#PTonICE Podcast

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 various types of taxes encountered in personal & business finance, how tax liability is calculated, and how to use tax deductions/tax credits to reduce how much tax you pay.

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, everybody. Welcome to the PT on ICE Daily Show. Hope your Thursday is off to a great start. My name is Al. I'm happy to be your host today. Currently have the pleasure of serving as our chief operating officer here at ICE and a faculty member in our fitness athlete and practice management divisions. It is Thursday. It is Leadership Thursday. That also means it is Gut Check Thursday. So today is Gut Check Thursday. A little bit kind of heavier and slower. We have a workout. 15 hang power cleans, 9 wall walks, 12 hang power cleans, 7 wall walks, 9 hang power cleans, 5 wall walks. The barbell weight for this week, 135 for gents, 95 for ladies. That should be a moderate weight barbell that maybe you even have to break up. Maybe you deadlift it up to the hip. Maybe you break those cleans into maybe 2 or 3 sets. and then you're really just kind of grinding through wall walks. It's going to be a very shoulder, upper body heavy workout designed for maybe the 10 to 15 minute time domain. Any modifications you need, suggestions on how to approach the workout, you can check out the post from last night on our Instagram page and see a bunch of different scaling and modification options. So that's Gut Check Thursday.

TAXES Today it is the middle of January, which means it is tax time. Hopefully you have already started to wrap up 2023 finances, personal and maybe also business if you happen to be a clinic owner. So I want to take some time and talk about different types of taxes, especially for those of you who are maybe dipping your toe in the water and thinking about What I might do if I were to open my own clinic, maybe you're somebody who is in the process of opening your own clinic Maybe you have a side hustle Treating folks from your CrossFit gym or your run club or whatever and a lot of this stuff is all brand new to you so we're going to break down the different types of taxes that you'll encounter and We'll talk about how tax actually works as far as how does the government decide what you owe them. And then most importantly to all of you, we're going to talk about different types of tax deductions and credits, the difference between a deduction and a credit, and a bunch of different things that you're probably not doing to reduce how much tax you owe the government, whether through your personal finances or through your business finances.

DIFFERENT TAXATION TYPES So let's start at the top and let's talk about all the different ways that we can be taxed in the United States of America. So very common that we all pay federal income tax. That's something you can't get away with unless you happen to make very little or no money. We also have payroll taxes. Inside of payroll taxes are two different taxes. That's our Medicare tax and our Social Security retirement tax. We talked about those two weeks ago when we talked about changes in Medicare for 2024. We talked about how we pay into the Medicare and Social Security system from our paycheck, and that is the payroll tax. If you're a W-2 employee, you pay half of those taxes. Your employer pays the other half. If you are self-employed or otherwise you work as a contractor, you the individual taxpayer, you pay all of those payroll taxes. Now some of these that I'm going to talk about may change based on where you live. So depending on the state that you live in, you may or may not pay state income tax. Depending on the state you live in, you may or may not pay state property tax if you happen to own a home. depending on the state you live in. You may or may not encounter sales tax. We're very familiar with sales tax. Anytime we buy something, we typically pay a tax. And then getting into kind of some more advanced taxes. If you do happen to own a company, you may or may not be paying corporate income tax. And hopefully if you're a larger company, you're not doing that. And if you have questions about how to avoid that, we have a whole course for you that I'll tell you about at the end of this episode. And then finally, if you do have any sort of investments in the stock market or retirement or whatever, if you receive any sort of money back from those investments, dividends or whatever, you will pay capital gains tax. So just about 15 different types of taxes that we encounter in our life that results in our paycheck being smaller than maybe we would like it to be. So that is types of taxes.

HOW ARE TAXES CALCULATED? Now, how does the tax burden that we owe get calculated? In the United States of America, specifically with federal income tax, we have a bracket system. A range of income, zero to $10,000. $10,001 to $19,999 and so on and so forth. You get the picture. As you move up those brackets, you can kind of think of it like ascending a staircase. As you move up that staircase, as you move into different income brackets, your amount of income that you are taxed on changes. So the percent of tax that you owe changes. Now that is essentially the name of the game when we're talking about how to pay less taxes over time both again for our personal finances but also for our business. Our goal as individuals and as business owners is to push ourselves back down those brackets reduce the percentage of tax that we pay, reduce the amount of what is called taxable income that's going to be calculated to determine how much tax we owe. How do we do that? We do that through a series of deductions and credits. Now, these are not the same thing.

TAX DEDUCTIONS VS. TAX CREDITS What is a tax deduction? A tax deduction may be commonly called a write-off or an expense. It is something that reduces your taxable income, which may potentially push you far enough down in that bracket system that you now enter a lower bracket for your taxable income and pay less of a percent of your income as tax. That is very different from a tax credit, which at the end of the day when you finish your taxes and you get told you owe X amount of dollars, A tax credit will reduce that amount owed one to one. So the key difference is tax deductions do not reduce your tax bill at the end of the day in a one to one fashion. They cumulatively push you back down those tax brackets. which hopefully results in you potentially paying less taxes. But that's not guaranteed. You can certainly have a lot of deductions, a lot of expenses, but maybe not enough to push you down a bracket, which means your tax bracket does not change, which means there's really a minimal impact on the tax you owe. Very different from a tax credit where you have a tax bill, you know how much you are owed, and the tax credit is going to reduce how much you owe in a one-to-one fashion. So now let's talk about what you probably all care about are what are all the different ways? What are all the different deductions and credits available? There are for most of us around 15 ish different deductions and credits. Some of them depend on if you have children or student loans or if you own a business. But let's rip through all of those and talk about them and see which ones may apply to you that maybe prior to this podcast, you didn't even know were a thing, which can maybe hopefully result in you paying some less taxes this year. So the first one is called the Child Tax Care Credit. Again, tax credit reduces your tax bill in a one-to-one fashion. This is about $2,000 per kid for the 2023 tax year. So if you don't have kids, you can't get this. The more kids, the more tax credit you get. There's also a Child Care Tax Credit, which is not as well known. This will allow you to get a credit for 35% of $3,000 of childcare cost incurred for one kid or 35% of $6,000 for two or more kids. So if you are sending your kids to daycare or you're otherwise paying out of pocket for childcare, you can reduce your tax bill by a little bit, 35% of whatever you spent up to three or $6,000 depending on how many kids you've had. If you are still in school or maybe you have college age kids, there are a couple different tax credits that are mainly going to apply to the person in school. So we have the American Opportunity and the Lifetime Learning Credit. Those are geared towards college students. If you're listening to this and you're not currently a college student, I would not recommend going back to college just to get these tax credits. That's definitely not going to work out. But if you are listening to this and you're a student or you know a student or you have a student in your family, then these may apply to them. This next one applies to almost all of us. You may not know that you can deduct, so again, not a tax credit, but you can deduct up to $2,500 a year of your student loan interest. So some of us may not have paid interest the past couple of years with the COVID forbearances for our student loans, but if you have been paying on your loans through the past couple of years, you have accrued interest and definitely at least this year going forward, with everybody's payments resuming, you will have interest and you can deduct up to $2,500 of that interest. So that is information available from whoever services your loans. They should send you an email or something in the mail telling you how much you paid in interest and you can deduct up to $2,500 of that. Adoption credit is another tax credit available. Again, probably not for most of us, but if you do happen to adopt a child, you should know there's a tax credit for that. You can get up to 60% of your gross income in deductions for donating to charity. So whenever you are donating to charity, you should keep those receipts. You should keep a record of that because that can be a very significant deduction for you on your taxes. Medical expenses saw a big change over the past couple years. You can only deduct medical expenses if that expense happens to be 7.5% or more of your gross income. So a medical expense that's probably going to be in the thousands or maybe tens of thousands of dollars. Again, probably not applicable to all of you, but possibly someone out there, this is relevant to you. You should know that you can deduct your property tax and any state sales tax that you may have paid. This obviously is going to require that you've kept a lot of receipts. And for many of you, this is going to be an automatic deduction that you take in lieu of needing to provide a receipt for literally everything you may have purchased in the past year. If you own a home or you're currently in the process of buying a home, you can deduct your mortgage interest. You can deduct any sort of contribution to a retirement account, IRA, 401k, HSA, whatever. And then these last two deductions and credits, I think are widely underutilized in general, but especially in the field of physical therapy. You should know that you can take a home office deduction if you do any portion of your work from home. This is very relevant to us. A lot of you are doing notes at home outside of clinic hours. Maybe you're not given time in the clinic. Maybe you choose to have a flexible schedule and instead of doing notes at the clinic, you peace out and go home and change into your PJs and you do your notes at home. Whatever you're rocking, if you're at home and you're doing work, you should not feel bad about taking that home office deduction, right? Especially in the era of so many people across the country working from home, you should not feel bad one bit about taking that home office deduction. And then the final tax credit I want to talk about is called Form 8826. We've talked about this specifically on the podcast. We've had some posts on our social media about this. This is a tax credit designed to improve access. through the Americans with Disabilities Act, the ADA Act, designing with the intent of improving access, essentially, to rehab and there is a limit on this credit every year and that limit is a $5,000 tax credit, which means if you have spent up to $10,000, half of $10,000 is $5,000, you can have a $5,000 tax credit. this year if you have justified spending that much money. So what qualifies? The tax credit is very vague. We love vague laws here at ICE. What does that mean? Things like high-low tables that I'm standing at right now. Maybe things for adaptive fitness. A wide base ski machine for wheelchair users. Maybe lap mats so that seated patients can perform dumbbell, kettlebell, barbell work in the clinic. Anything that you can justify as improving access. Maybe you got the push button door to your facility. Whatever. If you widen the door frame, you've made a bathroom ADA accessible. If you can reasonably justify that you have made your facility more accessible, you can grab that credit and that's a credit that you can use every year, year over year. So if you're out there, you're a clinic manager, you're a clinic owner, maybe you're thinking about becoming a clinic owner, start to think strategically about equipment purchases such that you can maximize that tax credit every year. So I'll leave you with this. We've talked about different types of taxes, how taxes are calculated, common tax deductions and credits.

WHEN IN DOUBT, HIRE IT OUT I'll leave you with this. If this stuff drives you crazy, if it makes you nervous, if you truly know in your heart of hearts that you're bad at it, when in doubt, hire it out, right? You can very easily get access to a high quality accountant who would love for sure to do your bookkeeping, but would love to help you with tax prep as well. I think often of accountants and lawyers is they are doing this stuff every day. To them, you coming in with whatever you have going on with your personal or business finances is as easy for them as when somebody comes in and they have low back pain, right? You will know what to do just like they know what to do. with your taxes or the law. So when in doubt, hire it out. Let the experts handle it. You can certainly do your own bookkeeping throughout the year. Keep track of your credit card statements or whatever and just hand it over for tax prep. There are also a lot of accounting firms that will do all of your bookkeeping for you. They'll go into your bank account or your credit card account every month, every quarter, once a year, whatever. pull out all of your expenses itemized for you and help you prep for taxes. I recommend, again, if you're not strong at this, if you don't want to become strong at this, if it makes you nervous, if you get worried about getting in trouble with the government, it's in your best interest to shed a couple hundred bucks and pay an expert to do it for you. So when in doubt, hire it out.

SUMMARY So if you'd like to learn more about opening your own practice, we'd love to have you in our Brick by Brick course. Our next cohort starts April 2nd. We talk all things incorporation, taxes, getting a tax ID, a type 2 NPI number. We talk about the differences between insurance and cash and hybrid. We talk about working with Medicare. We talk about budgeting. We talk about different types of EMRs, everything you need to go from maybe a pipe dream of opening your practice all the way to potentially launching your practice by the end of that eight week course. So the next cohort starts April 2nd. We'd love to have you. So taxes, complicated, but a lot of good information hopefully that maybe you didn't know about to save you some more money this upcoming tax season. So have fun with Gut Check Thursday. Have a fantastic Thursday. Have a wonderful weekend. We'll see you next week. 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. April Dominick // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses how to navigate a pelvic PT eval when a "hands-on approach" for assessment & treatment may be off the table due to an individual comfort level with pelvic examinations or when trauma is on board.

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. APRIL DOMINICK Good morning, everyone. Welcome to the PT on Ice Daily Show. This is Dr. April Dominick here from the Ice Pelvic Faculty Division. And today we're discussing how to navigate a PT eval when hands-on treatment and assessment isn't an option. Psychiatrist Jacob Marino once said, the body remembers what the mind forgets. Why should we consider a hands-off approach during an eval for someone with pelvic floor symptoms? Maybe the client has some trauma, maybe they experienced nervousness about what a pelvic floor assessment is, or maybe they've had previous discomfort during other pelvic examinations with other medical providers or in a different setting. So for some of these folks, that hands-on assessment and manual treatment just is not going to be the best go-to during the evaluation and maybe even for some subsequent, if not all, follow-up visits. The idea that an internal or external exam is a requirement to make pelvic PT a success is just not true. Is it helpful? 100%. But we are the detectives of the musculoskeletal system. And we take into account the cognitive and emotional state into consideration of the human in front of us. just like all great sleuths like Nancy Drew, she's not making her next move based off of palpating the person in front of her, but she's taking cues from the person in front of her. So I'll give you some tips today for how to go about a hands-off assessment for an eval specifically, from the subjective to the objective, through the treatment, and then post-session. Pre-session, We want to make sure that your intake form has an area for a client to share some trauma or abuse that may have happened to them, whether that's current or they have a history of it, whether it's physical, emotional, whatever the case is. Whether they mark something on that intake form or not, as pelvic PTs, we are dealing with an extremely intimate part of the body. And that means that someone may not even realize that they're holding on to some trauma until maybe in session. They have some sort of trauma response because you palpated their low back, right? Or because you brought up during discussion or during subjective, um, a certain word and that was triggering to them like, um, anus. And knowing that their executive functioning is probably not working optimally in that moment is very helpful for us to make that session for them the best experience possible. If someone has a trauma response, just thinking before we even dive into the subjective, just having that in our head is important. We want to be non-judgmental. We want to be compassionate. in our responses, we should be patient and supportive of a pause that that person may need to take. They may need to take a breath or ground themselves or stretch. I have these little small animals like a llama, this one doesn't have any legs, just for them to hold on to and little fidgets as well. So know that that may happen in session and later on, You could ask them when they're not in that traumatic response or in the next session. You could ask them, hey, what would be appropriate for me to do to help you through that? Do you know? They may not have any thoughts on what to do if that does happen again. During the subjective, let's talk about that. With these clients, I tend to rely heavily on the subjective. We want to be looking at the verbal and nonverbal communication from our clients. These can cue us for the need for a hands-off objective and treatment session, even if the trauma was not shared on the intake. From a nonverbal perspective, when you're looking at your client, do they have knees to chest? Are they folded in super flexed? Do they have minimal eye contact? Are they wringing their hands and fingers throughout the entire session? From a verbal perspective, type of words for pain. So in the pelvic setting, we hear a lot of really scary sounding words and words that sound harmful. Things like, it feels like there's a chainsaw in my vagina or every time I sit, it's like a hot poker is going up my butthole. So listening for those intense words when they're describing their pain, as well as a tremor in their voice, are they shaking? And then any sort of non-specific description of their pain. Oftentimes I'll be like, yeah, tell me, can you show me, or can you tell me more about where your pain is? And if they show me, they kind of like, point in this giant circle of like from sternum to mid-thigh is where their pain is, and for some that is where their pain is. But for others, their pain is at the tip of the penis, but they just aren't comfortable or maybe again, that is triggering to them to say the actual anatomical word. And then verbal communication from you as a provider is important. So we're thinking active listening, we're going to ask them about prior health visits, and then you're going to dial in some of your questioning. So from an active listening standpoint, they've probably been dismissed or maybe not heard in previous medical provider settings. So we want to be the ears for them. and asking them specifically about previous physical pelvic assessments, if they've had any, how did it go at the gynecologist or the urologist, or even if they worked with a prior pelvic PT, that can give you an idea for what worked and what didn't or doesn't work for them. And then get curious about some of their personal life events and their symptoms. So, If they've shared any sort of major surgeries or shifts in their personal life, ask with some compassionate curiosity, do you think that your jaw surgery is related to the urinary leakage that you're now having? And then they think back and they're like, oh my gosh, the urinary leakage started happening basically when I had my jaw surgery. So they have sometimes like an aha moment or if a family member died or if they shifted jobs or got fired from their job, that's when they started having intense pelvic pain. So you can, again, be a detective and kind of connect some events together and that can help them feel very heard for sure. And then I went during my actual, if I am going to do a hands-on assessment, before I even palpate someone, I always ask them, hey, is there anywhere that's off limits or that I cannot touch or assess? And I'm going to do the same thing with the person in front of me. If I feel like this is going to be a hands-off assessment, I'm going to ask them, are there any topics or body regions to avoid during our discussion or assessment? And then finally, for the subjective side of things, preconceived notions about the pelvic PT visit. Do they have any? What have they heard? Be sure that you are explaining the pelvic floor assessment thoroughly and that you ask them for their preferred learning type. So if they are a visual learner, is it okay that I show you this pelvic model? Even that, just the visual look of seeing the perineum could be triggering for someone. I had someone who I was showing them the muscles on the pelvic model and they had a visceral, nauseous, triggering response that we worked through. And they kind of actually had a flashback of when they had some childhood molestation. And then moving towards the objective, we want to reframe this appointment like it's a virtual visit. which virtual visits are hands-off. Same, same, but different. Lean heavily on your visual range of motion. Again, if that's okay with them. In terms of asking them to do standing or seated spinal range of motion, hip mobility, we can learn a lot from a seated 90-90 for their hips in general. Abdominal movement with breath. Offer hands-off assessment options that they can select. So is self-palpation of their own pelvic floor okay for them? Or can we do a visual assessment, no hands, but a visual assessment of their pelvic anatomy? And like I said earlier, an external exam, but especially an internal pelvic exam, whether it's vaginal or rectal, is not required to make a pelvic PT session a success. It can though be something that the client and provider work towards if that's something that the client is interested in. A previous client once told me, they said, thank you so much for saying that an internal exam was not a requirement because they had apparently gone to two previous PTs who were basically saying like, hey, if we are gonna figure this out, we're going to have to do an internal exam, which can be very triggering for them. Then in that objective, looking at functional movements like squats, lunges, you get a good idea of range of motion, strength, growth strength, and then the quality. Is it smooth? Is it rigid? Don't forget to collect some pelvic specific outcome measures or even at the very least, a patient-specific functional scale. And then moving on to the treatment section, tuck your manual skills away and focus on the exercise, the education, the ecosystem. Do they have mental health providers or resources on board? From a exercise standpoint, we wanna be thinking movement snacks for these humans, just to keep it short and simple, or rehab EMOMs that focus on mobility, strength, aerobic activity, maybe some self-mobilization or desensitization on a post-op or a C-section or a perineal area. Any sort of scarring, can they do some work themselves? Are they okay with that? Example of a remom for someone, it's got four exercise in it and I gave it to a client who had that traumatic response when I was showing the pelvic model. And they weren't very motivated to exercise. They hadn't been for six months, but they love to exercise. But because they had some onset of urinary symptoms and a recent jaw surgery, I made sure to ask her, what are your favorite exercises? and they said planks and bridges. So I made a EMOM that consisted of a bird dog with a row. So we've got some sneaky strength and motor control of midline, tapping into the pelvic floor based off of the urinary, the, sorry, upper extremity and lower extremity connections. And this is helpful, especially if they are just so disassociated from their pelvic floor. And then I had kettlebell swings. That's gonna tap into our aerobic piece. A deep supported wall squat with diaphragmatic breathing is going to help us kind of calm the sympathetic nervous system and maybe even help them start to connect with their pelvic floor. And then self-mobilization externally of the jaw. One thing to make sure is that these people are comfortable in the positions, the exercises that you suggest. Some of them may be a little triggering, so just make sure like, hey, is prone okay for you? And then for the objective session or treatment session, education is queen here. Okay, so keep it simple and short. A lot of times these folks don't have a lot of room for processing lots of detail. Use their learning style to connect with them. If they're visual learners, send them home with the animated video explaining the anatomy and physiology of the pelvic floor or your whiteboard drawing. And then, definitely tap into their ecosystem, ask them about what's their sleep like, are they getting adequate fuel and hydration, how do they manage their stress, and do they have any mental health providers on board. And then for the after session of this hands-off eval, make sure you follow up with an email or a phone call, check in with them, make sure that they know that you So appreciate them sharing these things with them. SUMMARY So when it comes to someone who is apprehensive about a pelvic floor evaluation or who has experienced some trauma, a hands-on assessment may not be in the cards. So be sure that in your pre-session, you've got something in your intake forms that they can check off for trauma or any sort of abuse or things like that. From a subjective standpoint, we want to be emphasizing active listening, looking at their nonverbal and verbal communications, and then dialing in our specific line of questioning. From an objective standpoint, remember that you can remind them they are in charge of the session and there are plenty of hands-off objective measurements that can be taken. From a treatment side of things, make sure that you give them movements that align with their preferences and that you're giving them a ton of education about the pelvic floor and checking in with their ecosystem and mental health providers. And then after the session, give them a roadmap of how the session went. So as a pelvic PT, know that it's okay. In fact, it may be better not to palpate during the first visit in order to establish trust and rapport. We know a lot of outcomes and symptoms can improve purely based on education alone. In our ice pelvic division, we have two live courses that I'll chat about in Hendersonville, Tennessee, January 26th and 27th. Alexis and I will be there. Teaching All Things Pelvic Health. And then the following weekend, Christina, Heather, and I will be in Bellingham, Washington, February 3rd and 4th. And there is still time to sign up for those. Thank you all so much for tuning in and until 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. Ellen Csepe // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses this new class of medicines and how they impact your patients and their overall journeys to maximize their fitness and manage their weight.

Take a listen 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. ELLEN CSEPEHey, good morning everybody. And welcome to the PT on ICE daily show brought to you by the coolest continuing education company in all of healthcare. My name is Ellen Csepe. I'm coming to you live from Littleton, Colorado. I normally teach with the older adult division, but today we're going to be talking about GLP one agonist medications and their impact on your patients. Um, You guys have probably heard about GLP-1 medications. They're all over social media right now. They're used to manage obesity and weight issues um and diabetes, so These medications are the medicines like ozempic that you've heard all about or the medication brand of that same Ozempic, but used for obesity, which is called Wegovy. So you've probably heard a lot about these medicines already. And if you didn't see them on your board questions, you might be feeling a little bit out of the loop as to how they could impact your patients. If you're like me, these medications have come out after I've already gotten my licensure as a PT, and these medicines are impacting our patients in ways that I'm not really familiar with. So, this podcast episode today is for you to know a little bit more about how these medicines could be impacting your patients as a rehab professional. This podcast is going to be a lot about introductory level information to talk about these medicines in context of our Patients with obesity this podcast is not going to be a conversation to talk about How these medicines are used by celebrities they're not going to be we're not going to talk about how these compound medications or Illegal versions of these medicines are flooding our healthcare scene and causing a lot of illnesses today, we're gonna be really talking about what they are and how they work, who they're for, what they do other than help people lose weight, and some considerations and practical tips for your patients. GLP-1 MEDICATION So let's talk a little bit more about how these medicines work. So in context of treating obesity, these GLP-1 medications are super helpful to kind of overcome the biology behind our body's resistance to losing weight. Let me break that down a little bit. I know it's really easy to look at somebody with weight issues and think, gosh, wouldn't they just feel better if they lost weight? And it's an interesting paradox because our bodies actually fight to regain lost weight. Our bodies might feel better. We might have less pain, less inflammation, less joint problems, but Unfortunately, when we lose a substantial amount of weight, our body's biology fights to regain that. Why? Because usually in the context of our human existence, losing weight has always been a bad thing and it usually means being in starvation. Unfortunately, our biology doesn't know that obesity can be just as much of a threat to our health as starvation. So, when our weight changes, unfortunately our ghrelin or the hormone circulating in our blood blood that's Tells us we're hungry unfortunately that increases when we've lost weight and unfortunately leptin or that satiety hormone is decreases when we lose weight. What does that mean for our patients? It means that losing weight is very difficult to maintain because our body is constantly fighting to get that weight back. So let's talk about these GLP-1 medications. I'd like to first start out by saying GLP-1 medications are the newest medications that are used to treat obesity, but they're not the only ones. They just have a lot fewer side effects than some of the other medications that we've used in the past. For example, oralistat is a medication that works at our gut to decrease the absorption of fat. It comes with a ton of really gnarly side effects. Google what steatorrhea is, and you'll see what I mean. Unfortunately, there are tons of GI side effects for people that use this medication that cause significant fat in their stools and a lot of loose stools with it. Another medication is fentramine or topiramate. Those medications used in combination Basically act as a sympathomimetic to increase our metabolism But those medications are really only effective for a short period of time and they can have a lot of cardiac side effects There are some medications that are used in combination to treat obesity specifically naltrexone was a medication to use to treat opioid addiction and bupropion is which is another antidepressant, in combination that kind of changes our satisfaction behind eating. Those are medications used to treat obesity too. And usually what we can guess is that those medications aren't going to be quite as effective as GLP-1 medicines. Just to kind of review if you're tuning in now, those GLP-1 medications are medications like Wegovy, Sexenda, Ozempic, although of note, Ozempic is only used to treat obesity as an off-label benefit. Ozempic is actually only, excuse me, only approved to treat diabetes by the FDA right now. MECHANISMS OF GLP-1 MEDICATION So let's talk a little bit more about what this GLP medication is. GLP-1 is a hormone that we naturally secrete in our bodies. and the GLP-1 medicines are receptor agonists that look pretty similar to that hormone in our bodies and that when used mimic that hormones actions throughout our tissues. For example at the pancreas that GLP-1 receptor increases our body's secretion of insulin and helps to make that insulin last better. So that's why it's also used for people with diabetes. Interestingly enough, we also have GLP-1 receptors in our stomach. So another way this medicine works is to slow gastric emptying and basically make our food last longer throughout our stomachs so that we feel fuller for longer. What I think is the most interesting is that we have these GLP-1 receptors in our brain, in our hypothalamus, and the way these GLP-1 medicines work is to suppress both hunger and cravings. A lot of people with obesity experience something called food noise. And basically because of the obesity, they have these constant and intrusive thoughts about food. They could be eating something and have no hunger, but already be thinking about their next meal. So this GLP-1 agonists, Turn down that food noise to make it less likely for them to experience these constant intrusive thoughts about hunger So we talked a little bit about how they work. Let's talk a little bit more about who they're for so GLP-1 agonists are used for people with obesity. So that means generally their BMI is 30 or more or they could have overweight and a BMI of 27 with comorbidities. Comorbidities specific to their weight significantly causing risks to their health. So these medications aren't just for people who are looking to shed a few pounds. Obesity is a disease and these medicines really help us treat that disease process, which is a long-term, lifelong problem that relapses and recurs, unfortunately, in a lot of patients. It's contraindicated in a few patients. Good news, patients' physicians have to figure that out, not us. But just for context, people that are pregnant, people that have gastroparesis, irritable bowel disease, those patients might not be appropriate for these medicines, as well as those with certain thyroid cancers or familial risks of those cancers. So these medicines are also used to treat diabetes and in patients with obesity and diabetes, this is a great new medication to manage both conditions at once. Interestingly, or Wigovy, which is the ozempic for obesity, is also used to treat those who are 12 and older. So it's not just adults that are using these medicines, it's also those with obesity who are children who are 12 or older and weigh 132 pounds or more and have obesity. So let's talk a little bit about what they do. So pragmatically, they really reduce cravings. We talked about that. They can result in about an 8 to 15 percent weight loss in the first year of use. That's a lot compared to some of the older classes of medication. Liraglutide decreases the risk of diabetes compared to a placebo. So in those with obesity, liraglutide decreases the risk of obesity development and that rate of onset much sooner. So these aren't just to lose a few pounds before summer and celebrities. This medication can be very helpful for people who are struggling with their weight long term. Notably, Long term is how long these medications have to be used. So unfortunately, in most users, if they discontinue this medication, weight is almost always regained, and about 66% of the weight that they've lost over the past year is regained when people stop using this medication. but again, this isn't just a cosmetic thing to lose weight and a lot of us as Providers think about weight in the context of how we look societally and how we feel but this medication in those with obesity and diabetes Decreases the risk of cardiovascular events decreases the risk of stroke atherosclerosis Heart attack. So these medications aren't just here to help you get shed a few pounds These can be really life-saving medications for those with obesity CLINICAL CONSIDERATIONS Let's kind of talk through some of the considerations for you as a clinician. So keep in mind these medications are injected by the patient at home one time a week. And the dose is gradually increased to a therapeutic dose over several months. Here's why that matters. Because there are quite a few side effects with these medications. It's not a medicine that comes without side effects. This is not the easy way out to lose medicine. It does not feel good to be on these medicines. And a lot of the most common side effects are going to be nausea, vomiting, GI issues, cramping, bloating, dizziness, headaches and fatigue, hypoglycemia, which is important for us to consider for our patients if we're going to be having them exercising, acute pancreatitis, and gallbladder disease. So how does that impact our patients? Friends, team, we are in the business of helping our patients maintain their muscle mass. That's our job. Our job is to be fitness forward, to advocate for our patients, and to be here for them through every season of life. And on the days that they're taking these medicines and throughout the week, there's a lot of stigma attached to these medicines that we have to be aware of as providers. Where I'm going with that is that they need a hype squad. Patients need somebody to cheer them on and say hey, I know you feel like crap. I know that this medication is hard What I want you to know is that I'm here in your corner You are making a big decision for your health and even if you only lose five to ten percent of your weight Overall, that is a huge huge way to reduce your risk of overall cardiovascular disease. HYPE UP YOUR PATIENTS So friends We need to hype up our patients who are on these medicines when it's appropriate and it usually is if it's prescribed by a doctor. This needs to be our goal to hype up our patients and encourage them to maintain their consistency with this medicine. A lot of patients stop because they plateau losing weight after about a year. And they still have the side effects. So they feel like crap. They don't want to take this medicine. They're not seeing the pounds shed off anymore. And they need a health care provider to say, hey, this isn't just a quick fix to lose a few pounds. This is a lifelong endeavor to manage obesity, which has serious risks to your health. So another consideration, our business is to make sure that our patients are sticking through these medicines and Also maintaining their exercise participation and their muscle mass So patients who are taking these medicines feel like crap. They need somebody to still say hey I know you don't feel great. We still need to have a plan to have you doing strength training. We still need to have a plan for you to get enough protein in your, in your, in your mouth throughout the day, because unfortunately these medicines work by saying, Hey, you're not so hungry anymore, which is how those medicines are effective. But unfortunately, if you're not intentional, you will lose not only fat mass, but muscle mass with this endeavor with using these medicines. So, Encouraging your patient. Hey, I know you're losing weight. This is awesome Let's really keep this ball rolling and be super Intentional to make sure that you're still able to get to the gym that you're still able to get enough protein in your diet I'm on your team. I am in your corner to help you and These patients are prime time for behavioral change to say i'm making a change on myself already with this medicine. How can I really? Maximize this and get as much as I can and we are on their team team I recommend patients to talk with their doctor about these medicines. I talk with my patients about their weight all the time in a way that's constructive and empathetic. I listen to my patients and recognize that losing weight is a struggle. These medicines can be super helpful for our patients who have struggled for a long time to manage their weight. And that's not because they're unmotivated or lazy, it's because their biology is fighting to get that weight back. This is not cheating and these medications can be super helpful. I often talk with patients and recommend them to go back to their doctors and ask if it could be helpful in their journey to manage their weight. A quick caveat on that, not all insurances in all states cover these medicines the same, which is very unfair. These medications can be really life-saving for our patients with obesity, and unfortunately, insurance is making it hard for people that need it most to get access to it, specifically those in poverty. Obesity disproportionately affects those from a lower socioeconomic status, and it's really important to recognize that in the treatment of obesity, those people are unfortunately going to be the last to get access to this stuff, and that stinks. So knowing that as a provider is another important thing that I've learned. You can't just shoot from the hip and say, oh, you've got to go talk to your doctor about this. It might not be covered by their insurance, and that's super demoralizing. So make sure that you kind of know that before you make this recommendation that, oh, you can be on this new drug, it'll be super helpful for you, and it's not covered. So friends, to wrap up this summary, so these GLP-1 medications are new but not the only way that obesity can be treated medically. They're very helpful and effective in helping those individuals lose weight but they often come with side effects. Our job as providers is to know what those side effects look like and feel like and how to still emphasize exercise participation to our patients no matter how they feel and come up with a plan to say, hey, we still need to do strength training. We still have protein goals to make sure that you maintain your muscle mass. Thank you guys so much for taking time out of your morning to join me to talk about these medicines. And I hope that it was helpful in the long run for you to know how they can be helpful for your patients. Have a great day.

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. Alex Germano // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Alex Germano to find out which lateral stepping strategy is associated with more strength and less falls during today’s episode.

She discusses how to assess this stepping strategy, which is preferable, and how to intervene!

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.

ALEX GERMANO
Good morning, everybody. All right. Good morning and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name's Alex Germano. I'm a member of the older adult division, and I'm really excited to be talking to you all today about something that comes up in our live course. We're going to be talking about reactive steps, particularly in the lateral plane. This may sound a bit specific, but picking up on our patients' tendencies to step a certain way when recovering their balance laterally can actually tell us a lot about their strength and inform us about better treatment interventions and inform us about our patients' fall risk. You may have noticed that we humans have a variety of stepping strategies available to us when we start to lose our balance. And you actually may be seeing this with patients in a formal way by doing maybe the mini best test. Or when you're doing challenging balance activities, you'll notice that different patients use a different stepping strategy, especially in the lateral direction. You may see a crossover step. So this is when the patient is standing, where if they start to fall, say, to the right, their left leg becomes unweighted. They take the left leg and they cross it. over the right leg. You may also see, we'll call it a lateral step or a lateral withdrawal step, where the, say they're again, falling to the right, and instead of moving their left foot, instead they kind of quickly push the weight back to the left foot and then step out big with the right leg to recover balance. So we've got two different strategies, crossover step or a lateral withdrawal step. Now on the mini best test, if you're doing this in a formal manner and you're running that assessment on folks, When you get to that reactive balance component, or that reactive balance section, you'll notice that you can get a full two points, you mean pass that part of the test, if you do either the lateral withdrawal step or the crossover step.

WHAT'S "BETTER": LATERAL OR CROSSOVER STEPPING?
Now, my question, and what I've been thinking about for a while here, is actually one strategy better than the other. Should they really be equal in our mind? Should I be satisfied with the crossover step? Let's talk anecdotally first, like my own clinical practice. I will say that I don't see the lateral withdrawal step chosen as often in my older patients. I see that If my patient is going to perform that lateral withdrawal step, they tend to be stronger, faster patients. I will say that the unloaded crossover step is seen in my weaker patients. And so I was trying to dig into the evidence to figure out, does this make sense with what's in the evidence? Can looking at this different type of step tell me more about the human in front of me? So I'll be talking about three different studies. I'll link them on Instagram after this. The first one was kind of diving into the crossover step. This first study pitted older adults versus younger adults. They saw that the older adults tended to select that crossover step more frequently. They also noted and described the crossover step as being passive in nature. It's a passive approach to maintaining your balance in that direction. They also noticed that when the crossover step was selected, that older adults tended to use more steps to recover their balance. and there was heightened inner limb collisions. That makes sense, right? We're crossing one leg over the other. The legs naturally may hit each other if they didn't take a far enough step forward or back. We also see that these crossover steps come, they take longer and they come with more alterations in trunk movement. None of these things sound great to me, but these were just observations of the step themselves. Then there was a systematic review of hip muscle strength activation in both balance and mobility tasks. This one confused me a little bit, but I'll walk us through it. There was a study within the systematic review that suggested that hip abduction torque couldn't distinguish who was going to take the lateral step versus the crossover step. But then another study in the review reported that older adults with greater hip abduction torque had a higher incidence of lateral steps. So maybe it's hard to say like, is lateral stepping predictive of strength? If my patient took a lateral step, does that mean they're stronger? I don't know if we can say that, but strength is looking to be more predictive of the lateral step. Like if the patient is stronger, they're more likely to choose the lateral step. Um, what the study did say, quote, is in this present systematic review, we identified overall during predictable and unpredictable induced balance perturbations, a lateral step requires greater hip abductor neuromuscular activation compared with other step types across the age group. So in order to take this lateral step, you do have to have better hip abductor activation.

STEPPING STRATEGIES & FALL RISK
Okay. Lastly, let's dive into maybe a patient-specific population. This will talk about patients with Parkinson's disease. Surprisingly, I was surprised, that they didn't see a huge difference in step selection in people with Parkinson's disease and without. However, they did find that people who use the lateral step had the least amount of falls. This suggests that maybe there's a more optimal stepping strategy. To put this all together, here's what the evidence maybe is leading us in the direction of, not just my anecdotal experience. Lateral steps are safer. I would prefer my patient use a lateral stepping strategy. I'm happy if they select any stepping strategy. Honestly, at this point, if you've done enough mini best assessments, you see a lot of people use no strategy at all. I'm okay with a crossover or lateral. If I start seeing the crossover, I know in my mind, I want to start training the lateral step. I would prefer my patient use them. They are safer because those crossover steps are a passive strategy. All right, the crossover step is a passive strategy. It's a strategy that has a risk of interlimb collision. It's going to take longer to facilitate the steps. It's going to cause more alterations in trunk movement. Now, we don't want to assume anyone is weak when they take the crossover step. Let's not assume that they're weak. but we know that you have to have pretty strong hip abductors in order to take the lateral step. Okay. You've got to have strong hip abductors. Older adults tend to take longer to activate hip abductors. So we need to work on increasing speed in loaded conditions with this group. So this makes me really reflect on this, like, uh, makes me really reflect on how much lateral power work am I doing? in my sessions with older adults. I think this is where we really could have a game-changing, more game-changing interventions for our older folks.

IMPROVING LATERAL STEPPING STRENGTH & POWER
So here's some simple ways, let's think of some simple ways to layer up lateral hip power exercises, okay? Think about all the ways that you can get your patient to move in the lateral direction quickly, right? And we wanna maybe do this first in unloaded conditions, where a patient maybe does a big step out to a target, and we ask them to stomp and step quickly. Maybe we give them a cue or a target to step to. We then want to start practicing this lateral step out. Because if you think about the mechanics of the step out, right? Like if they're falling to the right, they're going to have to take a leg, their right leg, that has all the weight on it. They're going to have to shift the weight back to the left leg quickly, then send the right leg out to the side. We can practice that. We can practice lean to the right, all right? Quick step left, right. Right. We can practice these kind of weight shifts onto a leg, then quickly weight shift off and then lateral step out to the side. Okay. Those are things we can practice. So you probably first want to start with unloaded limbs, working on the speed of an unloaded limb, then layer up the difficulty on the loaded side. All right. You can absolutely train the person's crossover step. I think about, I use grapevine stepping or karaoke, whatever you want to call it. all the time. I think that's a great intervention, but maybe you're training the crossover step to reduce inner limb like collisions, okay, reducing inner limb collisions. I also see the utility of the clock yourself app, right, you can use if you want to work on that that crossover step maybe you have the clock yourself app set up on one side of the patient and then you have the opposite leg reaching for numbers so they're having to work on some coordination of the crossover step. And then obviously we want to take all of this lateral hip power that we're going to start working on with patients, you want to move them to more reactive situations and scenarios. So reactivity could include using the big resistance band over the patient, pulling them in different directions so they're having to react quickly. You can do this while standing, while moving, ideally while moving and walking. In conclusion, we can learn a lot about our patient based off of what stepping strategy they use in the lateral plane. Are they using a lateral withdrawal step or are they using that crossover step? We know that we probably don't love the crossover step. It's not an ideal stepping strategy. It's not as safe It is associated with more falls. It is associated with inner limb collisions. We know that you need strong hip abductors to perform that lateral step. So we need to start training speed in the hip abductors under loaded and unloaded conditions during our interventions for older adults, during our interventions. So let's start seeing some really cool lateral hip power interventions here going forward.

SUMMARY
Now, we hope to see you at a live course. We actually get to practice this mini best test at our live course. We get to get hands on, we get to work on our guarding technique, and we talk a little bit about these strategies that are used. And we would love to see you at some of our live courses this year. We've got quite a few on the radar. I'm going to highlight some of our options in March and April. Just if you're a planner like me, I know you're probably not thinking about coming to a course this weekend, but if you're looking forward to an early spring course, we've got a couple on the radar. We are in Glencoe, Maryland, March 2nd and 3rd. We're in Rome, Georgia, that same weekend. Madison, Wisconsin, at the end of the month, the 23rd and 24th of March. We'll be in Urbana, Illinois, on the 6th of April, as well as Raleigh, North Carolina, on the 6th. So those are just five of many courses. Please head to the ptonice.com website to check out where MMOA is going to be. All right, I hope you all have a great rest of your Wednesday. Get stepping.

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. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko discusses a recent encounter with low back pain in the gym, offering lessons learned on empathy, the benefits of early intervention, and finishing the drill by returning to regular fitness activities.

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.

JOE HANISKO Awesome. Good morning team. This is your PT on Ice daily show podcast. It is Friday, January 12th. So it is a fitness athlete Friday. My name is Joe Hanisko. I am one of the lead faculty of the clinical management and fitness athlete division here at Ice. Uh, today's topic we're going to get right into it is the benefits of being injured as a physical therapist. And I know upfront saying that a little strange, By no way, shape, or form do I mean that having an injury is a positive experience. We know that injuries can be quite mentally and physically disturbing, but I've recently had an injury and it brought so much back in terms of the value of the experience for me and how I can better shape my practice and reinforce some of my own beliefs about what we do as physical therapists and how we can really bring a good one-two punch to kind of help people who are dealing with injuries as well. So I want to get into the story quickly just to lay the ground. This is like a month ago now, five, six weeks ago. Doing a workout, it was progressively heavy power cleans and intermittently decreasing rep schemes of wall walks. So as you had high volume cleans with a lighter weight, you had high volume Wall walks and you progress down and reps up and weight and down in the wall walks So a lot of just back and forth and I got lazy somewhere in the middle decently heavy bar about 225 Not my max range but an upper level range and I was just trying to get through these reps and I caught it Essentially almost like in a muscle clean position where I didn't do a good job Redipping under the bar and absorbing load and I sort of just got jammed up like it felt like I kind of like Compressed my spine and in the moment as it happened. I was more or less like that didn't feel so hot I dropped the bar. I was doing singles. Anyways picked it up felt. Okay, I Third rep into that, felt a little tight. Only had to do four, I think. On that fourth rep, I was like, oh, something's happening here. My gamer in me, I just kept going, hit the wall walks, but by the time I got back to the barbell, now at 245, man, I was pretty seized up. So, this is sort of like live and learn. I had an opportunity there to maybe back down, but it was just me and my buddy Dakota sending this workout. Couldn't leave him hanging. I continued to go through, and we'll fast forward to the end of the workout, in which I felt like I had a steel rod in my back. Preface this with, I've never experienced a back injury personally myself. Somehow I've been lucky enough to train for 15 years and not have any major back injuries to really talk about. But this was rough. Bending over, taking the plates off. It was one of those within a matter of a minute or two I was in a pretty rough spot and I was like, where is this going? Wasn't too confident about it. So that night though I went home and started working on it myself, doing what we should. pick that the move it or use it option here and we went after moving it i was doing some bat banded cat cows some cat camels but the real story starts with what I feel like came in the next day or two afterwards.

MAKING DECISIONS EARLY IN REHAB And this is where I feel like us as physical therapists, what we know from our injury rehab experience, and when it happens to us, we're able to make great decisions early on. This is what really started to highlight to me the benefit of having this injury and reminded me all the things that I need to do when I have athletes and clients who come to me with these acute injuries or injuries of any kind. So what I wanted to do basically is lay out the top three we'll call them experiences or lessons learned from this.

LESSON #1 - EMPATHY The first one being empathy. Had I not known what I know about the human body, about physical therapy, about rehab, about movement and how it is truly medicine, had I not known that this injury would have been debilitating. Not only physically, I was, you know, having a hard time getting around, doing basic things, putting the shoes on, getting dressed. Not only physically was it debilitating, but mentally I would have felt wrecked. I love fitness. Every day I get to show up in the gym and spend time there just like a lot of our clients and members at the gym. and clients here in the clinic, I love it. And I did not feel like I was anywhere close to getting back into the gym. I was wrecked. And having that empathy as a physical therapist now for what clients feel like, especially when they don't necessarily know that there's light at the end of the tunnel, and hopefully sooner than later, that was a terrible experience. Again, my ability to change my psyche on that was helpful, knowing that I wasn't doomed, I was gonna get this taken care of. I wasn't dealing with, neurologic symptoms or things that were overly concerning. No red flags in my history. But again, taking this from the perspective of people who don't have that, the ability of the therapist to empathize with people and say, hey, I understand where you're coming from, man. That back tweak is no joke. It really makes you feel like you're doomed and that you got no bright future ahead of you. But let me tell you that you do. I've had this, I've experienced it, I've walked it on, right side next to you, knowing what this feels like, and we are gonna get this better, and you're in the right spot. That empathy and ability to kind of connect on that emotional level with them after experiencing something like this, I think is super powerful. It puts you right in their shoes, and you've lived it, you've learned it, and you know that it takes a little bit of strategy on our part to kind of convince and educate people that they're gonna be okay when they're feeling like they're hitting the frickin' rock bottom after an injury like that. So empathy or relatability, you can combine those two. But I felt like that was probably one of the most beneficial lessons learned from this whole process is being able to connect with the patient on that level. So it's scary, it sucks, but. we have the ability to control some of that with our education and our ability to empathize and to relate with our patients. So lesson number one, empathy.

LESSON #2 - POSITIVE BENEFITS OF EARLY INTERVENTION Lesson number two, the positive benefits of early intervention. You cannot sell this enough. Uh, my experience was great. I have a team, uh, onward Grand Rapids. My employees were fantastic. I was able to get in 36 hours after my injury because it was on a weekend. Get in, I got some needles, some cupping, a little bit of manipulation. And man, I was within 36 hours. When I walked in the door, I was in rough shape 36 hours after this injury. When I got off that table, I was 75% better in the moment. 75% better. Early intervention for me was nice because physically I was feeling better and your patients will feel better as well, but this is where it starts to go back to a little bit of empathy and the psychological component of it. The fact that I could bend over, touch my toes with minimal discomfort, 25% of what I was dealing with before, was so, so rewarding to me and reminded me that there is no greater tool than early intervention, especially with these acute injuries. So the early intervention process and It kind of rolls back into patient education, especially if you're incorporating yourself into gyms and fitness. If you get an opportunity, workshops, if you get an opportunity to talk to somebody after an injury, you gotta double down on that because we know that it's so much easier to rehab an injury early on in the process rather than waiting three weeks, six weeks, whatever it might be. But also, psychologically and physiologically, the changes that you can make with these early intervention tactics can be so powerful. It certainly does take a good chunk of education on our part to let people know that, but I think we sometimes struggle as a profession to commit to what we know works because it seems like an inconvenience or it costs money or whatever it might be, but it's our jobs as professionals to relay what we do know and to be confident and to trust our own processes. And in my personal experience, that 36 hour intervention, it was more than worth it. I would have paid whatever it took to feel as good as I felt afterwards. Luckily, I got the free 99 coupon, which is nice, but I'm serious. That was huge So I had intervention at 36 hours and then roughly around 72 hours later and by 72 hours I was probably a 90% to 95% meaning that I could feel some stiffness with flexion. I wouldn't even consider it pain I felt like I could go back and do everything that I wanted to do.

LESSON #3 - FINISH THE DRILL And I did I got back in the gym and that was really my third lesson then of this after empathy early intervention is make sure we do a good job completing the drill. You know, this is me lacking my ability to walk my own walk and talk my own talk here. I, you know, three days essentially after this back injury was back to training and I chose to avoid intelligently and modify certain things. I wasn't going to go load up my max PR deadlift and just start cranking away. I think the first real workout that I got back to doing was a combination of dumbbell box step-ups, handstand walking, and goblet squats, like a dumbbell goblet squat. So a lot of legs, movement. I was like, man, and going upside down, a challenging position there where it sometimes can cause back pain with that overextension. I was doing really good. So I went from that to a ski erg and did some ski erg intervals, which is a lot of flexion, and I was doing really good. And I swear to God, 40, 50 minutes into my workout when I went to kind of do a little cool down recovery row, some zone two style stuff, it was within the third pull on that rower that everything literally seized up. I'm going to say at like 75% of the worst that it had been, but I just done all that stuff. Uh, I had been doing some rehab stuff for three to five days before that feeling good and I lacked the ability to commit to completing the drill. as a patient and as a therapist. Like I wasn't honest with myself and pushing myself to continue to do the stuff that we know works and building out a plan to really bulletproof and rehab something. I kind of took it as a grain of salt, like, oh, I'm doing so good so quickly. I can probably just go back to doing whatever I want to do. But I learned my lesson. I went right back to essentially square one, had to go back, see Hondo, one of our dogs here, the day after. Luckily, again, early intervention, second time around here. and got back on track. But now I'm four weeks after this process, five weeks after this process, I'm committed to really taking a stand on building some back strength back up. And even if it meant that I wasn't really essentially weak going into it or whatever, I know that I came out weaker from that injury and need to rebuild my foundation. And there's no point in just sweeping this under the rug. I really need to attack it. And so our jobs here as physical therapists with our clients is to reiterate a either empathetic or relatable experience in which we maybe didn't do a great job following through like I did and educate again on the importance of, Hey, even when you're feeling good, especially early on in your recovery process, this is the time to double down. This is when we go after the gas pedal, we floor it and we say, Hey, this window of opportunity that I have right now where I was doing terrible, the window is open, I'm feeling pretty dang good right now, that's the window that we need to double down, get after this, and really start to build back our capacity into whatever injury, region, interlocation that we're talking about there. So, a super, super valuable experience in my opinion. I don't want to understate the fact that obviously injuries are never truly a positive thing, but I tried to spin this as best I could and going after this process and learning about empathy, learning about early intervention and reminding myself about how important it is to complete the drill was so valued to me as a physical therapist because I can now take all these experiences and apply them back into my clinical experience here. Also, the bigger picture here at the end of the day is that it reminded me of why I'm doing what I'm doing from a fitness perspective. Yeah, I like to be competitive. Yeah, I like to throw heavier weights around, but really what we're looking for here is the long journey, the end goal, the healthy longevity lifespan approach. And I will take that back injury 1000 times. over all the other things that could come with not being willing to put your body on the line a little bit, build some resilience and strength and capacity, and suffer from chronic disease or other debilitating comorbidities that are out there just grabbing people left and right right now across the country. So I'm by no means deterred by this.

SUMMARY We need to remind our patients they should not be deterred by this. We are gonna get them better. You're going to relate with them. You're gonna provide intervention early, and you are going to complete the drill, and they're gonna be in a really good spot there. Hopefully that was helpful. Don't go get injured, but if you do, spin it, be positive, learn from it and help your clients. Or at least take my experience and help your clients and really do a good job selling our profession and what we are capable of because people deserve to feel good and to get back to their sport. Last little sign off here from the CMFA team. We got a couple of courses coming up. It's the New Year's 2024, so live courses are kicking off. Our first couple live courses In order are in January. We got one out in Portland and then we're gonna follow that up with Richmond, Virginia Charlotte, North Carolina, and then I'll be out in April in the Seattle area. I think Renton Washington so look at the PT on ice.com website to look for signups for those and And also early February, first week of February, the CMFA online level two is kicking off with Zach and Mitch and myself as well. That's February 7th, I believe, but definitely that first week of February. So hop on, let's get those Con Ed credits built up. We're looking forward to seeing you guys. Have a great start of your year and have a happy Friday.

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. Ellison Melrose // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses key set-up, anatomy, and technique to target the subscapularis muscle.

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.

ELLISON MELROSE All right, U2 is up. Good morning, PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of Ice. I am here to piggyback off of the Fitness Athlete Fridays for the past two weekend, or two weeks. Two weeks ago, we had Alan going over the evaluation process for determining if the gene is subscapularis muscle. And then last week, Zach Wong went over some treatment techniques, and he hinted at one of the most efficient ways to treat the subscapularis muscle, which is dry needling. So what I wanted to do today was to go over a demonstration of how to needle the subscap muscle safely and efficiently. NEEDLING THE SUBSCAP So in order to be able to do this muscle, our patient needs to be able to get 90 degrees of shoulder abduction with some moderate external rotation as well. So patient positioning, they're going to be laying with their arm up in this abducted and externally rotated position. My patient here has some decent mobility, so she doesn't have any issues getting into that position. But for someone that maybe struggled with maintaining that position for the duration of treatment, we can bring their shoulder down slightly. And you can also prop their wrist up so they're not in so much external rotation as well. But again, this patient doesn't have issues getting into that range of motion. The reason we need to have this position is because we need this scapula to be protracted out from underneath the thorax for this to be a safe and effective drain forming technique. So we need to be able to palpate the lateral border of the scapula and appreciate the difference between the lateral border of the scapula and where the lateral border of the thorax is. In this position as well, we can think about the rib cage. It's not parallel, or excuse me, perpendicular with the table in this position. It's kind of diving around. It's oval shaped, right? So it's diving around and posterior and a little bit medial there. So if we get that scapula out from underneath that rib cage, we have some good real estate to needle this muscle. This is a direct technique. So we go for different types of techniques. We have a threading technique and a direct technique. Typically, when we talk about direct techniques, they are direct to a bony contact. So in order to ensure that we're at the depth of the subscapularis muscle, we need to have a bony contact with our needle in that subscap fossa there. IMPORTANT ANATOMY So again, patient positioning here. Some other considerations in this area. A, we have the lung field. Appreciating where that rib cage is and how it's diving away and where our scapula is in relationship to that. But we also have some other sensitive structures in the axilla. So we have our brachial plexus that actually runs just anterior to the subscap muscle and exits down the medial humerus here. So we want to orient ourself to where the brachial pulse is as to avoid needling in that region, right? So the best window for subscapularis is going to be just distal in the axilla. If we go too distal, we're likely going to miss that bony contact that we need for ensuring that we're in the subscapularis muscle. Some other considerations here is we have a really strong and powerful motor branch or motor nerve, the thoracodorsal nerve, that runs along that lateral border of the ribcage, which innervates the lats. So if we were to interact with that, we would likely get some fairly strong um, lat muscle activation. So typically it kind of looks like that sprinkler, um, dance move that we all know too well from middle school dance. Um, but so those are our main considerations. So one field and some other sensitive structures, uh, the brachial plexus and brachial artery and vein in that axilla. So again, first we want to bring our patient into this abducted externally rotated position. If you feel like you can't appreciate the, or you don't have a good real estate of that scapula, you can assist by protracting, like grabbing the medial border of the scapula and pulling it laterally. So again, you should be able to appreciate lateral border of the thorax is there, lateral border of there. So we have a good two inches of room to play with. A lot of these athletes that have So we're thinking the athletic population would be one where we want to treat this. Crossfitters, for example, they also have fairly hypertrophy flats. So that's another thing that we have to appreciate is we're going to have to be sinking in to get, again, that bony contact on the scapula. Another common patient population that you may be needling this muscle in is going to be the thawing stages of frozen shoulder, right? So this person was able to They're now in that pain-free, able to access at least 90 degrees of shoulder abduction, or post-op rotator cuff, where they're really struggling with some of that end range shoulder abduction, external rotation, and shoulder flexion even. Sub-scalp is going to be a good muscle target for those patients as well. So before we do anything, we want to prep the tissues. So we're going to clean the skin. SUBSCAPULARIS TECHNIQUE I prefer to do most of my needling techniques in standing, especially for this muscle, as sometimes our fingers are not going to, like just our finger pressure is not going to be enough pressure to sink in to approximate that subscap fossa that we want to. We're going to be needing a longer needle than we think. So for Sam, I have a 75 millimeter needle. Some folks may even need longer and that's just based on excess muscular tissue, the lat, the pec muscle that we're kind of orienting ourself around, the skin recoil. So as we compress that tissue, once you release, that skin recoil is going to potentially move that needle. If we don't have a long enough needle and it will choke up on the handle there and it'll pull it off of that bony contact that we've Spent so much time finding. So we want to make sure that we have a long enough needle to maintain that bone depth. ADDING E-STIM Another thing to consider is when we're with ice, we are dry needling with e-stim, right? So we're not doing a ton of heavy pistoning. Again, there's a lot of sensitive structures in this area, so it's usually not very comfortable to piston a lot. So we're going to be wanting to layer in the strategy with Easton. When thinking about ECM, you always want to be thinking in pairs. So how can we pair this muscle with another muscle that may be doing something, a similar movement pattern that may be also restricted, or something that's going to reach that motor threshold at the same time? So we want to be thinking about muscle spindle density in our muscle tissue of what's going to reach that motor response around the same time. Typically, I like to pair subscapularis with the clavicular fibers of pec major. So we have another technique for pec major clavicular fibers. Of course. Of course. Why was I logged out? OK, well, I was logged out on Instagram, so we're just going to continue on YouTube here. So we want to maintain the or we want to be able to pair this muscle with another similar muscle that has a similar muscle density. And it's also going to be limiting some of that external rotation in this position as well. So I like to pair those muscles. For today, we're just going to go with the dry needling demonstration of subscapularis. SUMMARY So again, we want to orient our patient into abduction external rotation. We want to maintain an appreciation of that lateral border of the thorax. And then we're going to compress the tissue down, down towards the subscap fossa. Usually your palpation here is going to be the most assertive part of the technique. And you might get what we call the Grunner sign, where some people don't tolerate that very well. So orient yourself to that brachial artery. We can find the pulse. So typically I would come around to the other side, palpate the pulse here. Pulse is under my index finger, so I've oriented myself to where that neuromuscular bundle is, and I'm going to be treating just distal to that. So, right in here. All right, so we have an appreciation of that anterior surface of the scapula. Again, using a 75 millimeter needle. So I'm doing a firm palpation, my medial aspect of my hand, so my pinky, ring finger are appreciating that lateral border of the thorax. My needle angle is going to be perpendicular to the scapula here. So really, it's fairly directly anterior to posterior, almost paralleling, or excuse me, yeah, paralleling the ribcage, anterior to posterior. So we're almost, we're very close to that ribcage, but we're going, we're paralleling it, so we're not going to be interacting with in a postural space or lung field here. So again, appreciating lateral border, knowing where that neurovascular structure is, that means safety, lateral border of our scapula, firm compression down. I feel that muscle. You can always do a little internal rotation, good and relaxed, to feel that muscle activation under your fingertips, compressing, giving yourself a little treatment window directly anterior-posterior. and you're on bone right there. So if you look at this, you're like, dang, she's got a lot of needle left over, but let's allow for that tissue recoil. So as we let for that tissue recoil, we have about a centimeter left. So a 60 millimeter needle would not have been long enough to appreciate that depth of the sunscan. As we allow for that tissue recoil, you may start to see like the needle directions a little bit and it may look a little bit suspect, but knowing that we're on that bony contact, that needle tip is not going to be going anywhere once we've reached that depth of the scapula. So we can allow for that tissue recoil and set up our next needle and then set up the stem and feel fairly confident that that needle is not going to go anywhere. Main concern with safety here is if this person were to move their arm, right? That would be something to be concerned. or if we're interacting with that thoracodorsal nerve and we get a very big motor response into that sprinkler dance move. So when we are bringing the stim up and looking for that motor response, typically I would suggest maintaining that appreciation of where that lateral order is and kind of bringing that needle back into its original orientation. Once you feel confident that we're not getting any sort of interaction a less of a motor response than what we want or more of a motor response than what we want, we feel fairly confident that leaving that needle at that bony contact is a safe needling technique. We are rarely or really ever, we shouldn't be leaving our patients stimming with needles in them by themselves. I feel like that is a best practice to be in the area with our patients. And so if this needle were to move slightly or anything like that, you can always maintain contact or redirect as needed. So there we have the dry needling demonstration for subscapularis muscle. Again, my name is Dr. Allison Melrose. I am the faculty with the dry needling division. Some of our upcoming upper quarter courses where you can catch this technique and a bunch of other techniques. We have a three-day course in Longmont, January 26th through 28th. Paul will be out in Wisconsin, February 3rd through the 4th. I will be down in Greenville, South Carolina, February 17th, 18th. Paul will be out in Bozeman, March 2nd through the 3rd. And then I'll be out in Maryland. It's Sparks, Maryland, 22nd through the 24th. So there we have our upcoming courses. And this, hopefully, was a good review or a new driving learning technique that you guys can use in the clinic. Awesome.

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. Dustin Jones // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones covers some good accessories to have on hand (ha) when working with older adults. Links to these accessories and TONS of other equipment ideas are in our NEW Ultimate #Geri Equipment eBook. Download now by clicking HERE.

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.

DUSTIN JONES What's up crew? This is Dustin Jones. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'm one of the lead faculty within the older adult division. Today we are going to be talking about accessories for grip in hand issues. We do not want a sore hand, sore grip, sore wrist be the limitation of us being able to achieve higher intensities, right? This is a very common thing that we run into, right? When you are working in that old not weak mindset and philosophy that you are trying to put higher intensity loads on individuals, right? You're gonna run into bears, and we're gonna talk about how we can overcome these with different accessories and different strategies, all right? The first one I wanna speak to is a very important intervention that we will do very often in the realm of geriatrics, and that is weight bearing, floor transfers, think ground mobility, right? The ability to have confidence and independence in a floor transfer just has huge implications for folks in so many areas of life that it really reduces their fear, their fear of falling, and ultimately improves their confidence in what they can do. The walk across the room, if they fall, becomes a little bit less scary. And just think of the implications of that, right? But when we often go to do those transfers, when we go to bear weight on the ground, that can be kind of troublesome for the wrist in particular. but we don't want that to be the reason we don't do this type of intervention or transfer. WEIGHT BEARING: THE SURFACE So if we're bearing weight, one thing I want you to think about is the surface. If we're going to and from the ground or maybe a higher level like a bed or a therapy table, think about the The surface in the sense of, you know, you probably want a little bit of cushion, a little bit of softness is great, but if you have too much, that can actually be troublesome for folks. It may feel great on their knees, but it's not gonna feel great on their wrists for most individuals. If it's too soft, what ends up happening is when we go to bare weight, our palms really press down, we end up going into wrist hyperextension, which for a lot of folks is not a comfortable situation. So when we think about surface, when we're going to do floor-based activities, ground mobility, Soft, but firm. Soft, but firm. You don't want a super soft, cushy surface. Soft, but firm is going to be better, provide a little bit of cushion for the knees and a little bit better for the upper extremities and the wrists, for example. WEIGHT BEARING: CHANGE TE HAND Next thing you want to think about is maybe if we don't go open hands, maybe we go fists. That'll be a little bit easier. We could also think about using the forearms as well. And so that's the first trouble area, very common trouble area for a lot of folks. We can work around that. We could also use an accessory as well. This is the first one I want to bring out. This is basically going to be show and tell, all right? So for those that are listening, for those that are watching, I'm gonna share where you can get links to all of these things at the end of the episode, but if you're listening, I'll be sure to kind of describe these as well, so you'll get just as much out of it as the folks that are watching. So weight-bearing, floor-based activities, think about the strategies, think about the surface. WEIGHT BEARING: THE WRIST WRAP Also think about compression using something like this, a wrist wrap, a wrist wrap. Basically, a little elastic loop that you put your thumb through and then a lovely you know kind of elastic strap that you wrap around your wrist and applies compression and that can often allow people to bear a little bit more weight through their hands also typically allows them to to hold a little bit more weight particularly with something like a overhead press for example makes it a little bit easier on folks so wrist wraps our wrist wraps can be helpful in in the situation of a floor-based transfer all right so that's The first thing I wanted to mention out the bat, now I'm going to be talking about some different accessories that are focused more on working around hand grip issues, alright? WORKOUT GLOVES So, the first one, and I cannot believe I'm going to say this, because this is an accessory that I often have maybe made fun of, never thought I would ever recommend, or even wear at some point, and that is workout gloves. I said, I never thought I would say this, but workout gloves, yes. The ones with the fingers cut out and the padding, you know, you see them, right? You see them all over the place. A lot of our folks here at Stronger Life will wear them, and I was very critical of this initially, and then once I checked my bias and just dug in a little bit of why people actually like these, particularly for folks that may have arthritis, that may have a painful grip, With that workout glove, it obviously reduces friction so you don't get blisters and all that stuff. Whatever, right? I don't care about that. But what's really cool about these workout gloves is when you wrap that hand around that barbell, that dumbbell, that kettlebell, that padding basically increases the circumference of the grip and if you've ever worked with anyone that has you know that kind of arthritic pain just grip issues that the wider the circumference of the grip up to a certain point the more comfortable they're going to be. It can be very painful to kind of lock down on a barbell or a dumbbell or a kettlebell, but when you increase that circumference of the grip, even by a little bit with that padding, it makes it a lot more tolerable. And so we found a lot of folks really respond well to using workout gloves for that manner. Never thought I would say that, but I'm going to go ahead and recommend them now. So workout gloves is going to be the first one that can be helpful if we do see a grip kind of limitation or pain. WEIGHTLIFTING STRAPS Next one, weight lifting straps. All right, lifting straps. So this is basically a glorified piece of nylon that's stitched so it has a loop and you basically wrap that strap around your wrist and then you wrap it around either the barbell, dumbbell, or kettlebell. Traditionally you see it with the barbell, but I've used it with dumbbells and kettlebells with a lot of folks and they've responded really well. And it basically That strap helps support your grip strength so you can lift a lot more weight and it distributes that load more across the wrist and so you're able to hold more weight and it's usually a little more tolerable if folks do have painful, you know, painful grips while they're loading heavily. The only drawback with this one, particularly with the folks that I work with, we're talking geriatrics, I typically have to assist them in setting this up. It can be kind of clumsy to get a really good grip, a good purchase with that loop on the weight, and so I'm usually helping them out. If you're in home health or you don't have a weightlifting strap, you can kind of rig this up with something like a gait belt. Wrap that gait belt around the wrist, loop it around the weight and hold on on top of that and you've functionally created a lifting strap. So gait belts work. The only downside to that one is the thickness or the width of the gait belt is pretty big which can cut into the wrist a little bit and you're going to have a ton of extra slack or extra gait belt to manage, but it gets the job done. If you're having to help that person in any way, it's not too big of a deal. All right, so we mentioned workout gloves. Can't believe I said that. We mentioned workout or lifting straps. LIFTING HOOKS The next thing is going to be a lifting hook, a lifting hook. So what this is, is basically a Velcro strap around your wrist, and that has sewn into it a metal hook. So this is really helpful, particularly for folks that have painful grips, but also very weak grips that you can still load them up in a heavy manner, do a heavy deadlift with someone, even if they can't hold on to the bar. It is convenient for barbells, dumbbells, kettlebells. Also helpful if someone's had a stroke, for example, where they have one side of weakness and their grip is not up to par, but they can still handle some weight using kind of the rest of their body. So a lifting hook. This is really convenient. And all of these things are very affordable as well. Like we're talking, you know, south of $20 that you'll be able to find. And I'll show those links at the end. So lifting hooks. All right. WRIST WRAPS REVISITED And I also want to mention here, the wrist wraps again, because I find them helpful with weight bearing activities, but then also with anything where you're holding the weight particularly in like a front rack position or overhead where you're going to press particularly for folks when they are new to handling heavier loads and they're really pushing those higher intensities there's that adaptation period and all y'all probably felt this too right when you started to press heavy overhead or work on that clean or a lot of folks will feel when they start to work on handstand or inverted gymnastic movements, the compression can help. We don't want to use it as a crutch, we want to build tolerance in that joint, but it can help early on. All right, so those are some accessories that I've found very, very helpful in working with older adults. Now let's talk about what we can think about if we just need to take the whole upper extremity off the table in the sense of we don't even want to load the upper extremity at all, right? Because let's say I have someone with a right-sided stroke and they have a weak grip and so I'm going to use this lifting hook. Well, what if they don't have great right shoulder stability, right? That's not going to be great if I'm going to do something like a loaded carry for example, and they're not able to maintain that shoulder stability and could potentially, you know, sublux for example. So how can we distribute the weight just taking the upper extremity off the table? THE ALDRIDGE ARM So the first one I want to mention, it's a really cool piece of equipment, is the Adaptive Single Arm Lifting Attachment. And so what this is, it is a popularizer created by Logan Aldridge who is He has upper extremity amputation. He's now a Peloton coach, but he's really well known in the CrossFit space, definitely in the adaptive athlete space. And he's thrown around some super heavy weight, particularly barbell deadlift with the single arm lifting attachment. It basically hooks on one side of the barbell, goes up over your shoulder, and then hooks up on the other side of the barbell. And so the upper extremity is taken out of the equation. You're still able to load very, very heavy. Next up, kind of a similar philosophy, and that is a purse carry. So this is something that I learned from Alex Germano, faculty within the Older Adult Division, and that's basically taking, kettlebells are great for this, where you basically take that kettlebell, gait belts are useful, you loop that gait belt through the kettlebell handle, and then you just put that weight on like a purse, one side or cross body, and you're basically getting load through the trunk and you can do lots of movements, carries are great for this, but you're not asking hardly anything of the upper extremity. Gate belt, I typically use gate belts for this one. So that's the purse carry. We talked about the adaptive single arm lifting attachment, the purse carry. WEIGHTED VESTS Next, think weighted vest. How can we wear the weight not using the upper extremity? Weighted vests are a great option. Backpacks, loading them up with cans of beans if you're in home health, great option to wear the weight to remove the upper extremity. Belt squats is another great example where we have a belt Around our waist and that is that belt is attached to some form of resistance You can get some real fancy pieces of equipment You could use the gait belt again wrap the gait belt around the waist and then loop That the gait belt through the handle of like a kettlebell for example and get a similar stimulus but you're basically loading up the pelvis and the legs and and able to achieve a higher intensity, particularly for the lower extremities, without bothering the upper extremity at all. And then think about some different pieces of equipment outside the barbell, dumbbell, kettlebell, but think about like the rower, for example. Cardio piece of equipment that we still want to maintain that cardio fitness, you can get a single arm rowing attachment. So you are not having to use that upper extremity that's limited and you can use the other one. So there's lots of options. I think the big thing from this is that we don't want to let that sore grip, hand, wrist be the limiting factor in being able to apply heavy loads to folks. We can work around these issues so folks can achieve those higher intensities and get the results that we know they deserve. THE ULTIMATE GERI EQUIPMENT E-BOOK All right, so I've mentioned a bunch of stuff. I showed a bunch of stuff. You can get links to all of these things in one place. Last week, the MMOA division, we released our new e-book, the Ultimate Geri Equipment e-book. In that e-book, you will see links for all of these accessories, but also all kinds of ideas for other pieces of equipment that you would want in your clinic or gym if you're going to be working with older adults. This is basically, if we had a blank slate, what would we want in our spot? And the whole team contributed. We organized that list by what's fundamental and what's optional, but then also by benefit, strength, endurance, balance, and mobility. All right, so you can get that ebook for free. It's a free download. It's in the Humpday Hustle email that just went out. So it's the first link on there or you can go to ptonice.com and then click on free resources And you will find that at the bottom of that page Tons of good stuff on there. So check out that resource lots of good stuff Just to mention those links are not affiliate links or anything. We don't get any kickbacks for any of that stuff We just want to share helpful information and basically our wish list right of what we think is cool And hopefully you'll find some good ideas in there as well. All right, so check out that ebook. Don't let those grip or hand issues be a limiting factor in the progress of your patients. SUMMARY And before we go, just real quick, want to mention our CERT MMOA courses, our level one online, level two, and then our live courses. All three of those culminate into the CERT. Level one just sold out. Our next cohort is going to be March 13th. Level two starts tomorrow. There's some seats left there. Our next cohort will be around May or June. and then three live courses I wanna bring your attention to. We're gonna be across the country all year, so we're gonna be close to you at some point, but three in particular that are coming up pretty quick. January 20th and 21st will be in Greenville, South Carolina, and then Clearwater, Florida, and then on January 27th and 28th, we will be in Kearney, Missouri. We'd love to see y'all in the row. We'd love to see y'all in the online cohorts and pursue that CERT-MMOA. All right, appreciate y'all. Have a lovely Wednesday. Grab that e-book. I'll see y'all soon.

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. Paul Killoren // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren discusses key research supporting using dry needling with electrical stimulation to target peripheral nerves to reduce pain and improve muscular function.

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. We've got YouTube up. We've got Instagram live. Happy to kick off the PT on ICEDaily Show this morning. If we've never met, my name is Paul Killoren. I'm the current division lead for the dry needling division with ice. And this week you actually have a dry needling double header coming at you. On Thursday, our lead faculty, Ellie Melrose, is going to dive into technique Thursday. with some subscap tips. Zach Long, barbell physio, hit subscap pretty hard last week. So we want to bring you the dry needling tips for subscap on Thursday. That's with Ellie. Catch it live in the morning or catch the recording. Today is clinical Tuesday, and we're actually going to kick off a topic that really celebrates our advanced dry needling course. As a division, we have two courses going down this weekend. One of them is myself hitting the advanced dry needling course in Bellingham, which is really cool for all of the reasons. It's an advanced course, it's kind of the last part of our dry needling trilogy, our three course series, which will build out our dry needling cert with ice. It's really cool in Washington that that third course is what gives our kind of our inaugural group the 75 hours, which as of last week, the word is that in Washington, PTs will be able to dry needle patients as early as July. So really cool stuff happening this weekend. And the advanced course is really my direct segue into the topic this morning. PERIPHERAL NERVE STIMULATION If you saw the teaser yesterday, we're going to talk peripheral nerve stim. And I guess first to qualify our advanced course, the first half of the course is treating more technical or slightly higher risk targets. Muscles around the scapula, around the thorax, we treat the suboccipitals, we treat some more technical muscular targets. That's the first half of the advanced course. But the second half of the advanced course, we stop having intramuscular interactions with our needles and e-stim. And what I mean by that is we do tendon needling, we do scar needling, but we do peripheral nerve stim techniques. So I figured it'd be worth at least having a little teaser topic on the podcast to discuss What are we doing with all that? And really, this is a short format this morning. So what I'm not going to do is dive deep into all of the things and all of the reasons and all of the research as to why we might intentionally, directly interact with a peripheral nerve with our needling and e-stem. But I wanted to give you some research teasers, kind of a little sampler platter, a little charcuterie board of research when it comes to peripheral nerve stem. And again, without getting into all of the reasons we might do it, it might be obvious for me to say that there's actually some pretty sound research that says if we have a true nerve injury, it was injured in surgery or there's a degeneration or a palsy or a tractioning, but if there's a direct trauma to a nerve and we're trying to regenerate or we're trying to improve the nerve health, It might sound kind of obvious that there's quite a bit of research that says if we can directly stimulate that nerve with our needle and e-stim, that there's great benefit there. I mean, that's obvious, that's a home run. Treat the tissue that was injured, all of that stuff. What you might not necessarily immediately assume is that there's actually pretty solid research when it comes to direct nerve stim being the sciatic nerve for low back pain or for improving muscular performance. even some neuropopulation stuff. That might not be the immediate thought when we talk about influencing a nerve with e-stim. And again, what I'm not going to get into today is all of the stratifying, the decision-making process of when we might stim a nerve versus when we do our intramuscular stuff. I really just want to tease you with some research because these techniques are out there. These percutaneous neuromodulation therapies are actually becoming much more popular. whether it's for pain relief as an alternative to pharmaceuticals, whether it's post-surgical pain modulation or improving muscular performance. These techniques are growing in the rehab realm, in the sports medicine realm. So I want to tease you with some research. THE RESEARCH BEHIND PERIPHERAL NERVE STIMULATION The first one, it's kind of a pilot research study from 2019. The author is Alvarez-Pretz. That's a hyphenated last name. And what they did was basically did one bout, it was 10 trains of 10 hertz frequency, but one session of femoral nerve stim. And what they looked at, these are patients with unilateral knee pain, they looked at immediately before and immediately after strength output. So max isometric strength for the quads before and after femoral nerve stim. And it improved. Not only did it improve statistically significantly from pre to post, but it outperformed a healthy control. So pretty cool stuff. Again, I'm just giving you these little nuggets today. But here's the first citation that says femoral nerve stem improved quad performance. And these are knee pain patients. So again, you can get deeper into the inhibition mechanisms and why that might be, but immediate change in max strength output of the quads with femoral nerve stem. Since I brought up the femoral nerve stem, let me tease you with one more. It's a 2020 publication by Paola Garcia Barmejo. Again, she's looking at anterior knee pain. One bout of ultrasound guided femoral nerve stem improved knee pain, but also range of motion, functionality, and there was a crossover. So they did it on one side, and they saw changes on both. So again, femoral nerve stim, we have changes in not just quad strength, but knee pain, functionality, range of motion, all the things. But let's talk back pain. Or let's frame it this way. Let's talk sciatic nerve stim for a moment. Because the first research publication, 2008, it's by an O, Fascinating stuff. Because again, it might be kind of obvious for me to say if we wanted to improve blood flow to the sciatic nerve, if we wanted to send blood into the vasonevorum, like engorge the vessels to the nerve, improve blood flow to that nerve tissue, it might be pretty obvious for me to say that doing direct sciatic stim does that. And it does. But here's a research article that's fascinating and gives context as to other interactions. Because for this research, they're looking at blood flow to the sciatic nerve, and they had three groups. Group one, they actually did lumbar muscle pumping e-stim. So they didn't necessarily say multifidus, but they did that muscular motor response e-stim to the lumbar paraspinals, and then they looked at blood flow to the sciatic nerve. Group two, they did the sciatic nerve stim. They put a peripheral nerve stem directly on the sciatic nerve and they looked at blood flow. Group three, they actually did e-stem to the pudendal nerve. So a separate nerve, but again, they're looking at blood flow to the sciatic nerve. Here are the fascinating findings. 57% of the folks in that lumbar paraspinal group saw improved blood flow to the nerve. So whether you want to say that that pushes us kind of towards the the changan, the radiculopathic influence, or like the segmental influence of nerves, the myotomal influence you could say, 57% of the folks that got lumbar paraspinal e-stim saw improved blood flow to the sciatic nerve. But here's the rest of the fascinating findings. 100% of the folks that received sciatic nerve stim saw improved blood flow to the sciatic nerve. That was almost their control and it worked. But the last piece here is that 100% of the folks that received e-stim to the pudendal nerve, also 100% of them saw increased blood flow to the sciatic nerve. Fascinating. So we do have an influence approximately from that muscle pump of the lumbar paraspinals, but it's almost like we don't have to be nerve specific because we can put some e-stim on the pudendal nerve and we saw improved blood flow in the sciatic nerve. Again, I'm just going to tease you with more research. The next publication by San Mitro Iglesia in 2021. Love these names. I mean, I will say most of the research being done right now is overseas, international. For this research, they had folks with low back pain and they had three groups. Those three groups all received sciatic nerve e-stem. but they were in three separate anatomical locations. So group A, they put e-stim on the sciatic nerve proximally, so near the issue of tuberosity. Group B, they put e-stim mid-hamstring, so mid-thigh, just a different anatomical location for a sciatic nerve. And then the last one was actually the popliteal fossa, so you wanna call that tibial nerve, whatever. But they're stimming the sciatic nerve or sciatic components in three separate anatomical locations. Fascinating outcomes, these are folks with low back pain. Every single group that received eSTIM to a nerve improved in low back pain, in range of motion, actually in their balance tests, and in their functional scales. And there was no difference between these three groups. So with those last two kind of research nuggets, I'm calling them, it almost seems like we can have a profound impact with nerve stem, peripheral nerve stem, and maybe we don't need to be nerve specific and we certainly don't need to be location specific, meaning we're having a global impact here. And if you've, and if you're out there and you've taken one of our upper or lower courses already, hopefully you gathered that the nervous system influence is really the driver of our contemporary understanding for the therapeutic benefit, the therapeutic mechanisms of dry needling. Now that we're interacting with a nerve, a peripheral nerve, early indications are that we're having a very similar, but maybe a more profound, more substantial nervous system interaction. Maybe it's everything we talk about, muscle spindle and motor unit loop interactions up to the dorsal horn and then, you know, supraspinal centers going to the cortex and somatosensory, all of that stuff. We're now interacting with a much more sensitive much more nervous peripheral nerve structure, and that nervous system influence has to be times 10. So again, today I really just wanted to tease you with that. We do cover peripheral nerve stim techniques on our advanced course. Again, the first half of the course, we keep doing muscular interactions. We do the rest of the muscles that you didn't get in upper and lower, the more advanced, the higher technical muscles. But then the second half of our advanced course, we do peripheral nerve stem, tendon needling, and scar needling. And maybe we can grab a few more of these podcast spots throughout the rest of this year to say, why would we interact with a peripheral nerve? Today, I just set for you a little charcuterie board of research that says we can change, not just nerve health, not just nerve blood flow or neuro regeneration, but we can improve muscle function. We can change strength. We can change pain. And maybe there are patients like low back pain where the initial strategies of conservative therapy, maybe even our, our typical paraspinal or multifidus estim isn't working. We now have one more strategy, one more tissue interaction to consider. But again, that's all I wanted to jump on today was to give you a quick snapshot of nerve stim research. Not gonna give away all of our secrets on how we stim nerves. It's probably fair to say or fair to acknowledge that all of the research I just went through, almost all of the percutaneous neuromodulation, so peripheral nerve stim with needles, fair to say that almost all of that research is done under ultrasound. And that's to ensure safety kind of, but also ensure that it is a direct peripheral nerve interaction. We're not going to use ultrasound on the course. So really the beauty of the technique is how do we interact with it safely again, for sure, but consistently and effectively. So peripheral nerve stim is a big topic on our advanced course. We have a couple that will be popping up. Again, the first one is this weekend in Bellingham. If we're not sold out, we're nearly sold out. We have one in December in Colorado, and there'll probably be one or two more that pop up Q2 and Q3. Hopefully we're targeting the Midwest. We are probably going to be back here in Washington, because again, we need that for our 75 hours to treat patients. But peripheral nerve stim, if anything, I wanted to put that in your mind today. And I mean, big picture before we continue this podcast series about why and how and when for peripheral nerve stim. At the very least, I want to keep throwing out this topic because on the ground floor, if nothing else changes in your mind, I'd like to kind of decrease the paranoia or the concern of needling near a peripheral nerve. Or if you use eSTIM, I'm sure you've had that interaction where the needle goes in, all of the words from the patient are normal, achy, crampy, sore, no nerve words. But then you add yeast into the equation and clearly you're near a peripheral nerve and you generate a different response. At the very least, I'd like to turn off some of the alarm bells that we're so paranoid of interacting with a peripheral nerve that we don't acknowledge there's benefit there. Again, upper and lower, our goal is just to treat muscular targets. We're not intentionally trying to interact with a nerve, but advanced we will. So on the ground floor, I'd love for just The, we always respect nerves for sure, but we don't want to respect them so much that we don't see that there's benefit there. Again, you should be trained in a technique. We're not trying to intentionally or accidentally interact with the nerve. We need to know where they live. If you took a level one or a level two course from somewhere else, I'm sure they mapped the large vessels, the large nerves, and we want to avoid them at all costs. And you should do that to start with. I mean, there's, There's something very precise and very safe about knowing how to not interact with it directly with the needle. But then there is another layer on top of that, that eventually, especially when we use e-stim, so we're going to piston much less, we're going to use e-stim, there's value to knowing where these tissues live and interacting with them directly. So for now, I just want to put that thought in your mind. I want to decrease some of the paranoia, some of the nervousness of being around a nerve, and hopefully I can keep teasing you with certain research. We'll throw some stuff up on Instagram. If you've taken upper or lower through us, you can look for the advanced courses popping up. To complete the CERT for ice, it is upper, lower, and advanced, but you only need to take one of them to show up on the advanced course. So let me know what you think. I mean, do you have questions on peripheral nerve stem? Throw them on Instagram. Hit me up directly on Instagram if you'd like, at dptwithneedles. Otherwise, stay tuned for Thursday. Ellie is going to jump on and show you some subscap tips. Such a key muscle for your shoulder, folks. Again, go back and listen to Zach Long's episode from last week. and how he assesses it and how important it is to treat and how he loads it because Thursday Ellie's just going to bring the dry needling smoke. She's going to teach you how to get in there safely, consistently and effectively. It's a key target. So that's what we got coming at you. 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 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. Christina Prevett // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses her journey to becoming a pelvic floor PT.

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. CHRISTINA PREVETT Everyone and welcome to the PT on ICE daily show My name is Christina Prevett and I am one of the lead faculty within our pelvic health division Today I want to talk a little bit about kind of my journey in to pelvic PT and the reason why I want to do that is because when I first started in pelvic I was actually really adamant that I was never going to be a pelvic PT. It was not something that I wanted. It was not something that I wanted to do. And I want to talk to you a little bit about why I think that's important and where we have seen a shift in pelvic PT that I think is super beneficial. So you all haven't seen me on the podcast now for a while. You know that my start and my love is working in geriatrics, right? My PhD was in geriatrics. My business model was very focused on, with Stavoff, on healthy aging. I did a lot of bridge programming between one-on-one rehab and group fitness wellness for individuals with complexities with the idea of removing barriers to exercise, and optimizing as many facilitators as possible in kind of a medically supervised but not medically necessary type of way. And part of my PhD was really trying to get into this health and wellness space. And you know that fits the bias at ICE really beautifully because we truly believe in preventative healthcare versus our sick care system that we currently have. And part of that was to do a scoping review around where physical therapists could be involved in health and wellness. And I meant that as a primary and secondary prevention aim. So not once disease has already been established, but what to think about this bridge, identifying risk factors to potential issues, or to really think about population level health. And of course, there was a lot of things in the literature that lit up around, you know, chronic Z self-management and working and isolating at risk factors like blood pressure. But one of the other things that came up and came up really strongly in the evidence base was around perinatal care. And so a lot of people go into pelvic PT around their own experiences, and that was actually not the case for me. And so I had applied for a city grant. I was like, well, if this is where we are going and we want to take a lifespan approach, then let's try and get involved in exercise in the perinatal space. And so we applied for a grant, we were able to get grant funding, and we started a program called Strong Like Mom. it was a new area for me you know i did my research on like exercise this is a lot of postpartum exercise in canada we have a year of maternity leave so a lot of moms in the first year would bring their babies in it was really great i was kind of in a period of my life where my husband and i were talking about having kids so i got exposure to other moms and their experiences i got to talk through different pelvic health complaints. And from an external perspective, I was able to help manage a lot of those conditions. But I was not internally trained. And this was back 2018, 2019. And I was still adamant that I was not going to be internally trained. And here's why. I had this belief that I had to be a Volvo Cupcake type of person. And this is absolutely no, no negativity at those who go into pelvic and love it so much that they buy a costume where their head is the clitoris. Like we need those people because they reach individuals in such a unique way. But that was the way that I had interpreted going into pelvic. So I had my exercise class. I was talking about pelvic health issues. But I really truly thought that as soon as I became a pelvic PT, all I did was internal assessments. I stayed in the room with people in supine and I stopped getting an orthopedic caseload because everybody that I talked to, their entire caseload turned into pelvic. And I loved working with older adults. I loved working orthopedically. I saw a lot of people with complexities and multimorbidity. I loved that part of my job. And I did not want that to go away from me. And so in 2018, so I must've started this program in 2017. So we're talking some years now. In 2018, I was a national level weightlifter and I got pregnant with my daughter. And we got pregnant faster than we thought we were going to, which is such a blessing. But I was prepping for a weightlifting meet, trying to qualify for nationals again for 2019. And I already had the meat. I was like well into my prep. And so I was like, you know, I'm not worried about weight. I'm well off my weight category. I'm still gonna compete. And I remember the first time I went to snatch heavy and I made contact at my hip, I started to cry. And I knew that exercise was not bad. I had well gone into the literature with me being a PhD student around exercise and pregnancy, but the visceral, fear response and the thought that everything in my brain had said, I need to protect was real. And I was lucky. We had a referral network with individuals. We were working in a research program with a high-risk fetal medicine physician and obstetrician. And we were doing referrals back and forth for individuals with cardiovascular risk. That's a whole other conversation for another day. But in that moment, I reached out to him and I said, Hey, like I'm a weightlifter. And I sent him a video of a snatch. I was like, I'm prepping for a meet. What are your thoughts?" And his messaging was so clear. He said, that baby's so small, it is back in your pelvis, and your body is used to this. It's okay, you are going to be fine. And my fear melted. It melted. And I will never, never not be grateful for that interaction. And in that moment, I recognized one, how much fear we can have around pregnancy because it's so protected. But number two, how much that fear can be melted away by somebody in the obstetrical space that you trust, that allows that fear to extinguish. And so, This was all kind of happening. Again, I wasn't doing internal PT, but I started to feel this like gut pull to this space. But I still had this like interaction where I just did not want to do only internal assessments. This is kind of the origin story of pelvic. And so I was still not coming to terms with this, but I really wanted to start bridging towards this fitness. I had been doing Strong Like Mom for a couple of years. I was a national-level weightlifter on Instagram and social media. I was getting comments about my body prolapsing and all these things that were so fear-focused, and it started to just gut me that it was so fear-invoking. and I was going and I was interacting with other pelvic BTs, they were the ones who were making me afraid because they were the ones telling me that I was going to prolapse. They were the ones who were saying, and this is not against them because that is truly what we believed and what we were taught in our training. We have come so far to move away from that narrative, but that was where the narrative was in 2018. My staff member who was an internal trained PT and I went to fitness athlete and being in this space, we kind of took over a little bit, sorry guys. In this live course, talking about things like diastasis recti and talking about how to load the core and it very naturally for me became this teaching moment. And this was in 2018, 2019. And in that moment, because Alan was there, he was like, this needs to happen. This needs to happen. And even then. When I started teaching, I was like, I do so much externally. I've seen such great results. I know there's a referral network if I need it for looking at these interactions, but I'm not, I'm still resisting against it. So I was there and we have so much evidence around telemedicine. And it was just, it was still, I was still doing everything externally. And I was like, I'm not going to bridge that gap. And so you're probably wondering where it switched. It switched when I realized that I could do pelvic PT my way. I did not have to be a person who loved looking at vulvas on cupcakes in order to be unbelievably passionate about removing barriers to exercise. You have heard me say that very quickly, when people start interacting with the healthcare system, they start to be afraid. in females or peoples with uteruses where their fear often can start is in pregnancy because they want to protect and our medical system is designed to look for what is wrong and try and mitigate those risks. And I recognize that in order to be a frontline person, to be able to mitigate that messaging, the internal PT part was necessary. And so in 2019, I went back and started doing some internal training and the training was fantastic. I loved it, but it taught me the assessment. I spent a lot of time on the assessment and I was so thankful that my external training and just figuring out my own caseload over several years had allowed me to know the intervention side of things. And they had to marry. And so our online course is very focused on external techniques. That was where my expertise was. I started blending that with my internal techniques. And I realized that the internal assessment is a tool in our toolbox. It is not our profession. It is not our profession. And as I have started to interact and build more experience and all these types of things in this space, in tandem with some of the research side of things, I so sparingly use the internal assessment outside of often times if we're working with individuals with pain. But it is not who pelvic PT is. And when I removed that expectation, yeah, 100% this, when I removed that expectation that that is what my job was, that is what defined me as a pelvic PT, I became very free to explore this beautiful area of our profession. And I blend my orthopedic knowledge all the time. I use the information from the internal assessment to provide education. And as we were doing this, and as Alexis was coming into our division and all these things were happening, I realized that our online course would not be enough. It would not be enough because we had to be able to bridge from lying in supine to fitness. We were having this disconnect where we had exercise professionals who felt very good about being able to have all of these movements and interact with these different conditions. And then we have these pelvic PTs who are very good at the assessment aspect. But going from that assessment and early foundational graded exposure to getting individuals running and playing and expressing joy with different planes of movement and different unexpected changes in their body's positions, we had a disconnect there. And so our life course started to really take form in 2020. And I know that people may think that while we do it really differently in our pelvic course, than others and the reason why it's so different is that yes we teach the foundations of the internal but we teach it in the morning of the first day because it is a tool in our toolbox. It is not an entire entry-level course in our perspective. And so we teach it in Supine, and then we bridge that to standing because how are we going to figure out where people are leaking? Yes, Supine gives us tons of information, It allows us to get some orientation, and then we go into the standing assessment, and from there we bridge. And we spend the rest of the weekend bridging, because that is where our profession needs to go. Just like you were saying, we need to use the internal. It is an absolutely pivotal skill, but we need to do that and bridge to fitness, and we are not just pelvic PTs. We are pelvic orthopedic PTs that blend everything that we know within our medical training in order to drive a fitness forward message. And so now I am loud and proud that I am an internally trained pelvic PT and I leverage it in my practice every single week. I'm a part-time practicing clinician right now because of my research. and it gives me so much insight. My patients do amazing, but it's not because of my fingers and their vulva. It is because it is the basis of which we build our foundations, just like I'm not going to just do Kegels, right? I'm going to teach the coordination of the pelvic floor to bridge to function. That is the same thing that we are doing in this fitness forward pelvic PT approach. It is why I hope that when I share my story, that somebody resonates with it. Somebody who has hesitated and said, I do not want this to be who I become. And I hope it gives you freedom, that it gives you this unbelievable understanding of the bottom of the core canister. So if you are interacting with someone who has hip pain or back pain or abdominal pain, you are interacting with it. You are interacting with the pelvic floor. And it will give you this idea that the training is not going to put you into this pigeonhole that you cannot get out of. All right, that is end for me. If you are interested in figuring out our internal assessment, we have so many live courses coming up over the beginning of 2024. I'm gonna be in Raleigh, North Carolina. We only have three spots left for that course. This weekend, end of the month, Alexis is doing a course in Hendersonville. And then beginning of February, I am going to be in Bellingham, Washington. doing all things pelvic PT. So if you are interested, let us know. Otherwise, have a really wonderful start to your week and we will talk to you all soon.

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. Zach Long // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty discusses treating the subscapularis muscle for the fitness athlete. Zach discusses modifications for pressing, pulling, and Olympic weightlifting. In addition, Zach discusses go-to exercises to use for HEP with these individuals.

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

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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.

ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show, where it is not only the PT on Ice Daily Show, but it is the best day of the week here on the PT on Ice Daily Show, and that is Fitness Athlete Friday. I'm excited to be with you all this week. My name is Dr. Zach Long. I'm a faculty member inside of the Fitness Athlete Division, teaching both our live and advanced concepts course with the rest of the team there. Today, we are going to talk about subscapularis treatment with the fitness athlete. So the subscapularis muscle, I think, gets commonly overlooked in the fitness athlete's shoulder. Alan talked about it last week, so I'm going to follow up his discussion last week with a few other things. But like Alan said last week, this is the largest and strongest of the rotator cuff muscles, and I think it commonly gets overlooked when people are dealing with shoulder pain. And so we're gonna jump into kind of some of the different modifications and treatment strategies that I use when patients have subscapularis pain. Make sure you listen to last week's episode as well. A little quick recap of last week's for you just to set the stage here. SUBJECTIVE EXAM FOR THE SUBSCAPULARIS Subjectively, what I hear most frequently when people are dealing with subscapularis strains are that they have pain with dips, pushups, and the bench press, so with shoulder extension-based pushing motions. And then things like snatches, overhead squats, and kipping pull-ups, where their arms being really stretched overhead in that position. OBJECTIVE EXAM FOR THE SUBSCAPULARIS Alan talked quite a bit last week about testing positions for the subscapularis, and those were absolute gold for ruling in and out the subscapularis. I'm going to throw one more test at you before I move on to more of the treatment stuff. And I like this test because As Alan talked about last week, when you do like IR at neutral, the pecs are such a big muscle working right there that it's not going to be sensitive enough on your subscap. So that's why he talked about like the liftoff test in your arm. The one kind of issue that I have with the liftoff test, I use it with all my subscap people, is for those that are highly sensitive and you know that they're already really irritable, I find at times that just getting into that position really lights them up. So the test that I prefer to start with is that internal rotation at neutral, but we get rid of the pec involvement a little bit. So imagine somebody standing with their elbow right at their side, elbow bent to 90 degrees. You then put one of your hands outside of their lateral elbow and you have them push out like they're doing a lateral raise. You don't let them actually push away from their body, but they're trying to. And then you test internal rotation resistance with the other hand. And you'll find that that little lateral raise push gets rid of a lot of the peck involvement in there and will let you get a positive test for a lot of people that have a subscap strain that your standard IR at neutral would not. SUBSCAPULARIS TREATMENT So let's jump into treatment a little bit and modification. I'm going to say number one, from a manual perspective, like if you made me choose only one area of the body to needle for the rest of my life, and you said you can only needle one thing for forever, choose what muscle. Now this might just be because I treat primarily shoulders, hips, and knees in the clinic, but I would choose subscapularis dry needling over every other area of the body. It has just been the area that I find most frequently gets huge improvements in their symptoms after a quick dry needling session. So if you're not familiar with that, look up Paul iDryNeedle. Paul runs our dry needling division along with Ellie. and the great faculty that we're building over there, but check out their coursework. That is just a money technique to have. From a treatment perspective, so much of my treatment with this comes down to the combination of wanting to build the subscap up, but also wanting to make sure we're not continually overloading the subscap. So I have a lot of conversation with my patients on what sort of modifications they need to be making to their training to not further aggravate the subscapularis. And so, All of these are obviously based on somebody's irritability. So when they strain their subscap, if it's very, very minor, I'm not pulling all of these levers, but if it's very major, I might be. And as y'all know, our goal with the fitness athletes and all of our people in general is to keep them active. We don't want to tell them, stop benching, stop doing pushups, stop doing dips. We want to find ways for them to do those movements or similar movement patterns with less pain. So that's breakout kind of where I kind of go with modifications. MODIFYING HORIZONTAL PRESSING So if we start with like our horizontal pressing motions, which I think are the most common things that I hear people with subscap strains discuss subjectively, that's the dips, pushups, and bench press. I think the reason why those hurt so much is as we take the shoulder into extension, I think you can appreciate as your shoulder goes into extension that you're gonna create a little bit of compression on that anterior shoulder. And as we know, tendons don't like compression. So I think that's why extension is so irritable for these individuals. So one thing that I find myself doing more than anything else in people with subscapularis strains is I actually have them stop doing dips. And we end up replacing dips with, with push-ups or banded push-ups or some variation that doesn't take the shoulder into quite as much extension. When push-ups are pain-free, then we start moving back to dips. But generally, I find that dips are going to be really painful if the push-ups still hurt at all. So that's kind of a general rule of thumb for progression there on the dips. In terms of the pushup and bench press, I find that the most valuable thing we can do for people in terms of modifying is to just adjust the range of motion a little bit. So for the pushup, kind of the two modification, three modifications I make there are a lot of times I have individuals do a pushup down to an ab mat. So that ab mat's just gonna, they touch their chest to the ab mat instead of the floor. We reduce that range of motion, maybe an inch and a half or so with the ab mat there. And so frequently that is enough that we can now still do the prescribed workout with just that slight modification to the range of motion. Other times I find that having them really torque their hands into the ground or keep those elbows close to their side and making it a little bit more like a close grip pushup can help them out quite a bit. From a bench press perspective, very similar. So maybe instead of bench pressing, we do a floor press or a board press. So a floor press is simply a bench press where we're laying on the ground. So when the elbows get to our side, they hit the ground and you can't actually take the arm into extension. That can usually be enough that people can still press really heavy. The floor press is one of the best exercises you can do by far to improve your bench press strength, so it's a great modification in this time period. We can also do a board press where they're on a bench, but they go down and they touch one, two, or three 2x4 boards that are placed on their chest to reduce the range of motion. And then very frequently I also have, especially with more like my power lifters or people that care about bench pressing a lot, I'll use accommodating resistance. So maybe with a lightweight, they can touch their chest and not have that much pain, but if it's really heavy and they touch your chest, they get pain. So that's resist the bench press with bands so that at the bottom, those bands are unloaded a little bit, and then that weight increases as they go towards lockout. So that's a great way to really challenge the lockout, still train full range of motion, but not irritate that already irritated subscapularis. So the big key there is to probably reduce the range of motion a little bit and play with some of those variations to see if you can get people to not continually aggravate the subscapularis but still get in that horizontal pressing stimulus. MODIFYING KIPPING When it comes to kipping-based movements, so toes-to-bars are one that really tend to aggravate the subscapularis, I see quite a bit. I will Usually prefer to just get people to do a really tight kip where they maintain a lot of tension and they don't go into as aggressive an arch position. That is actually a performance advantage in the toes to bar. People will cycle their toes to bar reps a lot faster. So this is a great time to make people do smaller sets because a lot of times they'll fatigue more rapidly with this. but to actually work on a technique improvement that will help them out long-term. So those quick cycled reps with a little bit more tension. If it's more irritated, then we might just do an active hang, knee raise of some sort so that we're still getting the hanging stimulus. We're still getting the ab stimulus, but we're just reducing a little bit of the shoulder demands. And then when it comes to things like kipping pull-ups, if it's highly irritable and I don't feel like kipping is in their best benefit right now, we just turn that into strict band-assisted pull-ups that we maintain that high volume of the vertical pulling stimulus. We maintain those fast reps that keep our cardiovascular system up if we're talking about prescribing kipping pull-ups in a Metcon, but it will unload the shoulder just a little bit to do a strict band-assisted pull-ups versus kipping when somebody has a subscapularis strain. MODIFYING OLYMPIC LIFTING And then the final thing that I often modify is their snatches. So frequently, it's the turnover and the catch of the snatch that really irritate these individual symptoms. So at times, that just means we move to variations where we're not doing the turnover or the catch. So we're doing snatch grip deadlifts, snatch grip high pulls, snatch grip pulls, exercises like that. So we're still building their technique. and working on things that will help their snatch overall. But again, we're just not adding more fuel to the fire there. So that's the main modifications that I make when somebody has subscapularis pain. TREATING THE SUBSCAPULARIS: LESS IS MORE Let's jump now into treatment. And I think from a home exercise perspective, one thing that I'm really big on is that less for your HEP is more. We don't want to overload our patients. So a huge percentage of my patient population at this time are people that are seeing me for a second opinion. And I kind of see three things most commonly pop up when people see me as a second opinion. Number one, they were just underloaded. They didn't get a sufficient enough stimulus, their therapist was on the right diagnosis, but they didn't challenge them enough to actually build tissue strength up. Number two is they're on the wrong diagnosis, which we all see all the time. Somebody thought, you know, that because this person's pain was on the back of their shoulder radiating down to the tricep, they assumed that it was a posterior rotator cuff pain and they didn't do a great job screening out the subscapularis with the tests that Alan talked about last week and I talked about earlier. And so they're treating posterior rotator cuff when it's really the subscapularis instead. And then the third thing is people come in and they have an HEP list of eight exercises that they're doing for three sets. And I look at that and I'm like, man, that's going to take 40 minutes to get done. Less is more here, folks. So the rule of thumb I have here is that my goal, sort of like your post-op ACL that needs a full strength program, My goal with most of my individuals is to try to limit their HEP to 10 or 15 minutes or less, four-ish days a week. I think that that's pretty manageable for most of our people. It gets really crazy when you're asking people to do 30 minutes of work every single day. So to get this done in 10 minutes or less, that usually means that I'm trying to stick to three exercises, maybe four. So in the subscapularis, maybe they do some soft tissue work on their subscapularis. That's one minute. And then we do a nine minute EMOP. So that's 10 total minutes of work. We add in grabbing equipment. They get this done in less than 15 minutes. Less is more with these individuals. Try to really stick to that. And I think you'll see your HEP compliance go up quite a bit. So three exercises, less than 15 minutes, preferably less than 10 minutes is my goal. When I'm looking for exercises, I kind of have four different exercises that we might have in those three of their HEP. Number one is going to be obvious. Like if they have a subscapular strain, we're doing something to try to build that muscle and tendon backup. It would be way too hard for me to really describe these exercises here on the podcast, but if you go to my YouTube channel, Barbell Physio, you can search for all of these exercises. But kind of my general progression here, highly irritable. I'm doing internal rotation at neutral, but I'm going to do it similar to how I did the testing. So I take one band and I'll put it around their arms. So one big resistance band going around both arms. So they have to do that little lateral raise before they do the internal rotation. I'll find that that again isolates the subscap a little bit more than the pecs. Progress that to an IR punch. Progress that to an IR diagonal. Progress that to IR at 90 degrees. That's my general philosophies there. So number one, load the subscap. Number two thing to have in that HEP is to look at any mobility limitations that they might have. Like is their overhead positioning stiff? Is their Tyler test for that posterior shoulder capsule stiff? Do they lack shoulder extension? Does their thoracic spine suck? Does something as far away as their ankle mobility suck? And that's putting them in suboptimal positions for things like overhead squats or snatches. So the second component there is to dial in their mobility, The third component is lat strength. So the subscap and lats have a lot of similarities in terms of their function, but I'd say overall for the athlete doing rig-based gymnastic skills, when they have lat weakness on board, the rotator cuff ends up taking on more of the stress of those movements. I call the lats the glutes of the upper extremity. What happens when somebody has weak glutes in athletic performance? They strain their hamstrings more. They tweak their back a little bit more. Their performance overall goes down. Strong lats are so important to the fitness athlete population. So make sure you're thinking of that with individuals. That's number three on people with subscap strains is to load their lats up. 4. Something to pump a ton of blood into the shoulder tendinopathy, whatever you want to call it. And lateral raises don't bother their shoulders. So we do something like an internal rotation diagonal to directly load the subscapularis. Now lateral raises don't hurt, but we know lateral raises are going to challenge the deltoid quite a bit. They're going to challenge the supraspinatus. Those muscles are all around the subscapularis. So if I then have them do a set of 15 to 20 lateral raises, I'm going to pump a bunch of blood to the shoulder. What happens when we pump blood to an area that's currently injured? We help with inflammatory chemicals that are sitting out in that area. We help with, you know, an overall endorphin release. We just make everything feel better when we add a little bit of blood pump to an irritated area. So that's make that be our final exercise in that little EMOM for them. So I hope those modifications and HEP discussion help you out a little bit more when you see subscaps. Again, make sure you go back and check out Alan's episode. He did a great job discussing internal rotation and shoulder extension and why that's so important in this population as well. Hope y'all have a great Friday and a great weekend, and we'll see you here 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.