely a disaster. If you don't, if you've never experienced a derangement, I hope you never do, but spoken from someone who has that morning, you wake up and you can't flex. Everything's harder. You're considering asking your wife to help you get your pants on because it's so hard for you to move forward. We have to be able to flex. If we can't flex, all of those activities get way harder. And if we put forward the message that you need to be fearful of flexion because of your disc health, people are going to stop doing it. They're going to see those videos and they're going to say, you know what, that person's an expert. Let's be really careful with flexion. We don't want people being careful with flexion. Now I would never coach someone to lift a heavy load, a maximal deadlift with their back flexed. And that's partially due to, I do think end ranges are probably not the best for lifting, but a lot of it's performance, like straight lines or strong lines. I love when Mitch Babcock says that when we get the back flat, you can utilize your hips so much better and you can move more load. So from a performance standpoint, it makes sense to me to keep the back flat at heavy loads. When we're talking about putting our shoes and socks on, when we're talking about grabbing something off the floor, when we're talking about even doing things like ski, Yerg, GHD sit-ups, rowing, our backs are going to enter flexion. And if they don't, that will start to feel like movement dysfunction for the person. And if they try to stay perfectly flat through all of those things, it often drives this dysfunction pattern. So team, I really just kind of wanted to hit the high levels here of why our backs have to flex. And like I said, I see it over and over where there are different influencers who are vilifying lumbar flexion. And I think it's something that we as a PT community need to stand against. And it's not that we need to vilify those influencers. They are putting forth great information as well, but I do think it's a bit of an outdated narrative, outdated narrative for us to stop flexing the low back. Are there people who need to transiently limit their lumbar flexion? Absolutely. I see them all the time in the clinic. It is not rare for me to say, Hey, I need you to hold back on that motion for the short term. That said, do we need to drive a bunch of content towards making people fearful of that motion? No, much like knee flexion. We don't want people afraid of knee flexion. Same deal with the low back. It's just like everything else. It's a bunch of joints with a bunch of muscles surrounding it and a bunch of nerves giving it input and output from that region. That area needs to move. So let's not vilify it. The next time I'm on here, what I'm going to do is show you on a technique Tuesday. So we'll bring back technique Tuesday and I want to show you some mobilizations that I love to improve lumbar flexion in this person that we've been talking about. So that's all I've got for you today. Hope you have an awesome Tuesday and we will be back tomorrow morning. Same time. Thanks team. 14:56 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 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.

Christina Prevett // #ICEPelvic // www.ptonice.com  Christina Prevett // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Christina Prevett discusses current gaps in pelvic floor physical therapy research. 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. EPISODE TRANSCRIPTION 00:00 INTROWhat's up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today's PT on ICE Daily Show. 01:27 CHRISTINA PREVETT, PT Hello, everyone, and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. I'm so excited to be on the podcast. I feel like it's been a hot minute since I have been on here because our other faculty have been doing such an amazing job sharing content with you. If you're looking to get started and join us within the pelvic health division, we have our eight week online course starting today. So eight weeks going from preconception all the way to postpartum return to sport. We're going to spend a ton of time going through different concepts, research, all that fun stuff and then you get to hang out with us for the next eight weeks. So if you're interested, make sure you go to PT on ICE.com and you should sign up while you're there for our pelvic newsletter. So we're going to be talking about research today. That is where we send out new research articles that the faculty sees and we have a pretty big announcement coming into the newsletter. So if you are not on the pelvic newsletter, you should go to the resources page on PT on ICE.com and join because there's fun stuff happening over there. All right. So today we're going to be talking about gaps in pelvic health research. We have done an incredible job over the last several years of starting to fill in gaps in our knowledge. And part of the reason why we do not have as much research in some of these areas is because the rise in popularity of some of these movements or these exercise trends has really changed over the last five to 10 years. And research takes time. It's important for us to know where the state of the research is so that we know how much confidence we can give to our recommendations and assessments. When it comes to evidence informed care, it is three pronged, right? We have our evidence base, what research says. We have our clinical expertise and we have our patients or clients lived experiences and their hopes and desires. And when we don't have the evidence base, we rely on the other two. However, there is bias that gets introduced there. There's bias that gets introduced in research as well. But I think it's important for us to know what we can confidently say from a research perspective and what we can't. So today I'm going to go through five big gaps that I have seen in the pelvic health research. If you are interested in doing a PhD from somebody who is about to defend their PhD at the end of the month, here's great topic areas because our research base is really small or completely non-existent. And the completely non-existent one that I'm going to start at the very beginning because it actually blows my mind is on C-section scar massage. Scar massage after a C-section is the gold standard for helping with the rehab process. It creates more movement and motility. It allows us to get into more stretched positions. Some individuals have seen potentially some association between adherence and scar tissue and low back pain. Alexis did a podcast episode on a case study with that. But we have no research in any type that has looked at C-section scar massage. And that blows my mind because we are so confidently talk about using C-section scar massage. And it's because clinically and with our patients right there lived experience, we see such a huge benefit. Because we don't have any research, why? We can't even say is this effective or not. But the second thing is that we have no idea around dosage. Do you need to start at six weeks? Can you start at six months? Is it the same effectiveness? Should you be doing two minutes or five minutes? We don't have any research that is looking at what is the most effective dosage or does this work at all or is it a placebo because we're starting to desensitize our body to that surgical site. We don't really know. And so it's really neat to see and really important for us to recognize that there is a huge gap there that should be getting filled. All right. The second one that we see a complete lack of research in and this became really relevant with some of our athletes is around coning during pregnancy and its impact postpartum. Really confidently people say online that you should avoid doming and coning during pregnancy within our pelvic health division. We do not create fear around doming or coning. We try to minimize it as much as possible by getting recruitment from other core muscles because we think that is going to keep the pregnant core stronger, not because we are trying to mitigate damage, not because we are trying not to ruin anything, not because we are trying to prevent diastasis recti postpartum. But we know, pardon me, that when we reduce that coning that usually that also means that individuals are stronger. Unfortunately the prevailing messaging online is that if you cone during your pregnancy, you're going to have diastasis recti postpartum. And we don't have research either way about that narrative despite how confident people are saying that. What we do have research for is that individuals with postpartum diastasis recti are weaker than those that aren't. And so by scaring individuals around avoiding coning during pregnancy, we may be unknowingly or unintentionally deconditioning that pregnant person and their core. And so we need to be doing research on this about, you know, what if we don't do any modifications to their core training? What is that going to do for them postpartum? You know, when I think about a late term pregnancy, that stretching of the linea alba, when a rectus contracts, it comes together and there's going to be almost like an air pocket that occurs because of that lengthening of that tissue. In my mind, like that, especially a little bit of that is not something that I see as quote unquote bad. But I know that I am not not everybody agrees with that narrative. So we just need to be sure that we're doing more research on this. So that's number two. Number one, C-section scar massage. Number two, avoiding coning during pregnancy and its influence on postpartum outcomes. Number three is any postpartum protocols for return to activity. We have maybe the beginning of research in the running space. And largely in the running space, it's helpful because a lot of people enjoy the sport of running. It's an easy barrier. There's no barrier to entry in terms of just putting on running shoes and going on to the pavement or onto the trail. And so we're starting to see more and more research. But when we're trying to look at things like risk factors for issues with postpartum return to running, we're seeing a huge amount of variability. And that is where us and the pelvic PT space and us in the PT space in general are like well done because everyone is going to have different experiences, different support systems. All of those other factors are going to influence. And so we see some people are waiting a full 12 weeks before they go back to running. We have other individuals like our elite level athletes who are starting with four to six weeks and are back to 80 percent of their running volume by 14 weeks plus or minus 11 weeks at standard deviation. So a huge swing in terms of how long they are going back or how long they are waiting before going back. And so we need to try and look at some of this early return to activity and try to figure out different protocols to try and minimize risk for not only pelvic health concerns, but we're seeing also a larger risk for musculoskeletal injuries. And so we're seeing individuals returning to postpartum impact, which is running and are having lower extremity issues. So we have so much work to do. And then when it comes to the resistance training space, oh my goodness, we have literally nothing. In the cross-sectional study that I designed with our collaborators, we tried to give some descriptive data of when individuals are returning. But again, that is just scratching the surface of what is possible or what we may be seeing in this space. So number three is any postpartum protocols for return to activity. Anything that people are utilizing now is based on physiology theory and clinical experience. We don't really have anything in the research right now to identify those things. All right. Number four is information on pelvic outcomes with interpregnancy windows. And this may seem a little bit off to right field from me, but hear me out. So when we think about family planning, individuals kind of have often an idea of how close together they want their pregnancies to be, what sometimes these pregnancies are a surprise. Sometimes there are things outside of our control that leads to when individuals are having pregnancies. What we do tend to see in the literature where we do have research is on fetal outcomes. And we always kind of start on fetal outcomes where risks to baby increase when a person has a subsequent pregnancy less than six months after delivery versus those that wait 18 months. What we see clinically is that sometimes rates of pelvic floor issues and diastasis recti can follow that same trend where when individuals get pregnant really close together, they didn't have that window of time where they were able to recover their pelvic floor and their core strength back. And therefore they have potentially a harder time recovering after a subsequent pregnancy. Some of these fetal outcomes like increased risk for miscarriage and stillborn birth that can happen in those close interpregnancy windows may be a result of things like pelvic floor insufficiency or just not getting the strength back in those structures in the pelvis between pregnancies. And so we don't have any research on this, but as a faculty, we are super interested to see is it the interpregnancy window or is it the amount of time it takes individuals to get back at least close to baseline with respect to core strength and pelvic floor strength after baby. And so information around interpregnancy windows with respect to mom's outcomes, I think are super important. So number one, C-section scar massage. Number two, postpartum or coding during pregnancy. Three postpartum return activity and four information on interpregnancy windows. My last one and I left it for last because this is like where my research brain is right now is on lifting during pregnancy and appropriately dose resistance training. So if you guys have been following the podcast or you follow me online, you know that I was projects that looked at cross-sectional data on individuals who lifted heavy during pregnancy, over 80% of their one rep max at least at some point. And we tried to describe individuals experiences, what their labor and delivery looked like and what some postpartum issues or complications may have been. Now right now I am working on a project that is a systematic review on what we know from resistance training and pregnancy literature. So I am doing a complete scour on the research that is looking at what the dosage, what outcomes individuals are looking at and trying to make some, see some gaps in the research and make some informed decisions. Y'all, what we have so far is all exercises in sitting one to two kilos max weights. So five pounds max, we have fair band exercises and these are what we are using to make decisions. Overwhelmingly the outcomes are related to the fetus, right? So we are looking at and that is super important. Do not get me wrong. That is super important. But I think at this point we can say especially under dose resistance training is not going to be bad for baby. That is where the gross majority of our research exists. We have nothing that is heavier really than a person's purse that they use to walk in here and it gave me an unbelievable understanding of where our conservative under dose recommendations come from because all of our research was on therapy and exercises, stuff done in sitting, pelvic tilt and abdominal breathing was a protocol for resistance training. When is breathing resistance training? But that's the state of our research right now. And so we get upset about the fact that these are recommendations and yet there's this huge gap that we are seeing in the literature that does not have anything. And so because pregnancy is such a protected time, we don't want to make recommendations that we don't really have anything to base off of. And so we have so much work to do. And so here are my five, right? We have C-section scar massage, coning during pregnancy and postpartum diastasis outcomes, any type of postpartum protocol for return to activity, especially in the lifting high intensity space, information on pelvic floor outcomes and core outcomes for interpregnancy windows and the influence on pelvic floor dysfunction. And then my personal, like one that I am spending a lot of time on is around lifting and appropriately dosed RT during pregnancy. Like you all know that I am in the geriatric faculty as well and it's like just as bad, if not a little bit worse with respect to some of the RT dosage that I'm seeing in this space based on, or as compared to systematic reviews that I've done in community dwelling older adults that are struggling with mobility. And so that is saying something. And it just shows that we have so much work to do. And so I want to kind of finish off this podcast. I'm going a little bit long winded and I knew that I would talk to you about research is that we have work to do, right? We need to one show that these are things that individuals are interested in. We need to try and help inform practice. And then we need to be patient. You know, there are researchers that are working on this. I was at female athlete conference in Boston and I saw and got to connect with so many PT PhDs and other medical providers who were doing research that were trying to bridge some of these gaps for individuals who love exercise at any capacity, at any stage, at any level. It just it takes time. You know, where I'm getting ready to hopefully ramp up for perspective data, which means that I'm going to follow people through their pregnancy. But a pregnancy is 10 months and it takes time to recruit people and it takes time to go through ethics. And then we got to do all the analysis and then we have to write the research paper up and then it has to go through peer review. And that takes time as well. And so we are getting there. This is my I am so excited. If you want to do a PhD and jump into this army of trying to create research, I am here for it. And hopefully we are going to continue to see individuals pushing into this space and we're going to be able to close some of these gaps. All right. That's all I got for you today. If you are interested in learning more or you want to talk about PhDs and all those types of things and doing research, make sure you reach out. I did an entire thread in our ICE students group. So if you have taken an ICE course and you were in that Facebook group, I talked about doing research and I hope you all have a wonderful Monday and I will actually see you on Wednesday for the geriatric podcast. All right. I will talk to you all soon. Have a great day. 19:00 OUTROHey, 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.

Alan Fredendall // #LeadershipThursday // www.ptonice.com 

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discussed several strategies that can be employed to achieve intensity, which is crucial for cognitive changes. These strategies, including increasing load, decreasing rest, and increasing work time or volume, are part of physical training and can drive metabolic adaptation and enhance cognitive benefits. By challenging the muscles and cardiovascular system through increased load, individuals can experience improved cognitive function. Similarly, reducing rest periods allows for a more continuous and demanding workout, while increasing work time or volume extends the overall duration or amount of exercise performed. All of these strategies contribute to increasing the intensity of the workout, which is essential for promoting cognitive changes. Incorporating a dual motor task and cognitive layer during exercise can further enhance cognition. This can be achieved by integrating activities that require both physical movement and cognitive engagement. For instance, one way to introduce a dual motor task is by having individuals hold two cups and transfer water from one cup to the other while walking. This adds complexity to the exercise and challenges both the motor and cognitive systems. Additionally, engaging in mental tasks like answering questions or performing mental math while exercising can also enhance cognition. Starting with simple preference questions and gradually progressing to more challenging cognitive tasks can create a cognitive load while individuals focus on the physical activity, leading to cognitive changes. It is crucial to control the intensity of physical training by adjusting factors such as load, rest, work time, or volume to ensure the desired cognitive benefits are achieved. Shifting exercise sessions to a busy environment can introduce cognitive load and improve cognition. Instead of conducting sessions in a quiet one-on-one room, it can be beneficial to move to a busy clinic space, a bustling hospital hallway, or even an outdoor setting with unpredictable elements. Exposing individuals to a busier environment adds a cognitive challenge to their physical activities, such as skating or walking. This cognitive load stimulates cognitive changes and enhances the cognitive benefits of training. It effectively adds a cognitive layer to the exercise session and promotes neuroplasticity. Furthermore, incorporating a dual motor task, such as moving water back and forth, and asking cognitive questions like preference inquiries or mental math can further amplify the cognitive benefits of the exercise session. Overall, integrating a busy environment and cognitive tasks into exercise sessions can be a valuable strategy for improving cognition. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTROWhat's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're sure to use the code ICEPT1MO when you sign up, that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.  01:33 DR. JEFF MUSGRAVE, PT, DPTAll right. PT on the ICE Daily Show. Welcome. This is Wednesday. This means it is Geri on ICE talking about all things, topics to help make your care for your older adults as good as possible to really set yourself apart as an expert with older adults. What we're going to be talking about today is exercise that improves cognition. There are a couple different types of exercise training that is really superior for improving cognition for older adults and we're going to talk about what those are and then how to incorporate them into your care. Before we get to that, just a quick rundown of what we've got going on in the older adult division. If you were hoping to catch the next cohort of Essential Foundations, that'll be starting in August, August 9th. If you're looking to get your advanced concepts, if you've already taken Essential Foundations looking for that next step, that'll be October 12th. Next opportunity to see us live, you've got three opportunities in July. We're going to be in Connecticut, Georgia, and Idaho this month. If you have been itching to see us on the road, get to do some of these fun labs and things that you've probably seen on social media, book your seat, come see us. We're going to be all over the place as we do 2023. Many of our older adults are worried about their cognition. They may already be experiencing cognitive changes. Maybe they've got just mild cognitive impairment. They don't have an official diagnosis. Maybe they've got early stages of cognitive change all the way to advanced dementia. It's not uncommon for us to be treating community dwelling older adults or older adults in an institutional setting that have experienced some cognitive changes. When we're thinking about our exercise interventions and how to prioritize, making physical change while keeping in mind we know there's a cognitive component. Sometimes a cognitive component ends up being more critical than the physical component for some of our older adults. We're talking about safety. We're talking about independence and their ability to manage their home environment, for example. This can be huge. The reality is a lot of us don't know where to start when we're thinking about how do I do both get the physical training piece and keep in mind they've got some big cognitive impairments on board that I'm concerned about. There was a 2019 article titled, Preferred Type of Exercise for Cognition Enhancement in Older Adults. It did just this. It broke down what types of exercise we should be focused on. Once you get through this article, and I'll share it in the caption as well if you want to look it up yourself, but there were two types of exercise that we're going to cover. The third thing we're going to do is just talk about the practicality of how to get those cognitive changes for our older adults in our sessions. The first type of training that was most beneficial for driving cognitive enhancement was a category called physical training. If you're familiar with CrossFit or not, I'm going to describe a workout to you that would be very squarely in this component of physical training. So MERF, very common Memorial Day workout done to honor a fallen soldier. The workout is one mile run. We've got 100 pushups. I'm sorry, 100 pullups, 200 pushups, 300 air squats. So that would very much squarely fit into the grunt workout. You're grinding. It's a long workout with high metabolic demand. So the first category was physical training that was intense. High intensity physical training was the number one thing that they found was beneficial for enhancing cognition for older adults. So many of our patients are not going to be doing MERF. So the question is, what's this look like clinically? So any workout that's using compound functional movements and you're moving at high intensity where you've controlled the work rest ratio, you've controlled the number of repetitions or the volume, and you've controlled the pace, you can modulate to get up to high intensity. But high intensity training is superior for cognitive enhancement. So for a patient that may be doing a remom, every minute we're doing different activities. We've controlled the amount of work and rest time. The patient is going to pace that themselves. So say minute one, we're doing 10 sit to stands. Then the next minute we're going to do carries over and back across the room with the weight that's challenging. So there's maybe 10, 15 seconds of rest. And on the third minute, maybe we're going to be doing some supported jumping. So grunt work type movements. There's not a whole lot of thought involved. Hold this walk, stand up, sit down, put your hands here, jump. Very simple, basic activities, but their nature of them being compound functional movements where we've controlled rest, we're going to drive intensity and we're going to drive metabolic adaptation, which was key for enhancing cognitive benefits in training. So that's what we want to be thinking about. Category one, physical training. They found that the change happened because of changes in the metabolic system and hitting intensity was key. So high intensity grunt work style training improves cognition. That's good news. That follows right in line often with what we're trying to do with our older adults because we know most of them are sedentary and need physical training. They need to be stronger. They need higher cardiovascular capacities to really keep themselves on a healthy trajectory as they age. So the second type of training that was beneficial for enhancing cognition was a category they just called motor training. So a good example of this would be a Turkish getup. So maybe you've never done a Turkish getup, but if you can imagine yourself laying on your back, you've got one arm pointed at the sky with the weight in your hand. You're going to move from lying on your back all the way up to standing with the weight overhead. You're going to be balancing the weight the entire time and then going all the way back down to lying on your back. That would be an example of motor training. It's a complex task. There's actually 14 steps in a Turkish getup for just one side. A lot to think about, lots of positions to hit, complex movement, a novel task for a lot of people in general, but especially older adults getting up and down off the floor without using an arm, but also adding load and having to balance that weight makes it complex from a motor training standpoint. So maybe our older adults are not doing Turkish getups. Some definitely can. There are research articles that have shown that older adults can do Turkish getups and it's beneficial for them, but maybe a more practical example for a lot of us would be working on floor transfers. Many of our patients need to work on getting up and down off the floor, doing that where we're working around a cranky joint, a knee, a shoulder, maybe a hip that is super stiff or doing this at a novel environment. Maybe we take them outside on the grass where maybe they don't have furniture or they've got limited furniture where we've just created a complex, novel task. It's motor training that's complex and that's what's going to drive cognitive adaptation. This motor control category, the driving factor was complexity and it was direct neuroplasticity. So directly impacting neuroplasticity when we do complex motor tasks. So getting up and down from the ground in a different environment would be a great way to drive neuroplasticity directly. So we've got these two categories. We've got high intensity physical training and then we've got high complexity motor training. Those are the two different avenues we can use with exercise to improve cognition for older adults. So the question is, well, what do we do? Which one is most important? And if you've been around the ICE community very long, you've probably heard this before. Or if you're new to following along with the journey here on what we're doing with our clinical approach, you're going to know the answer to this. And that is and not or. We want to do both. So we want to be greedy when it comes to our patients. We want to give them the maximal benefit, the maximal value out of every single session. And we can do that by driving intensity while driving complexity of task. And the easiest way to do that is a strategy we call layering. So a good example of this would be, say we want to drive intensity with gait training. Lots of great ways to do this. We can put a gait belt on our patient and hang on to it and add some resistance that way. We can do the same thing with a resistance band. We can throw a weighted vest. We can have them hold weights. Gait training just got much more intense at whatever resistance is appropriate to challenge our patient by just adding resistance to that walking. So we've already achieved intensity there. So how do we add this motor training piece? How do we add complexity to also enhance cognition at the same time? Lots of different ways to do this. You could do a weighted vest and maybe we've got someone with two cups in their hand and they're transitioning water from one to the other while they're walking. Man, we've just layered on a dual motor task while we're hitting intensity with a vest. Another great example, we can ask simple preference questions. That's usually an easy way to ease in on the cognitive load. Just ask them some random questions that sound like conversation. You may already be doing this, adding a cognitive layer and not realize it, but asking them questions while they're concentrating adds a cognitive component. We can scale that up. We can ask for mental math while someone is doing intense gait training. That can be super beneficial. We can ask, what's your favorite color? We can ask them to subtract three from 74 out loud while they're walking under intensity. We can move them to novel environment. There are lots of different ways we can add that in. You want to control the two things you've got to do to put these things together. For physical training, you've got to control intensity. You can increase load, you can decrease rest, you can increase work time or volume. All those things will help you reach intensity, which is crucial for cognitive changes. The second piece is adding a dual motor task like we talked about the water back and forth. You can add the cognitive layer by asking questions, preference questions, mental math, those type of things. Moving them into a busy environment. Maybe you have your sessions in a quiet one-on-one room. Maybe you move out into busy clinic space or into busy hospital hallway, or maybe you're in home health and you can take someone outside or into busier environment where there's unpredictable things and there's some cognitive load on just skating and keeping yourself safe. That's another great way to add cognition. That's what I've got for you, team. You want to hit intensity through physical training. You want to add complexity with motor training. The third thing is you want to add layers. You want to layer up your intensity and cognitive difficulty as much as possible to get the most bang for your buck, especially when there are cognitive deficits on board. If anyone's got any cool strategies, layering tips, tricks, things they've done that they found fun and beneficial, or you've just got questions or comments, drop them. I'd love to see those and interact with you. I hope that was helpful for someone out there. Have a great rest of your Wednesday, team. See you later.  14:52 OUTROHey, 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.

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey discusses how to empower patients with osteoarthritis by shifting their mindset and behaviors. She emphasizes the importance of treating patients with MEDS (mindfulness, exercise, diet, and sleep) to combat systemic inflammation. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management 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. EPISODE TRANSCRIPTION 00:00 DR. LINDSEY HUGHEY, PT, DPT Good morning, PT on Ice Daily Show. How's it going? Welcome to the PT on Ice clinical podcast. Today is clinical Tuesday. I am so pumped to be with you all. I'm Dr. Lindsay Huey. I guess that would help if I actually introduced myself. Today, I am going to chat with you about how we let freedom reign in our patients with osteoarthritis. Last clinical Tuesday, I hopped on here and I wrapped on the underlying battle of systemic inflammation that we are fighting with these folks with hip and knee away and the importance of treating them with MEDS, which stands for mindfulness, exercise, diet and sleep. Check in for more information there from last week on what MEDS and how we can unpack that and prescribe it for our patients. This week, this clinical Tuesday, we're going to dive a little deeper into the trenches of battle by really discussing how we can impact our folks with osteoarthritis. Whether it's the shoulder, hip, knee, hip and knee are more common things we'll treat from an extremity management perspective. But this battle involves a lot more than manual therapy and exercise. It actually involves less. Today, I will discuss how shifting our patient's mindset and behaviors really helps fight that underlying systemic inflammation battle that our patients have. But before I tell you and dive in a little bit about that, I'd love to share with you some courses extremity management has coming up. So our next upcoming course is July 15th, 16th. So in a couple of weeks, we'll be in Holmes Beach, Florida. I've hopped on a couple Tuesdays and just let you all know what beautiful beach that is. It still ranks the top beach I've been to so far. Crystal blue water, I'll be with Melissa Reed out there. There's lots of spots left. So join us if you want to do some summer extremity management learning. And then July 26, 23, I'll be in Simi Valley, that course is now to 15. There's probably only three to five spots left. So if you're on the fence, definitely sign up for that course. And then onward Madison is July 29th and 30th. So lots of opportunities to hop in in July. And then in August, we are going to be in Rochester Hills, Michigan, and then the 12th and 13th. And then August 19th, 20th, we will be in Fremont, Nebraska. So be on the lookout if you're on the fence for signing in just because these courses are starting to fill up. And then other courses in the beginning of fall in September and October. We hope to see you out there. All right, let's dive into the topic at hand. So last week, we really last Tuesday established that hip and knee osteoarthritis is becoming one of the leading causes of global disability. So worldwide, this is affecting our society. And there are so many challenging aspects of treating these folks. The battle is not just in modulating their pain. It's not just an increasing range of motion and addressing strength deficits, you know, in their hip and in their knee. And it's not just about prescribing meds. And I really made a solid case for that last week. That mindfulness, exercise, diet and sleep. It's really about confronting the uncomfortable conversations. It's about challenging and changing thoughts and beliefs with these folks and some of their daily living behaviors. I think this is our hardest job as physical therapists, whether you're in outpatient or home care, even acute care. But it's our hardest job and our greatest opportunity with these folks to really address how they think about their body and then just daily behaviors. These conversations that I'm going to bring up, they are really uncomfortable. Addressing harmful thoughts and beliefs, behaviors, we know humans, we are kind of entrenched in our beliefs and our behaviors and it is really hard if we can reflect on our own challenges. It can be so uncomfortable. And so I acknowledge that this is very uncomfortable, not only as the provider, but for the patient. So some thoughts that we really need to start addressing. And I alluded to this last week a little bit, but the patient that thinks and says to you that first visit, I have bad knees, my dad had bad knees, my great grandfather had bad knees or I have bad hips, right? My great grandmother had bad hips. So it's just inevitable, right? That I'm going to have bad hips. You are not your ailment or your pain is one of the first things that we have to establish and break down with our patients. The thoughts of this is just inevitable, this is my path, right? To be in pain, which leads to disability and dysfunction. These thoughts take a human's mindset captive. It takes captive their whole way of living and being. If you think about some of these patients and they don't just often just have osteoarthritis, diabetes, hyperlipidemia, they might even have heart disease or history of MI, stroke, these are unhealthy systems. Every thought and decision and behavior starts to be planned around their pain experience. Going out with family or friends is planned around pain. How long does it take me to get to the front door if we're thinking about going out to eat or going to the movies? Can I actually make that distance? Or will I be in too much pain to even enjoy the dinner or the movie? Or I cannot do this because it hurts. Or I can't go to that family gathering because it hurts. Or because my knees or my hips are bad. Pain, OA, osteoarthritis starts to become the patient's identity. How they do everything in life is surrounded by this. This is all super uncomfortable and enslaving for your patient. If we're honest and we even think deeper about this, it starts to become the normal. So this discomfort, right? This pain starts to actually become the patient's comfort. It's how they do life. It starts to become their identity. I need you to start as clinicians and this charges to myself as well to start thinking about how we can help our patients do less harmful mindset. Do less thoughts about how much they're in pain and how much their knees are bad. How can we help shift their mindset to be healthier? To be more productive? Can we shift and say my knees have an opportunity to be stronger? Or yes, my knees hurt but I'm on the path to recovery. Yes, my hip hurts and it's limiting how I can walk right now. But I know with doing my program from Alex Drumano, our MMOA faculty, I know I'm going to be able to walk a little bit longer every day. Helping patients shift how they think right away is a must. If we cannot shift how they frame their pain experience, how they frame their range of motion deficits, how it impacts their life and amount of walking, we will never make an impact here, right? We can have the best manual therapy, the best exercise dosage prescription and it won't make an impact if they don't believe it can help. If they are telling themselves every morning they wake up, my knees suck, I don't want to get out of bed, my hip hurts, I don't want to do this today, they're not going to be successful. And so we have to give them little phrases to help them keep going, right? Yeah, it hurts right now but here's what I can do to help that, right? And it seems small but if we're not addressing this at all, we're really doing harm. We're not doing enough and so we need to implore less harmful thought patterns in our patients to help make an impact, to help really make our exercise and manual therapy be worthwhile. So I just want you to pause and think about what are some things or reframes I can start giving my patient in their mindset. Doesn't just stop though with our mindset shifts, right? It's not just thinking that influences our beliefs about our body. We also have to shift some of our daily behaviors and here's where it gets really tough. Folks with OA have a lot of comfortable behaviors that are quite destructive. And addressing these conversations by the way are nuanced and we have to do it in a loving way and of course we first have to build rapport with our patients before we start diving in to behavior shifts. And so it won't be our first conversation with our patient but it has to be a conversation that happens in our bout of care and it has to be ongoing. And it's behaviors regarding eating and exercise habits. They have to be addressed. It becomes really comfortable that person that's in pain, right? That's coming to see you maybe three days a week, right? They worked out with you for an hour. It's a lot more comfortable to sit around and watch shows. It's all day. It's a lot more comfortable after a big meal, after dinner, to turn on Netflix and binge watch Netflix, right? Two or three episodes. If you're a big Ted Lasso fan it's really hard not to just watch the whole season in one bout. It's really hard if it's in your process and family process to have dessert after every meal that you have, especially dinner, right? And then compound that with Netflix and sitting. Extra calorie consumption kind of goes under the radar with these folks. The eating piece and our behaviors around eating have to be addressed. And you know, the Netflix, the eating, this might not be your patient specific thing that they need to worry about doing less of, but I'll tell you in a lot of our folks with me and HIPAA, there is some very familiar trends surrounding our eating and our extra calorie consumption. Things that bring us comfort like Netflix, like that extra helping of food or dessert. We have to acknowledge that this is so complex and hard. These things are often tied to family, right? They're tied to connection and community and identity, especially if that's the time where you all kind of get together, right? You share a meal, you share dessert, and then you go watch your shows. Let's all come together and rewrite some of the ways we gather and do our meal time together or handle stress, right? Some of us are stress eaters. Sub that extra helping or that extra Netflix episode with taking a walk after dinner with your family. Or maybe instead of that dessert, right? You're already feeling full, but somehow you think there's a little bit more room for that dessert. Go for a walk with your family, right? Or go for a bike ride, right? These kind of behaviors help get that food moving and processed better, and then it subs those extra calories or it subs that extra sedentary time where you're just sitting. How about some of our folks with HIPAA and NEOA that are retired, right? Where they're watching their shows throughout the day, right? They love watching Price is Right. Yes, Bob Barker is better, but Drew Carey is doing his best, right? But these kind of behaviors, maybe it's a midday walk, right? Or suggesting they walk their dog midday. I know these HIPAA close to home, folks, and I'm going to tell you a lot of the behaviors I'm listing hit close to my direct family. I am sprinting away from metabolic disease. It runs on books, both my mom and my dad's side. Diabetes, heart disease, cancer, hyperlipidemia, myocardial infarction, stroke. Whatever list that you've probably seen on your patient list, my family has it. And so I totally, I am listing out behaviors that I know my family and myself has taken part in. I've witnessed them firsthand, but I also know they can be changed gradually, and I also know the change is uncomfortable. I want to fight this battle of OA because it hits so close. It hits for me, it hits for my children and my surrounding aunts, uncles, grandmothers, right, that have passed because of this. So I don't take the battle lightly bringing up this shift in beliefs and behavior. Think about this. And I know I touched on some hard ones, right? Everyone loves a little extra Netflix episode, dessert sometimes, that extra helping of food. It is comfortable. But no one says, I wish I hadn't taken that walk last night after dinner. I wish I had had that second helping, second and third helping. I wish I had had that extra slice of apple pie. I wish I had stayed up till 1 a.m. watching Netflix. I wish I had binged, watched all my shows all day and sat in a chair for three hours. I wish I had had that another beer. No, people don't really reflect and say that, right? They're usually the next morning, oh, I wish I would have had that earlier. I wish I wouldn't have had that extra helping. I didn't really sleep well. I wish maybe I would have gone on a walk or that bike ride when my kid or grandkid asked me to do it. Instead, I just sat here and I watched these shows. No one says they wish they didn't do that uncomfortable behavior. Uncomfortable shifts in mindset and behavior, they are always uncomfortable, especially when you're making the decision, especially when you're actually doing the thing, right? When you don't really feel like taking a walk after a meal or going for a bike ride. But there is nothing more ironic, more peaceful than doing the thing that's uncomfortable. While it may not feel great during you, if you can think about some uncomfortable decisions you've made and your patients, they will feel better after. They will be thankful after when they made these shifts in their mindset or in their behavior. There is so much reward in the discomfort. Of course, it's delayed and that's what's hard about human nature, right? Our psychology wants comfort, especially when we're in pain. But just think each day, the compound reward of making one to two uncomfortable decisions surrounding our mindset and surrounding our behavior around food and our eating behaviors. One less thought of my knees suck, I don't want to get out of bed. One less helping of dessert or Netflix binge. Imagine that compounds day after day, 365 days and that becomes a year and then you do it again, right? 365 times two, right? And it patients start to see the healthy reward of these shifts in mindset and behavior. Let's stop the acceleration of OA as one of the leading causes of disability worldwide. Let's help our patients handle and battle this low grade systemic inflammation by leaning into the hard belief and behavior shifting conversation. We have to fight for our patients, our loved ones and ourselves to have these conversations because we're not doing enough. It's still going up the levels of disability, right? Lifespan is increasing, right? But our health span, the quality of life is not. These are hard and uncomfortable conversations, right? But discomfort tends to birth opportunity and change and really only always for the better. If you can think about most of the uncomfortable decisions that you've done in your life, if you can think about the yield, the reward, we can and we must start to battle beliefs and behaviors if we want to impact this space. One little mind shift and behavior shift at a time. Freedom comes in the form of less for our folks with hip and knee OA. Yes, our primary drug of choice is exercise for our folks with hip, knee, shoulder OA. But if we want to have the greatest impact, we need to deal environmental modulators to manage symptoms, to maximize fitness. We need to deal mindset and behavior shifts that change lives. It will be hard, it will be uncomfortable for both parties, clinician and patient. But along the way, we also deal encouragement. We deal hope. We deal laughter, right? We laugh in PT and we are a partnership and alliance as the patient negotiates these new mindsets and behaviors We're there every step of the way when it's hard. Free your patience. There is freedom in choosing less harmful mindsets and less harmful behaviors. New beliefs and behaviors are for sure uncomfortable. But help your patients think about their hip or their knees more positively or help them walk instead of that extra episode of Netflix. Show your patience there is freedom in discomfort. Show your patience there is freedom in the reframe in their mindset. Let freedom and independence reign for your patients through introducing them to healthier mindsets and behaviors. Help them indulge less in destructive thinking and behaviors. There is so much untapped potential in this space. I'm hitting the 20 minute mark I need to shut up. But I want to say a final thank you to our military and our vets who have fought and continue to fight for our nation's independence. Happy Fourth of July. I'll thank you for letting me rap on something I'm super passionate about. Happy Clinical Tuesday. 19:30 OUTROHey, 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 CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. April Dominick // #ICEPelvic // www.ptonice.com  In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses when and how the tailbone/coccyx may be a contributor to a patient’s symptom behavior, as well as how to begin to assess & treat the region if appropriate. 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. EPISODE TRANSCRIPTION 00:00 INTRO What’s up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let’s chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you’re looking for an easy way to navigate payments, here’s what we recommend. Head over to jane.app slash payments, 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 several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you’re ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you’re in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today’s PT on ICE Daily Show. 01:27 DR. APRIL DOMINICK, PT, DPTWhat is up PT on ICE fam? Dr. April Dominic here. Today we are starting our two-part series on pain in the butt. And today you will learn how you as a clinician can screen for tailbone pain, some general assessment and treatment strategies, as well as in part two, next in two weeks we’ll cover soft tissue structures that may contribute to pain in the butt. Before we dive into tailbone pain today, let’s talk about some course offerings from the ICE Pelvic Division. So we have our eight-week online cohort that starts July 10th and we still have some spots left. So please hop on in and join us for all of that fun. And then we have our live course and this course is going to give folks the ability to learn pelvic floor basics and about the pregnancy and postpartum changes of the body. We’ll definitely dive into the internal exam in supine and standing with an option to learn another way if an internal exam is not for you. Then in day two, we are in the gym and we’re applying what we learned day one into all activity types such as impact work, rig work, barbell and more. And we learn how to coach and come alongside and offer modifications for this population and keep them in the gym during pregnancy if that’s what they desire, as well as help them feel confident returning back to the gym during postpartum. So our next course is actually going to be with myself and Dr. Alexis Morgan. It’ll be here in Denver, Colorado. That’s going to be July 29th and 30th. And then you can hop into our next course offering, which is in September 23rd and 24th, I believe, and that’s going to be in Scottsdale, Arizona. So tailbone pain. We’ve got people with pain in the butt and we’re thinking, hey, it may be coming from the tailbone. So what do we know about tailbone pain right now? Well, true to the pelvic health research world form, we are still learning and growing. We don’t know a lot about incidence rates for tailbone pain. It is under reported. It is multifactorial in nature. There are a lot of psychological and physiologic factors that are involved in tailbone pain. So with that, it is just a trickier diagnosis to treat. But I wanted to share about all of the things that you can do from a general assessment and treatment strategy today. So one study did find that comparing female to males, females tend to be affected by tailbone pain about five times more than male counterparts. We also know that typically speaking, tailbone pain can resolve within weeks or months with time. However, we do know that conservative treatment strategies are welcome and definitely help reduce that duration for some. So what is the tailbone? Or I’ll sometimes call it the coccyx. The word coccyx actually originates from the Greek word for the beak of a cuckoo bird. So like a tailbone, the beak and the tailbone have a triangular shape. The tailbone is three to five fused bones that articulate to the bottom of the sacrum. So everyone listening right now, let’s go ahead and orient ourselves to where the tailbone actually is. With your fingertips, I want you to try right now, locate the edges of your sacrum, which is going to be that bone that kind of sits inside of the center of the buttock. And I want you to head inferiorly or towards the toes and towards midline. You’re going to follow that bone until it ends. You’ll bump into a small bone and that is the coccyx. You might be like, whoa, April, I’m like right near the anus. Well, then you’re in the right spot because the coccyx is just superior to that anal opening. So the coccyx may be tiny, but it is mighty and it is not insignificant. I like to think about the coccyx as a leg of a tripod. And that tripod is going to consist of a sit bone on one side, a sit bone on the other, and then the tailbone in the center. It is the anchor for the posterior pelvic floor muscles. So there are all kinds of muscles that attach to the coccyx itself all around. Specifically, the coccygeus muscle is going to attach on either side of the coccyx. But wait, there are more. So what is really important and why I wanted to come on here today to talk about tailbone is that there are other structures that are not actually pelvic floor specific that are attaching directly to the tailbone. Those are the glute max. So we have hip insertions as well as the sacro tuberous and sacrospina ligaments. So if you’ve got someone coming in for tailbone pain, it is important to assess above the joint and below, of course, but assessing above the joint, like at the hip and the low back due to these attachments. Functionally speaking, the tailbone is dynamic. It’s going to move as we move throughout our day doing our activities of daily living. So when the pelvic floor contracts, the tailbone is going to draw in and come forward or come anteriorly. So let’s chat about actual functions that the coccyx is involved in. More specifically, the coccyx is involved in sitting, bowel health, so it helps to keep poop in or get out of the way to get poop out. It is involved in childbirth, sexual play, and transfers such as sit to stands. So let’s put ourselves in the subjective exam. You’ve got someone that came in and they’ve got some kind of hip pain or tailbone pain. So what are we going to hear from a traumatic mechanism of injury or a non-traumatic mechanism of injury? I’m also going to talk about aggravating factors here. So what are some things that you might hear during your subjective or things that you might want to dive deeper into in order to maybe put coccidemia or tailbone pain onto your hypothesis list? So from a traumatic mechanism of injury standpoint, we most commonly hear of tailbone injuries during labor and delivery. The tailbone should move out of the way to allow for the fetus to slide on down the birth canal as if it was that easy, right? And simple. But sometimes that birth doesn’t go according to plan and someone may need to have an instrument assisted delivery with the use of forceps or a vacuum. And that is going to put someone at a higher risk for a tailbone injury. Another traumatic mechanism of injury would be a fall. And that can be a fall during your sport, during an activity, or from a horse, which we hear often. So now I’m going to dive into eight common non-traumatic aggravating factors or contributors to tailbone pain. We have pregnancy. So during pregnancy, things are a-growing and that’s going to put a lot more force down into the sacrum, onto the tailbone. So some of those folks may start to say, hey, I’ve actually got a lot more pain when I sit during pregnancy. But you don’t have to be pregnant to have pain with sitting. So one of the biggest, biggest complaints of, or aggravating factors for tailbone pain is going to be pain with sitting. So especially for a prolonged time. The tailbone assists with weight-bearing support, especially in sitting. So let’s bring it to real life. In real life, we’re thinking truck drivers or maybe people who have jobs who you are sitting without any brakes or with minimal brakes. So just constant pressure and force down onto that tailbone. And then I also want us to take a minute and think about the social implications of someone who has pain, severe pain with sitting. So what is that going to prevent us from doing? Hey, maybe going on a dinner date, right? Or comfortably going to a movie with your grandkids or any sort of event at work or your job duties itself. So people who have tailbone pain and it is severe, just have some grace for them because we do a lot of sitting in our daily lives. Think about like even transportation, we’re sitting in a car, right? Not everybody has subways in their region of the United States. So just extend some grace to these folks because they, this is definitely interrupting their life quite a bit. Other reasons, or contributors to tailbone pain, rapid weight loss, increased stress might increase some overactivity of the pelvic floor muscles that surround the coccyx. We also have some sometimes tailbone pain after spinal injury. If someone has hypermobility, that is going to play into the mechanics of ligaments and of the tailbone, as well as oftentimes people will complain of pain in the tailbone with sexual play due to certain positions causing a little bit more force down into the tailbone. And then finally, exercise. You know, you’ve got those folks who are like, oh, it’s summertime, I’m going to get my hot girl summer on or whatever kind of summer they’re wanting. And they are recently starting some sort of exercise routine, whether that is doing a lot of orange theory or 45 where they have or CrossFit where they have a lot of biking or cycling or rowing that they didn’t used to have. And that’s a little bit more pressure on the tailbone or maybe the Pilates person who is doing like a hundred boat poses, right? So exercise can play a big role in a new onset of tailbone pain. And then from a medical perspective, bone spurs, infections and cysts can also contribute. So what are some easing factors? What are these people are going to say that may lead you to be like, oh, maybe if this is what’s relieving their pain, maybe I should be considering tailbone pain. They are going to say, you know, if I change positions or they might report being on their belly or standing or sideline, those are the positions of comfort. And that’s because we are not weight bearing onto the tailbone. So from an objective standpoint, let’s run through what are some bony structures we should be looking at. So hip and low back. Hopefully I’ve made that clear to you that those need to be screened out. Pelvic specific structures. We’re looking at the sacroiliac joint as well as the tailbone itself. And in our live courses for our pelvic class, we dive deep into assessment and treatment and help you just dial in those skills. So hop on into our live course for that. I’ll walk us through verbally how we would palpate the tailbone itself. So first, first, first, first, make sure it is actually the tailbone. I had a patient one time who is a health care provider and they were all through other subjective exam. They’re saying, yeah, you know, tailbone this, tailbone that, blah, blah, blah. I get to the objective exam. I’m doing my P.A. mobs on the spine. I get down to L3 through five. Boom. That is their pain. Tenderness. Ah, that’s it. That’s it. And so I’m like, OK, noting for later. And then we continue on into some tailbone palpation and nothing. Any sort of tailbone pressing or mobilizations does not reproduce the pain that they came in for. So just make sure that we’re all on the same page about what the tailbone is. Now, let’s just call it what it is. Palpating the tailbone is awkward. It can be uncomfortable for the client, but to quote Finding Nemo, just touch the butt. OK, touch the tailbone. You wouldn’t avoid palpation or assessment of the hip if someone came in with hip pain. Right. So we shouldn’t think any different about externally palpating the tailbone. So let me give you some options for how to do that. When we are palpating the tailbone, we are looking for reproduction of pain. And sometimes after you get a feel for a few tailbones, you can appreciate that some positions, some tailbone positions are a little more flexed or some are a little more vertical. And that usually comes with a little time after palpating a bunch of them. But the tailbone palpation, we’ve got three recommendations. So number one is externally, you can palpate as a clinician, you can palpate the client’s tailbone in prone, side lying or sitting. And in prone or side lying, it’s going to be the same way that I just walked us through how to palpate your own tailbone, except you’ll have as a clinician, a pincers grasp on that tailbone and you’ll be able to do some mobilizations and manipulations there. So these do make it difficult for getting a solid grasp on the bone. And then in sitting, I love this because this is a little more functional for the person. So you can have your fingertips on their tailbone in sitting and ask them to sit upright and then also slump. And that’s going to give you a good appreciation of the movement of the coccyx itself. And then another way to palpate the tailbone is they may be like, uh-uh, you are not getting anywhere near my tailbone. That is my tailbone. So that is okay. You can come alongside them and you can just walk them through how to palpate their own tailbone again in sitting or side lying. And you can ask them some subjective questions about what it is that they’re feeling and make sure they’re in the right spot. And then the final way to palpate the tailbone would be internally or interactively. And those with pelvic floor specialty, especially trained in inter rectal examinations, will be able to do that. So from a general conservative treatment strategy standpoint, let’s talk through some of those things. You’ve got someone that came in, you’re like, yes, they definitely have tailbone pain. Now what do you do? We’ll talk through manual therapy, exercise and education. So from a manual therapy side of things, you can do some direct coccyx mobilizations, whether that’s externally or interactively. So you’ve got your pins or grass and you are applying some mobilizations to that structure. You can also do it indirectly where your pins or grass stays on that tailbone. And then you ask them, maybe they’re in side lying, hey, can you do some posterior pelvic tilts, anterior pelvic tilts of the hips or can you move your hips while we are stabilizing the tailbone? That is obviously a more active way to get some manual mobilizations in there. We can also supplement with dry needling, cupping, e-stim. We definitely want to hit the glute max, the lumbar spine. And if you’re trained in it, the pelvic floor as well, especially those coccidius muscles that attach nearby, that touch directly to the coccyx. And then from an exercise standpoint, I’ll talk through some stretches, strengthening and aerobic activity. So my three favorite stretches for promoting down regulation of the nervous system for the tailbone pain is going to be throwing some diaphragmatic breathing in with these three exercises. So the first, I like my clients to be on hands and knees doing some rock backs. The second is happy baby. You can be in happy baby, maybe do some lateral movement side to side, but I love a good modified happy baby where the feet are actually on the wall that frees the client’s hands to actually spread the cheeks. It is okay to touch your butt. It’s your own butt, right? So spreading those cheeks is actually going to put a stretch onto the tailbone itself and for some people relieve some of that pain. And then a deep supported squat against the wall is going to be wonderful for those pelvic floor muscles that may be, again, a little overactive and pulling on that coccyx bone. Of course, in the long term, we’ll want to do some general loading, whatever that patient can tolerate and especially if hyper mobility is on board, loading of the hips and back and pelvic floor can be wonderful for these humans. And then finally, let’s blast them with some high intensity interval training of whatever they can tolerate. So bike and rower are probably going to be out the window, but they may be able to do some standing, arm bike intervals, brisk walking, treadmill incline, pull walking, anything to really hit the system to address that increased inflammatory state and promote some blood flow and healing. And then finally, education. Education is huge for these humans. So we’re going to talk about positioning, positioning in sitting. Let’s encourage a neutral or anterior pelvic tilt because that’s going to put a lot less pressure down onto the sacrum and the tailbone. Let’s identify the threshold that the patient is able to tolerate in sitting. So if they’re like during the subjective, they say, yeah, you know, around 30 minutes is when I start to feel my tailbone pain. Great. We’ve identified a threshold. below that and say, if you wouldn’t mind, let’s do some, some standing breaks or movement snacks around 20, 25 minutes of sitting just so that we don’t keep hitting that threshold of pain and continuing that ripping the bandaid off cycle of I sit for hours and hours and I have pain and then it starts all over again. So let’s do something about it. And then cushions. I love recommending a lumbar support cushion like a half McKinsey slimline roll. They can tuck that below the low back and that’s going to give them a little more anterior pelvic tilt and then also tailbone for the cushions for the tailbone itself. So some of my favorite models are the cushion your assets, tailbone support, the kabootie or a donut. And then during intimacy. So using pillows for support or maybe opting for positions with decreased tailbone compression like hands and knees or legs up or side laying. Those may feel better for that human. And then it wouldn’t be an ice podcast without talking about lifestyle factors. We want you to be talking with them about nutrition, reducing processed sugar intake, and especially for this population, stress management, increased stress with job, family, whatever can be a huge factor for keeping this tailbone pain around. So we want to make sure that we get them hooked up with someone or using some sort of stress management techniques to address that part of this diagnosis. And then finally, remind these people that it takes time. Tailbone bruises, tailbone pain, all of that. It just takes a really long time. And so it will get better, especially if they can implement some of these strategies. But unfortunately, they are going to have to be a little patient. So let’s review what it is that we talked about. Tailbone pain is tricky. It’s tricky to treat. It’s understudied and it’s underreported. But it is involved in so many life functions, including weight bearing support, especially pain sitting, bowel sexual function, labor and delivery. Due to the attachment sites to the tailbone, it should be part of your hypothesis list for folks coming in with back and hip pain. Actually touch the butt, but really touch the tailbone. Make sure that it is the tailbone that is possibly a structure that is involved. If you feel that the tailbone is involved, give it some manual therapy with some mobilizations, soft tissue love, and then supplement that with whatever kind of modalities you prefer. Cupping, dry needling, some supportive stretches like happy baby, quadruped rocking, getting some gentle loading in, and then offering some cushions for solutions for positioning. And finally, refer to a pelvic floor PT in your area or get yourself to one of our live courses because we dive deep into pelvic pain assessment and dialing in those skills so that you feel confident when you have someone like this in front of you. So happy Monday, everyone. Happy Fourth of July. And I will see you all in two weeks to discuss the soft tissue structures that may contribute 24:37 SPEAKER_02 to some pains in the butt. 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 PT on ice.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.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines cold plunging, discusses the research behind cold plunging, and how to practically approach practicing cold plunging. Take a listen to learn how to discuss cold plunging with your patients or athletes. 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 What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:25  ALAN FREDENDALL Alright, good morning PT on ICE Daily Show, happy Friday morning. Hope your morning is off to a great start. My name is Alan, I'm happy to be your host today. Currently, I have the pleasure of serving as a faculty member here in our fitness athlete division and the chief operating officer here at ICE. Fridays, our fitness athlete Fridays, we talk everything related to the recreational athlete, whether that's somebody in the gym doing CrossFit, powerlifting, Olympic weightlifting, bodybuilding, out on the track, the road, running, biking, swimming, whatever, that person who is getting after it. Four to six days per week is the focus here on fitness athlete Friday. We're biased, but we would argue it's the best darn day of the week. Courses coming your way from the fitness athlete division. Taking the summer off, we have some live courses coming up in September. You can catch Mitch Babcock out in Bismarck, North Dakota. That will be the weekend of September 9th and 10th, so the first September of the fall. And then you can catch Zach Long, aka the Barbell Physio out in Newark, California. That's the Bay Area. That's going to be the weekend of September 30th and October 1st. Online courses from us, our Essential Foundations, our eight week entry level online course starts back up September 11th. We're currently halfway through the current cohort. And then our Advanced Concepts course, our level two course that requires Essential Foundations, that drills down deep into things like Olympic weightlifting, gymnastics, programming, both for CrossFit and strength, injured athletes, all that sort of fun stuff. That starts September 17th. So you can find out more about our courses at ptenice.com. So today's topic, let's talk about cold plunging. You can't trip over a rock in public these days without finding somebody trying to get neck deep in some cold water somehow. Everybody's doing it. They're posting about it. There are probably a million ads you've seen on social media for this tub. This thing that looks like a bourbon barrel. This thing that looks like a fancy bathtub. All these different ways to essentially cool down your body. So I want to attack this topic from three different angles. I want to talk about defining a cold plunge and how probably most of the people cold plunging currently or certainly what we see happen on the Internet is not true cold plunging. I want to talk about the research supporting, not supporting the use of cold plunging. And I want to talk about the practical application of what we can recommend to our patients and athletes when they come into the clinic or the gym and ask us what we know about cold plunging. What's the best way to cold plunging and all that sort of thing. So let's start from the beginning. What is a cold plunge? We need to start at the top and understand that humans have a really large tolerance for heat at rest and a very poor tolerance for cold at rest. You can imagine it's much better to sit outside on a 90 degree day than a 30 degree day. So our perception of temperature is a little bit different. It's skewed based on if we're active or if we're resting. It flips entirely when we are active. You can imagine how terrible it would be to run on a 100 degree day versus running on maybe a 50 degree day. We would all probably much choose the 50 degree day because our bodies lose heat tolerance as our activity level increases, which is all that to say of we have a really poor tolerance for cold at rest, which means when we define the parameters of what's used for cold plunging in research, we'll quickly recognize that most of us, most of the people we see aren't doing it cold enough. They aren't doing it long enough and they aren't exposing as much of their body as they need to to the cold plunge. So a cold plunge is defined by the research is going to be exposure up to your neck or possibly your entire body for 10 minutes at 40 to 50 degrees Fahrenheit. That's a large portion of our body. That's a really long duration of cold exposure for a human being at rest. And that is relatively cold. Again, we have a really poor tolerance to cold at rest. Now, imagine we've we've all taken a bath. Imagine you you take a hot bath or sit in a bathtub and then you get that feeling of, oh, I'm getting really cold. Like this water has cooled down significantly. Again, our perception of temperature is really skewed. When we decide it's time to get out of the bath because the bath water has become too cold, we've probably started in bath water of maybe one hundred and five to one hundred and ten degrees. And it has only cooled down to maybe 90 to 95 to the point where we say this is cold, quote unquote, cold. I'm going to get out of the bathtub now. But really, 90 to 95 degree water is remarkably warm compared to what we define as cold plunge in the literature. So most folks are probably simply not getting their water cold enough to even define cold plunging. Again, the duration of support in the research is cold plunging of 10 minutes. So if you are doing it for 30 seconds or one minute, just know you are not anywhere close to reaping the effects or the positive or negative that we've seen in the research. If you're only dipping your toe in for a few minutes or jumping in up to your knees or your waist and hopping back out again in the research, exposure would define itself as being exposed up to the neck, at least. So many folks just putting their legs in a cold plunge, just going up to the level of maybe the knee, going up to maybe the level of the waist or maybe belly button mid chest or something. Again, if you're doing that to slowly gain tolerance, that's OK. But if that's what you're calling normal cold plunging, just know you're probably not reaping as much of the effect. Again, positive or negative that we'll talk about here in a second as you could be. So cold plunging 40 to 50 degrees up to your neck, duration of about 10 minutes. So all that to say, most people are probably not actually cold plunging when we do it ourselves or we watch others do it. Excuse me. Simply not cold enough, not enough for their body to get in effect and not enough for a long duration. I do want to give a special shout out to ICE faculty members Dustin Jones and Jeff Musgrave. They are unashamedly posting their cold plunges every day on social media and they really get after it. You can see that they have a bunch of ICE in their backyard cold plunges and they're sometimes exposing their whole body to the cold plunges. So they are doing it right. That's the way to do it. So let's switch gears and talk about what does the research say. The research in this field is becoming overwhelming of just looking at the trend and volume of research. Eight hundred and seventy articles published on what the research would call cold water immersion since 2008. So an exponential growth in the people studying, the amount of people studying and the volume of research studying this particular area of what we might call athletic recovery. I want to talk about just two journals today, two journal articles. There are literally like we talked about hundreds and hundreds and hundreds and hundreds. But I really want to talk about two. What I like about these two articles I want to share is that they are 30 years apart and they essentially say the same thing. So first, I want to go way back. 1985, I wasn't even alive yet. Journal of Applied Physiology, Peterson and colleagues talking about cold plunging exposure after exercise. These folks did three sessions a week of what the again the research calls cold water immersion or cold plunging. They did do it at 50 degrees Fahrenheit. They did it for 15 minutes instead of 10. So they went up to their neck. They did it for 15 minutes and they did it cold enough. 50 degrees Fahrenheit. They did this three times a week after resistance training. Evaluation here looked at a lot of different things. One rep max leg press, one rep max bench press and some ballistic things, counter movement, jump, squat, jump, ballistic push up. And this article really wanted to focus on what happens to muscular hypertrophy. This journal article, 1985, now 38 years ago, said you can expect to have less muscular hypertrophy if you expose yourself to a cold plunge after resistance exercise as compared to control. Control in this group was people who just sat at room temperature like you might sit on the boxes at CrossFit class or on the curb after a really long hard run. They just sat and kind of cooled down for 15 minutes compared to the cold plunge group. Fast forward 30 years, 2015, Journal of Physiology, Peking Colleagues, very similar parameters. That's why I picked these two papers. They are perfectly 30 years apart. They use almost exactly the same parameters and they found pretty much the same thing. Peking Colleagues in 2015, very similar parameters, twice a week of cold plunge exposure, 10 minutes at a time, also 50 degrees Fahrenheit. They followed folks a little bit longer. Peter Peterson in 1985 followed those athletes for seven weeks. Peak in 2015 followed them for 12 weeks. Almost same exact parameters, though. They looked at almost exactly the same stuff. They looked at leg press strength, knee extension strength, knee flexion strength, both one rep max and eight rep max. So they're looking at maximal strength and they're also beginning to look at kind of what is your ability to produce force over time. So what we call maybe endurance, which really is indicative of hypertrophy. This team also did some muscle biopsies and what they found with the group exposing themselves to the cold plunge after resistance training compared to the control group, in this case, a group doing active recovery. So not even resting, just doing active recovery for 10 minutes after the resistance training session. The control group, who continued to exercise at a low level, had a 17% improvement in hypertrophy, a 19% improvement in isokinetic strength and a 26% improvement in myonuclei per muscle fiber. So the control group blew the cold plunge group out of the water. Now, that is not to say that the cold plunge group got weaker or smaller. They did not get as strong and big as the control group. And it's led to believe because they were the cold water immersion group, that it's the cold plunge, that something about that cold exposure seems to blunt the body's natural response for healing to encourage hypertrophy gains and strength gains. The big takeaway from this study is the myonuclei per muscle fiber. We can think of myonuclei as if one myonuclei per muscle fiber is great, but more is better. It's almost like having a personal assistant for everything in your life. Your life would be a lot easier if you woke up in the morning and someone was there who had your clothes ready for you. If someone was there who had already prepped your shower for you, if someone was there who already made your breakfast for you, right? The more people you have assisting you in your life, the more efficient you will be at running your life because they're doing everything for you. That's a lot of the role of the myonuclei in our muscles. The more the better. The interesting thing about myonuclei is they stick around even during a period of training, whether it's injury, whether we get busy with life, whether we switch training modalities, maybe we start prioritizing endurance training to train for a marathon or something. Those myonuclei stay around and that's kind of what creates that strength across life of that person who comes into the gym who says, I haven't worked out in 10 years and then deadlifts 400 pounds. You're like, where did that come from? That took me years to build to that strength. This person just naturally has it. Yes, they may naturally have some genetic strength, but what they probably had in the past from training was myonuclei that are now living in their body. And so losing those myonuclei or rather not gaining them through cold plunge exposure not only affects strength and hypertrophy in the short term, but affects really long term fitness gains over time. So very interesting study from PEEK and colleagues showing that cold water immersion after resistance training seems to really have a negative effect on strength and hypertrophy. So it doesn't seem to help. It maybe seems to have a negative benefit, at least after resistance training. Most people aren't doing it correctly. What is the actual practical application? What can we recommend to patients and athletes who ask us about cold plunging? The first thing is to make sure that they understand what it actually is and that they're doing it correctly. Of, hey, if you're going to do this, you should have a way to expose yourself up to the neck, your whole body up to your neck. You should build up your tolerance to do it in sessions of 10 minutes at a time. And the water should be really uncomfortably cold, 40 to 50 degrees Fahrenheit. We don't like to see colder than that. That can be a little bit dangerous, but we also don't like to see warmer than that. Right. Remember, cold bath water is technically hot, 90 degrees Fahrenheit. So we need to see somewhere between 40 to 50 degrees Fahrenheit. We need to talk about timing of cold plunging. The research would really suggest we should never do it after training, especially if we're just training once a day. We're training for life. We're training to be strong and be training for life. And we're not training to be competitive athletes. We're not training multiple times per day. If you're somebody that just exercises once a day, you should not finish that exercise session with a cold plunge. Maybe you start your day with a cold plunge or maybe you cold plunge before you exercise to get the effects that cold plunging can have aside from apparently blunting our strength and hypertrophy gains. And then there's a little bit of a caveat there for competitive athletes, folks who are, you know, let's think of a CrossFit Games athlete. Let's think of somebody running multiple races, an Ironman, a long cycle race. Maybe between events is the time for a cold plunge. We need to recognize those events are already really destructive to the body. Nobody goes to the CrossFit Games and comes away fitter. They come away significantly beat up with probably weeks or maybe even months of repair time needed to recover from an event like that. So at that event, we're not as concerned about not gaining as much strength and hypertrophy as possible because of the short duration. It's only a couple of days or maybe even a one day competition is only a couple of hours. So maybe that is the time between events to use cold plunging. But after regular training, we should not use it. We need to recognize the point of exercise is to create a micro injury that your body will repair and heal from. Your tissues get stronger from a tensile strength perspective and your brain more effectively learns how to use those muscles so that we get stronger and bigger over time. We become more adapted to the stress. We have an increase in tensile strength. We have an increase in myonuclide per muscle fiber. And that's what really creates robust lifelong strength. I love the quote from Pique and colleagues. Remember that anything intended to mitigate and improve the body's natural ability to improve resilience to physiological stress with exercise may actually be counterproductive to muscular adaptation. Cold plunging, NSAIDs, antioxidants, anything that can slow the chemical reactions, the natural chemical reactions in our body to respond to that micro injury is going to affect our ability to recover and be more resilient to that stressor in the future. So a lot like discouraging folks from taking a bunch of maybe ibuprofen or injectable steroids, we should say, hey, if you're going to cold plunge, make sure you start your day with it. Make sure you do it before training. You should really try to avoid finishing that workout and jumping right out into that maybe that cold plunge in the in the gym parking lot, because this research is really so profound of you're leaving maybe 20% improvement in strength and hypertrophy on the table when you cold plunge after training if you don't. So cold plunging, what is it? How does it work? Does it have a negative effect? Yes, it seems to. But also, that doesn't mean that we should say just don't do it. If you enjoy it, if it helps you start your day, if it helps you feel less sore, by all means, cold plunge. But let's rearrange when you cold plunge in your day to make sure that we're not doing it after training. And let's make sure we're doing it correctly up to our neck in the water, cold water, 40 to 50 degrees Fahrenheit. And duration should be at least 10 minutes, right? If you're just up to your knees in 60 degree water for two minutes, you're not actually cold plunging. You should feel good. You're probably not going to get a negative effect from that because you're not doing it correctly. But you're also leaving a lot on the table by not doing it correctly. So cold plunging. Hope this was helpful. We just revamped week five of our Central Foundations course to include a whole bunch of different training modalities like cold plunging. We talk about hot tubs now. We talk about saunas, both infrared and traditional saunas. We talk about compression therapy, massage, pneumatic boots, massage guns, everything folks have a question about. So if you've already taken the Central Foundations, head on over, check out week five for that update. If you haven't taken it yet, remember, September 11th is your next chance. So have a fantastic weekend. I hope you all have a lovely long four day weekend for 4th of July. We'll see everybody next time. Bye everybody. 18:00 OUTROHey, 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 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. Jeff Moore // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the idea of letting an audience grow around the passion you have for a particular area of practice versus continually trying to change your approach in the clinic or with marketing to attempt to reach an infinite number of potential audiences. Take a listen to today's episode.  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 DR. JEFF MOORE, PT, DPT, OCS, FAAOMPTAlright team what's up? Happy Thursday, happy Leadership Thursday. Welcome back to the PT on ICE. Wherever you're taking this show in thank you so much whether it is here live on Instagram or YouTube or whether it's on the recording we love having you all with us. It's Leadership Thursday but if it's Leadership Thursday it's Gut Check Thursday. So let's talk about the workout. It is a doozy. So it is the last workout in the I Got Your Six. The Warrior Water. Friends over at Warrior Water have their virtual competition going on so our Gut Check Thursday has been mirroring that. So we've been loving the videos of all of you in groups of two nailing these workouts. This is the last one so it's going to be it's gonna have a time cap of I think it was 23 minutes in teams of two and you've got to do 10. So athlete one will do 10, 8, 6, 4, 2 box jumps. Only one athlete working at a time. Athlete two has to bang out 10, 20, 30, 40, 50 double unders. Then you both accumulate only one athlete working at a time a hundred deadlifts, 225, 155. Then you switch athlete rolls to finish up the box jumps and the double unders. So if you want to see that workout I know it's a bit more complex. It's over on the Ice Physio Instagram as always and please if you do it throw a hyperlapse on there. Grab a pic. Ice Train. Ice Physio. We love seeing that stuff pour in on Instagram. So cheers to Warrior Water. Hope the virtual competition went awesome. I hope that you were able to as always raise some funds for for veterans who are being helped by getting that fitness and nutrition stimulus as opposed to maybe more aggressive medications to help out with all things psychologically and quality of life. So cheers to the Warrior WAD crew. If you aren't following them get on that they're doing great things. Okay team let's jump in. So Gandhi once said that happiness is when what you think say and do are all in harmony. When what you think say and do are all in harmony. When what you're thinking is what comes out of your mouth. When what you say is backed up by action that proves that you believed in what you said. When all of these axes are in perfect alignment that is when you are truly profoundly at peace happy. Now in today's society it's hard to get that right in some level we are always trying to adapt to our environment. It's really hard. You come off as a bit of an oddball. If you had those perfectly executed all the time it'd be really challenging to fit in. So there's some level of kind of massaging those or working with malalignment which is probably why there's some level of disharmony in most people. Right you can't have this perfect pure energy flow between what you think say and do and still be functional in modern society. But the closer you can get to that undeniably the better because we are at our best. We are our most energetic. We are our most uniquely valuable. When we are sharing, when we are doing, when we are serving what we absolutely must. Right when those things are all in perfect alignment with our beliefs we are undeniably at our most uniquely valuable. So the first charge and I think if you look back at all of my episodes up to date this is probably the thing that falls out of solution most commonly. But our first charge is always to figure out what is that? Like what does line all of those things up for me and how do I figure that out? Well you figure it out by reflecting in real time on when you're in your flow state. Right when after doing anything you are more energized than you were before you did those are the moments of reflection when you've got to say whoa whatever I just did first of all felt effortless and second of all I think I have more energy now than before I did the activity. Those are your things team and a simple awareness of what are the activities that put you into that flow state. A great tip off can be when other people say boy you made that look easy and you think to yourself well it was easy but clearly to them it wouldn't have been. So when people start helping you identify these asymmetries when you're making something look effortless that to most people is not these are your activities whatever you're sharing right now whatever you're talking about whatever you just did those are your things that are aligning all of those axes and if you can identify what those things are and spend more time in that lane and drive fast you're gonna be not only more successful but significantly more energized and excited and useful in those activities that you're participating in. That classic quote the riches is in the niches which nobody in sales denies the reality of that right specialists win when it comes to business but a lot of people think that's totally explained by market dynamics and I do agree that if you can market a really specialized niche you can get the attention of people who need you but there's a whole other half to that when you're doing a really niche activity that you're particularly great at where you're spending a lot of time in flow state because you've drilled down to realize oh this is my thing a big part of why long term the riches are in the niches is because you're doing what you're in harmony while doing and that gives you unbelievable longevity it allows you to bring incredible enthusiasm to the plate so it is a combination of market dynamics in the fact that you're doing an activity where those axes are all lined up and in that space you are going to be unstoppable which brings me to today's message you gotta stop trying to please your audience and I mean this across all sorts of domains and I'll unpack that a bit in a second but you gotta stop trying to please your audience you gotta do you and let the audience be formed by those who resonate with it I'm gonna say that one more time you gotta stop trying to please who you think is your existing audience you gotta just do you and let your audience be formed by the people that resonate with that where I see a huge obvious sign of deviation from this is when we say things to our audience is like what do you want me to talk about that is one way to ensure that whatever you wind up talking about is not in perfect alignment because what are the odds right what are the odds that the answers are things that are absolutely in perfect alignment for you that line up what you deeply believe in that where you believe it you're the most useful to add value where you believe the greatest need exists what are the odds that what somebody else answers to that lines up perfectly with your needs now team this is not to say that the occasional call for topics or the occasional Q&A does not have great value because you can pick through what comes back and try to identify which things are in line but in general be a little bit wary of that method certainly is a primary component of your business be wary of that it is ultimately professional people pleasing right hey tell me what you want me to do and I'll dance right like this idea takes you out of alignment it doesn't put you into it the reframe to this is I'm going to talk about X because I have to right if you feel like that message might serve you please tune in or if you feel like this message might serve somebody that you know well please tune in but I don't have a choice right this is what's in alignment I have to talk about this I really hope for some of you that it resonates I tell ice faculty this all the after classes because oftentimes when we're recapping if I go to a live course and I'm and I'm trying to give some notes to see if we can't make the content even sharper a lot of times our faculty will say well I really feel like I need to talk about this and immediately my response is you don't need to talk about anything besides what you deeply feel you want to talk about what is real and organic and honest for you that's what you talk about this is a big part of the reason whole other conversation but it's a big part of the reason why ice since day one has never had close partners or accreditation or tied into other groups because I always want our faculty to feel at any given moment when something doesn't feel authentic to them they can drop it with no thought and change and say this is what I really need to talk about I have to say perfect that's our content whatever follows I have to say this that's our content it goes for ice faculty but it goes for all of you it goes for who you market to it goes for where you do workshops it goes to the topic of those workshops it goes to what population you want to treat you know who you need and want to treat you know who you are uniquely valuable for you know who after you engage with them you feel energized team 100% of your effort goes to that niche identify that and just stay in that lane you don't need to do what people want you to do what you need to do is what you have to do what is in harmony with what you're always thinking about with the words that you're always saying with your actions in your own personal life those things need to line up with whatever direction you choose in that direction doesn't have a whole lot of options right so it's like look this is me I've got to do this and I hope that some folks resonate with it I hope that some folks respond well to that treatment paradigm I need to be in this space it is what it is we got to stop asking our audience what they want we got to start doing us and let the audience or the patient base or the customer solidify around that now how do you know if you're doing it right how do you know if you're staying in your lane in driving fast the answer is a little bit uncomfortable but it's that your audience should be unstable you should be dropping people and gaining people if you're not trying to please everybody that's an inevitability but what you're gonna notice is that a core group in your audience solidifies and becomes unshakable team if you aren't losing people regularly especially early you're being inauthentic because authenticity should always offend people this isn't wrong it's just that people who have drastically different beliefs when you present yours in an undecorated fashion it should be moderately offensive and people should be like oh that's not my tribe great right that's the whole point of the drill right that's why your audience should be relatively unstable early on but you're gonna see that what people want is an authentic person delivering value in their area of need and they're gonna feel that match so while your audience is gonna be unstable on the outskirts you're gonna see that this tribe is crystallizing out of solution in the middle because people that do need to hear what you have to say that you need to say they need to hear it you need to say it when that match happens when those ends plug in together your true tribe crystallizes out of solution that's the only way that great cultures are created the person delivering it is being raw inorganic inauthentic and even though that offends some people the people who need to hear that message who belong in that tribe gravitate towards it and that match is made as soon as we start trying to please everybody nobody can actually connect because nothing real is actually happening and this is what happens with what can I say for you today as opposed to here's what I need to say and I hope it lands for some of you generally speaking in your marketing in your outreach as you're trying to build followers be real suffer the consequence of an unstable early audience and what you're gonna see is underlying that your true tribe is developing all along stop trying to give your audience what what they want say what you need to say and let your audience form as a result of that hope it hits team we'll see you next week PT on ice calm all the courses are on there tons of online courses starting up in July we had a little bit of a hiatus there in between our first q1 and q2 online courses they're starting to drop right now by the way we have finished our live calendar so if you're waiting for a new live course to show up in 2023 it's probably not gonna happen because all of our division divisions are done booking so if you've got your eye on a live course a new a new one that's more convenient probably isn't gonna show up this year so grab the one you're thinking about alright team have a wonderful week we'll see you next week 13:09 SPEAKER_00 on leadership Thursday 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 CU's from home check out our virtual ice online mentorship program at PT on ice calm 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 calm and scroll to the bottom of the page to sign up