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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the current state of the insurance-based healthcare systems, alternative practice styles, and the "magic" behind building a sustainable 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

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

ALAN FREDENDALL All right, good morning, PT On ICE Daily Show. Happy Thursday morning, I hope your day is off to a great start. My name is Alan, I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at Ice, and the Division Leader in our Fitness Athlete Division. It is Thursday, it is Leadership Thursday, that means it is also Gut Check Thursday. This week's Gut Check Thursday is another qualifier workout, so it's on the more aggressive end. So we have every four minutes for four sets. You're basically going to go through one workout of the Hero Workout DT. You're going to do 12 deadlifts. You're going to go 9 hang cleans. The caveat this week is that they're hang squat cleans. So they're going to take longer to cycle and they're definitely going to take more out of your legs than the traditional power clean we find in DT. Then you're going to finish with six shoulder to overhead. So for most folks, that's going to be a push jerk. The weight there is 155-105 on the barbell. Ideally, we're finishing one round of that complex in about two minutes. And then in any remaining time in that four-minute window, we're doing as many wall balls as we can. Guys are going to throw a 20-pound ball to a 10-foot target. Ladies, a 14-pound ball to a 9-foot target. The goal of that workout is to get through the barbell and get to the wall balls and accrue some wall balls. Great scores are going to be really anything above 50 reps. Exceeding 100, making your way towards 150 is definitely going to be an exceptional score. Modify the weight on that barbell, modify the reps if you need to make sure that you get off the barbell in about two minutes and that you have time for wall balls. There is no rest between sets, so keep that in mind as well. You probably don't want to be doing wall balls right until the whistle and need to turn and pick up that barbell without a break. You're probably going to want to allow yourself maybe 15 to 20 seconds of rest on the last set of wall balls and then go and pick up that barbell when the clock beeps. So have fun with that one. That's from a qualifier workout for a really awesome competition we have here in Michigan out on the west coast of Michigan out near Grand Rapids called Fresh Coast Fit Fest. Really fun CrossFit workout two day event on the beach. So some of our teams here from our gym at CrossFit and Fenton are going to be doing that. So have fun with that qualifier workout. THE CURRENT STATE OF THE PT INDUSTRY Today what are we talking about? We are talking about cash-based practice, insurance-based practice, or maybe in between what we call a hybrid-based practice, where is the magic? So today I want to make a couple points. I want to really have a candid discussion on insurance and really the physical therapy profession in general. I want to talk about what it means to open a sustainable and ethical practice. I want to talk about the down-low with payment methods and payment amounts as far as how much we get paid. and I want to talk about the concept that I call the golden rule of private practice. So let's start with that discussion on insurance. So Kaiser Foundation back in 2022 published that about 95% of Americans have health insurance. Why do I bring that up? I bring that up because if you only get information from social media, which unfortunately many folks now do, you might have this perception that cash-based therapy, cash-based medicine in general, concierge medicine, has taken off and that if you still accept insurance, you are somehow maybe 100 years behind what's currently happening. and it could not be further from the truth. Most Americans, most consumers have insurance. Again, 95% of people. So certainly while folks are getting more used to maybe their high deductible plan and that they do probably need to pay out of pocket for some or maybe all of their health care, Certainly that's not the case for everybody. In this idea, this mantra on social media that Americans have just rebelled against health insurance and none of them have it anymore and everybody is totally willing to pay cash for everything and you can charge whatever you want is the name of the game could not be further from the truth. In fact, 33% of Americans have Blue Cross Blue Shield PPO insurance which means they carry pretty nice insurance that they probably pay a lot of money for. So I say all that to say this, we need to be realistic that most of us will probably come and go from this profession before we really see a significant shift in how patients interact with the healthcare system, most notably from how they pay for their healthcare. Why does that matter? And why is that unlikely to change? I think looking at the state of the economy in general, again, if you get a lot of your news from social media, you may believe that the economy is on the edge of being destroyed at any minute. But again, that could not be further from the truth. We dodged the depression that was forecasted. The economy is at an all-time high. And that is shown if we look at insurance company profits. So let's go down this list. I love to look at data like this. Blue Cross Blue Shield last year, $457 billion. Almost half a trillion dollars. UnitedHealthcare right behind them, $414 billion. Anthem Blue Cross Blue Shield, so kind of a conglomerate of a bunch of different state Blue Cross Blue Shield associations, $109 billion. Cigna, that's a private commercial insurance, $76 billion. Humana is another private insurer, $55 billion. If we look at just the five largest health insurance providers in the country, they comprise 5% of the country's total GDP. All of the money that we essentially generate and spend across the span of a year. We also need to recognize as we've talked on here before that by 2030, 70% of Americans will be Medicare eligible. So if anything, what we see over time is that more people are carrying insurance, more people have nicer insurance, whether they're paying for that themselves or whether they're just being provided nicer insurance through their employer and that more and more Americans are also going to be carrying Medicare insurance as they turn 65 or whatever that age becomes over the next couple years. So why are we unlikely to see a significant shift in payment methodology in physical therapy or in health care in general? Look at all of that money, right? If we include all the other health insurers, we're looking about one-tenth of all of our money coming and being generated by health insurance providers. If we include what's being spent on health care, both through insurance and through private pay, that is beginning to comprise almost a quarter of our economy. What does that translate to practically? What can we glean from that? It really says that the chief product that the United States produces is sick, injured people in pain, and that our primary export is dealing with the subsequent secondary issues that come with a sedentary lifestyle that produces really sick people. So I think we're really unlikely to see things shift because a lot of people are making a lot of money either being on the health insurance side of the equation or being on the health care system side of the equation. And I think we are living in denial if we don't think that those giant companies that are making half a trillion dollars a year aren't making sure that some of that money goes to lobbying members of Congress to make sure that there are laws that require health insurance to make sure that we build brand new headquarters buildings that employ a lot of people where case adjusters and claims adjusters and all these folks that run a health insurance company can work and that that company can say to the government, look how many jobs we're creating. And when you really see that these companies are starting to take in nearing a trillion dollars, you recognize how much money is truly in this system. INSURANCE IS WEIRD & NEEDS TO CHANGE That being said, we need to be honest that insurance is totally weird. Health insurance is so weird. It is the most inefficient, weird thing that we probably do, right? We're used to having auto insurance. If you've ever had to make an auto insurance claim, you would probably say that by comparison to health insurance, it was a pretty easy process, right? If you've ever wrecked your car, somebody came out and probably said, Oh dude, that car is wrecked. Yeah, we're going to get you a new car. So we'll do some paperwork. And then you'll get a check and you can go get a new car, right? I just had a windshield crack. It was really cold here in Michigan. It was negative 20 degrees. Made a call. Somebody came out and said, yep, dude, your windshield is indeed cracked to the point where it's probably dangerous for you to be driving. Drop your car off here and in an hour somebody will fix your windshield. We don't see that smooth process with healthcare. We see a really weird process filled with a lot of paperwork, a lot of limitations on access to service, and otherwise, the health insurance company trying to hold on to the money that they're getting from patients. It would be totally weird to have insurance in a lot of the other things we do, right? Imagine you need to get your hair cut. I need to get my hair cut really bad. Imagine I go to get a haircut and they tell me, hey, your haircut insurance will only pay to cut half of your head today. You'll have to wait six months, and they'll cut the other half of your head. How impractical would that be? Yet, that's how healthcare insurance functions. So we need to acknowledge the dichotomy here. There's a lot of money in this system. It's probably not changing anytime soon. That being said, it's very weird and inefficient, and it's not working for a lot of people. So that being said, if this is the current state of our healthcare system, and our industry is physical therapists, how do we navigate this? NAME THE ENEMY We navigate this by naming the enemy, right? Corporate physical therapy with hundreds or thousands of locations, employing thousands or tens of thousands of therapists, overbilling patients, seeing multiple patients an hour, driving up that revenue for both their businesses and the health insurance companies, and really delivering low-quality care. We will never win against those folks one-on-one. We'll never be able to go toe-to-toe with them. If you missed Virtual Ice on Tuesday with Jeff Moore, our CEO, you missed a really good discussion on effortless clinical practice. And he really touched on the idea of the solution to high volume, low quality is not to try even more volume with even less quality. That is a losing game. We can certainly try the same strategy to win. What's probably going to happen is that It's not going to last very long, you're probably going to burn yourself out, and you're just going to become another clinic that gets bought up by one of those big chains. So we need to name that enemy, we need to recognize what's being provided, and we need to begin to chip away at them. We need to hit them where it counts, which is to take their patients away from them. How do we do that? We need to fundamentally understand and recognize and be comfortable with what an hour of our time is worth. WHAT IS AN HOUR OF YOUR TIME WORTH? This is something I heard many, many years now, almost a decade ago now from Zach Long, of no matter what you're doing, you should know what an hour of your time is worth and you should be trying to get that. It doesn't matter if you're treating a patient, it doesn't matter if you're doing back-end work, It doesn't matter if you're doing marketing for your clinic, you should be getting relatively the same amount per hour, and you should have a really good understanding of what an hour of your time is worth. Building upon that is how we build a successful, sustainable practice. We just crossed the halfway point in our most recent cohort of Brick by Brick, our practice management course, and this is something I really hammer on people with how to establish your practice, that before you launch, before you start seeing patients, Now is the time to make sure that you set your practice up so that you have a successful, sustainable practice because that is the only way that we're going to chip away at all of these high volume, low quality establishments in a way that we might actually turn this ship around. What's not going to work is doing the same thing of seeing and taking insurance that does not pay well, seeing two, three, four people an hour and getting stuck in the same volume trap that all of these clinics are already stuck in. $40 a visit is profitable if you see four of those visits per hour, right? We can't get caught up trying to fight fire with fire here. We need to go a different route. We need five high-quality, independent, private practices around every chain clinic to provide really quality service to take those patients away over time from the chain clinic and drive them out. And we need to replicate that across the country. The worst possible outcome of fighting fire with fire is that after a couple years, you decide that you're done and you sell your practice to one of those corporate chains, right? You become the enemy. you turn your practice into another version of something that already exists, the volume goes up, the quality goes down, you just become another cog in the machine. That is the worst possible outcome if you do not think about starting your practice sustainably. How do we do that? PAYMENT METHOD: THE PATIENT'S PROBLEM My third point is that it comes down to payment method. We need to understand and recognize that Some people want to use our insurance, but that some insurance simply doesn't pay us a living wage such that we can pay ourselves what we think we're worth. We can pay the people who may work with us what they're worth, cover our expenses and still turn a profit. We need to really think about sustainability. That means that you probably should not accept every insurance possible and that depending on where you live and depending on what an hour of your time is worth, maybe no insurance is good enough for you. And that's also okay, right? Hence, cash-based physical therapy. And that for the majority of folks, the magic is going to probably lie somewhere in the middle. Taking a handful of insurances that let you reach a moderate amount of patients, and everybody else is going to have to pay cash. With that comes the hard truth that not every patient is going to be able to see us. And that at the end of the day, how a patient pays for their service, their physical therapy, is really their responsibility. There are certainly ways we can help. We can offer cheaper rates. We can offer pro bono. And that's a topic for a different day. But at the end of the day, how they pay needs to be in a form that is sustainable for us to take. And I don't think we consider that enough when we're about to launch a practice. I think we go full spectrum. How many people can we reach? Let's take every insurance. Doesn't matter how terrible it pays. Doesn't matter how much paperwork is involved with seeing those patients. Let's take it all and then we'll deal with it later. And then later becomes, I'm tired of doing this and I'm going to sell my clinic to one of the big chains. Again, the worst possible outcome. We need to recognize that if we accept more insurance and we provide lower quality, higher volume care, that we're going to have a minimal impact overall, not only on our patients' lives, but on the profession in general. PAYMENT AMOUNT: THE OWNER'S PROBLEM Looking at payment amount, we need to recognize that there's a natural give and take between employer and employed. And at the end of the day, for those folks in management positions or leadership positions, We need to recognize and truly embrace the idea that the staff physical therapist, the person who comes to work every day and treats patients, is our frontline worker, and that they need to be supported more so than anybody else. Far and away in our industry, far and away across healthcare, the people who see patients are often treated the worst. They are the people who have been told, guess what? There's no money for a raise this year. Guess what? We're taking away your Con Ed money. Guess what? We were going to give you an extra week of vacation. We can't afford that now, right? We continually strip money and benefits and autonomy away from our frontline workers and then we're totally shocked that they leave and open up their own practice, right? Attrition is one of the worst things that can happen to your clinic and we need to understand that while payment method is the patient's responsibility, Payment amount is the owner, the leader's responsibility of controlling what we get paid is ultimately, for me here at our clinic, my responsibility. I need to make sure that we take in enough money, that the frontline workers are supported, and whatever's left is for the ownership. And far too often in clinics, it is the other way around. If the insurances you take aren't paying you enough to take care of your people, you should probably stop taking that insurance. If the insurances you take require you to hire another staff member to do all of their authorizations and certifications, you should probably stop taking that insurance. And if working with an insurance company requires you to reduce your quality or increase your volume and become a detriment to the healthcare system instead of a positive influence, you should probably stop taking that insurance. THE GOLDEN RULE TO SUSTAINABLE PRACTICE The golden rule, my last point here, what do I think the golden rule is? Is that you should only work with organizations that value and reward high quality physical therapy that pay you at or above what your desired rate per hour is. Folks often ask us, hey Alan, hey Mitch, why do you guys take insurance? Well, we only take three of them. We take our Blue Cross Blue Shield state PPO. we take Medicare and TRICARE. Why? Because they don't have any documentation authorization requirements, they pay at or above our desired rate, and they have a really quick turnaround on payment, usually 48 hours for Medicare TRICARE and about 10 days total for Blue Cross, about five to seven business days. So we have relatively no turnaround on payment and it pays at or above what we want to get paid. And I don't think enough clinics appreciate how important that simple rule is. SUMMARY So I think, will things be fixed? Probably not anytime soon. We need to recognize that most Americans have insurance. They want to use insurance. Cash-based therapy is getting more popular, but is widely dependent on geographic area and local socioeconomics. We cannot fall into the traps on social media where we see all of these paid ads maybe from cash-based physical therapy owners that tell you you need to be 100% cash-based or you're behind the times. We need to have some sort of compromise as long as that compromise doesn't require us to sacrifice quality in order to obtain really good outcomes at a volume of patient care that is sustainable for our therapists and ourselves in a manner that rewards them for the work that we put in. We need to recognize how much money is in the health insurance and the healthcare industry, and how little of it those of us going to work every day and treating patients are actually seeing. I laugh every time somebody lets me know they just scored a sick $500 quarterly bonus for treating 80 patients a week. Because I know that clinic probably made hundreds of thousands of dollars off those patients that quarter, and the staff physical therapist got $500. Whoopee, that means nothing, right? We need to acknowledge that amount of money, excuse me, and we need to know that that is part of the reason why things may not be changing as quickly as we want them to change. If we're thinking about opening our own practice, we need to make sure we do the things necessary to make it sustainable. We need to take a really long, hard look at our local socioeconomics, our population, In Brick by Brick, we have people do a SWOT analysis, strengths, weaknesses, opportunities, and threats. And one of the things we encourage students to do is who are the biggest employers in your area and what insurance do they carry. If you work in a town where 80% of the people are employed by the same employer and they have Blue Cross Blue Shield PPO or it's a military base and they have TRICARE, it's probably in your best interest to take those insurances provided it pays you what you want and the documentation requirements are acceptable to you. If not, we need to also recognize it's okay to not take every insurance and that hybrid practice is probably long term the best solution moving forward until we can make significant changes in the insurance market or until we can shift enough folks over to the cash based side of healthcare practice. So cash-based, insurance-based, hybrid-based, where's the magic? Probably somewhere in the middle as with most things, right? And not or, but also recognizing that we're on the same team, right? If you are operating a cash-based practice, if you are operating insurance practice or hybrid practice, and you are providing really high quality care, you are doing your part to chip away at the problem. And if you're working for a company that is not doing that, or you are part of the management leadership team at a company that is not, you do need to acknowledge that you are providing a negative impact on the healthcare system. and you need to be understanding and recognizing of that fact. So, I love this topic. I think about this topic literally a thousand times a day. So I'd love to hear your discussion, your comments on this. Have fun with Gut Check Thursday. I hope you all have a fantastic weekend. If you're gonna be at Fitness Athlete Live this weekend with Mitch, Don, and Raleigh, have a great time. Have a fun Super Bowl. Go Chiefs. Have a great weekend. 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. Christina Prevett // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how it can feel very overwhelming when your practice looks very different then what you are exposed to in a course like Modern Management of the Older Adult. You don’t need to change drastically overnight (though you can!) but we encourage you to take the first step. In today's episode, Christina takes you through 4 steps you can take TODAY, to level up

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

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE daily show. My name is Christina Prevett. I am one of the lead faculty within our geriatric division. And today I wanted to talk to you about something that we see a lot as we talk to clinicians across the country, across North America, sometimes internationally, about some of the barriers to implementing some of these exercise interventions that we know are so, so relevant and helpful to get our older adults as strong as possible, to give them as much reserve as possible. So when we go into different live courses, we have our two-day online, or we have our eight-week online course, we have our two-day live course. We talk to clinicians in the geriatric space who are in a lot of different practice settings, right? It's really great and really unique that one, we oftentimes have a multidisciplinary group. So we're seeing OTs, PTs, CODAs, PTAs. But then we also have a lot of people in the room who are in different practice settings. So in any course, we can have some people who are in acute care, in home health, in skilled nursing facilities, long-term care facilities, outpatient clinics, fitness. We kind of see this spectrum, right? And we know that with our older adults, that there is a spectrum. And in our courses, we try to speak to that spectrum. So we try to speak to the clinician who is working with really sick folks in the hospital, to the, person who's in fitness and is keeping older adults who are doing fairly well as active as they can into hopefully their 90s and 100s. But sometimes there can be these barriers that are maybe not to do with the client that you're seeing, but the clinician and the space at which the clinician is at in order for it to feel like an overwhelming barrier to get individuals to or to see some of the changes we know are going to lead to better outcomes. And this is not to cast any blame on the clinician, but to acknowledge that it is not just you working with the client, it's you working with the client within the system that is medicine and the system that is your employer. And it's something that we want to acknowledge. So I was at a course recently and I had a person come up to me and I just, I loved the vulnerability, but she said to me, you know, I am a worse clinician than I was five years ago. And she was, she's about five, six years out. And you know, I'm going to talk about what you can do today, but I want to acknowledge this first. And she said, I'm just so tired. And she wasn't saying it for, you know, sympathy. She was just wanting an acknowledgement that she knew that all of the things that we were talking about in this course were exactly what she needed to be doing. And yet all of the other stuff around the system that she was experiencing was making it so that she was exhausted and it made it hard to do the better thing, right? Because Seated Therax is not as cognitively demanding on us as clinicians. The safety profile is oftentimes a lot lower, is a lot lower, even if the returns are not as good. And I first, before we start talking about ways that we can start leveling up our therapy practice, like what is the next step that we can take? If this story is resonating with you, what I want you to do is know that we see you. We see how hard clinicians are working. We see how hard it can be to push back against a narrative that has been, you know, kind of placed into our system that makes it so that there are barriers that are systems and administrative barriers that make, you know, leveling up in geriatrics be difficult to do. It is especially difficult if you are the one trying to push against this and everybody else in your practice is not. And so I first want to just acknowledge you and say, you know, I'm going to start trying to give some practical tips around ways that you can take that next step. But if your biggest barrier is where you are at from a headspace perspective or where you are at from a cultural perspective, just know that I acknowledge that where you are. and maybe some of that reflection will help work towards, you know, I don't know what that next step is for you to try and help get you out of that burnout or out of that exhaustion state, but it may be your biggest hurdle when it comes to leveling up in the geriatric space. So I wanted to acknowledge that first. "WHERE DO I START?" Okay, so the next step is I have no idea where to start. and I have no idea what to do. And so where I want all of you to start, and this is gonna be my challenge for you for the rest of the week, is do one thing different. level up in one thing. So when people come and take our course, they think, okay, now everything that I do has to be different. And that would be like taking you and you eat fast food six times a day or six times a week and you don't exercise at all and you're not sleeping and you're over caffeinated and you don't know what water is. And then you say, okay, I'm going to go and I'm going to eat super clean. I'm never going to have any fast food ever again. I'm just going to drink water. I'm going to kick out caffeine and I'm going to exercise 150 minutes. of aerobic and two times a week of strength training. I love that goal for you, but we wanna make it so that it makes what seems impossible possible. And we're gonna start taking these little steps, right? So we talk a lot in MMA about graded exposure and acknowledging that process when it comes to our patients, but we acknowledge that that practice change also takes time. And if this is not an area where you are focusing with respect to intensity, and this is particularly true in the resistance training space, just know that we don't need to drastically change. LAYER IN STANDING EXERCISES We need to take the next step. And so what can that be? Let's go through three examples of what that can look like. So you have a patient who is coming in and you have been doing predominantly seated exercise. and this is no shame at all. This is where you are at with this person. They are tired, their joints are irritable, and you know that you're gonna have to do a lot of pressing to get that session to be mostly in standing. Great. I want you to get them standing for one. If that's one exercise, that's one set. If you are doing long arc quad, change that to a standing terminal knee extension with a band around the rig or around a doorknob or around the high-low table that allows them to do that exercise in standing. So the one next step can be is to choose one person on your caseload where the easier choice was to do the seated option, but you're going to get them to do the standing option. So that's taking the step Here, that was number one. START USING AMRAP SETS Number two, if you are a person who has had trouble finding a quantifiable baseline assessment of strength. And this is so many people in our profession, like we ask all the time, like how many people take a kind of estimated strength measurement before they prescribe strength exercise? And most people are saying, well, shoot, I don't really do that. And it was a big growth area for me too. So the first opportunity for leveling up, today in your geriatric practice is to get a person who you would have chose a seated option, but you're going to try and get them into standing for at least one set. The second one is going to be to pick one exercise for one person and do an AMRAP set. So we talk about using estimated 100 maxes. So an AMRAP set is as many repetitions as possible. We can use it for a quantifiable baseline amount of strength, You're going to choose a weight that you think individuals can do for 10 repetitions or less because there's a cardiovascular component if we're over 10, if you've ever lifted heavy weights for more than 10 reps, you know what I'm talking about. And I want you to put an AMRAP set in today. So that's number two. Number three is you take one person's session and you get an objective measure for every set. So this is my number three. So one is get a person in standing if we want to have them sitting even though we know they can stand. Number two is getting an AMRAP set to try and find a quantifiable baseline amount of strength. BEGIN TO OBJECTIVELY QUANTITY EFFORT WITH RPE And three is to find a rate using a rating of perceived exertion, an RPE, for each exercise. and try and get individuals in that moderate sweet spot between five and seven. Hey, if you want to push them up to 10, I'm here for it. But if we are trying to take the first step to level up, what we want to make sure is that we are asking our patients, how hard do you think this is? And some people are going to say it's hard because they're tired. Some people are going to say it's hard because of pain. or some people are going to say it's hard because it's effortful, and effort is the name of the game, right? Effort when we're bumping up against pain can be that we're kind of toggling in this wiggle room between this increase in pain and how long it takes for their pain to come down to baseline. It can be exertional effort, but effort is the currency that we are looking at when it comes to all of our rehab interventions. And so the step that I want you all to take is to take a rate of perceived exertion for every exercise. So if they are doing clams, if they are doing bed mobility, I wanna say how hard do you think that was on a scale of one to 10? Or was it easy, medium, or hard? And you want them at least in the medium. There are so many times where I think that I am hitting the right mark when it comes to intensity for my older adults, and then I ask them, and they're like, oh, it's like a three. And I was like, well, dang. Linda, I'm going to switch this weight for you." And we end up taking the weight and putting it higher. Of course, your clients learn that and they'll look at you and you'll ask and they'll say, eight. And I was like, I don't believe you. That's not an eight. And you switch that exercise out. But giving you a rating of perceived exertion, one, that's something that you can document to make sure that you're getting that intensity, is a great way for you to be able to level up your Jerry game today. Okay, I know I said three, but I'm gonna give you four. BEGIN TO MEASURE REST INTERVALS The fourth one that you can do, and then I'll kind of go through all of them again, is to record your rest. Oftentimes we do our sets and then we kind of wait and we wave a little bit and we think, oh, well, I'm getting bored or they're getting bored or they're finished with the story. Okay, we'll start the next set. And we have no idea what that intensity looks like if they are resting for 30 seconds versus 90. If you are working with an individual with a high enough amount of load, they should need that full minute to recover. And so if we don't Check how much rest they're getting it can be really difficult for us to know if we're hitting the mark again with intensity So I gave you a bonus one So I'll do three plus bonus that I didn't lie to you at the beginning of this session About or this podcast about what our ways for us to level up our Jerry game So let's bring this around full circle the first thing is I want to acknowledge you if the hardest part about leveling up your Jerry game is because of the mental state that you are in right now if that is because of your job if that is because of family stress if that has become because of work culture expectations that make it difficult. I want to first acknowledge that and where you are. And know that sometimes if you are sitting at a 40% baseline, your cognitive reserve, and you're giving 40%, then you're giving 100% of the effort that you have available right now. And I want that acknowledged. And I know that it's not just simple as like, let's just change these one things for individuals who are kind of in the throes of some of those difficulties. If you are able to get through and try one thing different today, I gave four options, right? So doing that AMRAP set, getting a person doing an exercise in standing that we probably would have biased towards sitting, taking a rating of perceived exertion for every exercise in a session, or measuring rest, putting a clock on in the background and having it roll up and just kind of getting an idea of how much rest individuals are taking. You'd be surprised how much of our exercises, our interventions are gone because of us taking longer rest intervals than are probably necessary. SUMMARY All right, if you want to learn more of these level up steps, you can hit us up at MMOA Live. In two weeks on the 17th, 18th, I'm in Oklahoma City, Oklahoma with Sam. It's going to be such a fun course. On the 23rd, 24th, We are in Gales Ferry, Connecticut. We actually also have a sold out course right now in Rochester on that same weekend, which is super exciting. I love when we see these big crowds. But Alex is going to be in Gales Ferry. And then March 2nd and 3rd, we are in Rome, Georgia and Sparks Glencoe, Maryland. So if you are looking to find us on the road, if you want to figure out all these level up techniques, That is the place to do it. It is two days. It is so fun. You get to hang out with us and our crew. Maybe we can give you that little boost of motivation that you need to take that first step forward. And we would love to be that little bit of a motivation boost and a culture for you if you are struggling right now with different aspects that are outside of your control and your patient's control. within our healthcare system. So I encourage you to see us on the road if you haven't yet. Have a wonderful rest of your week, everybody, and hopefully I will see you all eyeball to eyeball at a course soon. 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. Paul Killoren // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren takes a deep dive into how dry needling has been traditionally marketed and offers some tips to improve your marketing via your website & social media to demystify dry needling in a manner that results in more patients choosing your clinic for treatment.

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 our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling, Lower Body Dry Needling, and Advanced Dry Needling.

EPISODE TRANSCRIPTIONINTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

PAUL KILLOREN Good morning team. This is the PT on Ice daily show and I am broadcasting worldwide from my hometown of Appleton, Wisconsin. My name is Paul Killoren. I'm the current division lead for dry needling for ice. We just wrapped up a banger, an awesome group in Milwaukee last weekend. I am from Wisconsin, so wife, kiddo came with me and we drove up to Appleton, which is my hometown. So I am broadcasting from Appleton from my father's office. The childhood nostalgic vibes are strong. I've been in Wisconsin for a week, so you might hear some accent come out of me like, oh, you know, here we are in Wisconsin but wanted to grab this PT on ICE slot to jump on today and discuss how to market dry needling and even kind of how to market dry needling 2.0 maybe even differently than the other dry needling out there.

DRY NEEDLING MARKETING 1.0 So I'm gonna be quick this morning, but picture with me, and this shouldn't be hard to picture because almost any website, almost any social media post, if it's a clinic, state to state across the country, here's our list of services, manual therapy, BFR, dry needling, when you click on that dry needling tab, it jumps you to a page, what is dry needling? And that's the page I wanna discuss this morning. Because here is what 90% of those pages start with and look like. Dry needling is a technique that uses a monofilament needle. And from there, I mean, first of all, from there, most narratives, most websites, most explanations of dry needling still kind of go into trigger point-ish theories. So I'm going to give a few tips today. One of them is, is not to go down there, but, and if you've taken a course from us, you get that, that influence that we have better explanations, better narratives to how we do the technique, but what the benefits of dry needling are. But first I want you to picture that snapshot of you've jumped over that dry dealing page on a website. Before I get into the actual explanation, the content of the page, let's just talk how that page should be designed. Because we are in the social media, the Google web page realm where we're trying to get a three second impression to that patient. Everything we know now is that that patient is not necessarily going to spend two to five minutes reading one, two, three paragraphs about dry needling. So really we have above that scroll line, above that page to capture their attention, I mean make it visually appealing, but also give them enough info that either we answered their general question or intrigued them enough to keep scrolling down.

MAKE DRY NEEDLING MORE VISUALLY APPEALING So what is dry needling? Before I get into the content, this page. should be visually appealing. I mean, it should fit your website for sure. But here, when I say visually appealing, we have that main homepage. I think a good half or third of it, so large enough to be visible, central, and appealing, should be a video or a picture of dry needling. And here's where I'll say 90% of the webpages out there have a pretty generic stock photo of, you know, maybe a hand, maybe a hand without a glove, gently placing a needle. And I get it, we're using Canva, we're pulling from Shutterstock, we're using generic stock photo libraries for this. First, I think we could admit the stock photo libraries are getting better. So if you created your webpage years ago, there are more dry needling specific images out there to use for this webpage. So if you're not going to have photography of yourself, which first of all I think is a nice touch to have you with a patient doing the technique, but if we're gonna use a substantial portion of this above the scroll line presence on the what is dry needling page, make it a nice looking photo and make it dry needling looking versus acupuncture looking. I know from a still photo there's arguments that you can't tell, but find an image of a clinician using a glove. Find an image of, you know, a more assertive tissue grasp where it looks like the dry needling technique that we're going to do in the clinic. If you use electrical stimulation, find a nice image of a needle with the clip attached, or you the clinician or a clinician using e-stim with dry needling. So make it visually appealing and make that image or video informative. Again, if we only have this small footprint on a webpage or three seconds to grab someone's attention, or really answer their questions. Like, oh yeah, I've kind of heard about dry needling. They click over to your what is dry needling page. That image, that video should immediately answer lots of questions.

SIMPLIFY YOUR DRY NEEDLING EXPLANATION Part of why I think that visual is so important is now let's go to the text block. Now let's go to the content, the written information. I would say you have two good sentences that a patient is actually gonna read. Or to be even more extreme, I'll say, if your definition of dry needling says, dry needling is a technique done by physical therapists using a monofilament needle, I think you've already lost your audience. I mean, at this point, I think as soon as we say filiform needle, monofilament needle, they're like, I have no idea what a monofilament needle is, I'm out. We're not talking to colleagues here, we're talking to patients. So again, back to I think that image, that video or that image on the page is intentional. It shows a monofilament needle. They get it. They can see it's not a hypodermic syringe. It's not a blood draw or injection. we immediately answered one of their questions, which is, man, what does this needle look like? What does it feel like is what they're asking, but really they're saying, what does this needle look like? That's what the image is for. Don't waste half or a full sentence in your initial description of what is dry needling to say monofilament needle, which no one in the public has any idea what a monofilament or filiform needle is. So let's not start with that. Again, what we see a lot of over here is dry needling is a technique performed by PTs with a monofilament needle. From there it typically goes into to deactivate trigger points, improve tissue health, all of these things. I think we can refine this first sentence a little bit. And whether I'm saying that this is now how all of us as rehab professionals should market dry needling, or if I'm really just talking to this, to our ICE dry needling 2.0 crowd, I would say dry needling is an intramuscular technique with electrical stimulation. And from there we can say two, improve tissue health, decrease pain, improve muscle responsiveness, improve performance, evacuate fluid. So that would be my first sentence. From that first sentence, I removed that monofilament, filiform, that distracting word that patients don't know anyways. I did that with my picture. And I explained intramuscular. I mean, maybe that might lose some patience, but what we're trying to say in a word or two is this needle's going into a muscle, deeper into a muscle. Again, I think a video or an image showing that should be helpful. Use of electrical stimulation, that is key. And I'll take that point a step further in a moment. But we have an intramuscular with electrical stimulation and then why? And I think that why is just the generic. Patients are saying, why would I consider this? And if they're considering it to decrease pain, improve muscle function, maybe rehab a specific injury, improve muscle responsiveness, tissue health, all those things. That would be my first sentence. I'm not saying from that first sentence we've answered all of the patient questions, but we're starting to frame dry needling in a context that either they're going to form more questions, and I guess if I haven't said it already, the intent of this first paragraph, this first what is dry needling above the scroll line block is not to answer all of their questions. If you think we can answer all of their questions about what does it feel like? Is it acupuncture? Does it hurt? Is this the same as a blood draw or injection? If we think we can answer all those questions in one paragraph, I think that's going to be unsuccessful and to some degree is going to be a little scattered and chaotic. We have our webpage, we have an appealing picture that fits how we treat with dry needling. We started it with an explanation, ideally explaining that it is inside of a muscle using E-Stim and what the goals are. And we removed the words monofilament or filiform needle and removed the narrative and the explanation of trigger points.

DRY NEEDLING MARKETING 2.0 So big picture, let's say you were just trained or let's say you were trained years ago I'd love you to go back to your webpage, go back to maybe your most recent patient-specific or informative social media post for patients and look it over. And I mean, be that naive patient and say, take a look at that page for three seconds and say, man, how was that interaction? Could I update this picture? Could I invest in taking my own photos or maybe making a 15 to 20 second video post? If you do that, it should be you, your voice explaining the procedure, but also have the procedure there. Again, the visual of dry needling answers many questions. Everything from the size of the needle, what does it look like? to your specific application of, are we just placing needles like acupuncture? Are we pistoning a little bit? Are we using e-stim? Is it one needle? Is it 20 needles? That little snapshot, actual snapshot of an image or 15 to 20 second video is very helpful for patients. So from there, I think that might be a slightly updated version of preparing for this podcast. I really just went typed in dry needling and a few specific cities. So that the main hits weren't like Wikipedia and all that. It was actually like physical therapy clinics. There are some good looking websites out there. So I love that. But the what is dry needling page, I think needs to be better across the board. I think we need to be more succinct in our explanation and narrative of what dry needling is a little more contemporary, which again, is not just that sterile definition of a monofilament needle. One more thing I'll add is that we are now living in a world, depending on which state you're in, but really if dry needling has been more and more mainstream, really starting in the 90s, early 2000s, a decade, a decade. So let's say we're at least 20 to 30 years removed to where Dry needling has been a part of physical therapy practice in the public sector for a while now. What that brings is either confusion or patients with previous needling experience. More and more patients are saying, I've had dry needling. And whether they loved it or whether they did not love it, we now have to explain how we specifically, you specifically, are going to use dry needling. So if you are ice trained, I'm speaking to you all to say, how do you market dry needling 2.0, the training you all have had, how do you market that as slightly different than just other forms of dry needling out there? First of all, you all know, you should know, and you should be marketing pretty strongly, the use of e-stim. And really, if that patient comes in and says, You're talking about dry needling, I saw your poster, I saw it on your website, like, I really don't wanna do dry needling. Patient's always in charge for sure, but I have more questions first. I'm like, okay, respect that. Where did you have dry needling before? Was it a PT? Was it a chiropractor? Was it an acupuncturist that is just going to call it dry needling? What was it like? Did they piston? Did they just place needles fairly superficially, not very deep? Did they use e-stim? How many needles did they do? These are all questions that we kind of need answers to. If the patient is saying, I had dry needling and I hated it. I was sore for two days. I'm not sure if it helped. Okay. Was the needle dose, the mechanical pistoning, a little too aggressive? Did they not use e-stim? Did they not reinforce it well after the treatment? Or, I had dry needling, you know, I don't care about the needle, but I just, I didn't feel like it did much. That patient is like, well, okay, how did they use the needle? Did they displace it? All the same questions. So we kind of have to frame the patient's previous experience. And that's easy with a patient in front of us where we can do a quick Q and A. But let's say it is just general patients coming. Maybe you have a pretty good grasp of your competition, I guess I'll say, or people in your community who are marketing dry needling, maybe you already have a pretty good awareness of how they're doing it versus how we do it differently. we need to have that on our webpage as well. We need to market that actively as well. And at this point, it's my own sample size. It's previously not using as much e-stim to now I use e-stim almost exclusively. It is worth marketing that our e-stim or our needling, sorry, our needling with e-stim is a little different than maybe the dry needling that our patient has had at this other clinic or other types of dry needling. So I'd put that on the page, and I'd put that high on the page of, at DPT with Needles Physical Therapy, we do dry needling a little differently. We really believe on a little less tissue trauma, that's less pistoning, and using E-Stim. E-Stim allows us to be a little more deliberate, a little more tactical for pain relief, neuromuscular changes, moving fluid. However you need to market that, but I would market that. The E-Stim, The e-stim across the board might be novel and unique to your patient, but having the ability to decrease that post-treatment soreness and be more effective or be more intentional and tactical is worth marketing for the patient. And again, I think that has to be a pretty succinct written webpage, text block explanation, but there's value in having a really nice looking image or a 15 to 20 second video. So I think that's where I'm going to drop off today. And really what inspired this, I think it was a month or so ago. Mitch Babcock jumped on and he's like, how do we perform the art of that 15 minute exposure? He wasn't talking needling directly, but he was saying, you're at that CrossFit gym, that competition, you have your booth set up, your table set up. How do we master that 15 minute exposure? I think we can run something similar to that for dry needling in the future. But even before I got there, I thought it was worth kind of having this discussion of, we need to kind of update, we need to modify some of our social media and webpage appearances. I was gonna say explanations and that's part of it, but it's not just the words, it's not just the text block. We really have to update how it looks and feels on that first, what is dry needling webpage on your website or on social media. So, Go take a look at your own website or make a post today or in the next week and give it that fresh look. Give it the fresh look using Canva, do all your stuff or with an image, but give it a fresher explanation. I'm going to drop off there. If you've got questions, this will be, uh, I guess live is wrapping up now, not seeing any immediate comments. Thanks for joining those. See lots of folks jumping on. Um, but drop some comments, questions on Instagram or YouTube. Uh, I am at DPT with needles, otherwise at ice physio on Instagram. How does your dry needling marketing look if you have three to five seconds or if you have that above the scroll line page? That's the challenge today. Let's see how it looks, folks. Thanks for joining. We'll catch you next time on the Institute of Clinical Excellence, PTN Ice Daily Show. Out.

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. Alexis Morgan // #ICEPelvic // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the essential, yet often overlooked as aspect of early postoperative care. Alexis explores the wide range of concerns and adjustments individuals face postoperatively beyond the usual need for return to exercise. From emotional and mental health needs to navigating the logistics of daily life, we share valuable insights on how to care for individuals early postoperatively. Save this podcast and share it with your communities to educate them, and let them know what an early postop visit with you might would look like too!

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

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the essential, yet often overlooked as aspect of early postoperative care. Alexis explores the wide range of concerns and adjustments individuals face postoperatively beyond the usual need for return to exercise. From emotional and mental health needs to navigating the logistics of daily life, we share valuable insights on how to care for individuals early postoperatively. Save this podcast and share it with your communities to educate them, and let them know what an early postop visit with you might would look like too!

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

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. ALEXIS MORGAN Good morning, YouTube. Get Instagram going here. Good morning. Welcome to the PT on Ice Daily Show. Happy Monday. My name is Dr. Alexis Morgan, and I am one of the faculty with Ice Pelvic. In our pelvic division, we enjoy talking about all things around exercise. And, you know, if you are part of ICE, you know that and understand that. But sometimes our reputation scares people. It might scare our community like, oh, that's the exercise person. They're definitely going to make me exercise immediately. Today's topic is surrounding non-exercise topics for that early post-op care. non-exercise topics for the early post-op care. This is incredibly important, maybe because of the reputation that you have in your community, which if you have that, great, so do I. Awesome reputation to have. However, we need our potential patients, we need our clients, we need them to understand a lot of the things that we can do early post-operatively that don't necessarily involve exercise. And that's not just to get them in the door, but that's also because there's a huge role that we play in early post-op management. Now I'm discussing this with the lens of early post-op post C-section or post-op post hysterectomy or any of these post hernia surgery, any kind of core and or pelvic floor, pelvis type of surgery. That's the lens that I'm going to be discussing this in. However, I will say this is going to be in many of these cases pertaining to really post-op, any surgeries. And we've had a couple of great podcasts on this topic. And Lindsey Hughey has one that comes right to mind on things that we can do to educate to reduce inflammation postoperatively. But I'm going to add a couple other things to that list. So let's go ahead and jump right into those. ASSESSING VITAL SIGNS So number one, we need to be assessing vital signs. This is incredibly important in the postpartum period as maternal death rates are actually increasing in America. And for black women, maternal death rates are three times the rate as white women. Many of these are because of some type of cardiovascular event. We have got to check blood pressures. And in many cases, we as the conservative care providers, those physical therapists or rehab providers, we're some of the only ones that are checking postpartum. Or we might be able to catch something very soon before they might have a six or eight or 12 week follow-up postpartum. we've got to be checking their vital signs and assessing and making certain calls when necessary. That is absolutely important and definitely not exercise related at all. We can get them in and get their blood pressures checked. OWNING SCAR MANAGEMENT Additionally, we, we assess sutures or incision sites or whatever whether that was an abdominoplasty where they have an incision from ASIS to ASIS, whether that is a C-section incision, a little bit smaller, more midline, or that might be smaller little incisions all throughout the belly from some type of laparoscopic surgery. Whatever the case, We, as their rehab providers, assess that incision. We're gonna look for signs of infection and we're also educating about those signs of infection. We're assessing to see how the patient feels about it. Maybe we need to set some expectations surrounding what the C-section scar or what any of these scars are going to look like in a month and in six months. And with that, we can go ahead and begin some scar mobilizations. Now, very early postpartum, we're still in the proliferation phase, inflammation, then proliferation, and then maturation. We're still in that proliferation phase, so we're not gonna be doing scar mobilization on the actual scar, but we can come inches above and below and surrounding. We can teach them how to pull on their skin and press on their skin well away from the scar to go ahead and begin that desensitization. That is incredibly valuable. And just going ahead and painting the picture of what that scar rehab is going to look like over the next three to four months. Many individuals have a lot of fear and concerns surrounding the scar. And we are the best people to be giving them home exercise program, these interventions and helping them understand what it's going to look like. We know we're the rehab providers that have seen this all along the way in several other of our patients. So we can help them understand what to expect and If there's concerns where we need to refer to a mental health provider, then we're absolutely going to do that. That is completely within our realm to assess that and to refer out. And what a great opportunity to help someone. Body image is rather difficult. It always has been, but with social media and the way the world that we live in right now, It is incredibly difficult. And so we need a lot of times mental health providers to help us navigate that. So first we talked about vital signs. Now talking about sutures, we can absolutely discuss fueling. That's the podcast I mentioned with Lindsay Huey, so I won't jump into that necessarily. ASSESSING DAILY FUNCTION But next is ADLs. I was just looking through my messages, some screenshots that I've saved from various, um, various people who have messaged me about, um, pelvic floor related topics. And what I saw was this message from someone who said, I just went to my, uh, follow-up and they told me not to lift any weight. And the person asked, can I lift my baby? And they said, no. Now, obviously this is hopefully a one-off. Hopefully that word is not being said. And who actually, I don't know if the doctor actually said that, but the point is, is that this individual did think that that's what the doctor said. We are here to help them understand how can they be safe? How can they hold their baby? How can they get out of bed? How can they bend over and get the clothes out of the dryer, out of the washer? We can help them navigate these things. This is a great opportunity for occupational therapists as well. We can lean into their expertise here. Helping individuals with these ADLs can be really valuable for these individuals and can help them feel more confident in their body in that early postpartum period. Sometimes they just need to share their story. I think a lot of times we as rehab providers really feel this urge to do, do, do, put hands on, give home exercise program. I need you to do all three of these. We feel like so rushed in order to provide and sometimes The best thing that we can provide is a listening ear, is someone to be someone who can just ask questions about their surgery, about how they felt, about how they felt going into that and how they felt coming out of it. That can be incredibly helpful. ASSESSING READINESS TO EXERCISE While we're talking about non-exercise plans, I said that we wouldn't be doing exercise, but I didn't say that we wouldn't be talking about it. So when we have someone early postpartum, they might be an exerciser and they might be saying, oh, I'm not ready for exercise just yet. Well, that's okay. Let's talk about what does exercise mean to you? What does readiness look like to you? What do you want and what are your timeline expectations? And do they match up with what we have seen or what we expect? Having a conversation about an exercise plan and exercise expectations can be incredibly helpful. Some people may not understand that they can go ahead and start to move now. and they think exercise is any type of movement, and we can kind of break that down. We can discuss different exercises that individuals can do or that this person in front of us can do in this early time, like walking or some basic hip exercises or arm exercises. A lot of times there's several restrictions surrounding surgeries. But just because there's restrictions doesn't mean that there has to be zero exercise. So we can discuss that plan and kind of help them understand what that overarching picture of exercise and health looks like. I already mentioned one referral, but there are several other referrals that we can also make. So in the postpartum realm, referring back to their provider, their OB or their midwife. We can refer to a lactation consultant, to mental health providers. Postpartum doulas are another great referral source, particularly for people who are postpartum and maybe don't have a lot of family nearby. There are so many ways in which we can help people and We don't hold the keys to everything. I can't help with mental health. I can listen, but I don't have all of the tools, but I can absolutely refer to somebody who does. And together we can work to get this person in front of us feeling really good. SUMMARY So vital signs, checking the sutures or those incision sites, discussing fueling, helping them with their activities of daily living, their ADLs, listening to them, listening to their story, figuring out an exercise plan and referring out. The last thing I'll just mention here with pelvic floor and particularly with postpartum, we're gonna discuss with them expectations surrounding those. That's a whole nother podcast for another day, but discussing the expectations surrounding bleeding postpartum, leaking heaviness and pain and giving them what to listen to when we say, listen to your body, giving them a key to understanding what that exactly means. That way, once again, they can be successful. So that's just a little sneak peek into a whole lot of what you're going to learn if you take our online level one course. Our next cohort for our online level one starts March 5 so upcoming in one month at the beginning of March. It is going to sell out, just like this current cohort did so if you're on the fence about it, I recommend going ahead and purchasing that ticket because. If you wait too long, you're not going to get a seat. And we are very strict on keeping our student to faculty ratio at an appropriate level. That way you get your questions answered and you get the care that you need as you're learning from us in the course. So sign up for that. And we also have our first online level two course coming up at the very end of April. And so you're not going to miss that. Once again, that is definitely going to sell out. We are still months away from that, but only a few few seats remain for that. We're going to shut that one down pretty soon. So if you're on the fence about the online level to go ahead and sign up for that one. We are all over the place in twenty twenty four. Our next upcoming cohorts. for our live course. We're going to be in California, North Dakota, South Carolina, and Colorado. Those are our upcoming next courses, all in March and April. So be sure to check us out on the road. And remember, when you do all three of these courses, you are eligible for the ICE certification certified in pelvic. We are here to change the game when it comes to pelvic floor health and pelvic floor rehab. And we need more of you. So please consider hopping on the train, coming to our courses. We know you're going to have a great time. Thanks for being here this morning and listening with me. Have a great rest of your day and we'll catch you next time.

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

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty member Mitch Babcock discusses developing youth strength & conditioning programs, including optimal timing & frequency, age groups, and training progressions.

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

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

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

MITCH BABCOCKAnd good morning. Welcome to the PT on ICE Daily Show. It is Friday, that means it is Fitness Athlete Friday. We are excited you are here. If you're on YouTube, thanks for watching when you're catching this recording back. And if you're on Instagram, thank you so much for being here as well. Thank you to our listeners who are loyal and downloading this podcast on Spotify and Apple Podcasts and anywhere else that you get your podcasts from. If I am talking to you on your morning commute, I wish you a great day in the clinic. And if you're on your way home or anywhere else, I wish you a great day as well. So I am Mitch. I am your host of this Fitness Athlete Friday. I'm a lead faculty in the fitness athlete division. And I want to talk today about youth sport, youth fitness athlete programs and what you can be doing as a fitness forward clinic to really be reducing those injury risks that we all talk so much about in the youth athletes. Before we jump into that, I just want to draw your attention to two main fitness athlete courses that we have coming up for the month of February that we're in now. On Super Bowl Sunday weekend, I will be in Richmond, Virginia. I was getting a little worried. My Detroit Lions making a once-in-a-lifetime run at the Super Bowl. I was getting a little nervous that maybe I did some scheduling error there. fortunate or unfortunate as it may be, they won't be in the Super Bowl. So Super Bowl weekend, I will be in Richmond, Virginia. And I know what you're thinking, I don't want to take a course on Super Bowl Sunday. We're going to get out in plenty of time early enough for you to go make it to your Super Bowl party and enjoy the rest of the weekend with your friends and watch the game. So if you're in the Richmond area, join me there on February 10th and 11th. And then at the end of the month, February 24th and 25th, you can catch Zach, the Barbell Physio. He's going to be at his home gym in Charlotte, North Carolina. for a fitness athlete course as well. And we just kicked off our next cohort of our Level 1 Essential Foundations course online, and so I wanna make a special hello to all of you that are starting the process of the CMFA certification online with us. We're excited to do the next eight weeks together. We've got a lot of learning that we're gonna engage in, so I'm stoked for that. YOUTH INJURY REDUCTION STRENGTH TRAINING & CONDITIONING PROGRAMS So without further ado, let's get into our podcast today. Youth Injury Reduction Strength Training Conditioning Programs. Here's what we know about injury risk reduction. The screening tools that we have been given, the systems that were promised to help identify and reduce risk of injuries, they're no good. They don't mesh out in the data. We have enough long-term studies now to be very conclusive that these movement screen systems that we think that we're putting kids through to help reduce their risk of injury are in fact doing nothing to help actually reduce their risk of injury, and they're no better than a coin toss oftentimes of being able to identify kids that are at risk. What we know conclusively in the evidence, and then we're looking at now in adolescent athletes and also collegiate level athletes, is that the more that they're engaged in a strength and conditioning program, that the stronger their legs are, the stronger their core is, many of these programs focusing on those two elements primarily, that the better they do at reducing actual risk of injury and the more prepared these athletes are for the demands of their sport, whatever that sport may be. And so when you think about the constraints that the youth athlete is under, oftentimes, and we know this problem exists, where these kids are involved in a one singular sport for 9, 10, or even 12 months out of the year, they're hyper specialized into that one athletic arena. They're going from practice to speed and agility camps to to sport positional specific camps. They're constantly engaged in the demands and the domains of their sport and they're doing way too much in that arena and they're not doing enough either other sports or general physical preparedness. The GPP work that we know is the foundation for all athletic endeavors to be built upon. DEVELOP GENERAL PHYSICAL PREPAREDNESS So our pitch, our recommendation for our fitness forward clinics out there, and there are so many now that are branding themselves as being fitness forward, when you're going out and you want to reach this next population, you want to get ahead of these injuries. You want to do something for that youth athlete. You treat their parents already in the clinic. You know that their son or daughter is engaged in travel volleyball, travel baseball, their competitive wrestler, football, whatever that may be. You know their kids, you know their families, and you want to put a program together that gets as many of those kids as possible in your clinic, in your gym, and really helps to teach the fundamentals of strength training. Right? Because if we can get these kids in and start to help educate their motor control patterns, help to instruct them on strength training, under the supervision of a doctor of PT who's trained in the barbell, who's trained in the dumbbell, in the strength and conditioning community like many of you are, and taking our courses now, there is no better instructor to take these kids under your wing and really lead them to where they need to go, which is learning the fundamentals of how to move their body in space, how to get stronger, and therefore how to be more protective against injury. Stronger athletes get hurt less on the field. And if we can start teaching these movement patterns at a younger age, that gives us such a better upslide for being able to instruct and progressively overload these movements over time. So what we need to be doing as Fitness Forward clinicians is setting up some sort of camp, setting up some sort of program. Maybe you have the resources to do it year long, that's great. Maybe you don't. Maybe you can just divide six or eight weeks of your schedule out to fitting in these youth sport performance camps. And you can do them at various times throughout the year. What we have found to be successful is doing a camp in the summer because they're about to lead into whatever their fall sport is. That could be volleyball, that could be Football, I'm not even sure what sports going at that time if I'm being honest, but but getting them into that late summer Is a great time to run some sort of eight-week camp where you teach the fundamentals of strength and conditioning Keep it very simple. OPTIMAL CLASS LENGTH My first point here is to keep it brief 30 to 60 minute classes are gonna be perfect 30 minute class if you're just looking to instruct the strength component closer to a 60 minute class if you're looking to do strength and conditioning together and Okay, so your choice 30-minute class is about what you're gonna need if you're wanting to instruct at least a strength movement Maybe a 60-minute window if you're looking to add some conditioning in there, okay? Keep these programs at two to three days per week Keep in mind how much these kids are already training right how many times they're already doing their sport specific work their speed and agility work there and They're engaged in a lot of things already. If you can keep your program very precise during days of the week, maybe a Tuesday, Thursday, or we have tried like a Monday, Wednesday, Friday, whatever works for you and your schedule, two to three days per week, 30 to 60 minutes is gonna be ideal for these kids, okay? GROUPING BY AGE Now, what age groups? You can't just, we have had not great success by throwing kids anywhere from six to 14 in the same room together, right? The development of those athletes at various milestones throughout their development is so wide and so different that you're not gonna have a successful class with that many different types of athletes. What I would recommend doing is grabbing kids from the nine to 12 group When they hit about eight, nine years old, they're really development enough, they're cognizant enough, they're engaged in the sport, they like what's going on. So if you can grab a group of nine to 12 year olds, and then maybe have another segment of like 13 to 16 year olds. I think those are two really good spaces where you're getting kids at various ends of development, and you're teaching them very different things. At the nine to 12, our strength work for them is really motor control. The stronger they get is really just more repetitions they've had doing that movement. And so we don't really need progressive overload for that group, we don't need barbell training precisely, but really bodyweight and dumbbell or kettlebell loads are going to be perfect for them. and use the load as the reward. So the key here is that, good job, Timmy. Your air squat is looking really good. Because it's looking really good, I want to give you this dumbbell. Hold this at your chest. You're one of the leaders in the class right now. Hold this dumbbell. Keep your squats looking good. So you're rewarding good movement mechanics with load. In that 9-12 year old range, using dumbbells, using kettlebells to instruct your major fundamental movements, your hinge like a deadlift, your squat like a goblet squat, and a press, a dumbbell push press, overhead press, PVC pipe if they need a lighter load. You're instructing that overhead full lockout position, you're instructing a squat pattern, you're instructing a hinge pattern. And for your older kids, your 13 to 16, if they have been with you and they've shown you some good movement patterns now, now we can start to add the barbell in here. Now we can say, good job on your air squat. Let's go barbell front squat. Let's go barbell back squat. Let's go barbell deadlift. Let's go barbell overhead press, strict, or push press. Team, if you don't feel confident teaching those movements, please take a class with us this year. In two days, Saturday, Sunday, eight to five on Saturday, eight to five on Sunday, you're gonna walk away being very confident in your ability to walk right back into the clinic, whether that's with one person or 10 people, and instruct these movements that need coaching. Okay, so if you feel like that's a gap in your game, it is so easy to sure it up. Just join me in a class, join Zach, join Joe, find one of the fitness athlete courses that's in your area, and we'll help you close that gap very quickly, okay? So that's kind of your range of strength movements that you want to focus your energy on. If you've only got a class that's two days a week, do one day squatting, one day hinging, or one day squatting, one day pressing, and just kind of flip-flop your order that you're programming those in. For the younger kids, using load as the reward. And the last thing that I would, well, excuse me, I got two more things. TEACH THE FUNDAMENTALS OF BODY WEIGHT MOVEMENT Teach the fundamentals of body weight movement. You've got to have these kids doing more push-ups. You've got to have these kids doing bodyweight lunging. You've got to have these kids doing some form of a pull-up. And that can be in the form of a ring roll if they're not strong enough, or an assisted vertical pull. But these kids need to develop upper body strength and core strength, do more planks, do more lunging, do more push-ups, do more pull-ups. do a lot of them. It is so easy to teach them really well and give them to them for homework. Like not enough kids are doing that. And I run into this problem year after year with my teens program is that their ability to do a really sound pushup is lacking. And we can have the debate on generation after generation of how bad that's gotten year after year. Ultimately, I don't care. I don't care to engage in that debate. What I care to engage is that what are we going to do with it now? And right now I'm seeing kids that can't do a pushup. So add the push-up, add the pull-up, add a bodyweight lunge, a bodyweight plank. We need to develop some core strength and some solid bodyweight resisted movements. So keep them as a really good accessory movement to the foundational movement that you're teaching that day. ADD CARDIOVASCULAR FATIGUE TO MAKE LIGHT LOADS CHALLENGING And then the last thing, here we go, is adding your conditioning to make the lighter loads you're using more challenging. If all you're giving little Timmy is a light dumbbell or a PVC pipe, by the time I get them done with a 100 meter sprint and then they go back and do this movement, you're going to see some more variability in their movement. By adding that little bit of conditioning, that little bit of metabolic or heart rate duress to the system, you're going to start to see some changes in movement pattern that allows you to coach and improve. Which, guess what team, you can argue this all you want, but that's exactly what they're doing in their sport too. They're getting their heart rate up, they're running around, they're crashing into their friends on the field or on the sport. Their heart rate is going to be elevated and we still need them to move well. So that's what we're doing in the gym as well. Get them on the rower, have them bang out a 30 second sprint on the rower and then get off and do their squats. Send them on a 100 meter sprint, come back in, let's do some deadlifting now. right? Utilize that assault bike. Hammer out 10 calories as fast as you can. Get off. Let me see your vertical overhead press now. Utilizing the conditioning component first to make the load and the weight training that's coming second even more Exposed even bring to light some of the deficits that they have in their movement And that's really where they start to learn how to move soundly under the duress of the environmental constraints and in sport, right? SUMMARY So teaching the foundational movements the squat the hinge the press and using them with lighter loads, dumbbells, kettlebells, with your younger group for motor control, repetition, and with your older group, emphasizing and adding in the barbell. Utilizing a 30-minute session of all you're doing is strength work, stretching it out to a 60-minute session if you're going to add some conditioning work in there, which I recommend you do. And then recognizing that, hey, when I add the conditioning component into the strength component, that's going to really expose a lot of areas that I can coach and develop these athletes in. And through that process, whether you're doing a couple eight week camps throughout the year, you're getting them in maybe right after school, you've blocked off an hour for this at an after school hour or in the evening at the end of your clinical day, you've got this little camp. that you can run this. You're gonna make a couple hundred bucks per kid, and you're gonna get a room full of 20 or 30 kids in there. It's gonna be lucrative for your business and for your staff that you're getting in there to run that. So I really would highly encourage that these PT clinics that have the means, that you have the equipment, that you have the shared gym space, that you're partnered up with a CrossFit gym right next to you, that you can talk to them about utilizing and running this camp through. I highly recommend that you start getting out there in the community. and helping these youth athletes prevent injuries, getting them stronger, and then getting them excited about working out. I mean, these kids are so stoked. The kids that we have in our youth programs, they can't wait to come back to CrossFit. Their parents tell me all the time about how much fun they're having. So, getting them excited about working out might be the biggest win overall. Yeah, if we can prevent a few ACL injuries, that's great. But if we can get these kids excited at a young age about exercise and working out and not seeing it as punishment or something that they have to do, I think we're starting to build a generation of kids that really look at exercise a much different way than maybe our generation has. So that's the key points that I have for you today, guys. Thank you so much for joining. If you're on the Instagram Live, I saw a few comments. I'm gonna circle back and read through those later. Thank you so much. But think about how you can implement that in the clinic. And again, if you have some weaknesses, if you have some gaps that you need shared up, jump into a Fitness Athlete Live course, and let's teach those fundamentals that we need, and then get you right back out there to make a change in the community. Have a great Friday, have a great weekend, and go kick some ass in the clinic. See you guys. 

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. Zac Morgan // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses how to subjectively & objectively identify patients presenting with acute back spasms, how to treat spasm, and how to follow-up treatment with appropriate homework. 

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

If you're looking to learn more about our Lumbar Spine Management course, our Cervical 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

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.

ZAC MORGAN Alright, good morning PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty in the cervical and lumbar division, here to bring you a Technique Thursday talking about myofascial decompression or cupping for an acute back spasm. For those of you all who work with acute back pain, so this is something that early in my career I did not see an awful lot of, but as I have kind of entered the market of seeing more and more acute low back pain, you will see these people walk through the door that are clearly in a spasm. And I want to talk today about why cupping has kind of become the treatment of choice here for that exact presentation. ACUTE BACK SPASM PRESENTATION And let's just kind of narrow in on why we're focusing on back spasms to start. And the real thing is, this is one of those diagnoses you don't read a ton about in the literature, but it's one of those things that you know it when you see it. So it's fairly empirical. So every so often, people kind of walk through the door, and they're kind of in that shape of a question mark. They're really off to the side, and you can tell as they walk through the door that the severity of their situation is really, really high. Even just watching them move about the world, their activities of daily living are extremely challenging when they're experiencing a back spasm. They're not able to freely move through space and move that spine around because their erector or QL or some of that posterior musculature is in a full spasm. So this is something you will see if you're seeing people day of within a couple of days of a back pain episode. So it's certainly one of those acute low back pain scenarios. Now the issue is, you'll see a lot within our profession of people sort of argue about, well this is just going to regress to the mean. And I don't disagree. A back spasm is going to go away on its own, for the most part. So generally speaking, untreated, in my experience watching these things happen around the gym, having some of them myself, a lot of times people have some movement limitations for ten days or so, seven to ten days, maybe a week, maybe a little bit longer, but then they're usually back to normal life after that point. So it's not one of those conditions that sticks around for months the way like a radiculopathy would. It's just something that's acute, but while it's present, it's very severe. I think it's important for us to say We know it regresses to the mean. It will get better on its own. WHAT IF REHAB CAN BEAT REGRESSION TO THE MEAN? Here's the thing. With early treatment, what I'm about to show you all, I think we can take several days off of the episode. And I think that because of empirical data here in the clinic. So I'll watch people walk in in that situation that we just described. Very put off to the side, huge spasm in that erector. You can almost see it through their shirt. and they're unable to do much, and we treat them with some cupping, we treat them with some relaxation techniques that we're going to unpack here in a moment, and often that person feels tremendously better, tremendously quickly, so within a couple of days, maybe three max, versus that seven to ten. Now that's a difference, right? That's almost a week of time different that that person is going to end up walking around with pain or not walking around with pain. Why does that matter? When you think about how influential this spasm is to their activities of daily living, they can't do much. Now deconditioning is going to set in, even on healthy people. If healthy people move around the world for a full week without really flexing their back, without allowing it to move, they're going to have some deconditioning on board. And if we could have gotten rid of that a week earlier, we've given them more of an opportunity to maintain or even gain fitness during this period of time that they have some acute pain. So I think it's really important that we focus in on this because while it's not a usually a long-term disabling diagnosis, it is a short-term disabling diagnosis. And when people are in that disabled period, they're looking for short-term help. And I think we can be helpful with that. IDENTIFYING CANDIDATES FOR CUPPING So let's talk a little bit about identifying these before we actually get into the treatment. And from an identifying standpoint, you want to start with that body chart. So if you've been to cervical and lumbar management, you know we always start out with quantifying where are the symptoms on this person's body. When someone's in an acute back spasm, it'll be a little complicated to find the exact spot of symptoms. They don't usually point to one thing. They often kind of talk about that whole erector side. They might even point to that whole area of their low back and say it just feels locked up. I've certainly had plenty of clients who reported just like local pain sort of at the waistline, like right where the waist of your pants are. I've had unilateral, bilateral, it bounces around a little bit on the body chart, but typically whatever muscle is in spasm is where the pain is. And often the person has a hard time describing it because of the severity. They just say my whole back is out, my whole back's out of whack. So it's not one of those focal diagnoses on the body chart. Subjectively, you're going to see some common aggravating factors. The biggest one's flexion. The person probably won't even allow their back to flex. And when you look at that from the active range of motion standpoint, you see it's just hip flexion. The lumbar spine is not actually actively flexing. The person's just kind of absorbing into hip flexion. Any quick movements are often painful subjectively. So they talk about transfers, they talk about when they've been lying down to get up. Really anything where they have to move quickly will often be an aggravating factor. And then things like bending, sneezing can also be pretty painful for these folks. In their history, they'll usually tell you about some sort of fatigue-based activity that onset this. So this won't usually be like a one rep max deadlift. That makes me more think of a strain. Where this presents itself is in a workout with a bunch of deadlifts. So when somebody's, you know, several sets in and their back is already tired and then it just fully locks up and kind of worsens throughout the evening or worsens throughout the day, that's more of the spasm presentation. It's not just in weightlifters or competitive athletes. You'll see this really with any human who has exceeded their capacity. So I've definitely had plenty of folks that were gardening all day or mulching all day and just using their back a bunch and then it wound up in spasm. So it's really whatever over challenges that musculature tends to create the spasm. So subjectively, you'll see those common ags and then you'll also see that history where the person was either fatigued entering an activity or did an activity so much that it created enough fatigue that eventually created a spasm. Objectively, again, their lumbar spine, it's not going to reverse. When they flex, it's going to stay very flat. You're going to see a lot of guarded movement. The person's probably going to be very hesitant to move, and you'll notice that quite a bit through this active range of motion exam. You will even often see cervical flexion. bother that person's symptoms because the erectors, they attach all the way up in the neck, in the suboccipital spine. So you will see cervical flexion be bothersome, but then it's not like a sensitization thing from a neurodynamics exam because the ankle won't make any difference. So, when you see that cervical component create a lot of discomfort in that acute pain scenario, and then you dorsiflex and plantarflex the person's ankle, and it doesn't make any difference, that's ruling spasm higher on my list. So, objectively, that'll often be how it presents, and then a lot of it's just observation. You'll just look at this person's back, and like I said in the beginning, they'll be twisted off to one side. They may even be kind of in the shape of a question mark. Like you can see that that erector on that side has just shortened in the area of the lumbar spine. And so the person is fairly obviously uncomfortable. A lot of times the erector itself is swollen or hypertonic or larger, whatever you want to call that. And it'll be tender to the touch. So just palpating that region, a person is going to report most of their symptoms. So like I said, a fairly obvious diagnosis. And again, it's one that I didn't see a lot of until I got that really acute back pain person in the clinic. So that's sort of how they present. TREATING BACK SPASMS Let's talk about treatment. There are a lot of things that jump into my head that I would like to do. Like if you have acute non-radicular low back pain, the first thing that jumps into my mind is spinal manipulation. But often moving these people's backs through space is just not a realistic possibility for you on day one. Team, over the last couple of years I've spent a lot more time learning about cupping and doing a lot of cupping with clients and this is the one thing that whenever you see this presentation show up, whenever we drop the cups on that region, get it nice and relaxed and it doesn't even have to be all that vigorous. The person often gets off the table stunned at how much better they feel. So cupping has definitely become the treatment of choice and I like to just keep it really really simple. Now the biggest issue from a treatment standpoint when someone's in spasm is it's really challenging for you to get that person comfortable most of the time. They don't like laying in supine, they often don't like laying in prone, and then on one side or the other they're often really uncomfortable. If you can get them in side-lying, which is typically the most successful for me, you want the erector that is in spasm up. So I have Caitlin here behind me, and you can imagine in this situation, her left erector would be the one that would be in spasm. So that's the one that I'm going to target with treatment, and that side's up. You also want to prop a pillow between the person's knees just so that hip doesn't adduct and create even more tension on that lower back region. Instead, let's keep those hips nice and neutral and get this person in a relatively comfortable position. This will often be the position they've told you in the subjective exam that they like the most. So we're going to go right to that position and then treat in that position. So I'm going to move to the other side of the table, show you sort of where I put the cups, some of the verbal cueing alongside of that, and then we'll wrap this thing up. and summarize at the end. So anytime you're doing cupping you always want to use a little bit of cream. It's just a lot easier to glide the cup around and it's a lot more comfortable for your client. So make sure you add a little bit of cream to that region that you intend to cup just so that that way it's more comfortable for your client. You're then going to grab your first cup and localize it to the region that you think is in spasm. It doesn't have to be directly over it. Reminder, these muscles are literally all the way across the spine. So if the person's too pressure sensitive, you could certainly move away from it. But you want to be in that basic region. And then you're just going to get these things on. with a little bit of tension. So a couple of pumps to start is plenty. So I don't have this thing cinched all the way down where she's in a ton of a stretch feel. Instead, I just have a little bit of air out of the cup and a little bit of domed tissue within that cup. this gives you that nice decompressive feel if you're the client a lot of times they'll be a bit uncomfortable when you first do this but they're uncomfortable anyway they've been in spasm for a few days and so it's no major deal to them these cups are probably only like 30 to 40% pulled out. So typically if I'm being more aggressive with cups, I get it a little closer to that full capacity of vacuum. But for this, I've got a very severe patient in front of me, they're very fear avoidant, they're not moving all that much, and I've just got a little bit of tension in those cups. I start out just like this, like you all are seeing. So the person just kind of gets comfortable, relaxes, feels that pull. But after they've sat here for a couple of minutes, I'm going to start to try to cue that person to do a bit of a posterior pelvic tilt. The point of that posterior pelvic tilt is just to access a little bit of their lumbar flexion while they're in this nice, friendly, non-weight-bearing position. Anytime they're in weight-bearing, that erector tends to want to be in spasm. So I'm going to get them to just relax things a little bit here in sideline in a nice comfortable position. So I might have them move through 10-20 reps here, maybe even cueing some deep breathing in between if they're very severe. So 4-7-8 breathing pattern is often a helpful one, that physiological sigh. Either one of those are typical go-to's while we're in this position and the person's nice and relaxed. Now, for those of you all who treat human beings, you know a lot of times our female clientele is a little tougher than our male clientele. Sometimes the men are already sweating in this position and they're already having a lot of challenge. If that's the case, I'm going to stay right here and just have them work those pelvic tilts. If I do perceive that the person, if they're telling me, hey, this feels quite a bit better, you know, it seems like they would like a little bit more treatment, the next move I'm going to have them carefully make is getting into the position of quadruped. So they don't like prone and supine, so I'm going to leave the cups on and the person is going to ease their way to quadruped. And then from this position, they're just going to do some gentle angry cats. So I'm going to cue them up into some spinal flexion, telling them to separate the cups. They do have a tendency to pop off, so you want to keep that gun handy. But I'm essentially just going to cue her through 10, 15 reps here of angry cats, thinking about really elongating this whole erector. If you want to make it a little bit more vigorous, you can have them gently flex their cervical spine as they go into the cat position. That's going to give you even more stretch across the erectors and often feel pretty tight for the person, but quite good. Once we're done with that, I'm going to have them just lay back down in sideline in the original position. And this is where I think a nice little bit of massage can be helpful. So just popping the cups off, you may have some light bruising, but then getting in here and just showing that area some love and getting a little bit of massage going to that region. Team, I realize what I just showed you is quite simple. and I'm not trying to be overdramatic, but simplicity often makes this person pop off the table and feel dramatically better. FOLLOW-UP TO CUPPING I think what we follow it up with is very important as well. Earlier in my career, it was always, hey, let's load, load, load. Let's make sure we're getting this person moving. This person is overloaded. That's why they ended up in spasm. So what I'm actually going to target these days is a lot more relaxation techniques. So maybe that breathwork pattern we did with the cups on, I assigned for homework. I need five minutes of this a day minimum. Convince that person to give you some breath work. Convince that person to up their hydration by a bottle or two of water over the next few days. Hey, I really think this is going to help. If you're in a little bit more hydrated state, I think that muscle can relax more. Convince them maybe to add some electrolytes. Heck, I'm fine with a warm bath at night with some Epsom salts. It doesn't matter to me. I'm going to get this person to relax. I'm not going to go have them do more deadlifts. Their problem isn't necessarily that they're weak with deadlifts. It's that they got fatigued. Do we need to build the endurance of that region? Possibly. Maybe that's why it contributed to a spasm. But for right now, my main goal is relaxation. And team, I'm always going to argue for more treatment in this scenario. Earlier and more treatment. The reason being is imagine Kaitlyn is that person who has the back spasm. And she then loses 7 days of not just training, but also moving around like a normal human being. We only have 52 weeks in a year. I don't want to sacrifice an entire week of that person's life to fear avoidance, to lack of ability to move like a normal human being just because it's going to regress to the mean. Not when I could simply get in, assess it, help that person feel like, you know what, I think I'm going to be better in the long term. get them gently moving, teach them some relaxation techniques, and get rid of this thing seven days faster. It's gonna be hard to convince me that that is a harmful approach, even though we are utilizing passive tools to help that person relax. I think this is exactly why we need those tools, is to help put that fire out, and then in that process, convince this person to start addressing some of their lifestyle factors, to start addressing that ramped up nervous system, getting them to calm it down, to start addressing hydration. Some of the basics, right? Just the basics of what it means to be a human, people mess up quite a bit. So, we want to make sure that we check those basic boxes, and often you're going to follow up with this person in 48 hours, and they're going to say, Zach, feels tremendously better. Can't believe how much relief we have. and now we can perhaps get after some of that loading or regional interdependence or anything that you think might have contributed. But team, I think it's a simple approach and I don't think you should feel bad about treating people with acute back pain even though you know that they're going to regress to the mean. It's worth it to save them that week in my mind. I'm always going to opt towards more treatment. SUMMARY So team, that's all I've got for you this morning. Last couple things I want to leave you with is just the upcoming spine courses. So if you're looking for cervical spine this weekend in the DFW area, make sure you jump over to Hazlet, Texas. That course will be right there near Dallas-Fort Worth Airport, kind of north of Fort Worth. If you're looking a little bit later in the month, Simi Valley, California, that one's getting closer to a sellout, so don't wait if you're in that region, you want to take that course. There's not too many seats left. And then March 9th and 10th, will be in Kuna, Idaho. If you're looking for Lumbar, March 23rd and 24th, Brookfield, Wisconsin, that's right outside of Milwaukee, that'll be at Onward Milwaukee. And then April 6th and 7th, we have two courses going on, one on the west side of the country over in Carson City, Nevada, and then one right here in Hendersonville, Tennessee. And again, that's April 6th and 7th. So we hope to catch you at some of those on the road. We'd love to catch up with you, talk more shop like this, talk about the main patterns that show up in the back of the neck and how to best utilize them. Team, I hope you have a great rest of your Thursday. Crush it in clinic today and I will see you soon here on the podcast.

SPEAKER_00: 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.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave to discuss recent research evaluating the efficacy of high-volume vs. low-volume resistance training for older adults as it relates to facilitating muscular hypertrophy. Jeff breaks down the research but also offers practical implications for the clinic.

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

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JEFF MUSGRAVE Welcome to the PT on ICE Daily Show. I'm gonna be your host today, Dr. Jeff Musgrave, Doctor of Physical Therapy, currently serving in the Older Adult Division, trying to demolish things like underdosing, ending frailty, and I am super excited to bring to you a very interesting research study that just dropped January 4th of this year. So the title of this article we're gonna be digging into today is Higher resistance training volume offsets muscle hypertrophy, non-responsiveness in older adults. So, trying to dig in to figure out if someone is not responding to resistance training, what can we do about it? So, obviously if you're listening today, if you're following in the world of ICE, you know that resistance training is paramount. Getting people strong is how we're going to break the cycle for people that are coming in with pain and dysfunction, musculoskeletal disorders. There aren't any conditions where we can get people too strong. And we know specifically through the lens of working with older adults, when we've got things like frailty, adults who are pre-frail, who are very vulnerable to external stressors, or maybe one rep max living, we've got to bring them quality resistance training. We need everyone to have a path back to load. As quoted by Lindsey Huey in the extremity division, we love to say that load is our love language and all paths lead to load.

HIGH VS. LOW VOLUME RESISTANCE TRAINING So let's dig into this a bit more. So higher resistance training volume offsets muscle hypertrophy, non-responsiveness in older adults. So what we've got, we've got 85 subjects. over 60 years old male and female that had 14 dropouts and everyone was required inclusion criteria included they could not be doing any formal aerobic training or resistance training prior to being included in the study. Their nutrition was actually analyzed by a dietician, which I thought was really cool for this study that they were looking at that. They also acknowledged that variations in sleep patterns are going to impact people's ability to recover. They weren't able to control for sleep, but they did figure out that by and large, there weren't any huge variants in nutrition, but they did have everyone supplement protein So they did a 20 gram protein supplement in the morning and in the evenings in between meals. The purpose of this study was they were trying to figure out, can we identify strategies like what's gonna happen when we adjust volume at a set intensity for older adults? and then figuring out like what do we do with non-responders so we do have people that are going to respond to resistance training but maybe we may have some people in our caseload and you've probably seen this clinically that don't respond as quickly to resistance training and they were just isolating out the variable of volume, not intensity. So what they did is they had each participant was a study in themselves where one leg was identified for lower volume and one leg was identified for higher volume. What they did is they were looking at the quadriceps muscle They got a baseline cross-sectional area from an MRI, and then they did one rep max testing on a single limb knee extension machine. So single limb knee extension machine to get a baseline one rep max, and then they did an MRI to look at the cross-sectional area of the quad muscle. And then the right or the left leg was assigned randomly to a higher volume program and a lower volume program.

METHODOLOGY: WHAT IS LOW VOLUME AND WHAT IS HIGH VOLUME? So when we dive into the methods here a little bit, what we find is for the first couple weeks of the program, they were, the low volume group was doing one set. Okay, one set, trying to hit an eight to 15 rep max. And then the higher volume set did four sets at that eight to 15 rep max. So we got one set versus four sets. So that's what they're calling low volume, and that's what they're calling high volume. And that was for each person. So they were able to like kind of control for a lot of factors by testing the low and high volume on the same person, which I thought was really cool, a really cool way to test this. So after the first two weeks, they amped up the intensity a little bit and they were asking them to hit a eight to 12 rep max, still one set on the limb that was identified for low volume, and then four sets on the side that was for higher volume. So they continue that from weeks three to 10. So 10 week duration of intervention, we've got a low volume side and a high volume side. So what they did is they analyzed the results and they were looking to figure out who are our non-responders and who are our responders. So they're looking at cross-sectional area of the quad and changes in one rep max on knee extension. So what they found between all the subjects between the right and the left limb, they found that 60% went into their non-responsive category where they did not make statistically significant changes in their one rep max and or their quad volume. So those were 60% were deemed as non-responders. And then the responders, about 40%, it didn't matter, the low and the high volume side, both improved in their quad size based on the MRI and their one rep max. So really interesting here that they found that the responders, it didn't really matter the volume as long as the dosage was there and that maximal effort. And when you look at the literature for older adults, it is all over the map. And in general, this is a wide brush stroke here, okay? So not for every study, but a lot of the studies will say the more deconditioned someone is, the less, Intense a dosage needs to be to make change. So if you've been doing absolutely nothing Something is going to be beneficial But then the dosage for true strength training, you know, there are lots of studies Landmark studies for older adults like the lift more trial that's looking at you know hitting percentages of 80% for a five by five five sets of five repetitions, but when we you know dig a little deeper into this dosage and you know, based on the rep ranges for their intervention there, because they were doing eight to 15 rep maxes, sets of that. So we're looking at a 60 to 80% rep range, not rep range, percentage of a one rep max. So, pretty decent on dosage, but typically we're going to start people at a minimum of a 60% and then we're going to amp that up to 80%, maybe 80 plus, and then be adjusting the rep scheme. But this is just looking at maximal volitional output to muscular failure in that eight to 10 rep range. And what they did is if they hit more than that number of reps, then they would add a little bit of weight in increments of one kilogram. some weight away if they were doing multiple sets like on the high volume side.

CLINICAL IMPLICAITONS So really interesting to really think about the impact of volume but this isn't typically what we're going to do clinically right so if we're going to add a higher percentage of one rep max we're going to drop those sets and reps and not be doing these AMRAP sets for each set. Not a great experience, causes lots of soreness, can produce symptoms. And these were all non-symptomatic patients. These weren't people having pain like what you're going to see in the clinic. So there's one caveat there, but just keeping in mind like rep ranges and kind of these basic rules that we try to use for programming strength training. When you look at something like Perlepin's chart, for example, that's been used in the strength and conditioning and Olympic lifting world for years, you're going to see that Rep ranges are going to vary, but you know, if we're in that 70 to 80 rep range, we're going to be doing sets and reps of three to six. So add a total volume of about 18 reps total. And same thing for our 55 to 65% of a one rep max, we're gonna be doing sets of three to six, not these eight to 15 rep maxes, which I understand for the study design and to try to equalize this, that was necessary to be able to compare apples to apples. But clinically, we're gonna be doing smaller sets and reps, and we're gonna be, as we increase a one rep max, not this 8 to 15 maximal effort. So when we're looking at this through the lens of Prolepin's chart for the low volume to be doing one set of an 8 to 15 rep max, you're maybe not going to hit the minimum threshold on volume to make strength adaptations.

IS LOW VOLUME TOO LOW FOR SOME PATIENTS? And I know there's some studies that say, that are leaning into one maximal effort being enough for strength gains, but I would say clinically, that's not typically what we do. If we're gonna be using that 60 to 80% rep range, we're gonna be breaking that up into smaller sets and reps, and we're gonna be adding more volume than that. So I would question that the low volume group because we did not adjust the intensity up, it's not apples to apples here. Because if we're going to increase that percentage, we're typically going to be doing smaller sets and reps, but also going to be hitting more volume. So I feel like the low volume group probably didn't really hit threshold. And I think that probably impacted, this is all opinion of course, but I think that impacted the low volume group's ability to make changes. And I think that's why we're seeing 60% non-responders. But if we were going to dose this out at that volume, we would have been doing much higher percentages. And the high volume group is probably more a normal rep range and percentage that we would use if we were just going to create a program for someone. So I think that's a weakness in this study, but I still think there's some things we can take away from this.

USING RESISTANCE TRAINING DOSAGE TO OVERCOME BARRIERS So if we're thinking about training with older adults, we know that there are often lots of barriers. So our older adults come in typically with lots of fear. They may have beliefs on board that are going to limit our ability to be able to really push that intensity or push the weight because of fear, bad experience, or maybe just lack of experience with weight training, that they're scared, there could be histological barriers where maybe someone's coming in and their primary concern is they've had a fragility fracture or they've got low bone mineral density. And knowing the timeframes for healing on bone, we're gonna make muscular adaptations much faster than we're gonna make changes in the bone. So we may actually hit what's appropriate at that point we're going to be adding volume which goes in line with what this study is telling us is if someone's not responding to lower volume up the volume and we're not looking at high intensity and the other thing this study is not testing is it is not comparing low and intensity to high intensity resistance training it's moderate intensity and high volume or low volume which is not typically what we do but it was just looking at the impact of volume is all it's doing at a set intensity so for those people that we hit barriers where we can't go heavier then we're gonna have to add more volume. But keeping in mind that there are specific benefits to higher volume or higher intensity, higher load training that we will not get with moderate or low load training. But we will, if we want the strength adaptation, we are gonna have to adjust that total volume up. So our people that aren't responding or we've got barriers, then we need to up the volume. So I know all this digging in to say, If we hit barriers in hitting that higher load, then we're going to have to add more volume. But that's a reality of what we see in clinical practice, especially with older adults. And I think that's something that's valuable to keep in mind if we're working around injuries or belief systems or fear or time frames for healing. of tissue, especially like bone or cartilage that may have a longer duration of time, that we're going to have to supplement with more volume. So really from a clinical standpoint, I think that's helpful to keep in mind. But still keeping in mind that if we can hit high load, we want it because we're going to get strength adaptations, adaptations to the bone and other tissues faster and create more margin. Because with older adults, it's all about building as much strength and as much margin in the tissues, whether we're talking about strength or fitness or bone density, we want as much margin as possible. And the only way you're gonna get that is with high load. But if we can't, the next best option is to add volume.

SUMMARY Team, I hope this was helpful. I found this article really interesting. I'd never seen a study put together quite like this. If you have maybe taken our online courses and you want to get into live, where we do lots of practical labs, you've got some great opportunities coming up. So we've got MMOA Live in Kearney, Missouri, January 27th and 28th. We've got Oklahoma City, Oklahoma, February 17th and 18th, that same. And then the weekend after in February, we've got course in Connecticut and Minnesota on February 24th and 25th. Team, I hope you enjoyed this talk. I would love to hear your thoughts on this article or your experience with older adults with adjusting volume and maybe what you've seen. Other than that, team, have a wonderful rest of your Wednesday and we will catch you next time.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning 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. Mark Gallant // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses the current literature around best practices for degenerative meniscal issues, including graded manual therapy, self-relief at home, and loading. Mark also discusses how to begin with the highly irritable patient & progress through the full plan of care as symptoms reduce & tolerance to load increases.

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 Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

MARK GALLANT All right, what is up PT on ICE Daily Crew? Dr. Mark Gallant here, lead faculty of the Extremity Management Division alongside Lindsey Huey. Happy to be here today, coming at you on Clinical Tuesday. What I'd like to talk about today is degenerative meniscus tears and what is the best path going forward to treat them. So what we'll get into today is a few things of overall arching research and philosophy about degenerative meniscus tears. So those are those tears that person's around the age of 40. There's usually no relevant recent trauma. So we'll get into again, general research philosophy. And then what we're going to talk about is what do you do when that tissue is really irritated? How do you move them forward clinically? And then what do you do when it's, when it's less irritable and we're really trying to get them back to all the things that they love the most. GENERAL RESEARCH PHILOSOPHY So what we see with these degenerative meniscus tears in the research, a few interesting points. So first is, that when Horga et al in 2020 took 230 asymptomatic knees, ran them all through the MRI tube, what they found in their research is about 30% of those folks had a meniscus tear or some sort of meniscus degeneration. So even in asymptomatic folks, having some tissue changes to the meniscus tissue is quite normal. Then Thorland et al in 2018, they had a surgeon who went in and did a scope of arthroscopic surgery to over 600 knees and while the surgeon went in there determined is there damage to the meniscus or is there no damage to the meniscus. What they found was an equal number of folks with no damage to the meniscus reported signs of mechanical knee pain that we typically associate with meniscus injury. So things like catching, locking, and lack of extension of the knee, we have historically associated those with a damaged or torn meniscus. And what Thorland et al found is, no, this really is more of a sign of that the knee is not doing well, that the health of the knee is not at its max capacity. and that's likely why they're getting those catching, locking, lack of extension, not that one specific tissue or a couple of specific tissues are to blame. And then finally, over the last decade, we have study after study, systematic reviews, randomized control trials showing that if you compare someone who had conservative care like physical therapy versus having surgery to their meniscus, that after a year, the outcomes are the same, if not better, favoring the physical therapy side with far less medical cost. Last year, what came out is we now have Cochrane-level review evidence, a Cochrane study showing that scoping these meniscus knees, or knees that supposedly have meniscus damage, is no better than placebo. So again, many asymptomatic knees are gonna have changes to the meniscus, whether that's degeneration or tears, Most knees, whether they have a meniscus tear or not, if they are unhealthy and not doing well, they're going to show signs of mechanical knee pain such as catching, locking, and lack of knee extension. And when we take it even further and we look at who gets better if we treat them out for a year, again, Cochran level review evidence saying that we should not be scoping those knees, which has led my partner, Lindsey Huey, to often using the phrase, stop the scope. There's a couple podcasts here a ways back if you want to check them out where Lindsey went into more depth of the all the research showing why we should not be scoping degenerative meniscus tears or at least not scoping them as a first line of treatment. She also has a episode on our virtual ice where she goes in depth to the scoping the knees. STOP THE SCOPE: THEN WHAT? So what I want to talk about today is stop the scope, then what? Then what do we do after that? So how are we going to effectively treat these people to get them back doing the things they love? So Let's start with the highly irritable patients, someone who comes in, their symptoms are at that 7, 8, 9 out of 10 symptoms. How are we going to treat them? Well, modulating their pain is always a good place to start. So can you use your manual therapy, your joint mobilizations, your dry needling, your myofascial decompression, or your soft tissue techniques to take their symptoms from that 8 and get their symptoms down to a four, a three, a two, something that's a little more manageable. When we're doing our joint mobilizations for these folks early on, what we're going to do is we want to do them in more of a open pact or positions that are not challenging the end range as much. So both flexion mobilizations or knee extension mobilizations. Again, at this point, we are not trying to get after knee stiffness or range of motion limitations. We're trying to create fluid exchange. We're also trying to pump any chemical irritants out of the area. And really the biggest thing is we are trying to get a positive stimulus into those tissues so that the central nervous system will calm down a bit and allow us to load the knee, which will effectively improve its long-term health. So again, very mid-range, open-pack joint mobilizations. With your dry needling, what we typically see is it works well to go distal from the knee. So putting your needles in hamstrings, quads, glutes, tissues that relate to the knee, but are not going to create fear for that patient by putting the needle directly into the area or tissue that is sensitized. Same with your soft tissue mobilization or your cupping. When you, after you do your joint mobs, your dry needling, they're feeling a little better. Then we're going to give them a self-mobilization to follow it up when that person is more irritated. Again, we want that to be more of that open packed, less challenging end range. If they have a flexion deficit, we like to go on the floor doing a heel slide, but having a thick band provide an anterior tibial glide, which will further modulate their symptoms and allow them to get through a nice comfortable range of flexion. If their deficit is more knee extension and the pain and symptoms are high, we're going to have them do a quad set but put a towel behind their knee so that they know there's an end range and they're not going to bottom all the way out into their symptoms. You can also add a band to distract the tibia and that sometimes can be an added benefit for those folks. So you're going to do your pain modulation technique in the clinic You're going to give them some sort of self-mobilizLation to help further modulate pain at a fairly high volume, 15 to 20 reps to really pump that tissue. LOAD AROUND THE KNEE And then as early as we can, we want to load the tissues surrounding the knee. So the quads, the hamstrings, the gastroc soleus complex early on when things are irritated, it's going to be challenging to get a lot of tensile load through these, through these tissues. It's also going to be challenging to get them at an end range. So, we're going to do mid-range knee extensions and we're going to do Knee flexion, so either banded, monkey feet, whatever you can do to challenge those hamstrings with a light load and a mid-range at a high volume. And then whatever way you want to load the gastrocs and soleus, but again, going low tensile load, high volume. And then what sort of functional thing can you get that person into? A lot of times those folks have challenge with loaded knee movements. We want to get them back to that as early as possible. without stirring up their symptoms. Early on, what we find best is to go double leg activities that don't have a lot of shear involved with them. So not a lot of twisting and rotation. So we love a body weight squat and even a body weight squat to limited depth to keep that person comfortable early on. So again, symptoms are high. You're gonna go manual therapy, more for challenging symptoms, not challenging their end range. You're going to go self-mobes that have the same type of style where they're more mid-range, really creating a pump to that tissue, giving some positive input. You're going to start to challenge the knee extensors, the knee flexors, and the gastroc soleus complex with lighter tensile load. higher volume again thinking pump and getting positive positive stimulus in the system and we want to get them used to doing their functional activities double leg body weight squat with a depth that they feel comfortable with is a really nice way to do this now then that person is going to come back and their symptoms are going to be lower so they're going to tell you know what i was at an 8 out of 10 but over the last couple weeks, I've been hitting all the stuff we talked about. The manual therapy felt good. Now my symptoms are more in that two out of 10 range. I feel like I can get after it a little bit more. So now when we're doing our joint mobilizations, we are gonna go straight down to the end range and really challenge the end ranges of these tissues and make sure we facilitate that they can restore full flexion, full knee extension. For our dry needling, now we are gonna get much more direct at the tissues of the knee. So we really like to needle the popliteus, the hamstrings, the gastroc soleus, tissues that are right there interacting with the intra-articular knee tissues. For your follow-ups, now again, we want to get them right into those end ranges of tissues and really start to challenge them. CHALLENGE END-RANGE We love the classic terminal knee extension with a really thick band. Spanish squats can be another way to get after this. We also, for the knee flexion after the mobilization, we're gonna get into a child's pose position with a towel behind the knee. I'll come on tomorrow on our Instagram feed and demonstrate what this looks like. So they're gonna have a towel behind the knee with a band keeping it placed, and they're gonna rock all the way back into deep end range knee flexion to really challenge the end range of that motion. Now, loading up the local quad, loading up the local hamstrings and gastroc soleus at that point where they can tolerate more tensile load, we're going to go long arc quads, really loading that up, whether that's a classic knee extension machine, your monkey feet, banded long arc quads. you can hit spanish squats in this position to really load the quads up for our hamstrings we're really going to start to challenge the length tension relationship of those by doing things like nordic curls You can also do Nordic curls or bridge walkouts to really challenge those hamstrings can be another nice one. And then in this phase, we are really getting into the concentric eccentric in functional activities. We really like transitioning to single leg activities in this phase. your split squats, your kickstand RDLs, your single leg RDLs are very nice for this phase, really challenging that knee overall from both a proprioceptive balance and load perspective. When you're doing your squats and your deadlifts in this phase, really starting to load them up, how heavy and how much stress can that tissue take during this phase. Step ups are another really nice one to add in. So again, during that low irritability phase, now we are challenging end ranges of tissue. We're really trying to put positive stress into the quads, hamstrings, calves, Our functional activities, doing single leg, whether that's split squats, RDLs, heavier on the double leg squats, deadlifts, step ups, all work really well. Once they can tolerate that phase, with 2 or 3 out of 10 or less symptoms, then we've got to really get them back to their more dynamic activities if that's what they choose to do. Here's where we're going to do things like box jumps, rebounding jumps where they jump from one box height to the floor up to another box height. We're going to hit things like jumping ropes so they get their plyometric endurance up. single leg hops for distance, running for distance, cutting. This phase we really want to focus them on getting back to the activities that are challenging them and some pivot rotation movements that are going to challenge that sheer force to the knee. SUMMARY So overarching themes. For these degenerative meniscus tears or degenerative meniscus damage, surgery is never the first line of defense for these folks. When they're more irritable, our manual therapy is gonna be much more mid-range, calming things down, giving a positive stimulus to the nervous system. Our follow-ups are also gonna challenge more in this mid-range, again giving positive stimulus, mid-range knee extension, banded or monkey feet hamstring curls, low to the gastroc soleus, and typically double leg functional activities. Once they can handle those things where symptoms drop below that five, now our manual therapy gets much more into the end range of those tissues. Our follow-up MOBS are also gonna get into the end range of those tissues. I'll show that, Child's Pose Rock Back tomorrow on our Instagram feed. Our knee extension, our hamstring activities are gonna be much more higher tensile load. Our functional activities will switch into single leg or much heavier and stressful double leg activities. Once they can tolerate that at a two or three out of 10, then we're really gonna start getting into their running, jumping, cutting, dynamic motions overall. Hope this helps as far as treating out those alleged meniscus tears and avoiding them from going into an unnecessary surgery. If you'd like to catch us on the road, I'm gonna be in Highland, Michigan, just outside of Detroit this weekend. Lindsey will be in Scottsdale, Arizona this weekend. And then the next opportunity to catch us will be Lindsey will be in Carson City, Nevada, February 17th and 18th. Hope to see you all soon. Hit us up in the comments if you have any questions or things to add to this conversation. Have a great rest of your Tuesday.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how to get patients performing more fitness in their plan of care, as well as suggestions on how to help patients transition to becoming "everyday athletes" with a wide variety of home & community fitness programs.

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

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.RACHEL MOORE Good morning, PT on Ice Daily Show. It is 8 a.m. on a Monday morning, which means we are here tuning in for our ice pelvic. We are hanging out here today. We are gonna be talking about building the bridge to fitness in the pelvic floor PT space. So we talk a lot at Ice about being fitness forward. We've had Jeff Moore on the podcast a few weeks ago talking about what fitness forward means. and we really pride ourselves on being fitness forward right sometimes that can create this like mindset of if i'm not seeing athletes quote unquote how can i bring this fitness forward um style of therapy into pelvic floor pt WHAT DOES BEING AN ATHLETE MEAN? And first I want to talk about what athlete means, like define what that means in this space and kind of dive in from there. So when we talk about like athletes, quote unquote, in our space, that's anybody that's like intentionally moving their body for exercise. That doesn't mean that they're CrossFit Games athletes. That doesn't mean that they're super competitive. It just means that they are moving their body intentionally to get some effect. I would argue that every parent that is chasing after kiddos is an athlete in that case. And so if we take this term of athlete and broaden it out, we can apply that concept to everybody that walks into our clinic. This is a really huge key point in the pelvic space because there are so many people that are coming into pelvic floor PT that maybe have not ever exercised before or maybe exercise like back in high school played sports and since they graduated high school haven't done anything in the gym intentionally or haven't done any sport. So this season of life of pregnancy and even postpartum is a fabulous reintroduction into potentially the world of exercise. And that's where we come in. So when we have people coming in that are pregnant that want to get out of pain, maybe their goal isn't even anything to do with staying in the gym or getting back into the gym and their entire goal is to get rid of their back pain in pregnancy or get rid of their pelvic girdle pain in pregnancy. We can help not only accomplish that, like we know that. We talk about it in all of our courses, in our live course and in our online course, how we can use resistance training to mitigate pain and get rid of pain in these populations. But we have a fabulous opportunity here to literally change somebody's life. We can help them fall in love with fitness and fall in love with that feeling of being strong. a lot of times people are coming in and again maybe they haven't resistance trained ever and we put a barbell or a dumbbell in their hands and they kind of look at you like I'm not really sure who you think I am but there's no chance I can do this and so having conversations with them about like look this is a 20 pound dumbbell and your toddler weighs 30 so yeah you can and I know this looks scary because it is this little metal handle with two big old heads on the side But in reality, you're already lifting more than this. Let's just build your capacity by doing it intentionally at a higher volume. And then they start feeling those effects of that. We can have so many downstream effects from resistance training, not just getting them out of pain, not just giving them a new hobby. We can shift the trajectory of their life and impact things like metabolic diseases in their future. So this really is a powerful thing that we can do. And we have to recognize that every time somebody comes into our clinic, whether or not they've exercised before, we have a lot of opportunity to help build this capacity for them, not only physically, but also emotionally and mentally. In our PT sessions, we do a lot to help build confidence and rapport, right? Like we're in there with them. We're going over form. We're talking to them about like, okay, this is how you do a deadlift. This is how I want you to brace. This is what a brace means. Now we're going to practice it. Let's go apply it. Like let's actually lift heavy things while bracing. And when they're in the clinic with us, that can be incredibly empowering and amazing. And we love that, but sometimes that doesn't translate over into the next step. So great. WHAT TO DO AFTER FORMAL PT HAS ENDED? When I'm in the clinic and you're watching me do the things, I feel awesome and I feel like I can knock that out of the park, but I'm just not really sure what to do when I leave here. A lot of the times the way that I'll program HEPs is I'll do like our rehab EMOM style and I'll give them two or three workouts, if you will, and they cycle through them. But I think we all can agree that if you're just doing the same thing like three times in a week, so like A day, B day, C day, and do that for a few weeks, it can kind of start getting stale. And we kind of like crave that variety, right? Especially as people are starting to get a little bit more confident. So there's kind of this like gap between I'm done with PT, informal PT sessions. A lot of clinics are now coming out with like once a month or like once every other month kind of like check-in style appointments where you come in, you get a progression of your exercises, you get maybe some updated programming, and then you go off for another month or so on your own again. And those are really the two big things that we see. And then the third option is like, okay, you discharge and you're done. I'm here to talk today about another option, right? So when we have our person who's coming in and they've been coming to us for several weeks, they're feeling really great or maybe a couple months and they want to continue working out, but they want something a little bit more than once a month. and they don't really want to do like a full blown PT session. Like they just want to come in and work hard. We've got two options. We can create a program within ourselves and within our clinics, or we can get really, really good at helping find a home gym or a home space for them. If we're talking about the creating a program route, this is something we're about to roll out in my clinic. We're calling it like the bridge. Feel free to take that same concept. But the whole idea is when you're done with PT, quote unquote, like you're not in pain anymore, all your symptoms are gone. You're feeling really solid. You want to work out, but you're just not sure where to go and you're not sure if you feel like you can confidently take the things that we've done in our sessions. and apply them across the board, this is the spot for you. So we're doing it as a couple times a week and obviously this depends on what the capacity is within your clinics. We're rolling it out starting out two times a week and these are group HIIT style classes, where we're going to have a cardio component, we're going to have a strength component, we're going to take them through different movements, and so there will be a variety of movements that they can increase their comfort and their confidence in while they're in our classes. They're also building community here. They're meeting other people that are in a similar stage of life as they are. Not only are they maybe pregnant or postpartum just like they are, but they're people that are wanting to get into exercise and wanting a little bit more, but maybe haven't really known how to do that up until this point. So we're taking these people and we're bringing them together and then we're lifting heavy things together. So powerful. If you've ever set foot in a CrossFit gym or any type of like group fitness setting, you know how powerful these connections are that get built in under like shared suffering, if you will. This class, though, isn't meant to be forever. Like, its whole goal or the whole purpose is to build capacity, increase confidence, so that these people can go from working out a couple times a week, doing their PT exercises, and then coming to these bridge classes. But I want you getting to the point where you're like, let's send it five days a week, or whatever that looks like in your schedule. And truthfully, I want you to have more variety. Like I want you to get out and do different things and try new sports. BUILDING A NETWORK OF FITNESS PROFESSIONALS And so that's where option two comes in, where we as professionals need to have a really reliable, strong network of fitness providers. So we need to know not only the CrossFit gyms in our area, Because truthfully, not everybody vibes with CrossFit. That's OK. There's the whole phrase, like, CrossFit is for everybody, but it's not for everybody. So CrossFit gyms in your area, knowing those coaches, being comfortable with, like, if I send you there as a newbie, I know that you're going to be in really solid hands and be taken care of. But also the other types of workout spaces, too. So we're thinking things like F45 or burn boot camp, maybe having some options for, like, Pilates studios, where you've taken some classes there you understand how they teach the bracing piece of it and if it isn't maybe what the way that you've taught them you kind of have that conversation beforehand or you have an opportunity to educate those Pilates instructors on like hey this is how we do things from a pelvic floor PT side you've got somebody coming in that's postpartum or pregnant So this is kind of the messaging that we have. We also really love things like PureBar. We've got actually evidence for PureBar helping reduce stress urinary incontinence, not even full-blown pelvic floor PT, but just going to PureBar classes. So having a variety, knowing who these people are, knowing what these spaces are like, and knowing what the environment is like. It is powerful to be able to have your hands directly on give the people the thing that they need as far as improving their fitness and improving their form. But it's also powerful to then watch them take that and go off into the world and utilize it. And then you're seeing them maybe on Instagram months later, or you run into them at a workshop, and they've been going to these gym classes for like a year. And now maybe they're competing at different things that they're in CrossFit. And you can see this like spark ignite. And we have the opportunity to start that spark at our very first visit, our very first appointment when somebody comes waddling into our office because they're in so much pain, they can't even take a full length step because their pubic bone pain is so bad. We can be the ones that not only knock that pain out, because I know we can, but also create this bridge into a completely different life for this person. Increasing their capacity, increasing their confidence, helping them find community and support, and having that far reach outside of the realm of what our typical plan of care is. This is huge. This is a massive piece of the puzzle in the pelvic floor PT space. So if you are not somebody who has the ability or desire, totally understand, to create a group class within your own setting, whether it's in your clinic or your gym or whatever, start reaching out and start making those connections with providers, fitness providers in your area. Meet those gyms, take those classes, get out there and build that network. Have some cards on hand when your patients are talking about, hey, I just really think I'm ready to get out there and do more. Lay them all out. Here's everything we know about all the gyms in the area. Let's talk about all your options and help you find the perfect home for you. I hope that kind of lights a fire under you guys if you have an eval coming in this afternoon on the ways that you can really implement all of these strength training principles to change their lives and also to get out there and make some connections in your community. SUMMARY If you are looking to join any of our pelvic classes, we've got our live courses. We actually have a ton coming up in the next couple months. We've got one in February, February 3rd and 4th in Bellingham, Washington. And then we've got three rolling out in March. Our first two are gonna be March 2nd and 3rd in Newark, California, and March 9th and 10th in Bismarck, North Dakota. Our next online cohort comes on March 5th. If you're interested in that L1 online cohort, hop into it, because we are, man, we're getting full. So grab your spot before there's not one, because if so, you've gotta wait another nine weeks after that March 5th cohort to hop into the next one. I hope you guys have a great Monday morning. Absolutely crush it. Thanks for joining.

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses the prevalence of runners returning after joint replacement, risks of returning to running, and how providers can set these athletes up for success on their return.

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.

EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

JASON LUNDENHey, good morning, everyone. Welcome to another edition of the PT on ICE Daily Show. Happy Friday. My name is Jason Lunden. Uh, I am the lead for our endurance athlete division, and I am very excited today to talk to you about return to run following total joint replacement. So this is a topic that has held great interest to me for a number of years. Um, and really hasn't been a lot out there. Until more recently, there's still not a lot out there, but there have been some really neat studies that have come out in the past year that can help guide us with that. So today we're going to cover, one, do runners return to running following total joint replacement? Two, what are the risks that we and they need to be aware of? And then three, How can we set them up for success if they do indeed want to return to running?

DO RUNNERS RETURN TO RUNNING AFTER JOINT REPLACEMENT? So first, answering the question, do runners return to running following total joint replacement? The short answer is yes. I think we've all probably heard anecdotal stories of runners who've had a total joint replacement and returned to running despite being told that they should never return to running from their surgeon. Furthermore, a study from 2018 just looking at the prevalence of osteoarthritis in marathon runners made the observation that out of their cohort that they were studying, there were seven marathoners who were running with total joint replacement. So, you know, are these unicorns, you know, people who are going against the advice of their physicians and maybe their PTs and you know finding some success? Is it that they're finding very short-term success and then having to go on to you know early revision of their total joint? You know really didn't have any of that data until until recently. So a really cool study in 2023 came out by Antonelli et al looking at the return to run rate for runners following total joint replacement, namely total hip, unilateral knee, and total knee arthroplasty. And what they found is that yes, runners do indeed return to running following total joint replacement. And depending on the type of joint replacement they had, some of them return at a very high rate, while others return at a pretty modest rate. But overall, one of the interesting things out of that study is the number of people going into total joint replacement that classified themselves as a runner is actually really small when you're looking at the whole population out of the study. And that really, you know, reinforces our knowledge that we've been gaining recently that, you know, running is not a precursor to osteoarthritis and perhaps it may be chondroprotective. So that's one kind of neat takeaway from that study. The other really cool thing is that for patients following a total hip arthroplasty, if they're a runner prior to total hip, 75% of them returned to running after getting a total hip arthroplasty. With knee replacements, the percentage is much lower at around 10 to 15%. of those runners who were running, runners, and then going on to get a knee replacement, only 10 to 15% of them returned to running. And then even more surprising is a certain number of patients who did not run prior to joint replacement actually picked up running following joint replacement. About 1% of patients studied in the study. So yes, patients, can and do return to running following total joint replacement.

RISKS OF RETURNING TO RUNNING AFTER JOINT REPLACEMENT But what are the risks? I think we all have heard the narrative that you definitely should not avoid impact and avoid running following total joint replacement. And there are concerns for periprosthetic fracture, so fracture around where the orthodesis is or where the implant is. you know, concern for dislocation for total hip replacements, as well as polyethylene wear and loosening of the implant. Those are the kind of the four main concerns that surgeons have. And I think there, you know, is probably some validity to those concerns. And we do want to be thoughtful in having those discussions with patients if they are looking to return to run following total joint replacement. But another really neat finding out of the Antonelli study is that there was no difference in revision rates between those patients that went on to return to run following total joint arthroplasty and those that did not run at all. So the revision rate is around 5%, which depending on how you look at it, is either pretty small or still a pretty large number if we're thinking of 5% of people are having to go on to get a revision following the first total joint. And unfortunately, as with most surgeries, the second time around, the outcomes just aren't as good. So we definitely do want to avoid revision of a total joint if we can. And one way we can think about doing this is being really smart and methodical in how we're helping these patients return to running. Keep in mind that You know, following most lower extremity surgeries, patients actually see a decrease in bone mineral density, typically for the first year or maybe even up to two years following surgery. And that seems to peak in total joint patients at around three months, and then not actually improve, but the amount of loss peaks at about three months. So right around when we would be thinking about implementing a return to run program with a total joint patient, realize that their bone mineral density is probably at the lowest that it's been recently. And particularly if they are osteopenic patient or osteoporotic. You really want to go slow with them with implementing impact just to avoid periprosthetic fracture. So that also is making sure that you as a practitioner have knowledge of what's going on with the human in front of you, not just that they've had a total joint, but what's the bigger picture? Do they have a history of osteopenia or osteoporosis? And is there anything that they can do to help combat that?

SETTING PATIENTS UP FOR SUCCESS TO RETURN TO RUNNING So setting up our patients for success that do want to return to run following total joint replacement. One, we want to have a good idea of what's going on with them as a human and on a global scale and making sure that we're being specific to that. Two, regardless of that, we do want to have a slow progression with return to running and return to running volume. So this is a patient population where we definitely want to start with more of our walk, jog intervals than just going into straight jogging or running, making sure that they are able to tolerate a good walking program first. So being able to walk, you know, certainly 45 minutes or an hour without any issue, implementing impact in a controlled setting. So having them do stomping, um, you know, jump rope, uh, and, and things of that nature and making sure that they are tolerating some impact before we really get, uh, have them get to a lot of repetition, which running is a lot of repetition, um, for that. And part of doing that is really making sure that they are regaining and probably even gaining more strength than they had going into surgery, particularly with, if we're talking about the knee and the hip, quad strength, hamstring strength, and then global hip strength. So really making sure that they are, have had a good program with that and that they are at you know, 80 to 90% of what their contralateral leg is before even thinking about implementing a return to run program. And also making sure that what we're comparing their operative leg to with the contralateral leg isn't just comparing to, you know, crap numbers. So making sure that they do have a certain level of strength and fitness going into a return to run program. A couple things that we like to use as quick screening tools in the endurance athlete division are the ability to do single leg squats and the ability to be able to do at least 20 single leg squats with good form and with maintaining balance, as well as being able to do single leg heel raises and the ability to do at least, in this older population, 10 to 15 single leg heel raises to full height if possible. So we're really being methodical about how we're implementing that return to run program and progression of volume. We're making sure that prior to doing that, we have maximized their strength gains around the hip and the knee. And then we also want to make sure that they have the mobility to have, you know, the best gait mechanics that they can. So really making sure that they are getting, particularly with total hip patients, that they are getting hip extension, that they have good mobility of the rockers of the foot and ankle. So good ankle dorsiflexion, good, great toe extension, et cetera. And if they don't, working on that, either using your manual techniques or giving them some mobility drills to work on with that, And then bringing it all together with when we are implementing that return to run program, really trying to set them up for success by looking at their gait mechanics and then implementing some drills to help decrease impact at the hip and knee. Namely, if they do have decreased rockers, you know, and even with working on it manually and with some mobility drills, they're just not getting that back. getting them in a shoe with a rocker bottom to help with that can be extremely helpful in our older adult population. So something like, you know, Hoka has several shoes with a rocker bottom, as do other brands. And then if they're really limited in their, they're not able to get that hip extension or you're not observing hip extension at toe off, getting them to have a little bit of a forward lean, a forward lean not a forward bend so that they're basically just leaning their center of mass further forward to prevent over striding which over striding really increases impact at the hip and the knee and probably even more importantly it increases the the loading rate at the hip and the knee so those would be kind of two things to to really look for in your total joint patients that are returning to run. So in summary, you know, return to run for total joint replacements, yes, patients do and can, can and do return to run following total joint replacement. Much higher rate with, if they've had a total hip replacement compared to a total knee, but overall, those patients that we're working with that have had a total joint are likely to not be a runner to begin with. Two, we do want to be aware of what the risks are. There is no difference, at least in Tonelli's study, in revision rates between those patients that went on to return to run and those patients that did not return to run following total joint replacement, but those risks still are you know, I think valid with paraprosthetic fracture, risk of… hip dislocation, particularly if they were to fall, polyethylene wear, and implant loosening. So just really having a good understanding, particularly the bone health of the patient in front of you. And then lastly, set your patients up for success. Get them strong, work on their mobility, have all that tie into good gait mechanics, and slowly progress their volume. That's all I got for you today. Uh, thank you for listening.

SUMMARY If you are interested in treating endurance athletes, um, or you do treat endurance athletes and are looking for some CEUs, uh, we do have a variety of offer offerings within endurance athlete division. Uh, for coming up first is our second cohort of rehabilitation of the injured runner online, um, starting in early March. Also in March, we have our first offering. of the year of professional bike fit in Texas. And then we have a bike fitting offer, the professional bike fitting course offered also in April in North Carolina, and then in May in Minneapolis. And then our first rehabilitation of the injured runner live is going to be early June in Milwaukee. Come join us for those courses. We have a lot of fun and I think you pick up some really good skills and clinical pearls with treating endurance athletes. Have a great weekend, everyone. Get outside, do something fun with friends and family, and we will catch you later. Bye.

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