#PTonICE Podcast

Dr. Ellison Melrose // #TechniqueThursday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty member Ellison Melrose discusses how to dry needle the occiput to address headache complaints. Elli orients listeners to the anatomy of the occiput as well as muscles to target when needling. She also discusses what stim parameters to use when treating headaches.

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, good morning, Instagram and YouTube. Welcome to the PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division. We're gonna dive right into things today. I am here to bring you dry needling for the suboccipital headache. And why I say that in quotations is because oftentimes when people are complaining of headaches at the base of the occiput, If we actually take time to palpate those tissues, it's not the true suboccipitals, okay? So we are thinking about the occipital insertion of things like upper trap and semispinalis. Those are our two main culprits when we have patients that complain of the headaches that start at the base of their occiput. So before we dive in, first of all, I have already cleaned the tissue of my patient here. but let's orient ourself to the anatomy of this occipital area. OCCIPITAL ANATOMY So in order to do so, we are gonna start by palpating for the external occipital protuberance, which is the protuberance, which is the nice bump on the back of our head here. So that's going to give us that orientation of where that superior nuchal line is, okay? Superior nuchal line is going to be the superior border of those occipital insertion of upper trap and semispinalis. We can follow that superior nuchal line down towards the mastoid process here. That's going to give us our, again, superior border of where those needles live. If we follow the mastoid process medially, it dives deep, but the inferior nuchal line is going to be the inferior most border of where we're needling today. What I want to do is I wanna take some time to find where the true suboccipitals live as to avoid needling in this area. So in order for us to do that, we're going to, there's a couple ways to find this region. First, we can palpate that EOP, external occipital protuberance, and drop down. The first spinous process we come in contact with is going to actually be spinous process of C2, as C1 does not have a spinous process. So that is going to be the inferior aspect of where the true suboccipitals live. Let's come back towards the mastoid process. From there, if we drop just distal, feeling the lateral like pillars of the neck, that is going to be the transverse, the first thing we palpate there is a transverse process of C1. So the true suboccipitals live between the spinous process of C2, transverse process of C1 and that inferior nuchal line. So we do not want to be needling in that area today, as it's a little bit more of an advanced technique. And I think when we're talking about the headaches that present at the base of the occiput, it's actually not the true suboccipitals. So for orienting ourself to where the muscles are, we have two main muscles, but we have bilateral tissue. So we're going to be treating bilaterally for this headache presentation. We are going to find that external occipital protuberance. If we step just about a finger breadth lateral to that, we can palpate a tootsie roll shaped tissue, and that is going to be your upper trap insertion on the occiput. When we're needling this area, we want to be mindful of some sensitive structures around this tissue. For example, what kind of is around the upper trap insertion is going to be greater occipital nerve. Essential anatomy is going to make it really seem very easy to find and it's not necessarily easy to find. One way that we can avoid too much interacting with this nervous tissue is going to be limiting our pistoning in this area. NEEDLE INSERTION ONTO THE OCCIPUT So for treating these occipital insertion musculature, we want to be using our E-STIM with pain modulating parameters. Okay, so EOP, first step lateral, is going to be that tootsie roll of upper trap. From there, we can take another finger breath lateral to that and we can find semi spinalis muscle belly as well as it inserts on the occiput. So let me do that on the other side. EOP, upper trap, we got a good old tootsie roll here. And then just stepping just lateral to that, we have semi spinalis. There is an area we want to avoid in this area, region as well. And it's going to be, if we find the mastoid process, about one finger breadth medial to that, there's a little sulcus. That sulcus is where the occipital artery lives. And if we go too deep there, we can interact with things like the vertebral artery and such. So we don't wanna be interacting with that tissue there. So we are gonna be keeping, it's pretty small territory here, but keeping our needles about, you know, two finger breaths away from that EOP is where those needles are going to be living. Let's talk about needle application. So in this area, the occiput is kind of diving anteriorly, right? So we want to have a bony backdrop for these muscles, and that's going to be on that occiput. We want to be using a firm palpation to mitigate the sensation of the needle inserting into the tissue. There's a lot of tendinous tissue here, so sometimes it can be a little bit more sensitive of an area to needle. So we can mitigate that sensation with increasing our palpation and our compression there. Our needle angle, let me just grab a guide tube out and we can kind of go over that. Our needle angle is going to be almost perpendicular to that occiput. So if we're thinking about the needle angle is like so. So for upper trap, we're thinking about angling that needle almost towards the eyeball or on that ipsilateral side of that muscle. For the semispinellas, it's a little bit more lateral. The occiput is diving, again, anterior. So there's some 3D anatomy here. We wanna be inserting, again, perpendicular to that occiput. So our needle angle, may look a little bit more flared towards midline, or that needle angle is going towards the contralateral eyeball, okay? So, again, let's orient ourself, and we'll then start placing some needles, because that's why we're here, right? So, palpating external occipital protuberance, stepping just distal to that and lateral, so we're underneath that superior nuchal line. If we are at the level of the EOP, we're going to be in more tendons. We wanna be a little bit more distal between superior and inferior nuchal line. Finding that tootsie roll, that's going to be upper trap. We are using a firm two finger digital compression to rock climber grip that upper trap against the occiput. We're using some short needles here. So I have 30 millimeter needles, and that should be sufficient enough to access this tissue. My needle angle for upper trap is going to be, compress, create a small treatment window between my fingertips, and I'm letting that needle settle. My needle angle is directly towards the eyeball on the ipsilateral side. Firm tap, and then we're going to advance our needle towards a bony backdrop on that occiput. So there we have upper trap on the patient's right side, And then our semi-spinalis is going to look very similar to that. We're just thinking just lateral to that insertion of upper trap, okay? So this is a petite anatomy here, so we don't have a ton of space between that kind of mastoid process and the upper trap needle that we just placed, right? So what we're going to be doing is the same sort of thing, hook, rock climber grip, Now my needle angle's a little bit more flared towards the midline, towards the opposite eyeball. Firm tap needle towards occiput. So now we have placed both upper trap and semi spinalis needle on the patient's right side. For treatment purposes, I would be doing bilaterally. And we can walk through that if, let's do it. Why not? Let's do it again. So, again, we're gonna find EOP, drop just distal to that, just distal to that superior nuchal line, stepping one finger breadth laterally, that's gonna be our upper trap insertion. Needle direction is towards the eyeball, perpendicular with the occiput here. Two finger digital compression, firm compression, creating a small window between our two fingers, firm tap, advancing the needle to a bony backdrop on the occiput. Again, we're limiting the pistoning in this area because we have some sensitive structures like that greater occipital nerve, really close to the upper trap insertion there. We are then going to step just lateral to that to interact with the semispinalis insertion at the occiput. So again, one finger breath lateral to that, avoiding that sulcus between the mastoid process and this muscle tissue, compressing tissue. Now my needle angle is a little bit more towards the contralateral eyeball. And we're again, looking for a bony backdrop here, maintaining that depth as we let that tissue recoil. So again, optimal treatment for these muscles is going to be setting up a circuit for pain modulation, and treating that tissue there. We want to limit pistoning in order to mitigate interaction with some more sensitive structures, including the greater occipital nerve. Again, for these suboccipital headaches, we are not treating the true suboccipitals. We are a little bit more proximal to that. We are thinking we are at the occipital insertion of upper trap and semispinellis. We want to orient ourself to this anatomy by finding the EOP mastoid process, and the region of the true suboccipitals as to avoid that area. We're using a firm compression to mitigate the sensation of the needle insertion. Upper trap is going to be perpendicular to the occiput. Needle direction is towards the eyeball, ipsilateral eyeball. Semispinalis is just about a finger breadth lateral to that, and we are angling the needle towards the contralateral eyeball. So there we have the needling technique for treating the suboccipital headaches. Um, there's actually the occipital insertion of upper trap and semi spinatus So that's all I have for you guys today. If you guys can catch us out on the road next spring We have some upcoming live courses in january. We're kicking off the the new year strong I will be teaching in rochester, minnesota the second weekend of january. I believe that's the 12 through the 14th, and Paul will be up in Bellingham, Washington for our first advanced course that same weekend. Then you can find me teaching the upper quarter in Longmont, Colorado two weeks later, so the last weekend in January. And Paul will be continuing some courses out in Seattle. So feel free to hop onto PTOnIce.com to check out where we are on the road. Again, this is We're starting the new year off really strong with some upcoming courses and our first advanced concepts course that Paul will be leading in Washington. So hope you guys have a great rest of your Thursday and I am signing off. See ya. 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. Julie Brauer // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the importance of fracture risk screening & osteoporosis management, including utilizing the FRAX tool & DEXA scans to better help assess & manage fall risk with patients.

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. JULIE BRAUER Welcome to the Geri on Ice segment of the PT on Ice Daily Show. My name is Julie Brauer. I'm a member of the Older Adult Division. Excited to be talking to you all this morning all about the big critical piece that is missing from our fall prevention and management frameworks. The big critical piece that is missing from our fall prevention and management framework. So before we get into the goods, I want to let you all know about our courses that are coming up in January because we are hitting the new year just right out the gate. We are absolutely slammed. So our L1 and L2 online courses kick off January 11th and January 12th. And then we will be on the road all throughout the month. So we will be in Columbus, Ohio, We will be in Santa Rosa, California, Clearwater, Florida, and Kearney, Missouri. So we would love to see you in our online courses or out on the road starting the year off strong with us. FRAMEWORKS FOR ASSESSING FALL RISK Okay, let's dive in. I want you all to think of your typical frameworks for your fall risk assessment and your management plan. I want you to think about it. So I want you to think that 70 year old Betty is coming into your clinic or you're going to see her at her home or in her hospital room. She's been referred for strength and balance deficits. She's had a fall in the past. I want you to think about kind of that long list of assessment pieces that come into your head. You know, what you're probably going to evaluate or be thinking about. So when I think about that long list, here are some of the things that come to my mind that are probably coming to your mind. You may do some evaluations and assessments like the short physical performance battery. You may run a tug. You may look at strength. You're probably going to do a gait speed. Maybe you want to do a mini best and check Betty's vision, check her cognition, talk to her about her environment. Maybe you do a medication review or you check her shoe wear. Maybe you're going to check her vitals, right? This list could go on and on. It's definitely not all inclusive, but I would bet that a large percentage of you that for a large percentage of you, the piece that didn't make that list was fracture risk screening and osteoporosis management. FRACTURE RISK SCREENING & OSTEOPOROSIS MANAGEMENT This is our critical missing piece, fracture risk screening and osteoporosis management. So we are going to start by setting the foundation and talk about why that piece is commonly missed. We are going to talk about why as fitness forward rehab professionals, fracture risk screening and osteoporosis management has to be on our radar, especially given the fact that we have the goal, especially in this crew, we have the goal of identifying, seeking out, and absolutely destroying one ret max living in order to make our older adults as robust as possible. And in this specific case, helping to make their bones as robust as possible. And then I will give you guys a few clear, easy to implement actionables that you can start getting after this week that are going to be able to give you a very comprehensive clinical picture of your patient's skeletal health. Okay. So first and foremost, we need to think about why is this not on our radar? You know, why for many of us was fracture risk screening and osteoporosis management not something that came to our minds. And if you're like me, I didn't really learn about that in school. It wasn't emphasized. I definitely didn't learn it out on clinical. And I really didn't address it in my clinical practice. If someone, one of my patients had osteoporosis, I kind of just assumed that it was going to be managed by their PCP or the medical team. And I didn't really have a big role to play, right? And we also have to realize that we understand that falls and fractures are important, right? Like falls and fractures, especially in working with older adults, this is on our mind a lot. And we know that as our older adults age, falls and fractures are going to increase. And we know that This results in years and years and years of disability that our older adults have to live with. So we know that it's important. So we have to start thinking like, why isn't this on our radar? So I want you all to start getting really curious about your patient's skeletal health. And when we look to the literature, we further see that this is an undertreated and an underdiagnosed condition. In the literature, it'll be deemed as the silent disease. And there are so many retrospective cohort studies that show that individuals who sustain a fracture after a fall, a very alarming high percentage of them were never scanned. They never had a DEXA scan. They were not on osteoporosis medication. And a very high percentage of them will go on to have another fracture in a few years. So this is a massive, massive problem that we are seeing and we have to realize that we have a role here and we can be the individuals to help screen and identify this as a problem and interrupt that cycle. So when we start to get curious about our patient's skeletal health, I want you all to think about Betty, right? About 75-year-old Betty who's coming in to see you. And we're really good at looking at Betty and assessing Betty and thinking, like, Betty's got a lot of muscular weakness on board. So if we know that Betty is weak muscularly, we have to remember that it's called the musculoskeletal system, and that those bones also may be very weak as well. So as soon as you identify muscular weakness in Betty, I want you all to be thinking, okay, I need to start thinking, hmm, are those bones weak as well? The other side of this, though, is that Betty may blow that, you know, 30 seconds to stand out of the water. Her gait speed may be great. Like she's really kind of crushing it on her on these outcome measures that we're running. And we may think like, oh, she's thriving. However, we can't automatically assume that those bones are thriving as well because there are so many factors that go into bone health that are not visible to the eye. So don't make the assumption that her skeletal system is absolutely crushing it. You want to continue to be curious and you have to start thinking there's so much more that goes into this. I need to do some assessments and do some screening to really get a clinical picture of what Betty's skeletal health is actually like, right? And we need to start thinking about this in terms of urgency. In the older adult division, the urgent situation is identifying someone who is at one rep max living, and then triaging our fitness forward approach, because that individual needs our fitness forward approach the most. So if you think about it, and Betty is coming in, and you're running assessments on her, and she's at risk for falls, and you haven't even looked at her skeletal health yet, Well, you're going to say, whew, Betty's at risk for falls. I definitely need to really triage a fitness board approach for her. But then if you also assess her skeletal health and you realize that she has weak bones and she's at risk for falls, my God, that is an incredibly, incredibly urgent situation. That individual needs our fitness forward approach the most, but we're not going to be able to know how to intervene, how to appropriately intervene if we don't even know the problem exists. So we have to be able to identify that this is a problem. We are the providers that can make this silent, invisible disease very visible. So how do we do that? Let's talk about some actionables here that you guys can start doing immediately that are going to be able to give you really critical data in order to gain a comprehensive picture of her skeletal health. Number one, it is the lowest hanging fruit. It's the easiest place to start. SCREENING FOR FRACTURE RISK: THE FRAX TOOL You can screen for fracture risk and you can do that by using the FRAX tool. The FRAX tool is so easy, so quick to implement. I will link it here for you. It takes two minutes, but the algorithm gives the 10-year probability of a fracture. So it's gonna give the 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture, so of the spine, forearm, hip, or shoulder. In the questionnaire for the FRAX, ask some questions that start giving you an idea of things that affect bone health. So really easy, they're going to be asking just age and height and weight, right? These things you can get from EMRs or your patient. really quickly and then they're going to be asking some questions like have they had a previous fracture? Did one of their parents fracture a hip? Are they smoking? Are they on medications like glucocorticoids? Do they have an inflammatory disease like rheumatoid arthritis? Do they drink excessive alcohol? All of these factors that can really affect our bone health negatively. It will also ask for their bone mineral density. And you do not have to have Betty's bone mineral density in order to fill this out and for it to be to give you a validated probability. The frax has been validated without a bone mineral density value. However, Betty may have her bone mineral density. She may have a DEXA scan, and you can use that value, but only for the femoral neck. It is only validated for the bone mineral density of the femoral neck. So that's the caveat there, right? So really quick and dirty, you can do the FRAX tool. It's going to shoot out a probability. What happens next? This is going to start to give you an idea, like, whew, there's a lot going on here that I didn't realize with Betty. Her skeletal health isn't really thriving. And let's assume that Betty has not had a bone mineral density scan. And you're really thinking, well, I mean, gosh, she smokes, she's been on glucocorticoids, she drinks alcohol, she has had a previous fracture, like, she should probably get a DEXA scan. and you're thinking like, but you know, what are some, like, should I suggest that? The great news is that there are guidelines that tell us if we should suggest that Betty get a bone marrow density scan. I will link the clinician's guide to prevention and treatment of osteoporosis as well for you all to look at, but it just gives some general guidelines. A lot of the things that you have just heard about from the FRAX tool. So, it will tell us that we should consider BMD testing if with individuals based on age, based on the clinical risk factors such as taking glucocorticoids or having an inflammatory disease, individuals who have had a fracture. So we have guidelines to tell us this. TESTING FOR OSTEOPOROSIS So You've run the FRAX tool, you've looked at the guidelines, you are sure, you're like, Betty needs to go get a DEXA scan. So you're gonna communicate this to Betty. But what you're gonna do next is not, hey Betty, I really want you to go get those bones looked at. So schedule that with your doctor. I'll see you next week. That's not what we're gonna do. you're gonna help Betty set that appointment up or call a doctor, right? You are going to help her advocate for herself. You're not just gonna give that piece of education and then peace out, Betty. So what can you do? You can get the doctor on speakerphone during your session with Betty. and you can guide the conversation while she asks to set up an appointment to get a DEXA scan done. You can make sure Betty knows how to get into her MyChart so she can send a message to her doctor and you can help guide her on how she should formulate that message so she's communicating effectively. Make sure that you are a guide during that process and that you're not just throwing an educational piece at her and expecting her to take care of it. Help her through the process. Okay, so let's say we got a DEXA scan scheduled for Betty and she goes and has her appointment. She gets her DEXA scan. She has her results. This is where you can have a major role, not only in helping to deal hope to Betty once we are looking at those results, but it's also gonna be your guide when you start to implement your interventions. And it gives you very critical information, okay? So if you all have not seen a DEXA scan in the wild and what that looks like, I'm gonna tell ya, it's not patient friendly. I have seen one after my mom had to get one before she had a lumbar fusion surgery. It is chock full of scary words like osteopenia, fracture, osteoporosis. There's a lot of negative values, right? Like her T-scores all over the place and there's these negative numbers. It'll say increased risk for fracture. It is not easy to comprehend. and it deals a lot of fear. So this is an opportunity to help Betty interpret what this means. And you can really offer a lot of hope here. So with the DEXA scan, right, and with this data, you can be looking at it, and it's gonna give you that T-score, right? Betty may be looking at this and be like, oh my gosh, this number is so low, this is awful, right? I'm so scared. you can deal hope because you know, based on the law of initial values, those lower T-scores are going to respond to bone loading the best. They're gonna have the best result from starting to load those bones up. That's an amazing thing. You can share that news. So even if that T-score is really low, you can say, Betty, that's all right. That low score, those bones, you're gonna respond the best. And together, we're gonna help get those bones stronger. So right away, you can start dealing some hope. It's also going to tell you where those low T-scores are. The location of where the osteopenia or osteoporosis is is incredibly critical. How many of you have had patients come into your clinic and say, I can't lift that because I have weak bones? And you know, Betty, if it was Betty, she may assume that her weak bones are all over the place. However, that DEXA scan could tell you that the only place where she has weak bones is in her radius. Okay, well, all those squats and the jumping and things that Betty's like, absolutely not, I can't do, they're kind of irrelevant because it's in her radius and not in the legs, right? So to help Betty alleviate some of that fear, you could reassure her where those weak bones are. And that could really work in your favor when you're trying to get her to buy in to do exercise. However, you are also thinking, I need to know where and where is important because you know that bones are going to adapt specifically to where load is put on them. So let's say the low T score is in Betty's hip. You know that you have to load that hip up in order for that bone mineral density to increase. However, you also are taking this information and being cautious to say where it is so that Betty knows, yes, it's weak here. She may be a little apprehensive to load that area. So you know that you can give her the hope of, hey, it's weak here, but your bones are strong in these other places. So we can start loading where those strong bones are. So you can gradually expose her and mitigate some of the fear she may have. The other piece of information that is really important from the DEXA scan that you get as a provider is that it just gives you the severity, right? How low is low in that T-score? Because that is going to determine your rate of loading progression. So you have to know, hey, maybe this is someone where we are not going to start with impact exercises, we're going to start with just resistance exercises. And maybe I'm going to modify where I place that weight based on where that low T-score is. And maybe if we do start impact, or when we start impact, it's going to be upper extremity assisted versus just having Betty do jumping right away. So it's incredibly important so you know where the entry point is of appropriate and safe loading. So the bone mineral density scan, helping Betty interpret that information and you using it as a guide, sets you up to be able to appropriately intervene and start loading those bones up. All right. That is it, that is what I got for you all. I want you to start getting really curious about your patient's skeletal health, and then get after these two easy actionables. Run the FRAX tool, advocate for a bone mineral density test. Once you get the DEXA scan and you get that information, interpret that with Betty, use that as your guide, use it to deliver hope to Betty. After that, it is off to the races with your loading interventions. this framework of how to manage osteoporosis. This is one small piece. We expand on this so much greater in our L2 course. We talk about medical management. We talk about further into guidelines and how to load and what's appropriate to load. And we dig into the research. We would love to see you in that L2 course so that you all can really get a comprehensive really get comprehensive knowledge of how to manage this condition. In our live course, we have an entire lab focused on impact training, so it gives you all the ideas, all the ideas. You get to try them out of how to initiate bone loading for your athletes who are seated and they are non-ambulatory, they're in wheelchairs, all the way up to a very high, highly active older adult. That's what I got for you guys. I would love to hear if you all run the Fractual this week or interpret your patient's DEXA scan with them. I would love to hear how that goes. Have a wonderful rest of your Wednesday.

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

Dr. Ellen Csepe // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses using the "Five A's" model in the clinic with patients to begin to address obesity management as part of a plan of care.

Take a listen or check out the episode transcription below.

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 CSEPE Hey, good morning, everybody. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'll be your host today. My name is Dr. Ellen Csepe. I'm with the MMOA Older Adult Division, whose life's mission is to give grandma gains this Christmas to fight off frailty and level up what it means to be a geriatric clinician. So before we get started today, let's talk about our upcoming courses. We have two courses online that are eight week long cohorts where we talk about discharging the ankle pump and dialing in our skills for dosing in the level one course, which starts on January 10th. January 11th, our L2, level two course, we take it to the next level to really dial in our skills for older adults with specific conditions like osteoporosis, osteoarthritis, and even we have a new segment recently added on cognitive changes in dementia. So we're really glad that you're here today. Our topic for today is gonna be on obesity in the five A's framework. So your job, as a clinician and managing obesity in the Five A's framework. So I don't need to tell you guys, obesity is a growing health concern. Obesity and pre-obesity affect nearly 70% of the American population. This is obviously a big concern for us as a community, as a country, and as clinicians. And believe it or not, most patients believe that this is our job to manage, Managing obesity is something that is within our scope, and talking about the health considerations and health behaviors that contribute to obesity are within our scope as providers. But we have to take on this responsibility with excellence. We do everything here with excellence. And it's unfair to give this patient population anything less than that. And I've been saying this for a while, friends, but Our profession is uniquely positioned not to just add our opinion on how we should manage obesity, but in my opinion, we should be the leaders in health care. for how to manage obesity. We squander so many different resources that puts our profession above others. Things like time. We have more time with patients than any other provider and we often waste that resource because we're not confident in managing this problem well. We spend so much time with our patients and we have the strongest therapeutic alliances with them. We know our patients and spend hours with them as they recover from injury where they're kind of uniquely positioned at a position for behavior change. They're really primed to make the most with their health because they're afraid, unfortunately, because of their injury, because of what happened to them. prime time for us to change behaviors and we really waste that opportunity for lots of different reasons. And friends, we can no longer pass the buck off to other health care providers and say that this is their job. You know what I'm talking about. We ask our patients, does your doctor ever talk to you about exercise? Does your PCP ever talk to you about nutrition? They're like, no, they've got five minutes with me and they didn't do that. And we raise our hands and say, this is the problem with our healthcare today. No, we have a job to play in managing obesity. We have a role in this and we have to do it well because Friends, if you wish to treat obesity, you're responsible for not just identifying it as a problem in your patient population, but knowing what's going to work. For example, if I have a car and my battery is dead and I know my battery is dead and I take it to a mechanic and that mechanic says, yeah, your battery's dead. Good luck. That didn't help me at all. I need a mechanic that can identify the problem and then take the next steps to helping me fix it. We can no longer merely identify that obesity is a disease that causes significant harm to our patients. We cannot just merely identify it, cross our arms, look down the end of our nose and blame our patients. We can't do that anymore. We cannot just watch our patients suffer with a chronic illness and do nothing pragmatically to help support them. With that in mind, that same analogy of a car battery, if you had a car that needed a new battery and you came to me and I was your mechanic, I have no idea how to change a car battery. No clue. But if you came to me and I said, oh yeah, I've got this handled. I can help you out. That's an even bigger problem. We cannot address this concern with merely confidence. We have to have the skills to help our patients manage obesity. We can't just have confidence that we're providers of choice and that we're excellent. We need to have real skill in treating this concern. And friends, patients know that their weight is contributing to their problem. That's not that telling them is not the skill. That's not the skill. We need to be able to create an environment that's free of stigma. free of bias and filled with empathy for our patients that are struggling. Because patients know their weight is contributing to their issue, but in this void, in this vacuum of clinically meaningful discussion around weight and around behavior change, things like fad diets, diet pills, failed attempts at managing weight, ignorance to what might actually work, poor access to health care, and really at the bottom line, addressing their health alone. That's what happens if we don't bring skill to this discussion. If we can't bring skill to this issue, to this massive health crisis, what happens is the flip side. Patients having to figure it out on their own. So what I mean to say is there's a big difference in shooting from the hip and saying, yeah, you know, you'd probably have less pain if you weren't overweight or obese. There's a difference in that versus, can you tell me more about your exercise habits? Can you tell me, have other health care workers talked about how your weight might be changing or your weight might be impacting your condition? There's a huge difference and what that skill, if I could really articulate what that skill is, this skill is the hardest job that we have. The skill that you need is really the soft skills of being a good clinician. That's the hardest job we have. It's way easier to needle somebody's trap than it is to develop therapeutic alliance with them and make sure that they know that you're on their team and that you're an empathetic listener. That is way more abstract of a skill than just being able to do one small part of our job tactically. And I would argue that it might be the most important skill that we have. Patients need empathy if they're facing a health concern. Patients need us to see them as a person and not just as a patient. We need to address our own biases to really be impactful for this patient population. We need to acknowledge that if it were easy to lose weight, everybody would do it, but it's hard. Obesity is a relapsing chronic health condition that's multifactorial and it has a lot of psychological impact or impact bi-directionally that we don't even really fully grasp yet. Obesity is not easy to change and we need to address that first. So the next part of our discussion today, we're going to be talking about the five A's in obesity management. Now, when we talk about workouts, we're often given ideas and options to scale a workout. And so friends, if treating your patients with empathy and understanding and listening and patient-centered language is too big of an ask, I'm going to give you an option to scale this discussion with them. If the 5 A's and treating your patients with dignity and empathy and listening and respect sounds too hard, here's your scaled option for this discussion. You can say, it sounds like you're concerned that your weight is a contributor to this issue. I can refer you to a colleague of mine that has more empathy than I do and can have this discussion with you better. Bottom line, if you don't have empathy for your patients, if you haven't done the work to check your bias and how you might look down the end of your nose towards people struggling with your weight, looking for your help, then please step to the side and let a clinician come in to intervene that can have empathy and listening. Because unfortunately, you're likely doing more harm than good. Patients know that you're biased against them. They don't need you to tell them. Your face says it. And unfortunately, negative interactions with health care providers with weight bias often leads to further binge eating episodes for patients with a binge eating disorder. So no, you're not just telling them what they need to hear. You're actually being supremely unhelpful and likely making their problem worse. So if you can't have empathy, please scale this discussion and relay them to a provider that can actually be helpful. THE FIVE A'S MODEL So what are the five A's? The five A's model originates from the U.S. Department of Health and Human Services where it was developed as a framework for encouraging smoking cessation because, believe it or not, sticking your nose up in the air and saying, you know, those things are going to kill you actually doesn't help anybody quit smoking, shockingly. The same is true for older or for people struggling with obesity. So this framework was really developed to help put the patient who needs to make decision making changes in the driver's seat for their behavior change. So the five A's. ASK The first A is ask. Ask, is it okay to discuss lifestyle factors today during our session? Is it okay to talk about how weight might be contributing to your condition? Is it okay for us to talk about contributing factors like sleep and stress and nutrition? Have other health care workers discussed your weight in a way that was helpful or meaningful? So the five A's first, we want to ask for permission and some patients might tell you, no, that's okay. If somebody says, no, you know what? This really stresses me out. I'm not interested in talking about this with you. I just met you. That is understandable. We don't need to have a wrestling match with our patients. And if you have these soft skills, it should not feel like a wrestling match. It should feel like a natural discussion because again, patients already likely assume that their weight is contributing to their problem. You can ask which factor of their health they want to address today. So whether we know that sleep, stress, weight, exercise, diet, all interweave in regards to behavior change. We know that those things are interwoven and impact each other. ASSESS So our next A is assess. Assess, so you can ask a patient, hey, what do you want to talk about today? There are a few different things about your lifestyle factors that might be contributing to your condition. Yeah, your weight might be part of it. Also, sleep has a bidirectional relationship with weight. Exercise habits, dietary habits, stress, which do you kind of want to dive into today? And then let that drive the next tool of assessment. So if your patient says, you know, I actually don't know how much I weigh, do you have a scale here? Of course, that's within our scope to weigh our patients, to calculate BMI, to look at waist circumference. An important note should be that we do that in a private area because discretion with privacy is super important with this patient population. So we can't make good decisions with bad data. That's from our CEO, Jeff Moore. We can't, give patients and shoot from the hip that they need to lose weight when we don't know anything about their body composition. So weighing patients, providing that information about their waist circumference or their BMI is our next A for assessment. ADVISE The next advise, so the third A is advise. advising patients that sleep, exercise, appropriate nutrition management can be helpful in reducing pain. Most patients come to see physical therapists because they're in pain and so understanding that those factors deeply influence our success with rehab, and those are things that we can modify, that is hugely important for our patients to know. Also, not setting the goal too high. We might say, here's what your BMI window would be if it were normal, but who cares? Our goal initially should be to manage weight for five to 10% because even small percentages of weight change can be hugely impactful on lifespan. There's a lot of discussion about whether or not weight cycling and trying to lose weight only to gain it can be bad for our metabolic health, and meta-analyses recently would show that, hey, even if you lose weight and regain it, that can be beneficial for your overall health long-term, and you can still have a decreased risk of experiencing diseases. Noting that, you know, advising the patients that, hey, if you've tried losing weight in the past and it was a real stressor for you, we can talk about just increasing your activity level. It doesn't have to be a goal to lose weight. That does not have to be our goal. We can advise patients to just increase their activity level or decrease their added sugar, irrespective of weight changes, and that alone can be helpful in managing pain and managing injury. Third A is advise. AGREE The fourth is agree. So this is super important for our patients. We have to agree. We have to come to an agreement as to what we're going to do next. This is a pro tip. Let your patient set the goal. set what they want to do. Being told, okay, we are going to agree for you to stop smoking. We are going to agree for you to cut back to two cigarettes a day. Nobody likes to be told what to do. So asking your patient, what would you like the goal to be for the next week before we see each other again? Let's agree to talk about this again in the future, but I want you to set the goal for what sounds realistic for your life. I'm not going to tell you what that is. ARRANGING And then the fifth A, likely the most important, is arranging. So arranging for services for our patients. This is probably where we like to, you know, shoot from the hip and say, have you tried cold plunges? Have you checked out this latest app? Have you seen this new meal subscription plan? So arranging for our patients to access services is a huge, role to play in a patient's weight management, I would advocate for you guys. Really challenge your biases here. If you had a patient that had a resting blood pressure of 200 over 130, you'd be like, shoot, man, you are in danger. You are not okay. We need to send you to your PCP to talk about blood pressure medicine. That's what it's there for, right? Friends, if we can say that about blood pressure medicine, Why can't we say the same thing about medicine that would help manage obesity? We know obesity is a chronic, relapsing, difficult to treat condition. We know that it's a disease that requires medical management in some cases, and that people with just diet and exercise alone still struggle with success with managing their weight. If we're going to say that our goal is to manage weight for people that struggle with obesity, why are we so against referring them to get medicines. Why are we so averse to referring out to clinicians that would do this better than we would? It's no shame to say that you might need medicine to help manage a chronic health condition. So referring patients back to their primary care doctor to determine if it's appropriate for them to be a candidate for bariatric surgery, or talk with a nutritionist, or talk with a dietician, or be on medications. That is within our scope as well. And you really, friends, have to check your bias. If that puts a knot, a ball of wax in your throat, that you're like, oh, I really don't wanna do that, that's cheating, cheating. It's cheating for a patient to use medication to lose weight. They should do it the hard way. Like, we're not gonna be effective to patients coming at a chronic health condition with that bias. Can people be successful with managing their weight without medicines? Absolutely, but those medicines are underutilized for the people that truly need them and overutilized by Instagram models. So I think that we can do our patients a favor and check our bias when we're talking about medications and other procedures related to weight loss. SUMMARY First, ask. Then, assess. Third, advise. Fourth, agree. Fifth, arrange. So those are the five A's for obesity management and the conversation that we had around them. Friends, I am so honored that you would spend your time with me to talk about how to serve this patient population better. This patient population deserves our best stuff. They deserve excellence. They deserve people who are truly compassionate. And friends, we have a strong role to play in this huge problem in society. You know, it's really easy to acknowledge that chronic pain, um, chronic pain and over-utilization of obese or of opioids is a huge problem in our world. We know that overdosing from opioids is a huge problem that physical therapists can be super impactful in treating. I would argue that we have a much bigger role to play in managing obesity and supporting our patients than we assume. We really don't do enough for our patients because we're often limited by fear. We're often limited by a lack of skill and a lack of knowledge into what we should do. And I am so honored that you would spend your morning with me sharpening those skills. Our patients suffer in the void of these meaningful discussions. Our patients suffer by themselves, not knowing if there's a clinician who has empathy and support for them. I'm so thankful that you listened to this podcast today to really better serve those patients who are vulnerable in our healthcare world. Thank you so much for joining me. Have a great rest of your 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. Christina Prevett // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the role of estrogen in the body, the important role estrogen (or lack thereof) may play in rehab outcomes, assessing menopause in the clinic, and hormone replacement therapy.

Take a listen to learn how to better serve this population of patients & athletes.

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

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

EPISODE TRANSCRIPTION

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 Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. And y'all, the pelvic division has been just really busy over the last couple of weeks, couple of months, heck, the entire year. But if you did not see, we actually just sold out our first online cohort for 2024. And so that is sold out. So our next cohort for our online level one is March 5th. Our brand new inaugural cohort for level two, if you've taken level one, is April 30th. And in 2024, I am going to be in Raleigh, North Carolina with Rachel Moore, January 13th, 14th. And Alexis is going to be teaching in Hendersonville, 27th, 28th of January. And then we're heading over to Bellingham, Washington, February 3rd and 4th. Those are the first three courses of 2024 if you guys are interested in coming to our live course and doing some of our skills check for cert. ESTROGEN & REHAB Okay, so I kind of want to talk about estrogen and specifically estrogen in later life and lack of estrogen and how it influences rehab. So this has been something that I've been really kind of geeking out about over the last little while around, you know, not just as pelvic therapists, but as anybody working with a person going through menopause, if you are working with anybody over the age of 50, a female over the age of 50, you are interacting with a person who is going through estrogen depletion in their body. And As I've learned more about the influence of estrogen on our bodies, the more I am recognizing even outside or maybe even especially outside of the context of pelvic health when I'm seeing people who are postmenopausal, but in my orthopedic rehab, how much it is influencing our outcomes. and just a person, a person who is a female in an aging body, what the lack of estrogen may do for the way that we experience aging. And then I kind of want to cap this podcast off talking a bit about some of the myths and misconceptions around estrogen replacement therapy. or menopause replacement therapy. And we'll talk a little bit about the change in the labeling of these types of treatments and where some of the thoughts around risk for things like sex-related cancers has come up. So to start this off, I want to start with a story. So I was working with a woman who was coming in. She was in her early 60s and dealing with shoulder pain. She had a history about 10 years ago of frozen shoulder. So when it comes to adhesive capsulitis, we know that being a female and being kind of in middle age is a risk factor. And I never really thought about that risk factor being linked to estrogen status or like the beginning of perimenopause. Still wasn't really thinking about it. But she said, you know, that was a really long journey when her shoulder froze. And but it got better, got better over time. She realized that she was going through hormone replacement therapy or she was going through menopause. She got put on hormone replacement therapy. She was on it for 10 years. And then her doctor on a follow up where she was trying to get a renewal said, actually, you've been on it for too long. I'm going to take you off of it, which that That's a whole other ethical scenario, especially because we should be weaning off estrogen replacement therapies, not just going cold turkey. But however, took her off and within a couple of months of that weaning process, her other shoulder started to freeze. I've obviously been in the weeds of this research right now around the influence of estrogen on our body, but I was thinking about and reflecting on how many women I have worked with over my career. THE INFLUENCE OF ESTROGEN ON OUTCOMES I've been a PT for 10 years, so very still early on in my career, but how many have I not recognized the influence of a person's estrogen status on our outcomes? And so when we think about estrogen, we think about fertility, rightfully so. We think about pelvic floor physical therapists kind of specializing in the fertility space, granted, but estrogen, when we have a depletion in estrogen as women go through menopause, it affects every part of our body where there is an estrogen receptor. And I don't think that many orthopedic therapists or people who kind of aren't niching into this space, myself included until I got into this arena, recognize just how widespread that is. And in pelvic health, we've done an incredible job of advocating for individuals in the perinatal space. We still have, of course, ways to go. However, you know, there's this rise of individuals going through menopause who are starting to advocate that we need that same type of education. And too frequently now that I've been asking are my patients saying to me, oh, well, my doctor said it was just part of aging and I shouldn't be on hormone replacement for this long or like have just been dismissed about their symptoms and have not linked some of these other body systems and the experiences that they're having in these other body systems with their estrogen depletion. I have a client seeing me for ankle pain and she's kind of in that postmenopausal window and she said, I am trying to learn a new body that I do not understand. And I think that was such a profound statement because so many individuals are feeling this way and we have a huge role to play in rehab. And I'm not talking pelvic, I'm talking generally. THE ROLE OF ESTROGEN IN THE BODY And so when we think about estrogen, estrogen has receptors in our brain. It has receptors in our joints and muscles. It has receptors in our heart, and it influences our bone, right? Bone is probably the easiest one. We know that individuals who are postmenopausal are at increased risk for osteoporosis osteopenia, that there is an accelerated rate of decline in bone mineral density loss with estrogen as rates of, estrogen helps rates of bone build up. And with estrogen depletion, we see a switch in the slope of the line where bone breakdown exceeds rate of bone growth. And so rates of osteoporosis go up postmenopausally. We also see that individuals who are in an estrogen depleted state have higher rates of joint pain. So kind of an umbrella term of joint arthralgia. and we see links to risk factors around things like adhesive capsulitis in individuals going through perimenopause, but very little research has actually looked at individuals' experiences of musculoskeletal pain in the postmenopausal window. So we could have individuals who are not responding as quickly to rehab, even though we're throwing everything at them that is evidence-based and evidence-informed, because they are going through menopause and it's the influence of their hormones is changing the way that their body is responding to some of our rehab interventions and we don't know about it. Our body also has estrogen receptors in the heart. And so we see that men tend to have a higher rate of cardiovascular disease and heart disease than women, but that change in rate between men and women starts to change in that postmenopausal window. So rates of heart disease start to go up postmenopausally because of the protective effect of estrogen on the heart. What we also see from a metabolism perspective is that there is a change to the way that fat is laid down when individuals are postmenopausal. So where we have the protective subcutaneous fat that tends to be something that is kind of a net, potentially neutral way of laying down fat, the more dangerous fat is visceral fat lay down, and that tends to accelerate in a postmenopausal female because of estrogen deficiency. which then increases risk for a whole bunch of different metabolic diseases, including, you know, heart disease, stroke, Alzheimer's disease, like all these diabetes, all of these things that we know are linked to pro-inflammatory cascades. It accelerates for individuals as they go through menopause. And then finally, from a cognition perspective, we have systematic review evidence that Individuals who go through premature ovarian insufficiency. So individuals who go into menopause before the age of 40 are at an increased risk for cognitive decline. So rates of Alzheimer's are higher in individuals who go through early menopause. And we see that there may be a protective effect, preventative effect of the development of cognitive decline for these individuals who are going through menopause early if they are on hormonal contraception. Which gives a very strong argument for the link between estrogen status and cognition. And when we think about symptoms of menopause, we kind of put them into different buckets. We talk about, you know, vasomotor symptoms, which are night sweats, issues with sleep, sleep disturbances are very high around the postmenopausal or menopausal transition, and hot flashes. Right? And there's kind of like this immediate withdrawal effect of estrogen. Like you could almost think about it as like a drug withdrawal. Like when we get withdrawn from estrogen, those vasomotor symptoms kick up. And then eventually our body gets used to being in that state of estrogen deficiency and those withdrawal symptoms kind of go away. But genitourinary syndrome of menopause is really focused on the aging of the pelvis and its influences. And so when we're in pelvic health and we're talking about estrogen deficiency, we see, you know, adhesions in the labia minora to the labia majora. We see an increase in friability of tissues. We see an increase or a changes to the pH of the vaginal microbiome. And so these all have influences, but the genital urinary syndrome very much focuses on the pelvis. ASKING ABOUT MENOPAUSE And so if you are not in pelvic health, you may not be really considering it a reason to be asking about symptoms of menopause and when you went in through menopause. But if you are an individual who is working with anybody who is a female over the age of 50, you should be asking, are you in menopause? Have you gone through menopause? When did you go through menopause? And menopause is diagnosed as the 12 month mark of not having a period. So when you have not had a period for 12 months consecutively, that is considering being in menopause. Average age is 50 to 51 in the United States. asking around changes in symptoms around the menopausal transition. Did you notice a change to your mood? Did you see a change to your sleep? Did you see a change to your cognition? Did you see a change to all these other things? Because we know that if you're depressed and not sleeping and your joint pain is up, we're probably gonna have a lot of conversations that we need to have around recovery. It's gonna influence the way that our treatment is going to go. And then we can be an advocate for ways to manage. Too often, and there is nothing that makes me more mad. Like when I see individuals who have gone to their doctor and they say, I am suffering with vasomotor symptoms. I am suffering with all of these things. And they say, I have no libido. And they say, well, you are going through menopause. And that's kind of the way it is. Men will get Cialis or other types of hormone replacement for their sexual dysfunctions very readily. And it is met with hesitation when we are talking about female reproductive aging. And I was just at a course where it has some individuals who are part of the military and the military nurse practitioners were there, which is really cool. But they said, you know, we are so willing to prescribe Cialis but we are very hesitant as a division to give hormone replacement therapy. HORMONE REPLACEMENT THERAPY And so the next part of this conversation, one, estrogen affects everything. It's absolutely gonna influence our pelvic floor. It's absolutely gonna influence our pelvic health. But then the next thing that people are asking is around estrogen replacement therapy, sex hormone replacement therapy, and its safety and efficacy. So I wanna do a little bit of a history lesson here around where this risk is coming from. So there is a large longitudinal study called the Women's Health Initiative that has been collecting data on women for a very, very long time. And early, early on in about 2001, a study was released from the Women's Health Initiative that said that there was a 25% increased risk of sex-related cancers for individuals who are on hormone therapy than individuals who are not. This was, potent, like kind of true, but it missed the forest for the trees. And so when we kind of zoom out and we look at relative risk of sex-related cancers, that, well, that translated into, instead of it being three in 1,000, and these are not perfect numbers, I don't remember off the top of my head, it changed to a four in 1,000 rate or incidence of sex-related cancers. When if you think about it like that, that is not the biggest difference. However, that one study came out and it changed everything. It was largely disseminated, many media outlets put it up, and it made everybody very, very fearful of prescribing hormones. So there's a couple things nuanced to this. When we are taking any type of medication and our sex hormones are not anything different, there is always going to be potential risks. Those have to be balanced by the benefits. We see, for example, that individuals who are on replacement therapy have a lower risk of Alzheimer's, dementia, especially if individuals are going through a menopause early. We see sexual health, sexual, satisfaction increases on hormone replacement therapy. We see an increase or rather a decrease in rates of urinary tract infections. And if you are working in the geriatric space, move this into Wednesday. It makes a huge difference. A urinary tract infection can change a person's life. A person can die of a UTI because it can end up, they get in hospital, UTI becomes sepsis, sepsis becomes a full blown, you know, it's now a full blown infection and individuals don't get out of hospital or they see a consistent change in function. All of these benefits for many are going to outweigh that slight increase in risk. Now, we have evidence since then that that risk percentage may have actually been when we replicate a study, which is super important before we're making very broad sweeping statements. There is a range of that relative risk and it actually might be lower. And because of that, we now have good evidence for individuals who are going through chemo to be able to have, because it can irradiate and bring you into a low estrogen state, where they may use topical estrogens. We have more evidence for individuals who are on estrogen receptor blockers, like tamoxifen, to, again, have topical estrogens. Because, obviously, we're not gonna wanna ingest estrogen when we're trying to block it so that cancer doesn't regrow, but to put it on the external genitalia, that would allow us to remove some of those pelvic-related symptoms for individuals being in low estrogen as a consequence of cancer treatment. And this evidence is continuing to grow. NO EVIDENCE FOR AN OPTIMAL HORMONE REPLACEMENT WINDOW The other question, when I go back to my patient that I talked about, is that he said, well, you've been on it for enough, this physician, and I'm gonna take you off. We actually, again, don't really have any evidence around where that window is. Like how long you can be on it before the risks start to outweigh the benefits. And because we don't know, individuals are just creating a risk tolerance zone for themselves and then unilaterally kind of applying it in their practice. And so we still have so much work to do in this space. We are starting to see a change in our language around hormone replacement therapy, and it's being changed to MHT, menopausal hormone therapy. And it is actually encompassing a variety of different treatments. It is not just a systemic pill that you can take that is a natural replacement, there is those. There are progesterone replacements. There are estrogen and progesterone combos. There is evidence for testosterone replacement and testosterone replacement helping individuals with hyposexual disorders. And then there are topical estrogen therapies where individuals who are experiencing recurrent UTI, individuals with issues with labial adhesions, individuals with clitoral adhesions, all these different things can see a huge benefit to this type of hormone replacement. And so, The role that we have to play here, if you were a pelvic clinician listening to this, we have a ton of advocacy to work on. Staying up to date with the evidence, referring back for potential counseling on hormone replacement, and continuing to have those conversations with our physicians is gonna be super important. If you are a person who's an orthopedic specialist, you need to be asking about estrogen status. Have you lost your menstrual cycle? That puts you in low estrogen. Have you recently had a baby? If you're a postpartum and you're dealing with a wrist injury, that low estrogen is gonna impact your ligaments. It's going to make it so that you may be more likely to have things like mom wrist decorvains tendosynovitis. And then if you're working with individuals who are older, then again, we're gonna be asking about when you went through that menopausal transition and how you're feeling. A lot of people feel like, oh, well, I'm going okay through my menopause right now. I don't really need it. The thing is estrogen deficiency is accumulative. So it is also a discussion around the preventative aspect of continuing to have individuals on hormone replacement. I don't know the answer to this, but it is a continual conversation. It is one that is happening in lots of spheres and one where there is a role for rehab. And this has been such an important part of the development of our research base in pelvic and a huge portion of the proportion of individuals that we are seeing in our practice that we have put it into our level one. So we have an entire week on the influence of menopause on the female body and an entire module on the way that we would work towards treating individuals and advocating for individuals who are going through menopause, who are subsequently feeling issues with pelvic health. So if you are interested, get into our March cohort. I could rant about this all day. I'm already 20 minutes in. I'm gonna get off here, but it's important. And it is not just important to our pelvic health clinicians. It is important for everybody who is working with a female body over the age of 50. And we're not even going to go into the perimenopause part because perimenopause could be 10 years before. So if you're working with anyone over the age of 40, this is relevant and it influences our rehab outcomes. All right. I hope you all have a wonderful week. Merry Christmas. If you are off, happy holidays. Whatever denomination you are, please hopefully have some time to spend with loved ones. And I hope that you get some of the rest and relaxation that is just something that you are looking for. I have two little ones, four and two, and the magic of Christmas and the holiday season is so alive and well in our house, and it is such a beautiful thing. So I hope you all get that. You are so welcome for me talking about this. I promise you, I will be diving more into this onto my personal Instagram, and it's definitely gonna come onto ICE because I think it's really important, and I think it's a huge miss that we have. So thank you for listening, and I am so excited to continue these conversations. Merry Christmas, happy holidays, and hopefully you get all of that rest and relaxation for the end of 2023.

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses how to adapt the @concept2inc rower for patients & athletes who cannot use both legs, both arms, or seated athletes.

Take a listen to the episode or read the episode transcription below.

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

EPISODE TRANSCRIPTION

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 FREDENDALLAlright, good morning everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Fitness Athlete Friday. We talk all things CrossFit, Powerlifting, Olympic Weightlifting, Endurance Sports, Triathlons, Marathon Runners, Cyclists, figure skating, all that wonderful stuff. If you are working with a person who is recreationally active in the gym, on the road, whatever, Fitness Athlete Friday is for you. Today, we're going to build upon an episode from three weeks ago, introducing you all to the Concept2 Rowing Machine. We're going to build and show you how to adapt this machine for a lot of different folks who might show up in the gym or in the clinic, post-op, adaptive athletes, all that sort of thing. Before we get started, just a heads up about courses coming your way from the fitness athlete division. Your next chance to catch us online for our level one course, online course, eight weeks, entry level course previously called Essential Foundations will be January 29th. So our Clinical Management Fitness Athlete Certification, Level 1 online, prerequisite for Level 2 online, that class begins February 5th. And then our live seminar is its own standalone event. Those are all over the country this coming year, so check out PTENICE.com and look for Fitness Athlete Live for courses coming near you. And then check out our two online courses beginning in January and February. Just a reminder, all of our courses currently priced at $6.50 will jump to $6.95 on January 1st. And really, we don't want to pressure you, but most of our quarter one courses, live and online, are selling out. Our pelvic level one online course just sold out yesterday, about a month in advance. So we're seeing about a three to six month sell out window currently. So if you had an eye on a course, we'd recommend grabbing it sooner rather than later, especially if you can take advantage of saving some money on that price increase. So that's courses coming your way from the fitness athlete division. ROWING 102 So before we get started, I'm going to show a lot of stuff today. So if you are listening on the podcast, and you are a visual person, or you're not very familiar with the rower, I would recommend you stop the podcast, you jump over to our YouTube channel, and continue watching this episode here on YouTube so you can actually see what I am doing. So I'm going to reference two previous episodes as we talk about today's topic. So we're going to get into some advanced mechanics of the rower, how to adapt the rower with different equipment. Go back three weeks, episode 1606, where we talked about the very basics of the Concept 2 rower, how rowing works mechanically, how to put yourself in the best mechanics to row, how the rower itself too works as far as what are the different pieces of equipment, how to clean them to make this machine last you, 10, 15, 20 years, and then also how to use very basic things on the rower like drag factor to understand where you should place your damper on the flywheel, again, to optimize the very basics of rowing. I want you to go back two weeks to Guillermo's episode, episode 1611, to learn a little bit about how intervals, he specifically talked about research on assault bikes, but how intervals on earth machines in a very small time window, two to three times a week, for eight to 20 minutes of work can have a significant increase on VO2max. So never forget, when we're working with patients, working with athletes, especially those folks already active, at the very least, we can help them maintain their current level of fitness, being intelligent with how we use machines, how we adapt the machines, and that's the point of today's episode, of how to adapt these machines. So folks coming in, they can only use one arm, they can only use one leg, they're pregnant, they're postpartum, whatever, how can they get on this machine and at least maintain their fitness as we work through their rehab. 1-LEGGED ROWING So I want to talk about how to set up the rower to row with just one leg. I want to set up the rower and show you how to row with just one arm. And then I want to show you what many people don't know is that the rower actually breaks down in half. Yes, to make it easy to store, but also to get rid of the rail so that seated athletes in a wheelchair can roll up to the rower and row on a Concept2 rower. So the first thing I want to show is very simple, one-legged rowing. So what you're going to want is one of these little things. If you've ever changed your own oil on your car, you know what these are. These are little caddies that roll underneath your car. So they have wheels, six axis, they move in any direction, and they're mainly designed to hold tools and stuff if you're working underneath in your car. So you can get these at an auto parts store for 10 or 20 bucks. You just need one of them and they'll last forever. Alternatively, you can also use a skateboard or something like that. But what we want is we want something that we can place someone's foot inside of that moves, ideally moves what we call six axis, right? Forward, backwards, side to side, and then each diagonal, right? It can potentially move 360 degrees so that as a person rows, their foot can move alongside the rower. So let's set that up. So for example, let's say I can't use my left leg, maybe my left leg is locked in a knee brace, I'm locked in full extension, maybe after ACL reconstruction or something, I can still get on the rower and row with one leg. So I'm going to get on my rower, I'm going to strap in, grab the handle, Until my wife was on the rower last, she cinched the straps all the way down. And now, instead of putting two feet in, because I can't bend this knee, right, it's locked in extension, I'm going to kick it out to the side of the rower, and I'm just going to let it rest in this whale caddy. Now, I can still more or less perform all of my normal rowing mechanics. I can still drive with my right leg, I can still lean back, and I can still pull with my upper body. So this is fantastic, folks maybe working with an amputation, folks locked in a brace, maybe folks that just can't tolerate that loaded knee bend, knee extension with that leg for whatever reason, we can have them still row using something like an oil caddy or a skateboard. So that's one leg rowing. 1-ARM ROWING Now, one arm rowing is totally possible. You're going to want a device like this. This essentially just looks like a hook. You can get this from Adaptive Training Academy. So if you don't know Adaptive Training Academy, we highly recommend them. They have a wonderful course on basically adapting all things fitness for adaptive athletes. So it's a course that has its origins with CrossFit, but now has expanded into the rehab community as well. How rehab providers and fitness professionals can work with adaptive athletes to get them moving, keep them moving. They have a wonderful store full of all sorts of really, really, really cool things to help you work with adaptive athletes. And this is one of the tools they sell. So these hooks are going to latch on to the handle of the rower, and they're going to allow me to row with one hand. If you'll notice on the rower handle, in the middle, it has places technically to row with one hand, but they're not very comfortable. you need to essentially weave your fingers through and then you have the metal chain kind of bashing against your knuckles the whole time you're rowing with one arm. It's also very wide, so you'll sometimes see people row with a neutral grip and that's just not very mechanically advantageous. This is designed to improve that. To bring the handle in so that I can grab it with one hand, I can technically even hook grip this to really get the most out of my grip on my right arm or left arm and row to my chest and maintain my normal rowing mechanics. This is also fantastic for pregnant women who maybe don't tolerate the flexion on the rower anymore because of their stomach or the extension because of the stress it places when they lean back. What's great about these is you can build them on each other and you can essentially reduce the range of motion needed to reach towards that handle. So this can even be great for kids to get them on a rower at a younger age or maybe they literally don't have arms long enough to reach the handle, we can bring the handle to them. So I'll show you what that looks like with one arm rowing. So sitting in the rower, taking the hooks, latching it onto the handle, and now it's reduced the range of motion by about six inches towards me. And now with one arm or the other, I can pull and I can maintain all of the same mechanics of rowing. with one arm. I'm still able to drive with my legs, lean back, and pull the handle to my chest. Again, if needed, I can put another one of these on here and continuously bring that handle closer to me. So this hook is available again from the Adaptive Training Academy store if you want to pick that up for your rowing. DISASSEMBLING THE ROWER FOR SEATED ATHLETES/PATIENTS The final piece is breaking the rower in half. Again, a lot of folks don't know that the rower actually disassembles into two pieces. That's to make it easy to store. It's totally possible to break this rower in half, and if you have a larger car, an SUV, certainly a truck, you could take the rower with you, maybe if you're a home health clinician, and bring it into people's living rooms. it is made to break in half and all things considered once it's broken into half it's not very cumbersome and it's not very heavy. So let's talk about how to do that and then adapt that for the seated athlete. So right here at the base of the foot plates you're going to see a black piece and you're going to see a little handle to lift up. If I lift this handle up you'll see that the rail of the rower is just sitting on metal rod that's connected to the flywheel and the computer portion of the rower. So if I lift this up, I can now disassemble the rower into two pieces. So now the rails here, this weighs almost nothing. This weighs a couple of pounds. Again, this would be very easy to throw in the back of an SUV or a truck. The heavier part, of course, is going to have the damper and the flywheel, and all of the computer parts, but now I have the front part of the rower. Now I can have somebody in a wheelchair roll up to this. We can play with different variables. In the gym, we like to lift it up a little bit, and we like to put sandbags or plates to anchor it down, and we like to sit it on some sandbags or plates. So depending on the type of wheelchair that your patient or athlete has, you may need to bring the rower up a little bit so they can roll up, get into a good position and row. And then definitely, because it's no longer as heavy as it once was, you're going to want to make sure you weigh it down so that as they begin to pull the handle, this thing doesn't move around. But with a little bit of ingenuity, this is something you could even bring into someone's home, maybe wheelchair bound, where they're able to row, maybe do some intervals on the rower. So make sure you understand that the rower breaks down. This also makes it really easy to store rogue fitness. So you can see one over here in the corner, my bench is hanging on it. They make hangers that can be mounted to a wall that can hang either benches or it's designed to hang the front part of your rower off of. If you're thinking you're in the clinic and you don't have room on the ground for a rower, that's okay, you don't need it. You can break the rower in half at the end of the day and you can hang it on the wall. So make sure you understand that the rower breaks in half. That's made for storage, for travel, but also really important to make sure that we can get seated athletes using a rowing machine. So rowing, this is a very versatile piece of equipment. Make sure you understand how to use it. Make sure you understand that you know how to adapt it for different patients and athletes that present to you in the clinic in the gym and get more people rowing, get more people working on or maintaining their current level of fitness as you help them through the rehab process. I hope this was helpful. I hope you have a fantastic weekend. Our very last live course of the year is this weekend. It's happening right now in Salt Lake City. It's a dry needling course with Ellis and Melrose. So if you're there, I hope you have a fantastic time. Other than that, I hope you all have a wonderful Christmas, a very happy new year. Have a great Friday. Have a great weekend. Bye everybody.

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

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses how the pursuit & achievement of clinical excellence solves many problems. Individuals who produce high-level outcomes in the clinic tend to be the ones who get paid more, work less, dictate their schedule, and overall feel a significant return on the time investment they spend in the clinic.

Take a listen to the podcast episode or read the full transcription below.

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

EPISODE TRANSCRIPTION

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

JEFF MOORE All right, team, what's up? Welcome back to the PT on ICE Daily Show. It is Thursday. I am Dr. Jeff Moore, currently serving as the CEO of Ice, and always thrilled to be here on Leadership Thursdays, which are always Gut Check Thursdays. Let's get it out of the way. Let's talk about the workout, and it's a banger. We've got three sets of the following rep schemes and movements. We've got 21 burpees to target, followed by 15 devil's press, Okay, it's gonna be with 35s or 20s. Okay, so going into that deficit push-up, pop into a squat, weights above the head, and then back down. 15 of those, nine burpee into a chest-to-bar pull-up. Then, however long that took you, you're gonna rest one-to-one. So if that took… Let's see, maybe three-ish minutes, right? You're now going to rest for that same amount of time, and then you're gonna fire back up set number two. The workout is three sets with that one-to-one work-rest ratio for time. That, I'm looking at that, I'm gonna need to settle into about 20 minutes or somewhere on that workout. That is going to be rough. Okay, as far as upcoming courses, one thing I wanna mention is that Pelvic Live, I'm sorry, Pelvic L1 Online only has four seats left. I also wanna say a lot of the courses in January are looking that way. Remember, our prices go up January 1st. It's only 45 bucks. It's from, all the 650 courses go to 695, but if you're gonna grab a Q1 course, they're already all on the schedule. Make sure to jump in and grab that course before January 1st, because right now you can buy them all for the $650 price. So if you have any courses you're looking at in 2024, you know you're going to take anyways, just jump on there and grab them before that price jumps up to $695. on January 1st. So you've got a couple weeks, that being said, a lot of them are selling out. So try and scoop up those tickets over at PTOnIce.com as early as you can to save yourself a few bucks going into the new year. So that is my course announcement. EXCELLENCE SOLVES EVERYTHING Let's talk about excellence. So the topic of today is excellence solves everything. And what I mean by that is, There is a threshold of excellence at which no barrier survives to your success. This is where the idea of becoming undeniable feeds in really well. Now, we're going to chat PT, but you can think about this anywhere. Think about that musician who doesn't have a major record label. Think about that busy restaurant in a horrible building or a terrible part of town or bad location, what have you. Think about the individual player with a mediocre teammate who still wins the championship. There is a level of excellence at which once achieved, nothing else matters. That being said, that's very, very high level from a success perspective. Now I want to drill down and talk about a specific thing that possessing that excellence gives you or benefits you or arms you with because it is so relevant to today's practicing professionals. EXCELLENCE DRIVES AUTONOMY Possessing excellence, certainly at a level like we discussed before, allows you to always be deciding. And as I look at why that's so important, it's because autonomy is, from my vantage point, the most modifiable and important burnout variable or job satisfaction variable. Autonomy is the most modifiable. Burnout or job satisfaction variable. I was talking with Adam Fritsch down at South College I work with Adam over at South and that he and his colleagues over at Bellin published a paper I think it was in March of this year titled feeling exhausted how outpatient physical therapists perceive and manage job stressors and in that paper All the things you would expect kind of fell out of solution, right? Like if the workload was unmanageable or perceived to be unmanageable, that was stressful. If cultural differences were present, that's stressful. But what pops out at me in that paper, because it's so directly modifiable, is the lack of control or this idea of not having autonomy. Namely that if people did not perceive themselves to have control, they felt more burned out. Everybody I talk to making their way up the professional ranks, that constantly jumps out at me. Now, let me talk about why excellence takes care of that problem. That is because it allows you to always be deciding and that's what autonomy is. When you achieve a certain level of excellence, You get to always be deciding. You get to always have control. And I think the data shakes out to say that will prevent burnout and maximize job satisfaction. Let me give you some really specific examples of where you get to always be deciding that other folks might not that are going to lead to you perceiving that feeling of control that avoids burnout increases satisfaction. Number one, which insurance is to take? When you hit a certain level of excellence, you're deciding that. You can say to the insurances, look, your customer's gonna come to me either way. They're just gonna be furious that you're not covering it. But they're not gonna make a decision to not come. They're gonna come and then be mad at you. At a certain level of quality of service delivery, you will hit that reality. Right alongside that, how much to charge. You're the one deciding. The solution to burnout is appropriate return on your time investment, another huge variable. You can't balance an equation with the wrong numbers. You need to be able to drive what you receive for your time delivering services. at a certain level of excellence, you get to decide that. You're not thinking about what might this market handle or what's the, you're thinking, this is what I'm gonna charge because this makes sense for my model. Now, you're gonna combine a few things when you do that. Number one is make sure the equation works, but number two is putting that price point in a spot where you actually get to serve all the folks that you want to serve, that you feel called to serve. So, it's multivariate that coming to that number. but you get to come to that number, right? That's the beautiful thing about it. Number three, when to work. There are few things that decrease stress like having complete control of your schedule. This is the one that hits me the most personal. I have no issue giving you massive volume of work days. I have no issue being up at four, 4.30, getting after it, putting out a lot of production. I have no issue with that as long as Right now I'm holding 4.30 to 5.30 because my kids might text this morning they wanna hit CrossFit. As long as I have the autonomy to hold these parts of my schedule that are non-negotiable, I have no issue with the work output on the other part of the day. It's being able to control when you work that I think is probably a bigger variable or a bigger factor than the amount of work and people just haven't put that together yet. But again, at a certain level of excellence, you control that. Because when you say to that patient, I can only see you at seven a.m., if you're good enough, if they perceive you as valuable enough, they're gonna say, well darn it, that isn't a perfect time for me, but there's no way I'm not taking the appointment. They're only saying that if you've achieved a certain threshold of excellence. So now you're deciding when to work. You're deciding how or even if you want to market. You may choose to not spend any time in that space. I wouldn't advocate that from kind of a business consulting perspective, right? All the best companies market when they're busy. That being said, you could decide that. at a certain level of word of mouth demand, right? But certainly when you do market, it doesn't have to be salesy. At a certain level of excellence, you're simply reminding people that they want to come see you. They've already heard from nine other people they should. They've already been thinking about coming in for a long time. Now your marketing simply becomes creative reminders, which is a much nicer way to go about engaging with your audience than always trying to sell them something. So you get to decide at that certain threshold of excellence how or even if you market. You decide whether you stay at your job. You no longer need to stay at your job because you have to. You stay at your job because you love it. Because the people that have created the environment have done a great job. And you can't get enough of the culture. And you're learning a ton. And you're serving people you care about. You're staying for all the right reasons, but none of the wrong reasons. Because you can walk any day. You think to yourself every morning, need this. The people want to come see me no matter what. I'm choosing to stay here because I love it. That's a lot different professional world. You don't feel stuck. You're driven by choice because you've achieved that level of excellence. Excellence is so unique. because it solves all of those problems. Those are all problems that every business guru is trying to sell you an individual solution for, right? How to navigate the insurance market, how to come up with your pricing, right? How to get more control of your schedule. You could find individual products that would try to solve only one of these, all of them. EXCELLENCE: THE CLEAN SWEEP Excellence is a clean sweep. Once you get good enough, every single one of those problems gets erased at the same time with one thing. But there's one other thing before I sign off that I want you to think about that is so unique about possessing excellence. And that is that it travels with you. I don't think enough people think about this. Excellence travels with you. Relationships, local marketing, et cetera, all of those things, if you change where you're working, if you move or relocate, all of the other business hacks, if you will, that you leverage have to be started back up. But your excellence travels with you. It's gonna meet you there, right? Right from patient one, they're going to perceive the asymmetry and the quality of what you deliver, and all of those problems are gonna vanish without you having to restart any of the other machines. Excellence travels with you wherever you go it meets you there. This is why it is hands down because it solves all the problems at once and wherever you go it meets you there, it travels with you. This is why it is the greatest and most urgent investment. I'm not telling you not to leverage all the business tools. I would totally encourage you to leverage a wide variety of business tools and strategies. I'm just saying for the greatest ROI, Get good first. Get good, then busy. Because excellence is the greatest decider to your overall success and certainly the greatest driver of your individual autonomy. And that's what I think results in incredible levels of job satisfaction and very, very low levels of burnout. Get good. You'll get busy, but you'll also solve every other problem in the process. Team, PTOnIce.com is where everything lives. Thank you all for being here this morning. Have a wonderful Thursday. We'll see you next week.

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, Modern Management of the Older Adult lead faculty Alex Germano discusses how relationship, communication, motor learning and environment can impact your outcomes and plan of care delivery while working with people with dementia. 

Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

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
Hello everyone and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today's segment of Geri on Ice. My name is Alex Germano. I'm a member of the older adult division and we just finished up our last cohort of our level 2 course. this past a week or so ago and we just debuted our new week all about cognitive impairment and I found one of the articles to be very impactful and I wanted to review that here with you all today. It is called a framework for rehabilitation for older adults living with dementia by Julie Reese from Marymount University in Arlington, Virginia. We'll dive into these four best practice domains that you can incorporate when working with this population and then how that'll really change kind of your outlook and how you see exercising and rehabilitation in this population. So before we dive in, I just wanted to orient you to some of the new courses or the courses that we have upcoming in the new year. First, we have MMOA Level 1 and Level 2. Those are our online courses. Those begin in early January. So we would love to see you hop into those cohorts. They typically sell out or get really close to it. So we'd recommend you jump in early. We also have upcoming live courses. I'll name some of the spots through February here. So we've got Santa Rosa, California, Greenville, South Carolina, Kearney, Missouri, as well as Oklahoma City, and Gales Ferry, Connecticut. So we hope to see you on the road in 2024.

BARRIERS IN DEMENTIA CARE
Now, let's dive in. So first, many rehab providers recognize that people with dementia would benefit from rehab services, but we run into many barriers and biases when working with a population that impact the delivery of our services. We have problems like, well, they're non-compliant. They don't cooperate. They won't get better, so they don't need our services. Or they don't have caregivers, so our services aren't trainable, and therefore, it's not gonna be necessary. Or if you're like me, you run into a lot of personal frustration. And I will speak to myself, or for myself only here, but it seems to, I've had some recognition from other providers that they also feel this way. I struggle bringing my fitness forward approach to this population, right? I'm, if you know me, I'm very like exercise heavy, like doing very traditional strength and conditioning movements. And sometimes those types of sessions don't work well for subsets of patients with mild cognitive impairment or really dementia. I struggle when I have goals in mind for the session, And then we get none of them done because most of the time I'm managing behavioral outbursts or orientation problems. And when I only get three out of the 10 exercises I wanted to do get done, when I got those done, I feel like a failure, right? Three out of 10, that's not great for me. And I feel like my immediate reaction is sometimes, oh, therapy, I'm not going to work for this person. But really it's the type of exercise I'm providing, how I'm delivering it, that isn't working. Okay, so it's not them, it's me. And my thought is that many of us are out here fighting to push our agenda on patients with dementia, when in reality, maybe our role as providers in this space is to be someone who's providing an opportunity for movement and letting go for the concern of what type of exercise and how much exercise that we need to get done in the session.

REFRAMING SUCCESS IN PATIENTS WITH DEMENTIA
I've started to reframe my vision of success during a session with somebody with dementia who may not follow those typical exercise instructions. I have started to realize that by me just being there, if we moved at all, that's 100% more movement than they were going to do if I didn't show up. or they didn't have me that day. And no movement is, there's no movements out there that are bad movements. And there's no exercise that is bad exercise, especially in this population. So any movement or exercise should really be success for us, right? If we got them moving at all, that should be successful. And so if we change our expectation, I think the number one way, that's the number one way we can really fight some of the burnout that we're experiencing when working with this population. Now, how to structure these sessions. Let's jump into this paper because I really found this super interesting. This paper explains a model with four domains that we should focus on or emphasize when working with patients with dementia. We have relationship, communication, motor learning, and environment.

RELATIONSHIPS OVER EVERYTHING
First, let's talk relationship because this is where we're going to spend a lot of the time. A lot of the time. Nothing is going, we prioritize relationships over everything. That's your new mindset. Relationship over everything. Nothing will get done if we don't have a personal connection with the patient and understand with great curiosity what they enjoy in life, who they find important, and what makes them tick. So in our evaluations with patients, we're not only trying to solve their movement problems or screen those, we need to find out about this person. Give me some details. Give me a list of names that's important to them. Who are your loved ones? Also, what were your past hobbies? Even when we don't have access to a ton of personal information, our approach in prioritizing a relationship will matter. We need to be consistent. We need to be empathetic. We need to always enter these interactions with the expectation of success. Our patients can feel that energy coming off of us and it's important that we bring that to the table.

MANAGING SYMPTOMS OF DEMENTIA
Now, a giant barrier to exercise is managing behavioral or psychological problems and symptoms of dementia. This can get in the way big time of that fitness forward approach or bringing exercise to the patient. Now, first, these symptoms, and it's important to recognize that these symptoms are often a manifestation of something else going on. It could be an acute medical problem, could be a UTI, could be an infection. It could be unmet needs. They're hungry. They're tired. They need to use the bathroom. They feel unclean. It could be from a lack of a meaningful activity. It could be from stress from a caregiver or a loved one, they can feel that stress, it could be an uncomfortable environment. So before we write people off, we have to go, hey, maybe we need to problem solve some of these things and really clear and make sure none of these things are going on before we say that they're non-compliant with therapy. And we need to lean into that problem solving during the sessions. That's why we're there is to solve this problem of why won't this person move much, right? So we're going to spend time solving the problem. Now, I'm not saying that we can spend 10 sessions with a person doing absolutely no physical interventions. I don't think that's terribly appropriate. And I think Medicare at some point would be wondering how they could reimburse us for all that time. But I am saying that we are going to spend time during sessions working on the behavioral problems, working through it to get to some type of skilled, meaningful movement. All of that time, all that problem solving, that behavioral management, that's skilled time. That's skilled and that's billable. We just need to do a good job in our documentation of explaining what we did, how we did it, and what the result was. And then we use that information next session to kind of guide us and get the patient hopefully moving faster and getting them up and going quicker.

POPULATION SUBSETS: IS THIS PATIENT APPROPRIATE FOR THERAPY?
Now I'll show you an example though, because I understand there are going to be subsets of this population we meet that wouldn't be appropriate for therapy after a certain amount of time. So I'll share this example of how behavioral management led to a discharge for me. I had a gentleman in the very end stages of dementia. I think I saw him during the last year of his life. He was very agitated and very aggressive. He wasn't very fit. He wasn't doing well physically, so he could not hit me, but he sure did try. And he became very agitated and very upset in my presence more often than not because he started to associate me with movement and he could not get his body to move how he wanted right he knew he there was some perception he knew what i was asking him to do was very difficult and very hard um and he associated me with that and that frustration and Stayed on for I think like 10 plus sessions like quite a bit of time Trying many different techniques trying many different behavioral management strategies giving them different equipment to use Showing really the caregiver and the wife how to do exercise with him in a meaningful way There was a lot of cursing me out. There was a lot of near hits to the face, but I Well, we started to realize that I was his trigger and that he was much happier exercising with the caregiver or the wife. So I gave them as many skills as I could. And then I bowed out. I got out, right? I was his trigger. So we parted ways, but I was able to provide some meaning and some context and at least explain how to exercise with him to his caregivers and loved ones with whom he'd exercise much better with. So I'm not saying every patient we need to fight through these issues, but we need to do a good job problem solving and giving as much meaning and value as we can. All right. Relationship number one.

COMMUNICATING WITH PATIENTS WITH DEMENTIA
Next up is communication. Highly important. We should be using communication with short, simple phrasing, yes, no options. We should consider eliminating distractions using repetition in our language, using body language, visual cues, and being comfortable with silence. So having a lot of patience. What's more important though than slow speech, because it could be that we see people and we're like, they have a cognitive impairment. So we're just going to go really, really slowly. That's not what we should do. Instead, we should speak at a normal pace, but allow more time for processing. So we're going to consider the pacing at which we're giving information. Now we should not see this diagnosis with dementia and automatically go to the most basic communication level. That can be, that can absolutely be wrong. People with mild to moderate, even dementia can actually understand, have meaningful conversations and execute multi-step commands. So don't just see the diagnosis and go straight to the bottom levels of communication. Always consider eye level positioning, getting down onto their level. It kind of reduces this hierarchy effect that we can have if we're talking above them. We're going to use lots of positive body language and gestures. You've been seeing me gesture at you for the last 10 minutes. We're going to use lots of gestures. Remember that our patients do communicate through unwanted behaviors. So if they're getting tired, if they're getting more confused, and that may cause disengagement and looks like they don't want to do therapy, We need to recognize that and work to find the problem before we start saying people are uncooperative, before we start giving these super unhelpful labels. Also consider your cueing strategies in this population. I think these cueing strategies are for everyone, but especially in the context of dementia, it can be easy to jump right to physical cueing. We want to start first with a verbal prompt. move towards a visual cue or model the behavior. We then may use a tactile cue or some physical guidance. And then lastly, physical assist. So we're like waiting to do physical assist to the very end.

REMEMBER MOTOR LEARNING
All right, the next category is motor learning. We want to encourage implicit procedural type movements and training with folks. Learn by doing is our mantra. We need to prioritize both salient and functional tasks for the patient. It's gotta mean something to them. That's why digging into their hobbies and their life is really important. So if we wanted to do squats with somebody, potentially doing sit-to-stands from their favorite chair may actually improve participation. When we design sessions for older adults with dementia, we want to consider using a lot of repetition, the same exercises very consistently. We want to do a lot of blocked practice. So instead of maybe programming two very unique sessions each week, we would prefer keeping the same exercises in both sessions instead of using random practice like our AMRAPs, EMOMs, supersets. We may have to focus on one exercise at a time or maybe just two. Okay, so keeping it a bit more simple. In patients with Alzheimer's disease as well, we see that we need to set them up for a lot of success and do more exercises that encourage errorless learning as errorless learning is more superior to errorful learning or really effortful learning. So we want to get our patient to move without a lot of mistakes. Obviously, we'll have a range of mistakes that we deem allowable, but we want to really try to cue right before an error is made and not let them error through a movement. That struggle is not as beneficial to this population.

MAINTAINING INTENSITY
Lastly, we want to ensure we have sufficient intensity and challenge. The article writes, I love this portion, this article writes that we can confidently and competently oversee intensive interventions and encourage patients to work hard. We find that by people feeling challenged by exercises and activities, this is a positive and rewarding experience associated with increased confidence and self-esteem in individuals with dementia. So it seems like more intense exercises actually may be better perceived by this population, right? No infantilizing exercises here. So we need to monitor for intensity. We need to look for any observable physical signs of intensity, but also, behavioral signs, cognitive signs. One of my favorite things the article goes on to talk about was excess disability. That a lot of people with Alzheimer's disease have this excessive disability, which they're more functionally disabled than they should be given their impairments. And this is often a result of diminished opportunity for task performance, driven by well-intentioned or time-sensitive caregiver assistance. Loss of opportunity leads to loss of skill. Loss of opportunity leads to a loss of skill. So we need to encourage our caregivers to find small pockets of opportunity for the patient during the day to help maintain their activity levels. So the caregiver relationship is a whole different podcast, but really talking with that caregiver about, hey, when you're structuring your day, what can the patient get involved in doing? Where can we get them a little bit more activity during the day? Loss of opportunity leads to loss of skill. So that's something I talk often about with caregivers because unfortunately they make a lot of decisions to kind of cut out the patient in the process for very good reasons. I have an 18 month old at home. I understand why people do this, but it's having a lot of grace and trying to see where are some opportunities that we can get this person to practice more.

THERAPEUTIC ATMOSPHERE
Now the last environment was domain. Super simple here and probably pretty intuitive. We need to be mindful of our therapeutic atmosphere to encourage success. We need to prioritize patient safety. We need to keep them comfortable. Us documenting on a computer in a really busy environment may not be it for this person. We need to keep things routine and consistent. Don't send in Different person for therapy every time this person's probably gonna need a very familiar face. So you're gonna want to keep the same provider at the same time at the same place Consistency is everything we want to minimize distractions and create an atmosphere of joy. I know that sounds really simple. I But these changes in particular can make a big impact. Honestly, changing my attitude was one of the ways that's really helped me when working with this population. I have become super joyful when I walk into the room, no matter what I am met with. I am very curious about what the patient has to offer that day, what excites them, what makes them tick. And it's made one of the biggest impacts on my ability to care for this population. and give them meaningful sessions. So changing expectations is what we, you know, about what we should achieve. Letting our patients guide more of the session. That's really reduced a lot of my own personal burnout and stress surrounding these interactions and sessions. I have just come to recognize and document all of these strategies that I use and what impact that they had on my ability to deliver care and to deliver movement for this population, right? I've recognized that these skills and these decisions that we're making are skilled behaviors. And I value my own time and bill all of this while I'm with the person. Remember, you're providing an opportunity for movement in this population, an opportunity for movement. I hope this article gives you just that sense and boost of motivation that you were needing to feel successful in treating these folks. You guys are out there doing an absolutely amazing job. I hope this just makes your job a bit easier. All right, y'all have a good rest of your Wednesday and we'll talk 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. Mark Gallant // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses isometric exercise, in particular, that isometrics are beneficial for more than pain reduction. Mark cites research from the tendinopathy space about the importance of not using isometrics as a quick fix for pain, but as the starting point to gradually reintroduce functional, full range of motion exercise including concentric, eccentric, and power movements in order to fully rehabiliate a tendinopathy.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MARK GALLANT What is up PT on ICE crew? Sorry for being a minute or two late here having some technical difficulties over on the YouTube side. So it looks like that is trying to get going as we speak. We will see if that that comes online here as we're talking. What I'm what I'm currently seeing for you YouTube folks is just a spinning wheel of death saying going live, going live, going live for the last three minutes. So hopefully that'll that'll pop up here over the next second or two for you all. So I'm Dr. Mark Gallant, lead faculty for the ice extremity management division coming at you here, clinical Tuesday. We are done with live courses for the year. I believe there's one more live course, dry needling course this weekend. And other than that, we've got a few weeks off. So we'll be sharpening the iron over the next few weeks, gearing up for for the next year of the ice season. And we can't wait to see you all out on the road. So all of our courses, all of our online courses will be kicking off in January. And all of our live courses will be kicking off the first and second week of January. So if you all haven't been on here the past couple weeks, checking in, there will be a price increase for all ice courses starting January 1. If you've been eyeing those courses and you know a course you want to take over the next few months, we would highly recommend popping in, purchasing that now, save yourself $50. ISOMETRICS: CLINICAL VALIDITY & CLINICAL APPLICATION So what I'd like to talk about today is isometrics and their clinical validity, what they're good for in clinic. And isometrics have come up a lot recently. If you've been a daily listener to the podcast, what you'll have seen is Jordan Berry came on here two weeks ago and he talked about using isometrics for specifically for low back pain and then Alan Fredendahl came on last week and he did a podcast talking about how using the rack pull can be a nice way to add isometrics into a more functional movement, getting your folks back towards the gym. So clearly as a company, we really enjoy using isometrics and we believe that isometrics are a key part of clinical practice. However, isometrics have been under fire recently on social media, in the research, because they got touted as being a silver bullet for pain relief a couple years ago. So where this all came from, Ebony Rio published an article in 2015 looking at six male volleyball players who had patellar tendinopathy. And what she found with these six male volleyball players, if they held an isometric contraction at 70% of their max volititional contraction, for five sets, 45 seconds, that we would see a dramatic decrease in pain. And that's what she found. So for these young, healthy male volleyball players who had about five to seven out of 10 anterior knee pain, their knee pain was fully resolved after doing those isometrics and 45 minutes later. And so, of course, as a profession, we got extremely excited, like, oh man, these isometrics are the key to relieving pain. for our tendinopathy patients. We've gotta use these for everyone, so we extrapolated that to not only patellar tendinopathy, but to rotator cuff tendinopathy, Achilles tendinopathy, lateral elbow tendinopathy. We really just ran the gamut as far as tendinopathy goes, looking at this research. Again, it was one study, six healthy males, With that extrapolation, what of course followed was a lot of repeat studies. So this has been looked at about 10 times over the last eight years. So we've had people look at it in the rotator cuff, in the Achilles tendon, in the lateral elbow. We've had a couple editorials written. We've had one systematic review. And what's shaken out is it's been very inconsistent over the last eight years. There were a couple studies that showed very similar to what Ebony Rio showed, that there was a dramatic pain reduction using isometric contractions. And other studies did not get the same magic bullet results when it comes to isometrics. PAIN RELIEF OVERSHADOWS TENDON HEALTH And we really believe that this study has overshadowed the bigger picture with isometrics. and why we really love isometrics. So of course we live in a society that wants that instant pain relief. That instant pain relief is such a central nervous system component and it is unlikely to actually benefit the person who's got a true mechanical musculoskeletal problem long-term because what we see is if you get that dramatic quick pain reduction, although it's great, everyone wants to be out of pain, Oftentimes, that leads to the person not continuing out with rehab over the long term. And we know from a lot of research that most quick changes within the first six weeks are mostly central nervous system changes when it comes to how tissues respond, certainly to pain. And then at that six-week mark, we start to see a lot of muscular changes. And then for tendons, it can really take six months and up to two years to get a dramatic change. And so if we get that instant pain relief, we may actually be doing a disservice to the long-term health of that overall tissue and rebuilding that capacity. I don't like reading directly off of things, especially while we're here on the podcast, and I don't think that I need to defend Ebony Rio. She's one of the premier researchers in the world. listening to a lot of lectures that Ebony Rio has done, listening to her on multiple podcasts, reading basically every article that she's ever published. I believe that her intent was not for these isometrics to, for this small, small case study article to create such a huge wave and ripples across the rehab professions that anytime you listen to her speak, what she really dives into over and over and over again, is that isometrics are a nice starting spot and that we really need to rehab these people fully out with isometrics, heavy concentrics, eccentrics, dynamic speed and power training over a long period of time. So I want to read a quote from Ebony Rio that came out two years after the article with the Patella tendinopathy that sent ripples through the profession. And what the quote says, simply taking away someone's pain with a medical intervention may not result in a positive medium to long-term outcome, it is possible that simply removing pain does not equate to a positive tissue adaptation. So there's Ebony Rio directly saying that that quick removal of pain is not directly correlated to positive tissue changes. If we look at Karin Silbernagel, who's another premier tendinopathy researcher, and her response to the fad of isometrics being a huge pain reducing intervention. She states, a change in focus from improving resilience to a focus on acute pain relief may likely misguide patients and clinicians into thinking there is a quick fix. So what both of these women are saying, who are premier researchers in the tendinopathy spaces, there is no quick fix, that we need that long-term loading regardless of whether we get quick pain relief or not. THE LONG-TERM FIX: TIME UNDER TENSION, INTENSITY, SYMPTOM MANAGEMENT So why, despite all that, are we at ICE still advocating for and sticking with isometric interventions, both with our tendinopathy patients, our low back patients, literally for every region of the body, isometrics can be a nice tool to get your patients moving along the way. So let's break down why we believe that. So when we're looking at tissue care, there are a few things that we know have to be true to move and adapt those tissues in the long term. Number one is time under tension. There has to be enough time under tension for the nervous system in that tissue to respond to adapt. If it's just one quick motion that never gets repeated and has no time under tension, the nervous system doesn't have, isn't easily as easy to adapt to that stimulus. So time under tension is number one. Number two is intensity. There has to be enough of a stimulus to that tissue to create mechanotransduction to have that tissue adapt. And then number three is that we have to manage our patient's symptoms while trying to maximize the other two. So that's what makes us unique as physical therapists is we're creating time under tension. We're creating intensity while we have those symptoms on board to manage. It's really like this seesaw that we're managing. So we have symptoms on this side, we have time under tension and intensity on this side. It may start out that we've got more symptoms at first and we're trying to balance that scale and eventually have less symptoms, more time under tension, more intensity to our interventions. What isometrics, what we've gotten into over the last eight years is Even if you have 7 out of 10 pain while you're doing this, go ahead and do it because it's going to eventually reduce your pain overall. And we just need to get that time and attention. Well, what that creates with someone who's got fear of exercise and apprehension is a lot of yellow flags. So that's when you get people saying things like, I hate going to physical therapy. Oh, it's so uncomfortable. I really don't want to do this. And they start avoiding their intervention. The first thing we want to make sure is whatever that stimulus we're giving to the person, that they feel psychologically ready to tolerate that. Are you cool with exercising into three out of ten pain? Oh, you're not? One out of ten pain would be more tolerable to you? Okay, let's find an intervention that we can do there. So those are the three big components. Getting their symptoms, getting a stimulus that puts them in a symptom range that they can tolerate, creating a lot of time under tension, and creating enough intensity. ISOMETRIC EXERCISE: CONTROLLING MULTIPLE VARIABLES The reason we love isometric so much early on is because it's a much easier intervention to control all the variables that will allow you to balance those scales. So we go back to a podcast I did a few months ago talking about the guitar amp and things that stress tissues out. What we really are looking at is our knobs that we want to play with is the overall work volume, how much work has been going into that tissue over the course of a few days or a week. How much load has been going into that tissue? What is the actual weight on the bar, the body weight, the resistance of the band that you're looking at? What is the compression and strain on the tissue? So is that tissue all the way compressed in like that or is it strained all the way stretched out? That's gonna be one another way that the tissue can be stressed out and then the speed of the the speed of the intervention so if i do a heel raise versus sprint that's going to put a definite a very different type of force through that achilles tendon so again we've got overall work volume we've got the actual load on the bar we've got compression or stretch or strain and then we've got speed as all ways that that are going to manipulate and change the stress of the tissue. The beautiful thing about isometrics early on and why we're recommending them is you can control all of those variables much easier. So the overall work volume, you're going to be able to very cleanly set that with your patients. I want you to do five sets of 45 seconds or five sets of 30 seconds. whatever the agreed-upon work volume can be, and then it's clear with that isometric. It's very well set. As far as the load, that's not going to change with the isometric. You're going to determine with your client or patient, okay, I want 5 pounds on the bar, I want 10 pounds on the bar, I want 15 pounds on the bar, and then that becomes static. For compression and strain, you're going to find the range of motion they can tolerate. Okay, it's in a mid-range, that angle does not change. So we are no longer getting a change in compression or strain or say we bend it to 90. Now that's the new angle. There is no change during the actual intervention in compression or strain. So we have now controlled that variable. And then for speed, the speed is literally zero. Once you get that weight and that load into the position you want it, it's not moving for the remainder of that intervention. you can really control all the variables quite easily with the isometrics so that you know when something gets challenged or something gets flared up, well, ooh, it's really only these one or two variables that we're manipulating, and so you can much easier control the progression of treatment. So if we're looking back at Alan's example from last week, it's like, okay, Julie, we're gonna hold five sets for 30 to 45 seconds of this rack pull. We know very clearly that you can tolerate 135 pounds of weight. We know the angle of the hinge that you do well with is at about your knees pulling up there. And then once you start pulling, you're immediately going to get the block of that rack. So those angles are not going to change. You're not going to get any change in compression, stress, or speed from that movement. And then as you move that person on, okay, we can progress. Let's change the angle a little bit. or maybe we're going to change the load a little bit, and you can very isolated change these variables until that person's symptoms reduce enough, where then you get into your concentrics, your eccentrics, then you can progress them to your dynamics. So we are not looking at isometrics as this silver bullet of dramatic pain relief early on in tendinopathy. We're looking at it as a nice entry point into giving enough time of retention, enough intensity to a tissue while managing symptoms, because we can control more of the variables. And once those symptoms come down and we don't need to control those variables as much, then we can get more into our concentric eccentrics, more into our dynamic exercise where our buoys are a little bit wider. So Hope this helps. Hope this explains why we've been so excited about isometrics over the past couple days. For those of you on YouTube, sorry about that. I'm still getting the spinning wheel of death, but wanted to make sure that I got on here. Again, to repeat, isometrics, if they work for your patient as a dramatic pain reduction, that's wonderful. That's a home run. Make sure they understand that they've got to continue loading over the next six months to a couple years to get all of those positive tissue adept patients. If you do not get a dramatic reduction, it's six out of 10 pain down to zero, not to fret. As long as you can control their symptoms with the isometrics by controlling all the other variables, it is a wonderful entry point into moving those patients forward. Hope you all have a wonderful rest of the year. Have a happy holidays. Can't wait to see you on the road. Make sure you get those tickets to courses before the prices increase in three weeks. Have a great new year.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how to better educate patients on prolapse, including a three-step framework focusing on education, risk factors, healing timelines, and empowerment.

Take a listen to learn how to better serve this population of patients & athletes.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.RACHEL MOORE Good morning, PT on ICE Daily Show. My name is Dr. Rachel Moore. It is Monday morning, which means it is pelvic day on our podcast here. So, we are going to dive in today. Our topic is using words that heal to talk to our patients about prolapse. So we want to make sure that when we are talking about our patients that have prolapse or maybe have been given this diagnosis of prolapse, that we're using words that are going to empower them. So we're going to dive into that today. Before we do that, a couple of housekeeping things, just letting you guys know the courses that we have coming up within our pelvic division. So we are done for December, nothing left in 2023, but we are kicking off 2024 strong. We've got two courses on our live docket in January. So we've got one January 13th and 14th in North Carolina. We've got one January 27th and 28th in Hendersonville, Tennessee. And then February 3rd in Bellingham, Washington. So we've got three chances within the first like month-ish of 2024 to catch us on the road. um on the those live courses that's where you'll be taking your certification test if you're interested in having that pelvic certification which includes taking all three we now have three of our pelvic courses our next online level one cohort starts january 9th and the sign up for our level two is now officially open so if you want to hop into that cohort it starts april 30th and that will be the first cohort of our level two so Really excited to kick that off and just kind of get that rolling.

TALKING PROLAPSE So without further ado, let's dive into our topic of the day. We talk a lot about ICE or talk a lot at ICE about using words that heal, not harm. We preach it a lot and sometimes it can be really tough to figure out how to explain like difficult diagnoses. Especially things that are maybe controversial when it comes to the postpartum space and we're gonna see that with things like diastasis or prolapse and a lot of times our patients are coming in and maybe they've been given this diagnosis by another provider and it's not really explained very well and so they go down this scary Google rabbit hole and they come in and with all of these preconceived notions um oftentimes mostly negative preconceived notions from all of this research that they've done and they feel like they're empowering themselves with knowledge but in reality there's a ton of negativity and fear-based messaging about these topics so today we're going to talk about prolapse later on in a future episode we're going to talk about diastasis and i really just wanted to talk about some actual quotes that i use with my patients or kind of an outline or a framework of how we can break these scary diagnoses down, especially if you're newer to the pelvic population, you haven't had a lot of reps practicing talking about this, so that we can make sure that all of our patients are leaving their sessions feeling very empowered and excited to be working with you.

EDUCATE So the first step of our three-step framework is going to be educate. I can't tell you how many times I have people come into the office and they're sitting there and they're squeezing their legs together because they are so terrified that if they aren't constantly contracting their pelvic floor and squeezing their legs together that their bladder is going to fall out of their vagina because they've been told that they have a bladder prolapse. with no other explanation this happens so often people will go to a provider the provider maybe will be doing a well women's exam or a check for whatever reason postpartum follow-up whatever and they tell them you have a bladder prolapse or you have a rectal prolapse and then that's it and they don't really tell them anything else and maybe they don't even really prescribe them physical therapy and they just wander into your clinic um on their own but there's not a lot of follow-up in most cases. So the very first thing that I'm doing when I'm sitting down with patients is breaking down. Okay, you were told you have a prolapse. Did anybody explain to you what that is? And usually that's followed with no, I went on Google and I saw a bunch of scary things. I'm like, okay, great. Like we're going to undo all of that. And even sometimes if they were explained, it maybe was using a very medicalized definition that can be, again, terrifying if you don't really know what's going on. So I'll bust out a whiteboard and I will draw out the pelvic organ. So if you're watching on Instagram or YouTube, you can kind of see with my hands, but if you're not listening, just visualize. I'll draw out, like, here's our bladder, here's our uterus, here's our vaginal canal, and here's our rectum. All of these organs sit within our pelvic bowl. When we have pelvic organ prolapse, essentially what that means is there is a descent of one of these organs or a drop down that pushes onto the walls of the vagina. at this point usually i'll take a minute to explain to people that the vagina is not a hollow tube it does not look like this it actually looks more like sides of soft tissue coming together most people don't realize that because every picture we've ever seen of a vagina in a textbook in anatomy books anything Looks like a hollow rigid tube. So a lot of times even letting them know like hey your vagina is not like this It's like this you'll see a light bulb moment where they're like, oh Okay, so maybe that's not a prolapse that I'm seeing maybe that's actually just my vagina. So that alone can be really helpful We'll talk about the fact that the vagina is not a hollow tube and that it is soft tissue and with that it is influenced by other things around it and so then we'll kind of break down here's your bladder maybe you have a descent of your pelvic organs and we see this kind of drop down if vaginal canal is here and our bladder is dropping down slightly and pushing onto that vaginal wall what we may see is a slight drop down of that vaginal wall oftentimes we're doing this test on our backs Oftentimes gravity is pulling everything down a little bit more and so when we take this person who's upright like this and put her on her back, our bladder drops down and we can kind of see and maybe feel that drop down sensation. When we layer in gravity with standing, we're upright, we drop down, we can sometimes feel that heaviness sensation from the vaginal wall not necessarily supporting that drop down quite as well. It is really important to highlight and differentiate an organ falling physically out of the vagina which can happen if we have a uterine prolapse where the uterus is dropping down into the vaginal canal versus an anterior wall or a bladder or a posterior wall or rectal prolapse where it is not the physical organ dropping down, it is just the wall of the vaginal canal dropping inwards. That education is huge. You will see people have this like weight lifted off of their shoulders knowing that their organs are not actually falling out of their bodies. Education is important.

DISCUSSING RISK FACTORS Talking about risk factors is also incredibly important. Letting them know what the top risk factors are. Genetics and connective tissue immobility, BMI, chronic constipation, which comes along with that straining, that consistent straining mechanism where we're bearing down repeatedly over time, pregnancy or parity, and vaginal delivery. A lot of those aren't things we can necessarily control for, but what's important to let them know is that exercise is not one of those factors. We want to make sure that our patients know that they didn't cause their prolapse by doing too much too early, especially if they're in the postpartum space or if they have this like shame associated with, I have a prolapse and I did it to myself. That's not the case. More often than not, if a prolapse or a pelvic organ position change is going to happen, it's going to happen in a vaginal delivery after a pregnancy. And it's not necessarily something that they're causing by doing activities later on. Letting them know that they didn't cause this thing to happen, again, can be huge for somebody's mental state. If they're feeling like, oh, I did too much and I caused this, that can kind of cause this negative spiral of fear for movement in the future.

DISCUSSING TIMELINES Finally, we want to talk about, on the education standpoint, timelines. It doesn't make sense to have somebody at six weeks postpartum come in and say, yep, you got a grade three prolapse. Your bladder is dropped down and your anterior wall is coming out of your vagina. We expect there to be changes. we expect that after a vaginal delivery, those tissues aren't just going to pop back and get to their original position or even a new baseline for a longer timeline. So talking about the fact that early postpartum is not the time to be diagnosed, quote unquote, with a prolapse or to even really be concerned about where things are. Instead, we want to talk about ways to talk to them about um body mechanics and um their strategies for bracing we want to talk about bowel health and making sure that they're not continuously straining and bearing down and let them know that when we layer these two things in And then we allow time as a factor. Where they're at at six weeks postpartum is going to look different than where they're at at six months postpartum, even if that was the only things that they did. So education is huge. Educate them about what prolapse even is, educate them about what the risk factors are, and more importantly, are not, and talk to them about the timelines for healing. The next step in our little three-piece framework is going to be normalize. there is so much conversation happening in the pelvic floor PT world that a prolapse or a like a grade one prolapse which is just a slight descent of pelvic organs might be normal in the postpartum population. Just like we don't expect our breast tissue to look exactly the same after breastfeeding, we can't expect our pelvic organs to be in the exact same position after they've undergone nine to 10 months of low load, long duration stretch that creep has set into those tissues. And then we also potentially layer in a vaginal delivery. A grade one might not be a big deal at all. That might just be a typical postpartum change. On top of that a grade two might even be somewhat of a normal finding I have not yet seen a grade zero quote-unquote after a vaginal delivery I think it's a unicorn that actually doesn't really exist and we've had a lot of conversation about this within our pelvic crew of has anybody ever seen that The consensus so far is no. And so if you guys have, drop it in the comments. I'm curious. But we want to talk about normalizing this change. We expect physical changes in our body after pregnancy. We expect physical changes in our body after vaginal delivery. It's OK to look like you've had a baby. It's OK for your body to show those signs. this can be a big thing for people to wrap their heads around because there's a lot of talk within our culture about bouncing back to what your body was before and Switching up that conversation to we're not worried about what it was before We're getting to a new baseline and that might show changes that have happened and that's okay Normalizing the fact that our bodies are going to change during pregnancy after a delivery is important The other part that we want to normalize is that in the early postpartum timeline, those muscles are recovering, especially following a vaginal delivery where they've had a stretch injury, they've been stretched out, elongated, they're returning back to their resting state. We expect those muscles to have a lower threshold for activity than they did before. as pts this makes sense as patients it not it doesn't necessarily um come to the forefront of the mind so reminding them these are muscles think about any other muscle in your body maybe you've pulled a hamstring maybe you've pulled your quad maybe you've overstretched your shoulder those few days maybe weeks afterwards it took less activity for you to feel something in that area in this case specifically what I'm really kind of preaching to people is that if you get up and you're feeling good one day and you go for a walk with your kiddo around the block and that's the farthest you've walked and then later in the day you start feeling some heaviness you didn't cause a prolapse likely those muscles are just tired. They worked harder than they have all this timeline leading up to this. And so they're fatigued. And just like every other muscle that fatigues when it fatigues, it doesn't work quite as well. And so we feel that heaviness sensation. normalizing that heaviness sensation. I love to do this when people are pregnant, set that expectation. Hey, look, as you start moving more, you might notice that you feel a little bit of heaviness. It's not a big deal. That's kind of our buoy lets us know where we're at. You're not causing any damage. It's going to be okay. That heaviness will resolve and over time you're going to build up your capacity where that heaviness sensation comes on later and later and later normalizing what a prolapse is, normalizing what the grades are, normalizing the changes of our body that happened during pregnancy and postpartum and normalizing recovery of those muscles and potentially having an onset of symptoms.

FINISH WITH EMPOWERMENT Finally, we want to empower our patients. This is where our bread and butter lies. This is what we are here for. We are all about empowering women in this pelvic space. we have evidence that we can reverse a prolapse up to one grade. So that means if somebody comes into the grade two, then potentially we can get them to a grade one. Realistically though, at the end of the day, I don't even really care about that. What I'm really harping on more, really focusing on more with my patients is that We know that the degree of prolapse or the descent of those pelvic organs and how much they are descended has no correlation with your symptoms. You can have a grade three and be highly sensitized and feel everything. You can have a grade three and have no idea that you even have a change on the flip side. You can have a grade one and feel like things are falling out. so talking about the ways that we can directly impact that by calming down the system giving them tools like laying on their back with their feet elevated adding in some bridges to get some muscle activation kind of taking the pressure off of the pelvic floor so that they can decrease that symptom of heaviness discussing things like bowel health, like we chatted about earlier, avoiding straining, using a squatty potty, making sure that they're drinking enough so that they're not falling into this chronic constipation camp, and then talking about body mechanics. That's one of the biggest things that we really want to focus on. We have to know what they're doing when they brace. We have to know what they're doing when they bear down. We have to know what they're doing when they do a pelvic floor contraction. we need to collect that data. We need to calibrate to make sure that they're not dropping down with their pelvic floor and increasing that heaviness sensation with their daily tasks. That is a huge piece of the puzzle. So our three-step framework, when we're talking about somebody coming into the clinic day one terrified that they have a prolapse. The first thing we're going to do is educate them. We're going to talk to them about what a prolapse is. We're going to talk to them about the risk factors and what potentially caused it and what definitely did not cause it. And we're going to talk to them about timelines. We're going to normalize. We want to make sure that they leave feeling like their body, their vagina, their pelvic floor are normal. And even if you have somebody come in with a grade four, We're still normalizing. We're still talking about all of the ways that we can help. We can work on prehab. We can take those same tools and improve things so that going into a potential surgery, they have better outcomes. And anything less than a grade four, you better believe I'm normalizing. You might have a change in your pelvic organ position, but you know what? That's totally normal after having had a baby and a vaginal delivery. The third step is we're going to empower. We're going to make sure that our patients feel confident in movement, feel confident in that bracing strategy, feel confident in what they're doing in their daily lives so that we can build a stronger and more resilient human being who can tolerate more things before symptoms come on. I hope you guys enjoyed this. I hope it helped clear some things up, especially if you're newer in the pelvic space and you really understand what prolapse is, but you're just not quite sure how to talk to patients about it. It can be intimidating, but I trust that you guys have got this. If you're not confident in treating heaviness and pelvic organ descent, um, and that sensation of heaviness hop into our live course, we spend a ton of time going over bracing. We talk a lot about what prolapse is, We have a whole matrix and kind of framework about treatment approaches for each of these little camps, whether they have symptoms objectively or subjectively and what the combinations are. I hope you guys have a great Monday. Get out there and crush it. Thanks.

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long discusses Testosterone Replacement Therapy, including research supporting its use, side effects, understanding dosing, and common clinical presentations related to TRT use.

Take a listen to the episode or read the episode transcription below.

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

EPISODE TRANSCRIPTION

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. It is Fitness Athlete Friday, the best day of the week here on the podcast. I'm excited to be with you as your host, Dr. Zach Long. And today we're going to talk about a topic that's a little out there, like it's not something we talk about a whole lot in the profession, and that is testosterone replacement therapy. And we're going to discuss four or five things that I really believe that those of us in outpatient orthopedics need to understand about testosterone replacement therapy because you are for sure seeing these patients in your clinic with certain conditions and being aware of a few things will help you out clinically. Before we jump into that topic, upcoming courses that we have inside the fitness athlete division. Our live course is, we have one more for the end of the year. That's Colorado Springs, Colorado this weekend. Mitch will be teaching that. If you can't make it to that in quarter one, we will be in Portland, Oregon, Richmond, Virginia, Charlotte, North Carolina, and Boise, Idaho. So check out those courses, pglnice.com. We also have our advanced concepts course. We'll be going live at the beginning of the year. That course always sells out. If you've already taken level one, you can jump into the online level two, but that sells out. So you want to look at jumping in and booking your spot as quickly as possible.

TESTOSTERONE REPLACEMENT THERAPY Let's jump into testosterone replacement therapy and what physical therapists need to know about that. Testosterone replacement therapy is injecting testosterone into your body, which is the male sex hormone, prescribed by doctors at times to treat hypogonadism. We've seen a giant increase in the number of people and the acceptance of people being on TRT in the past few years and I think that's why it's so important for us to understand that because so many individuals are now when they you know get into that 35 40 50 year old age range where their libido goes down a little bit. They stop improving quite as much in the gym as they used to. They start to have a little bit more general fatigue, anxiety, et cetera. We're seeing more and more men jump on TRT. I found a research study from 2017 looking at the rates in the US population of people being on TRT. And in 2017, they estimated that between 1% to 3% of men were on testosterone replacement therapy. which that number was a threefold increase in the number of prescriptions of TRT from 2007 to 2017. So threefold increase in those 10 years. And I would even say since then, in my opinion, it has become more popular or at the very least more accepted. Back in 2017, you wouldn't hear a whole lot of people talk about being on TRT. And now I feel like I see it all the time. I see big time influencers talking about being on TRT. all the time on social media, when I'm talking to people at the gym, they're regularly talking about their doctor just put them on TRT, whatever. So there's a lot less stigma around it and there's a lot more people getting on it. And I think that's really important for us to understand because there are gonna be a few things that we see in the clinic in people that are on TRT. And so asking this question more frequently to your male patients, especially that are between the ages of say 30 and 50 years old, is going to change a few things that you might be thinking of clinically. So three-fold increase in those 10 years and probably a little bit more than that. Another really interesting study that I found with testosterone replacement therapy was this study called Testosterone Dose Response Relationships in Healthy Young Men. So this was a really cool study where they took individuals that had previous resistance training experience and they told them that they weren't allowed to exercise during this six-month study. So If they've done previous resistance training, we kind of know that they're going to be through their beginner gains, their newbie gains in the gym where they would have really easily put on several pounds of muscle. So these aren't people that you're going to expect to see drastic increases in muscle mass in a short period of time. especially when they're not working out. But what they did in this study was for six months, they put these men on testosterone replacement therapy at different dosages. So the dosages were 25, 50, 125, 300, and 600 milligrams of testosterone for 20 weeks. So a wide range of doses from 25 milligrams a week to 600 milligrams a week. And they looked at a number of different things, such as their fat-free mass and their leg press strength, and then a number of other different physiological factors. But I'm gonna focus on those two, mostly muscle mass here. So again, we wouldn't expect these individuals when they're not resistance training, but having had previous resistance training experience to gain a lot of muscle mass in this time period. But what they found was that the group on 125 milligrams a week during those six months gained six pounds of muscle on average. The group at 300 a week gained 12 pounds of muscle mass on average and the group at 600 milligrams a week gained on average 19.5 pounds. So a lot of increase in muscle mass during that time period, especially when people aren't doing any resistance training.

UNDERSTANDING TRT DOSAGE And so I bring those dosages up because I think that's one really important thing when you have a patient on testosterone replacement therapy, I want to know what that dosage is. So when you're treating hypogonadism, less of this like people getting on TRT to try to improve their sports performance, their aesthetics, their strength, et cetera. What you tend to see is much lower doses in terms of testosterone replacement therapy. Like getting on those low doses under typically 200 milligrams a week is what you'll see a lot of doctors prescribe here. And that's going to do a lot to help improve libido and anxiety and other symptoms like that of hypogonadism. But when you get to that 125 milligrams a week, that's when we start to see a large increase in muscle mass. And what you'll often hear referenced by doctors prescribing TRT is sports TRT dosages versus hypogonadism dosages. And the cutoff there that you'll hear most people discuss will be 200 milligrams a week. So when you're taking 200 milligrams or more, that's when you're getting into a bit more of the sports performance arena than just purely addressing hypogonadism. And I think that's important because of the next studies that we'll talk about in a second here. But 200 milligrams a week, when people are on that, I'm thinking, all right, we're on a pretty good dosage. And if we go back to that study where the milligrams per week range from 25 to 600. It's important to note that testosterone is obviously a performance-enhancing drug. It can be used for medical reasons. It can be used for recreational and sports performance reasons. And when people typically do like a steroid cycle, not TRT, like trying to put on as much strength, muscle mass, sports performance as possible, the dosages that people will typically be at will be at 300 or more. Typical dosage that you'll hear a lot of people talk about doing a starter steroid cycle is like 500 milligrams a week So this study was really aggressive in the dosages that they did there like especially the group that was doing 600 milligrams a week for six months like they were doing a full-blown steroid cycle, but remember 200 milligrams a week is kind of your cutoff there in terms of sports TRT versus just standard TRT.

THE RELATIONSHIP BETWEEN TRT DOSAGE AND TENDINOPATHY Why that's important and why I want to know the dosage that my patients are on if they're on TRT is because One thing that I clinically see quite a bit is that those individuals on TRT, I'm frequently finding them showing up to the clinic with tendinopathies more than any other injury out there. In fact, when I see a male between the ages of 30 and 50 years old that's coming to me with a tendinopathy and I know that they're exercising and they look relatively fit, this is a question that I will just straight up ask them. because I think it's valuable information to know. And the reason why it's valuable is that there are actually two research studies out there that have found, one of them found an increased risk of rotator cuff tears in men on testosterone replacement therapy, and another one found an increased risk of distal bicep tendon tears and increased risk of needing surgical intervention to repair that distal bicep tendon tear. And so if we know from these two research studies that these men on TRT are at increased risk of a tendon tear, that would suggest that there's likely some degeneration already happening to some tendons in men that are on TRT. Now, why that is? Can't for sure say though. One theory could be here when we go back to that dose-response relationship study where men taking 125 milligrams or more per week are putting on significant amounts of muscle mass in a six-month period. It could be. those muscles are responding really fast, and those tendons are responding a little bit lower. It could be that maybe these men had low energy, anxiety, depression, they get on TRT, now they're feeling better, and they go from a low amount of activity to getting more aggressive in the gym, so they see training load spikes that challenges those tendons more than they're able to recover from. Whatever reason that is, it happens. We're probably seeing degenerative changes in tendons of men on TRT.

TENDON HEALTH ON TRT And we need to be aware of that because that might lead us to want to have more discussions with individuals. on taking care of their tendons if they're on TRT. Like maybe they need to spend a period of time every few months doing heavy, slow tempo work on their spots. Like if you're in CrossFit, maybe not always bouncing out of the bottom of the hole as aggressively as possible. Maybe they have to spend a period of one month every six months where that tempo's going really slow. Maybe we need to be prescribing some extra rotator cuff loading, tendon work, or maybe even different supplements that might have a positive effect on their tendons, such as taking Collagen and vitamin C. There's some research by Keith Barr on that potentially having some positive effects on our tendon health. But that's definitely something worth discussing and having in the back of your mind when you see men taking testosterone replacement therapy is what can you do to help improve their tendon health?

INJECTION SITE MATTERS WITH TRT And then the final thing that I think is important for us to understand with TRT, I would have never thought of this unless Jordan Berry, my business partner at Onward Charlotte, also a faculty member for ice in our spine division, hadn't treated somebody that was on TRT and came into the clinic with incredibly debilitating neural tension. So this guy had previously been a bodybuilder that had abused performance enhancing drugs and now was on TRT, but the guy could barely walk, couldn't pick anything up off the ground, had a 10 degree straight leg raise. As Jordan evaluated the guy's lumbar spine, the lumbar spine was completely clear. And Jordan kind of recognizing in this guy's body type that he looked like somebody that may have previously or currently was on performance-enhancing drugs, Jordan went ahead and kind of broke out that with the individual, started talking to him about his previous performance-enhancing drug history. It turns out the guy was still injecting testosterone regularly. He was on TRT after years of being on more performance-enhancing drug dosages of that. And Jordan asked him where he was injecting. And the guy was injecting his TRT dead center in the middle of his… to inject TRT or the place that's safest to inject it is actually going to be glute med. So if I'm looking at your butt from behind, if I drew a line straight down the middle of your glute, both horizontally and vertically, we want to be in that upper outer quadrant or in the vastus lateralis. Those tend to be the safest areas to needle. When he was going dead center in the glute, he was constantly hitting his sciatic with his injections. And so hitting his sciatic nerve as he was giving himself TRT injections resulted in some scarring on that nerve. And that was what was leading to his intense sciatic and neural tension. So I hope that gives you some ideas and things to think of clinically when you see guys on TRT, or at least makes you more aware of the prevalence of this, and that when you see people with it, you might want to be thinking of some different strategies and different questions if they're coming in with things like tendinopathy or weird neural tension. Hope that helps. Hope we see you on the road at a future Fitness Athlete Live course. Have a great day, 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.