Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses ways to identify and treat medial tibial stress syndrome (MTSS), commonly known as shin splints, in the cross-country running athlete population.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog

If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses SHOWING patient progress, SHOWING justification to be paid more, and SHOWING patients how you are different than the competition Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog. 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.

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com

Dr. Miller Armstrong // #ClinicalTuesday // www.ptonice.com

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com

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

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the difference between myofascial decompression & cupping, if myofascial decompression works or not, and how to elevate the use of myofascial decompression in practice

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

ALAN FREDENDALLMyofascial decompression. What is it? How does it work? Does it work? And how can you elevate what you're currently doing practice if you're already implementing this style of soft tissue treatment?

WHAT IS MYOFASCIAL DECOMPRESSION? So let's take it from the top and let's talk about what is myofascial decompression, sometimes abbreviated MFD. and how is it different from cupping? So you may consider these in your mind to be synonymous and that is very very wrong. Why? Calling myofascial decompression cupping is really a misnomer because if we dig deep people have been cupping each other for many many many thousands of years. It comes from eastern medicine and you may have seen it in practice, maybe you do it in practice, maybe you've seen it on social media or the internet, and you see people laying in a static position, sometimes with their whole body covered in plastic or glass cups, right? And so that is cupping, that is sitting in a static position, that is using things like meridian or chi points, the idea that maybe we're removing toxins from the body, and you may even heard of something called wet cupping, where we pull blood to the surface with a cup, and then maybe we puncture it with a needle or a knife and we draw blood out of people. So all of that is kind of in the sphere of the term cupping. And what's very, very, very different about myofascial decompression is that we are using some sort of pump, manual or automatic, to get a decompressive effect through the tissue. And in the context of myofascial decompression, we are always, always, always, always, including movement. We are never having people lay statically with just cups on their body. We are not educating them that we're removing toxins from their body or altering their chi or anything like that. And certainly, hopefully, you are not cutting people open and using the decompressive pressure of the cups to suck blood out of their body, right? And so that is the difference between cupping and myofascial decompression. Both use plastic or glass cups, but they come from very, very different paradigms in why we're using it, what we're doing, and the effect that we're hoping to have. So with myofascial decompression, we know now with MRI studies that when we put these cups on, if we have enough pressure, we know that we can put hundreds of millimeters of mercury of pressure through this cup, and that we can sometimes reach the level of the bone. And so we are decompressing not only just the skin and the fascia beneath the skin, but down to the level of the muscle, fascia between levels of muscle, and even deeper levels of muscle all the way down to the bone. And so thinking about the various levels, when you look at your forearm, for example, what is between you and the outside layer of your skin and the bone? Several layers of tissue. We have our epidermis, we have our dermis, we have super fascial tissue and fascia, we have deep fascia, and then we get into the fascia in and around the muscle. We have the epimysium, we have the paramycium, and we have the endomysium. And that we know with a large enough cup and enough pressure from one of our pressure guns that again we can reach the level of the bone. So we're using higher pressures combined with movement to create this decompressive and sometimes sheer force effect on the tissue, combining the decompression with the movement, that is myofascial decompression. And that is how much different it is from traditional maybe Eastern medicine, quote unquote, just cupping. So the second question that we often get and the second point I want to make is often, does it work? There is a lot of myths on social media and the internet that this is not doing anything, that this could never cause a change in tissue. and that is team Patently Untrue. Certainly, if you do this wrong, you can be very ineffective with this style of treatment, but if you do it right, it can be very, very effective. So I wanna give a shout out to Dr. Chris DiPrato. He's a physical therapist out in the Bay Area of California. You may have heard of him. He owns the company Cup Therapy. He teaches myofascial decompression courses. We had the pleasure of taking one of his courses a couple weeks ago when he was here in Michigan, and we had a great time. In particular, I love to learn all the research he had to share. And some of that research around does this actually work is pretty mind opening. And my point with today's podcast is that when we elevate our techniques, we elevate the efficacy and the efficiency of our techniques as well. And again, certainly, if you do this wrong or sloppy, you will have a minimum effect on the tissue. But if you do it right, you can have a profound effect on the soft tissue of the body.

DOES IT ACTUALLY WORK? And Chris shares that in his course when he seeks to answer the question, does it actually work? Chris has used cups with myofascial decompression on embalmed cadavers. He has used them on fresh or what may be called wet cadavers. And he has used them on live living people in an MRI tube and looked at what is happening to the tissue when we have a large cup with a lot of pressure in it. What do we see? And what he has seen over the years doing these studies himself of having people in MRI tubes is that with a large enough cup and enough pressure, again, we can begin to decompress multiple layers of tissue, fascia, muscle all the way down to the level of the bone, which is pretty significant. And that in general, the more hydrated the tissue, the more decompressive effect we have seen. So when he has tested this on embalmed cadavers where all of the body water, liquid blood, everything is removed and the tissue is essentially dried out, we see a minimal effect when we use this technique. But when we use it on a fresh or wet cadaver or a living person that still has blood, all the sorts of fluid that we have inside of our body, that we get a much more profound effect. And more importantly, looking at these MRI studies, we see that not only do we see that effect in the moment, but that we see that effect for at least three to five days after we have done the myofascial decompression. So what is it? It is a technique using high pressure with movement to create a decompressive effect and some sheer force on the body. And does it work? Yes, if you do it right. So that's what I want to spend the rest of this podcast episode discussing.

INTERLUDE Before I do that, I just want to introduce myself. My name is Alan. I have the pleasure of surfing as our chief operating officer here at ICE and a faculty member in our fitness athlete and practice management divisions. This is Technique Thursday. On Thursdays, we either cover leadership topics or we cover technique topics. Today is a technique topic today. And it is Technique Thursday, which also means it is Gut Check Thursday. This week's Gut Check Thursday comes from our own fitness athlete faculty member, Joe Hinesco, who sent me a nice little number for you all to do this week. It is every two minutes, hop on a fan bike, an echo or a salt bike, hammer out 20 calories for the guys or 15 for the ladies. And then any remaining time in that two minute window, you're going to do max repetitions of a barbell thruster. with the prescribed weight of 95 for guys and 65 for ladies. The goal there getting hopefully at least 10 thrusters every round and your workout is finished when you hit 75 thrusters. So the moment you hit that 75th thruster you are done with the workout. So it rewards an aggressive start, it rewards somebody who can be aggressive on the bike but still hop off and pick up that barbell and do big sets of thrusters. So If you try that and you hated it, send all that shade towards Joe. He's the one that came up with this workout, so send that his way. And then I just want to plug again, Chris DePrato cuptherapy.com. He has live and online courses, a level one course, a level two course, both live and online. And if you finish today's episode and you want to learn more about this, maybe you're like me and you kind of just started doing this without any formal training. I promise you, if you take his courses, you will come away with a lot of very actionable stuff that's going to do nothing but elevate these techniques in your own clinical practice. So let's talk about this.

PRACTICAL APPLICATION Let's talk about practical application. First things first, if you have done cuffing before, You have probably seen clear cups. What's the difference? We also have cups. These are rock pods. We have these in the clinic as well. What is the main difference? The main difference is that I cannot control the pressure with something like a rock pod. All I can do is essentially stick it on my skin and get whatever pressure comes out of it, right? That might be not enough pressure to do anything and I may have to reset it. And then I basically am just getting lucky maybe with enough pressure for the patient to maybe feel something. But this is not ideal. It does not have a way for us to control the pressure. It does not have a way for us to objectively measure how much pressure we're using. And most importantly, we can't see through this, right? We can't see the tissue. We can't see what's happening underneath the tissue. There is some important stuff that can happen inside of a clear cup that you'll want to see. and I won't steal Chris's thunder, I'll have you take his course to learn that, but it's really important that we have a clear cup, and that we have some sort of control over the pressure, that we have some sort of pump gun, automatic or manual, to pump up the pressure, and really be sure we're just not getting a random application every time we put on a cup like a rock pot. So what does that look like? We have a manual gun, right? It has a trigger here, you connect it to the cup, and you pull pressure out, right? You decompress. And then with this style of cup, you just squeeze to let the air out. Now, what's great about Chris and Cup Therapy that has really made me feel good about this technique is they have solved the problem of how much pressure exactly am I using so that I can be sure if I repeat this treatment in the future, or maybe somebody else has to repeat this treatment for me, they're using the same pressure as me. Lo and behold, the automatic pressure gun, right? So you can see right here, if you're listening on the podcast, you can't see anything. So go over to our YouTube channel, or our Instagram page and watch me on the video. But what you'll see here is we have a pressure gauge, right? And it's measured in millimeters of mercury. It goes from zero up to 760 millimeters of mercury. And as you apply the cup, you will see the pressure gauge change. And that can dial you in more on how much pressure you're putting through the cup. And again, let you hopefully repeat that treatment in the future. And also be sure you're reaching the levels of tissue depth that you want to be working at. So this is a very, very great tool. This is brand new as of this year, I believe. So if you've taken his course before, you'll want to jump on cuptherapy.com and buy one of these. But this is very, very, very, very nice. And so I'm going to put this on myself. I'm going to put some, just some free up, and then I'm going to show you all how great it is with this auto pressure gun. So just putting some lotion over the area where I'm going to apply the cup. I'm going to apply the hose to the cup like so, and then I'm going to squeeze the pressure gun. Doing this one handed is super tough, but I think we can get it. There we go. And so you can hear the gun working a bit. And now as I take the hose off, you can see some pretty darn good pressure, right? A lot of tissue deformation right there, a couple of inches of skin fascia and muscle pulled into the cup. And I can tell you, this is a very different feeling than just having something like a rock pod or otherwise just a squeeze application silicone cup. This is right on the border between discomfort and pain. However, it is enough pressure that I could move those muscles. I could do a bicep curl. I could do pull-ups. I could move my forearm through whatever range of motion I wanted to, and you can see that cup is not going anywhere, and that comes down to making sure that we have enough pressure through the cup that we're reaching not only enough pressure that we can move with the cup on, but again, that we're reaching the levels of tissue depth that we want to achieve. And that is very, very easy to do with the automatic pressure gun. Let's talk about those pressures. What are they? If we really want to reach deep muscle or reach even the levels of intermuscular tissue and fascia, we need to have a lot of pressure through these cups. We need to have 300 to 600 millimeters of mercury. What is the problem with a cup like this? Or what is the problem with the manual gun? I have no idea what pressure I'm at, right? Hence the importance of the pressure gauge on the new automatic gun. Going down in pressures, if I just want to reach the level of the deep fascia, the pressure comes down a bit, 200 to 400 millimeters of mercury. And then if I want to stay superficial, even maybe if I just want to promote some lymph flow, maybe a patient has some swelling or some lymphedema, I can keep the pressure really light, 40 to maybe 150 millimeters of mercury. Again, how can I be sure I'm keeping pressure light enough to only promote lymph flow? Well, with something like a silicone cup or even the manual gun, I have no idea how heavy or how light my pressure is. And so again, it reinforces the need for that automatic pressure gun. And now I would say the key here, and again, the difference between myofascial decompression and cupping is that when we have these cups on, we're doing some sort of movement, right? Chris will take you through a whole protocol in his course of how to get the cups on and how to slowly introduce movement to an area, especially maybe if it's very restricted or very painful, but also different applications using lighter or deeper pressures to inhibit or facilitate different muscles. For example, he's a big fan of putting cups with heavy pressure on the traps for somebody who does a really contrived trap shrug when they lift overhead. And if you want to maybe isolate the deltoids or the upper back, and sort of think about turning the traps off a bit, we can stick some cups on the trap and really put a lot of pressure through those cups. It's going to be really hard to engage and move those traps, and it's going to promote movement through the muscles that we want to target. Again, maybe the deltoids or the upper back. And he has a number of different examples and circuits scenarios for you in his class but the key is the pressure matters and we can't know what pressure we're at if we don't have an objective way to measure it and then track it over time and for me that was a big game-changer what I learned is I was simply not using enough pressure using something like a silicone cup or or using something like a clear cup, but with just the manual gun. Simply not putting enough pressure into the cup to get the treatment effects that I was looking for. And certainly, probably not being light enough on the other end, if I wanted to do something like promote lymph flow, or I just wanted to have some cups on some muscles to facilitate muscle activation, I was probably going too light for deeper structures and too hard for more superficial structures. or movement facilitation. And again, the automatic gun with the pressure gauge changed all of that.

SUMMARY So what is myofascial decompression? It is not cupping. It is using pressure, specifically various ranges of pressure depending on the level of tissue that we want to target. always combined with movement to promote movement through that muscle, movement through that tissue. That is very different from cupping where people typically lay in a static position, have a number of different cups applied to them, usually with no idea how much pressure is being put through that cup. Does it work? Yes, if you do it right, it works. As with most things in life, if you do it wrong, it won't work very well. And so understanding that if we have enough pressure through a large enough cup, we can move through several layers of tissue, including all the way down to the level of the bone, which is probably much more of a pronounced effect than maybe we ever thought possible. How can we get better at this? I would recommend if you haven't yet that you take Chris's course. You learn where to put these cups to target different muscles, to target different movement patterns, and that more importantly than anything else, you get yourself that automatic gun either from Chris's website or that you get with the level two course where you have that objective pressure grade knowing that different levels of pressure will target different structures and have different treatment effects. So it's really important we know what those are and what we're trying to achieve with that patient in front of us. us. So I hope this was helpful. Big shout out again to Chris. I reached out to him before doing this episode and just ran this by him and we really appreciate all of his collaboration. You'll notice that ICE does not have a myofascial decompression course. We think Chris is doing it better than anybody else and if it's not broke, don't fix it. So just go see Chris if you want to learn more about this. He runs a fantastic course, very evidence-based, Very movement focused, which you know, anything from us here at ICE, that's what we're all about. So just go see Chris if you want to learn more about this. I hope you all have a wonderful Thursday. Have fun with Gut Check. I don't think you will. Again, if you hate it, just send Joe those nasty messages. Just pass me right on by and go right to Joe. And I hope you have a wonderful weekend and a fantastic Thursday. Bye everybody.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. 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. Julie Brauer // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses important tools for acute care PTs: a good attitude, a backpack, a white board, resistance bands, sticky notes, and gait belts.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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

JULIE BRAUER Good morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division. and I am coming to you live from my garage. So this morning what we are going to dive into are fitness forward tools that you can use in acute care and I'm going to do my best to demonstrate some of these tools that you can use to start loading these really sick folks up early. All right so We are going to dive in first by talking about the most important tools that you need to have with you as you go through the hospital and you go visit your patients in their rooms. TOOL #1 - THE RIGHT ATTITUDE So number one, the most important tool that you need is the right attitude. You have to have the right attitude about this. So let me unpack that. Bringing fitness forward care to sick older adults in the hospital. It is not about getting them to do a sexy deadlift with a dumbbell. It's not the sexy thing. It is not, holy crap, I just got this patient, they're in a hospital gown, they're super sick, and they're doing a deadlift with a dumbbell in the hospital. It's not about that. It's not about being able to get the video of that or the picture of that and being able to share that. That is sexy and that is cool and it is badass. However, the meaning is deeper. What the attitude you need to have is, is that you have this beautiful, amazing opportunity to plant a fitness forward seed in this patient who is sick, who has a ton of medical complexity, and you only get to see them potentially one time. You've got one shot to plant that seed and potentially be the catalyst that sets this person up on a better trajectory of health. That's an amazing opportunity. And I would encourage you all to be obsessed with that opportunity. Okay. Every single time I would go into a room, I thought, wow, I have this opportunity. I've got one shot. I could be the catalyst that changes their lives. And the thing about you all who work in acute care, man, you are doing some dirty work, right? You are seeing folks, whether they're young or old, they have multiple types of diagnoses and medical complexities. You are seeing them at their worst and you are seeing them in a very, very vulnerable situation. The fact that you are able to plant that seed yet you don't get to see the sexy outcome and yet you give them your whole heart and whole soul is so important. And it's hard to be in acute care and know that you're not going to get to see a sexy discharge where a patient is lifting a super heavy barbell or they are going all out on an assault bike. You're not going to see that. And that's tough, but you have to reframe it to be, I'm going to be obsessed with having the attitude that I could go into every single one of these rooms, plant the seed, and the patient is able to walk into an outpatient clinic. They want to do fitness-forward care because I planted that seed. And I think that's an incredibly, incredibly important story to tell yourselves so that you can continue to have the motivation to go in and see these folks who are sick day after day. And many times you may not actually get to get them to do the cool fitness board stuff. Okay. So that's the most important thing is having that right attitude. Okay. TOOL #2 - A BACKPACK So the second tool that you're gonna need to bring along with you to every single room is a backpack, all right? You absolutely need a backpack. So this is not the backpack I used in acute care. I used the backpack that they gave us as like a Christmas gift one year. This is a Nomadic. This is my travel backpack. This is a very sturdy, but very expensive and nice backpack. I do not recommend getting something like this to go into hospital rooms, okay? But I do recommend that you get something that's sturdy because you're going to be carrying around a lot of stuff in it. So get yourself the backpack. So what are we putting in the backpack? You're going to put weights in the backpack. No, most acute care therapy offices do not have weights. But you can bring your own. So I would bring a 15 pound dumbbell. and an eight-pound dumbbell, and I would put that in my backpack. Now, some of you are not able to bring a backpack potentially into the patient's room. Cool, then you bring it around and you leave it at the nurse's desk, okay? But the idea here is that you're bringing everything with you so that there is no excuse that you don't have the equipment because you're in the hospital. So you have your weights. Now, I've had people say, well, Julie, isn't that tough to carry around? And I say, yes, it is tough, it's heavy, but who else would want to be able to go rucking through the hospital with weights more than fitness-forward clinicians who are here listening this morning? I thought it was awesome. I felt like I was getting a lot of fitness in by carrying this stuff around throughout the hospital all day. TOOL #3 - THE WHITEBOARD Okay, so after weights, you're gonna have a whiteboard, okay? I'm using a whiteboard right now for my talking notes for this podcast. you all are going to want to use a whiteboard to create workouts with your patient. So have your dry erase markers and as you are digging into their meaningful goals and you're coming up with functional movements that match those meaningful goals, you are writing this stuff down, you are coming up with reps and sets, you are doing this with your patient. Now, I will say, you're not going to buy these and leave these in patient's rooms, right? This stays with you, okay? You can take a picture of this and give it to your patient, or the really cool thing about acute care is that they typically have whiteboards in the patient's rooms, and they're usually filled with some random information many times they are covered up with Call don't fall signs Those become great whiteboards. Okay, so I usually they're not helpful We all can can agree that call don't fall signs are not something that prevents somebody from falling. So I they're great whiteboards so I would take those down turn them around and with my dry erase markers cut right down the whiteboard on those signs then I would leave that in the patient's room maybe I would go find a couple extras and I would put some motivational phrases on there like uh i remember one very specifically i'm trying to kick covid's ass so i can get home in shopwood something like that or something that lets the providers know a little bit more about this patient their name is something that i always put on these signs their name and something about them a goal an interesting fact i want to try and have every provider who walks into the room treat this person a little bit more like a human than a number or a diagnosis and that's a way to do that so whiteboard, slash use the hospital whiteboards, use those signs that are all around the room, turn them over, use those as your whiteboard. TOOL #4 - RESISTANCE BANDS Okay, next, resistance band and TheraBands. Okay, so both. So resistance band is something like this, okay? These offer a lot more resistance than a TheraBand. However, I usually would bring a bag of theravans because i want to be able to leave some with patience right you can do endless things with the TheraBands. I would tie them to the bed rails many times. So even folks who are typically they're just lying supine majority of the day because they're so deconditioned, you can tie those around on the bed rails. They can pull from above, they can pull from the side, there's a lot of stuff you can do with them just tying them to the bed rails. with the resistance bands, this is where I would many times get people up into standing and I would do something like a paloff press. So if they're standing here and this is attached to the bed rail, I can have them do a paloff press to work some core. I can have them do some rotations, you can do rows, you can do a whole bunch of stuff with those resistance bands, but those come with me. I'm not leaving those in the room. TOOL #5 - STICKY NOTES Okay, next are sticky notes. Okay, sticky notes are amazing because they're versatile. So I have sticky notes and then even better than sticky notes, I have a really bright, uh, note card. And then I've also used paint swatches that you can get for free at Lowe's or Home Depot. Okay. So what I do with sticky notes or these things, they become targets, right? So if I'm gonna have folks be reaching for things or stepping to things and maybe I'm calling out colors or I will write on a sticky note a number and then they're not only doing a motor task, they're also doing a cognitive dual task perhaps, These are great tools. They're light, they're easy, they're cheap. The other thing I like with the sticky notes is I'd like to put little notes on them for people. So if I'm using targets with a sticky note, perhaps to show them exactly where I want them to do their deadlift, pick the weight up from and put it down on, I will put a note here that just says like, you're a badass or never give up or something like that. And then that's something that the patient can keep. So they're wonderful for targets. They are wonderful to do some dual tasking. So you can have people reach for yellow or reach for a number that is written on one of the colors. So you can yell out the color or the number. Very versatile tools, very easy to carry around with you. TOOL #6 - GAIT BELTS All right, and then also obviously a gait belt. You need to have a gait belt. obvious reasons for safety but also i have used a gait belt before and i have put it around the bed rail and okay i have never ripped a bed rail off of anything by putting the gait belt around it and tugging on it okay so i'll just say that are they the most sturdy things in the world no i've never ripped one off so that's my preface there. But I have looped this around the bed rail and then perhaps someone is sitting in a wheelchair and they have a really hard time just sitting up tall in their wheelchair, their core is very weak, I will do almost a modified rope climb where the gait belt is around the bed rail and they are pulling themselves up to sit tall, and then going back to the back of their seat, the back of their wheelchair, and then pulling themselves up to sit tall. I've done this in home health, where I looped this to the end of the bed, the bed frame, what am I calling it, footboard. But typically, in acute care, there really isn't a big enough space in those footboards, maybe some of them, but definitely a really cool tool to use to do unmodified rope climb really get that core activated for someone who is so weak that they barely can even sit tall in their wheelchair. TOOL #7 - SNACKS Okay and then lastly You need snacks, okay? Don't forget your snacks. I became so much more efficient and so much more productive when I started bringing food up on the floor with me and putting that in my backpack. So, get you some nuts, get you a bar, a little bit of healthy sugars, maybe some, I always had like clementines or mandarins, those were one of my favorite snacks. Make sure that you have some fuel so you are not having to really put a big stop in the middle of your day. You're not going down to the cafeteria, getting crappy cafeteria food, and it just kind of keeps you focused. When you take that break and go down to get a snack or a coffee, I think it just puts you in that mindset of like, I'm going to just chill and not work as hard. When you just keep hammering throughout your day and you're able to do that because you have fuel, it's really important. Okay, so that is what I put in my backpack. All right, so let's talk about some specific acute care hacks to load up your patients when you don't use the weights. Okay, so let's throw the weights out. My favorite hack, one of them, is to use towels. All right, now this is a towel that I have soaked in water. All right, because a soaked up towel is really heavy compared to a towel that's not soaked in water. So I will roll a towel up and I will put it in the toiletry buckets that are in every single patient's room. So usually these buckets come with soaps and little doodads, things like that. I just get rid of that and I soak up towels and I put them in the basin. Now, you can do a whole bunch of stuff with this. So for someone even in sitting, even having to hold on to this basin, can be very challenging. We can increase the difficulty by going overhead. We can increase the difficulty by doing some marching in sitting. We can do a deadlift from sitting. We can then get up into standing and we can do a deadlift as well. So the great thing about this is it's a great way to introduce the hinge to a patient who is post-op lumbar fusion. Yes, I am loading up someone who is post-op lumbar fusion day one. Why? Because they're going to be discharged. They were probably never taught how to do a hinge in the first place, which contributed to them ending up having surgery. and I want to be the person to break that cycle, right? They're gonna go home, they gotta empty the dishwasher, lift up Fluffy's kitty litter box, whatever it is, why not teach them here and now? So I will put the towel in the basin, and then I will teach them how to properly hinge with an elevated surface in the basin. So I'm teaching them a hinge pattern, loading it up a little bit so that they know how to properly hinge when they go home, okay? And less amounts of things you can do with that basin. The next piece of equipment that I love are your bedside commode buckets. Yes, the things that poop usually goes in. But this is not what we're using them for. We are using clean bedside commode buckets, okay? So the cool thing, buckets, they usually have a handle, okay? So it makes it a lot easier to hold on to than potentially the basin. So what I will do is I will put a bunch of crap in the bucket. So I will put my weights in there or I will go and get a bunch of ankle weights because typically therapy departments and acute care have ankle weights, put them in the bucket and now we got some load. So you can do the same thing. You can deadlift with the bucket, okay? you could do my favorite, which are carries. Okay, so loaded carries. So as you're walking with your patient, they could carry on to the bucket. And the cool thing is that it adds a little bit of a perturbation. Okay, so they're getting an internal perturbation just by holding on to an object. There's a truck coming by, I'm sorry. I am out in my garage. and there is destruction going on in my neighborhood. And it's disruptive. So I'm gonna wait until they go by. Okay, they're hanging out. I'm just gonna talk louder. Okay, so with the bucket, Come on, my friends, keep it moving, keep it moving. Don't say no on a live podcast. Okay, with the bucket, what you can do is if someone is non-ambulatory, they can hold on to the bed rail and they can go like this, back and forth with that bedside commode bucket full of equipment and full of weights, okay? They could hold on to it, hold on to the bed rail and march, just like this. They can swing that bucket forward and backwards. There's a lot of things you can do with the bedside commode buckets to add in a little bit of a perturbation. Okay, lastly, we'll talk a little bit about how to put all this stuff together. So when you are with your whiteboard, right? And you're talking and you're sitting with your patient and you're figuring what movements that you're going to do. This is where you can start introducing what an EMOM is every minute on the minute. You could start introducing what a rounds for time is. So very, very early on, typically patients don't hear about this stuff or feel what intensity is like or load until they're way into their journey and they go into outpatient potentially, right? So the amazing thing is that you get to start introducing them to what a workout is like this early on. Imagine that seed that you've planted, then your patient will understand what it's like to lift heavy and to work hard. They go to home health or they go to inpatient rehab and then they go to outpatient and they're able to advocate for themselves and understand, okay, This is too easy. I don't need that yellow TheraBand or I'm not working hard enough. This isn't challenging enough for me. You are able to give them that opportunity, which is absolutely amazing. And remember, you can be the one that has an impact on them. Farther down the road, you are not going to see that sexy discharge, but you were able to be the catalyst to spark some change. Okay. All right, my friends, that is all. The next time I come on here, I will actually show you an example of like an EMOM or a rounds for time, some examples of what I would actually do with patients in acute care. I will also, on the ice stories, I will post some of my reels I made back when I was in acute care, going back into the archives. I will post on our story my reels that show some of this stuff in action. Lastly, talking about our courses that are coming up. MMOA Live will be in Alabama, we will be in Minnesota, Wyoming, and Oregon for the rest, not the rest of September, we're not in September yet, but in September, so many opportunities to catch us live on the road. Alright everyone, have a wonderful rest of your Wednesday.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Justin Dunaway takes a deep dive into a series of three studies tracking the same cohort of patients over 10 years and what they say about the importance of short term changes!

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about our Persistent Pain 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

JUSTIN DUNAWAYAll right, team, good morning. I am Justin Dunaway, lead faculty with the Institute of Clinical Excellence, coming at you live from Portland, Oregon. Welcome to another Clinical Tuesday. I am lead faculty for Total Spine Thrust and also our Persistent Pain Comprehensive Management course. 32nd cohort just began yesterday. So if you're thinking about jumping in that will the registration will remain open for another day or so So if you're thinking about it, go ahead and take a look But enough about that. Let's get into today's topic today we're gonna talk about full thickness a traumatic rotator cuff tears and looking at physical therapy or Surgery and what what kind of predicts that stuff? and it's really cool because it's a series of three studies over a decade that looked at the same same kind of cohort of humans and And while I'm going to talk a bunch about these three studies, realize that this really is more than a story about rehab for rotator cuff tears. This is really a story about the importance of our ability to demonstrate within session and between session change, early, often, and frequently. And at Ice, we often hear that we are obsessed with incessant change. We are obsessed with our ability to show short-term changes. And I couldn't agree with that sentence more. Like, totally. I am absolutely obsessed with that. The second half of that, though, which I don't agree with, is that short-term change, within-session change, those things don't matter. What we're really talking about is regression of mean or natural history. And short-term change doesn't predict long-term change. And I couldn't disagree with those sentences more on lots of different levels. But I think that the story I'm about to tell, the three studies that we're about to walk through, give some of the best evidence and support for the need for short-term and within-session change, for at least one of the many reasons why this stuff is so important. So let's dive in. First study, study number one, the effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears, multi-center prospective cohort study by Kuhn and Dunn, 2013. Mouthful. But basically what they did is they took a whole bunch of humans, 452 of them, that had full-thickness chronic degenerative rotator cuff tears, and all of them got six weeks of physical therapy. And then at the end of the six weeks, they were asked, you know, how are you doing? And they got one of three options. They could stay cured, in which case they were done, and we'll just check in at 12 weeks, and then at a couple time points over the next two years, or they're improved, in which case they would get another six weeks of physical therapy, or no better, and then they could opt for surgery. And then at the 12-week mark, the people that were left, that weren't cured in the first six, asked them the same question. If they were cured, awesome. If they were anything but cured, they were offered surgery, and then tracked over the next two years. The physical therapy protocol, I couldn't get my hands on the full version of Appendix A that went into detail about what they actually did, but in the study, in the methodology they just talked about doing the physical therapy was range of motion, was postural control, was scapular training, was mobilizations, was general strength training stuff. And I've got some thoughts on that and we'll dive into here in just a second. But the outcome here is what they found is that less than 25%, okay, full thickness chronic degenerative rotator cuff tears, less than 25% of the 452 people in the trial at the end of the 12 weeks needed surgery. At the six week mark, only 6% of people opted for surgery. At the 12 week mark, that number was up to 15. And then over the next two years, a few more trickled in and that went up to like 24%. So at gut shot, 75% of people with full thickness rotator cuff tears went on to have excellent results in pain, disability, range of motion, strength, functional stuff, and went totally back to life. That's awesome. That's huge, right? The second piece The thing I want to think about here, though, is I think that number could be a bit better, right? I'm going to make an assumption that once we dive into the exercise protocols there, were they really doing strength stuff? Were they really looking at multi-joint movements, overhead presses, rows, pushes, horizontal presses, things like that, and dosing them appropriately for strength? you know, thinking about low or high sets, low reps, two to three minute rest at roughly 80% of their calculated one rep max, or are they doing like three sets of 15 with a band? And call it strength. I have no idea. My assumption is that we probably could be a bit more aggressive with exercise, and I bet that number could get a bit better. But 75% is awesome. So let's run with that. And the conclusion of this first study, which is super important, That if I'm just gonna read the quote if a patient avoids surgery in the first 12 weeks He or she is unlikely to undergo surgery at a later time point up to 12 up to two years So this is the first point here if the patient doesn't opt for surgery in the first 12 weeks They're probably not going to get surgery so our ability to to show them functional improvements in the first six, in the first 12 weeks, is absolutely huge. Because if they don't feel like they need surgery at the end of the 12 weeks, they're not going to get it probably ever. And when we think about conservative management versus surgery, both these things can be effective. But there is massive risk to surgery, right? There's massive financial risk. It's super expensive. And then thinking about the risks of anesthesia, of something going wrong during the surgery, of infection, of interactions, adverse events with the medications, opioid addiction. All of these things are risks of surgery that don't exist in conservative management. Okay, so that's the first study. If you don't opt for surgery in the first 12 weeks, it's unlikely that you're going to. 75% of humans got totally back to life without needing surgery. Study number two, predictors of failure of non-operative treatment of chronic symptomatic full thickness rotator cuff tears. Same research team. This was published in 2016. Again, looking at the same cohort of 452 individuals, This time what they wanted to see is, okay, 25% of you failed conservative management, failed physical therapy. Why? Is there anything in there? Is there anything about you that predicts whether you will or won't do well with physical therapy? And this was really cool. So they looked at all the patient demographics. They looked at age, they looked at sex, they looked at pain, severity of the tear, disability, chronicity, activity levels. They looked at work status and education and handedness and really everything under the sun. And what they found, the first thing they found is that structural factors were not predictive at all. Tear didn't matter, pain didn't matter, disability didn't matter, what your MRI didn't look like. None of that stuff predicted whether you needed surgery or not. The number one most powerful and really only significant predictor of whether you went on to need surgery or not for your full thickness rotator cuff tear was belief that physical therapy wouldn't help you. That was it. If you believe physical therapy would help you, you succeeded, you didn't need surgery. If you didn't believe that, then you opted out and went for surgery. And then smoking status moved the needle just a little bit, which makes sense. If you're smoking, your body is widely inflamed. Things heal slower. Your pain systems are far more sensitive. And then the other thing that was a very small predictor was activity levels. If you had higher activity levels, you were slightly more likely to opt for surgery early. And that makes sense too, right? My shoulder hurts. I can't do all the things I want to do. I'm still trying to do them. Things aren't getting better quick enough. Give me the magic bullet. The important thing here, again, one, structure was not predictive. Two, the only real strong predictor was your belief in physical therapy. Now, this is where it gets interesting, right? If that is the thing that determines whether you get surgery in the first six to 12 weeks, or that's the thing that determines whether you get surgery, and most humans are gonna make that decision within the first six to 12 weeks, you cannot make the argument that within session change and short term changes don't matter and probably aren't the most important thing there is, right? Because I cannot, if the thing that determines whether you need surgery or not, whether you get into that MRI tube, whether you get in the OR suite, whether you're getting those injections, pills, things like that, is your belief that physical therapy can help you, I cannot think of a more powerful way to foster that relief than having some tools in my toolbox that when you walk in the door, very quickly, I can modulate your pain, I can change your pain, your pain pressure threshold, turn on painfully inhibited muscles, gain some access to proprioception, and then get out into the gym and do some things that actually build capacity in humans, and demonstrate that thing within session, and then session after session after session. Short-term change and within-session change are the things that get patients to believe in physical therapy. And belief in physical therapy is the thing that keeps the patient out of the OR. Simple as that. That is the most important tool we have to foster those beliefs. Okay, study number three. This one just came out like last month. The predictors of surgery for symptomatic, atraumatic, full thickness rotator cuff tears change over time. Same research team, again, looking at these same humans that were in this study. Now this is tracking them down 10 years later. The first thing that pops out is that at the 10 year mark, only 27% of these people went on to get surgery. So you think about that, at the two-year mark, it was around 24%. So just a few more people kicked into the surgery over the next two, between two years, year two and year 10. Most of them, over half, opted for surgery before the six-month mark, and then the rest of them slowly trickled in over the next 10 years, with it kind of being less and less each year down the road. At the six-month mark, And everything prior to that, the most predictive thing, again, whether you need surgery or not, was belief in physical therapy and nothing else, right? So those beliefs are gonna be powerful all the way up to the six month mark. Everything we can do in that window to convince patients. that this is the path they need is gonna be the thing that keeps them off the other path. Beyond six months, it doesn't switch to structure, it doesn't switch to pain and disability and any of that stuff. The only two predictors beyond six months were if you were on worker's comp, and again, if you reported high levels of activity. Now this is super important too, right? Because okay, we're six months, we're a year, we're two years, we're five years out. We've done physical therapy, it didn't work, we've kind of forgot about it, that's off the table. And now, the stuff that's really bugging us is the fact that, okay, we're still having trouble at work, we're on workers' comp, we're kind of in that system, we still have all these activities that we want to do that we can't do the way we want to do them, now it's time to do something else. It's important to realize that overall, at the 10-year mark, 70-ish percent of humans, again, didn't need the surgery. And this is an interesting bullet point, too, because one of the things that you'll frequently hear is that, great, people do well with conservative management for rotator cuff tears. But if you don't repair it anyway, you set the patient up for degenerative changes, arthritis, problems down the road. What this study showed us is that the 10-year mark, the 70% of humans that did well with conservative management 10 years ago in that six to 12-week PT window, All of them were successful. And the success that they gained 10 years ago didn't decline over time. They didn't have more disability. They didn't have increased pain or arthritis or things like that. Their gains stuck. And this is one of a few studies that look at conservative management for rotator cuff tears, track them out over long periods of time, and show that there is no negative mechanical effects from not repairing that thing. So, the important stuff here, the key clinical factors here, is that team, at the end of the day, beliefs and expectations are the foundation. They're everything. They're the thing that drive the decisions that patients make, right? And if we don't have the ability to demonstrate change to our patient, if we don't have the ability to show them, not just tell them, But show them time and time again, ruthlessly, within session and between sessions, slowly building up functional outcomes, session after session after session, they're not going to buy this. And if they don't believe in what they're doing, if they don't believe in physical therapy, if they don't think that this is the thing, that's the stuff that determines, OK, am I going to get shots? Am I going to be taking pain medications? Am I going to end up in the OR suite? We need, what this research tells me is that we really need to drill down on our ability to have tools in the toolbox that create quick, transient changes in pain, range of motion, muscle activation. And I get that that's transient, but what we're doing is we're open a window. And then once that window is open, we absolutely have to jump through it, get right into the gym and start doing the large functional movements that build capacity in humans. And then be ruthless about your comparable measures, your functional stuff between sessions and your objective stuff within sessions. and make sure that multiple times every session, you're showing patients change. In every session, when they walk in the door, you can show them change over time. This is where you started. This is where we were after the first week. This is where we were after the second week. The better we get at that, the better we get at demonstrating change in the moment and showing them incremental change over time in the short term, the better our odds of keeping these patients out of the surgical suite. If the only thing that separates these two groups, physical therapy or going under the knife, is their belief in the power of what we're doing in the clinic, then we have to invest everything we have in our ability to demonstrate those changes. All right, team, hope you're half as excited about these three studies as I am. I think it's a really cool thing to look at and then track these patients over the last 10 years. If you got any questions, throw them in the chat. Have an awesome day in the clinic, and I look forward to seeing you out there.

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.

Dr. April Dominick // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick discusses 4 topics to cover early in rehab for an individual who had a prostatectomy surgery in order to promote optimal physical and mental recovery!

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

EPISODE TRANSCRIPTION

APRIL DOMINICKPost-op prostatectomy, unique considerations for the PT. Let's talk about them. Today on the podcast, we'll talk about four topics that are unique to post-op appointments when it comes to treating someone with a, or after a prostatectomy. Overall, we address the person who comes in for prostatectomy care with similar basic foundations that we would any other post-op person, like rotator cuff repair, post-op knee replacement. We do this in regards to respecting general tissue healing guidelines and timelines, restoring mobility and function, as well as using those progressive overload principles in order to achieve those goals. Don't let the prostate piece scare you. It's basically the same, except for a few considerations that we'll talk about today. You are the musculoskeletal expert, and you can use what you already know for these general post-op sessions. The post-op PT eval will be, like I said, similar to the pre-prostatectomy eval that I talked about in my previous episode, number 1765. In that episode, I outlined some basic education on prostatectomy, options for surgery. I go into detail about what a rehab session would look like from the subjective to the objective to the treatment and, uh, week over the most common complaints, which are urinary leakage and erectile dysfunction. So the biggest takeaway from that episodes besides how to outline your eval and session is that pelvic floor muscle training prior to a prostatectomy is key for having incredible impacts on improving health-related quality of life post-op. So again, the outline of a prehab evaluation for someone prior to their prostatectomy will be very similar to the post-op. So I just wanted to take out some key pieces or topics to focus on today that are unique to someone who had a prostatectomy. So we'll talk about how to educate, intervene, and I'll give you some tools for four different branches of our post-prostatectomy tree. The first branch we'll talk about is surgery specifics and general pelvic floor knowledge. The second thing we'll talk about is bladder function. Then we'll go into sexual function. And our fourth branch is the psychosocial piece. So let's dive in. SURGICAL CONSIDERATONS Branch number one, surgical considerations to ask the patient. So the patient comes in, they've had their prostatectomy. What do we need to know about their surgery? Well, first off, we need to know which type of surgery did they have. And we're today talking about a full prostatectomy, so removal of the prostate and some seminal vesicles. So which type of surgery was used? Was it open, meaning they had much larger incisions in the abdomen in order to get to the prostate? which is gonna have a huge effect on rehab. Number two, is it a laparoscopy? And that's gonna be a lot smaller incisions on the abdomen, or was it robotic assisted? Generally speaking, those are smaller incisions. They have less trauma and much shorter hospital stays. Another important question to ask is how long was their catheter in? And on average, it's about one to two weeks. If it's longer, there is a big potential to impact short-term bladder function, like urgency, frequency, leakage, and there is a greater risk for UTIs. And then if they know about this, a lot of times they don't really know about this, but if they know about it, any information about how much nerve sparing was achieved during the surgery. We know now the greater the nerve sparing, the likely that there is better function from a bladder side of things, as well as sexual function. So that's just some general surgery considerations. Now we'll dive into pelvic specific education that we can give. In terms of the pelvic floor, most people don't know what the pelvic floor is and don't know how it's related to the surgery they just did. So ensuring that the individual has some visual models or pictures of the pelvic floor itself and how these muscles relate to bladder, bowel, sexual function, supports, and things like that. Then making sure that they know, hey, this is the surgery that you had. Here's what happened, if they're okay with you talking about it. That way they understand why they're experiencing certain side effects. And then asking them, very much understanding what is it that they need in terms of lifting? Do they have a toddler at home? Do they have a grandchild that they're lifting or a caregiver? What are their job duties? Does their work require that they lift? And making sure that we have those in mind so that we can prioritize those with their rehab goals. Still under our pelvic branch, we can also get some objective measurements from them, outcome measures that are really helpful for this population. From a bladder side of things, the International Prostate Symptom Score is helpful. They also ask about nocturia or nighttime leakage. And then the NIH chronic prostatitis symptom index, it talks about impacts of symptoms and their quality of life. From a sexual function standpoint, the erectile hardness scale and then the international index of erectile function, those basically have them rate their erections and the quality of those. And then psychosocially, there is a prostate cancer specific index cancer patients and it measures health-related quality of life, physical function, as well as emotional well-being. So those are some outcome measures that you can track changes of with your patients. And then still on the objective side of things for the pelvic floor, we want to get a general orthopedic assessment and pelvic floor specific assessment. And during that pelvic floor assessment, we are looking at hyper or hypotenicity. We are understanding what their awareness is of their pelvic floor, their connection, coordination, strength, so many different things that we can look at. And you can do an external visual palpation of the pelvic floor. And you can do an internal a digital rectal exam. However, that's only going to be once they are cleared by the physician around six to eight weeks. So that was all the surgery considerations that we want to ask, then the pelvic floor, just kind of like things that we want to go over, objective measures. BLADDER FUNCTION Now we're going to move into the bladder function and talk about education, exercise, and some general tools and resources for that branch. So education wise, we want to be educating these individuals that urinary incontinence is extremely common in this population. It can be significant and very much improve. We usually see most improvements within the year. Clinically, I've seen a lot of improvements in that first three to six months, especially if they're able to come in for PT. And then we want to be telling them about, hey, here's some education on pads, how you can use the weight of the pad to be a specific measurement for whether or not they're improving in their urinary leakage. So weighing the pads is a lot more objective of a measurement than asking, How many paths do you go through? And then teaching them, hey, there's different levels of absorbency of the pads. That could be another measure. If you need one that has a much lighter absorbency, then that can be another sign that you're improving. And then from a daughter's side of things, educating them on taking note of your daytime leakage and nighttime leakage. Reminding them that, hey, if you After the surgery, once you become more and more active, you may notice at first some more urinary leakage and we expect that. for some people. And as they do therapy, we also expect that to get better. So also being mindful for these tracking changes and suggestions. Some individuals may have a lot of anxiety with tracking these changes. So being careful with who it is that you actually recommend being very diligent about tracking. And then from an exercise standpoint to help with bladder leakage, we're always going to start with pelvic floor muscle training. And that can be isolated at the very, very beginning. And then, and we can start that as soon as the catheter is removed. There aren't any solid research-based protocols on how many reps exactly and how often and whatnot, but we generally want to be starting with isolated pelvic floor muscle contractions and then pairing that with functional movements pretty much right off the get-go. I'm gonna say sit-to-stands are one of the biggest and most common ADLs that someone post-op will have leakage with and because think about how many times we stand up to during our day as well. So really harping on mechanics and breathing and bracing strategies to help limit the urinary leakage with that. And then of course lifting, walking, returning to specific sports or job duties is going to be how we also want to pair our functional activities. our pelvic floor muscle training. Then we want to be teaching about breath mechanics and bracing strategies. So really leaning into, hey, there is a spectrum of breath mechanics like using an open glottis versus using a closed glottis. That's going to be a lot more intraabdominal pressure. And really teaching them how to gauge that pressure at the beginning to reduce the strain that they have with activities like standing up. Also ensuring that, hey, when they are lifting, they are not straining. They are not, as we like to say in the pelvic division, going down to the basement. And because that is going to increase unnecessary pressure on the area that is healing. And then progressively building up to increasing intra-abdominal pressures as well as external loads as they return to lifting or impact or return to their sport. From a bladder side of things, the tools that we can use, a penile clamp would be a tool that lightly puts pressure around the mid-shaft and then in doing so it kinks the urethra and that's going to over time increase bladder capacity and help them if they are struggling quite a bit with urinary leakage. All right, so that was the bladder branch. SEXUAL FUNCTION Now we're onto the sexual function branch. The sexual function piece, often the most distressing post-op change. Education-wise, we want to make sure that they understand, hey, there is no longer going to be wet ejaculate post-op due to the removal of the seminal vesicles. You may have a loss of penis length, Expect that. And then also reminding them that, hey, there may be some changes in your erection and orgasm, such as delayed onset or reduced intensity, maybe some increased pain or reduced sensation, but that is why you're working with me. We'll work together on some of those pieces. and then from an exercise or modality perspective for sexual function. Obviously, pelvic floor muscle training is going to be really helpful, making sure that they have an understanding and awareness of which muscles or where they need to be working if there are restrictions to the pelvic floor. So we can teach them some self-mobilization techniques, not only at the pelvic floor, but also globally at the hips and abdominals as well. And this is going to help promote local blood flow, which is what we need for sexual function and for interaction. And then modalities like dry needling plus stim are helpful for local and global blood flow. And then of course, regular aerobic exercise, 150 minutes a week, that is going to 100% improve their blood flow and just overall physical health in general. Other non-musculoskeletal tools that they can use to help with sexual function, penile pumps that can help with erectile function by increasing the local blood flow and maintaining penile length. There are various protocols for using these. And then a lot of folks are also recommended to use medication like phosphodiesterase to help with post-prostatectomy and sexual function. PSYCHOSOCIAL CONSIDERATIONS And then our third branch, the psychosocial branch. While this surgery removes something physically, we cannot forget the ricochet effects it has on the person's mental and emotional well-being. exercise levels pre and post-op, let's use this as an opportunity to create lifestyle change, to increase their aerobic and resistance exercise frequency so that they're not leading that sedentary lifestyle post-op that maybe they did pre-op. This is going to obviously improve mental health and the physical effects post-prostatectomy. While the surgery does affect the client, it also affects their social life. Say leaking or wearing a diaper, going out to happy hour, not a great look. And then also it includes the romantic partners or maybe even caregivers. So ensuring that we are addressing not only the individual who was affected from the surgery, but others in their life. And then tools wise, the Prostate Cancer Foundation, it's a great resource for finding providers, treatment centers, support groups, and there's a space for caregivers. So I really liked that website. Then there's the Mojo app, and that focuses on the psychological side of sexual function for erectile dysfunction. So it's created by a psychotherapist and pelvic floor physical therapist. There's lots of different exercises, little modules that they can go through. A support group is also included. It is not prostatectomy specific, but I think it's a great resource from the psychosocial side of things. And then of course, mental health providers are huge, especially those that are versed in pelvic conditions or even someone who's a sex therapist. SUMMARY Okay, in summary, we know that prehab is vital for these prostatectomy patients in order to improve their outcomes post-op. Post-op prostatectomy, the general guidelines of tissue healing are very similar in how we would use progressive overload principles, very similar as any other kind of operation or post-op. There's just those unique considerations that we talked about. We talked about that tree with some different branches, so making sure that surgically we asked them about specific questions like what was the type of surgery, how long did they have their catheter in from a bladder function branch. We talked about education of the pelvic floor itself and anatomy so that they understand why leakage is happening. We talked about breathing and bracing strategies and using those to up or down ramp the pressure to affect urinary leakage. And then we talked about pairing the isolated pelvic floor muscle contractions and coordination work with whole body strengthening and functional activities. Definitely focusing on sit to stands as they have the greatest urinary leakage. And then we talked about sexual function, ensuring that they know there are changes in their penis, like the erection, orgasm. They can do self-limbalizations to help with restricted areas. They can use the Mojo app, the penile pump, to assist in erectile function. And then from the psychosocial piece or branch, we talked about resources like the Prostate Cancer Foundation, mental health providers for both the client and the caregiver. So our next online cohorts, if you all are interested in pelvic classes through ICE, Our next online level one cohort starts September 9th. Level two starts October 21st, and that's where we really deep dive into post-op considerations. And we also talk more in depth about prostatectomies. Our next live courses are in Hendersonville, September 7th and 8th, Milwaukee, September 14th and 15th, and Galesbury, Connecticut, September 21st and 22nd. Thank y'all so much for listening, and I will catch you next time.

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