#PTonICE Podcast

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the "golden triangle" or the foundation of personal & professional success where time, money, and autonomy overlap. Alan shares research supporting a direct relationship between money earned & happiness, as well as the importance of respecting time & autonomy in the workforce.

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. ALAN FREDENDALLTeam, good morning. Welcome to the PT on ICE Daily Show. Happy Thanksgiving. We hope your Thursday morning is off to a fantastic start. We're here on Thursday, Leadership Thursday, talking all things small business management, practice ownership, that sort of thing. Thursday, Thanksgiving Thursday, still means it is Gut Check Thursday. This week's Gut Check Thursday is a little bit of a tradition around here at ICE. We are gonna do a hero workout called Burp. This is a very long bodyweight workout. Starts with 50 burpees, a 400-meter run, 100 pushups, a 400-meter run, 150 walking lunges, a 400-meter run, 200 air squats, a 400-meter run, and then now we're going to come back down that pyramid. 150 walking lunges, 400-meter run, 100 pushups, 400-meter run, and then finally finishing with 50 burpees. So, very long workout. This is gonna take most human beings about an hour to finish. Obviously, you can tell a lot of redundancy in there with the running, the lunges, the air squats, and then the burpees and the pushups. So, if you do not have an hour today to work out, scale this. Cut all the gymnastics reps in half. Maybe cut the runs down. If you know you're a better biker than a runner or something like that, sub out a rower or a bike for the run. Obviously, the more you reduce the volume, the less time it's going to take. This workout is not for the faint of heart. This is going to make your upper body and lower body sore between all the lunges, squats, pushups, and burpees. But it is challenging. We love how simple it is. You don't really need to warm up or really have any sort of particular skill or range of motion to do this workout. So that's why we love Burp. Courses coming your way, I don't want to bother you with those today. Check out p10ice.com, click the Our Courses tab, and see what's coming your way. We do have a couple more weekends of live courses starting back up again next weekend before we take our final holiday break over Christmas and New Year's. So check out ptonice.com and click on our courses if you're interested in jumping into a live course before the end of the year. THE GOLDEN TRIANGLE Today I want to talk about a concept that I call the golden triangle. Talking about when folks reach out and they describe maybe an employment situation that they are not happy with. This is kind of how I evaluate what I think of the three pillars to success when you are not only working for someone else but just working in general. Even if you are self-employed, even if you do run your own business, carefully managing the three sides of this triangle, I believe is really important for your own personal and professional success, but also for those of you leading others in charge of others, I think even more important to fundamentally understand these concepts. So those three concepts are money, time, and autonomy, and we're gonna break each of those down here in a little bit. I want to start here though first, and this may be a weird place to start, but I promise we'll bring it back around again. I want to talk about what is the role of the human brain. A lot of us may think the human brain is for high-level computations and calculating the physics of a black hole, but that's not how most people's brains work. That's how very few amount of people's brains work, but for most of us, Our brain is a survival mechanism. It is a comparative analysis engine. And it's really good at making comparisons. Your brain is making one billion billion calculations per second. That's a one with 18 zeros. That is a million times faster than today's standard cell phone laptop or desktop computer. We call that an exaflop. It is the most powerful processor on the planet. It is always gathering data, both internally and externally, and making comparisons. Am I hot? Am I cold? Am I hungry? Am I thirsty? Am I not making enough money? Is my coworker making more money than me? Is my boss doing better than me because I noticed that he just bought a speedboat? Those sorts of things. Yes, very basic survival mechanisms, but also higher-level stuff. And that kind of brings up the next point of Maslow's hierarchy of needs. If our brain is this comparative analysis engine, what is it really focusing on? Well, psychologists would say it's focusing on comparing ourselves on this pyramid, this hierarchy of needs, where at the base we have our physiological needs. Am I hungry? Am I thirsty? Am I tired? The next level up is safety and security. Do I have a safe place to rest and sleep at night? Do I have a place maybe that in my mind when I compare to others I call my home? The next level up, the third level, love and belonging. Do I have friends? Do I have a family? Am I raising children? Not only do I have them, but do I feel like I'm thriving in those relationships? And now as we get to the top of that pyramid and we approach that peak, the fourth level is esteem and the last level is actual actualization, self-actualization. So do I feel like I am doing something meaningful, and do I feel like I'm doing something meaningful very well basically You know what is my life's work, and how am I doing at that? And now the brain is always comparing both to environmental factors and to other human beings where we sit on that hierarchy. Trying to chase the top tiers before addressing the bottom, I think is the cause of a lot of dissatisfaction in our daily lives. So shelving that for a little bit, the brain is a comparative analysis engine and hierarchy of needs. Let's get back and talk about the golden triangle. MONEY The first I want to address is money. Money is uncomfortable for some people to talk about. It's often a pain point for almost every single one of us. I think really understanding that about three-fourths of people live paycheck to paycheck and about half of all people now work two or more jobs. really helps us understand that we're not alone in being concerned about money. Most people are concerned about money, but also that it's okay to be concerned about money, right? That kind of sits at the base of that pyramid of those physiological needs, that safety and security. We do need money in modern society to do things like buy food and pay the rent on our apartment or the mortgage on our house. There's often an adage of don't focus too much on money because money can't buy everything or money can't buy happiness. And I would refute that. I would say that that is categorically untrue. We have some really interesting research from the 90s and 2000s that found money and happiness do correlate. There seems to be a plateau, at least in the earlier research, of around $100,000. Research from the 90s and early 2000s found that if you make about $100,000 a year, The more money you make. beyond that doesn't really seem to increase your happiness. Now, the thing to recognize is that if you're not making that, there is room for happiness between that and $100,000. New research, specifically from this year, an article from Killingsworth, I love that name, Dr. Killingsworth and colleagues, this year, March 2023, from the Journal of Psychological and Cognitive Sciences, titled, Income and Emotional Wellbeing, a Conflict Resolved. Strong title, I like it, let's talk about it. These folks repeated the studies, some of it their own research from the 90s and 2000s, and they're looking specifically at the relationship between income level and happiness. What they found this time is interesting that folks tend to fall into categorization buckets. Hey, we know all about that in physical therapy, right? What are these buckets? Well, human beings tend to fall into three different buckets. The first bucket is what they labeled as the least happy group. These were folks who kind of demonstrated the same results as the initial studies, where these folks seem to have a happiness plateau at about $100,000. What does that tell us? That tells us this group of people is probably motivated enough by money that once those initial levels of the pyramid are met, they're able to feed themselves every day. They're no longer worried about their next meal or making the rent or paying their bills. Beyond that, they don't seem to get any more happiness from an increased amount of income, right? So this could be somebody who, I imagine these people is the folks from the documentaries that have to you know free climb El Capitan or summon a mountain or something of that's really what drives their brain and kind of their intrinsic motivation and having enough money to do that stuff gets them to the level of happiness where they can pursue other things. The next group of people they labeled, the researchers labeled the medium happy group. These folks had a linear increase even beyond $100,000 a year with happiness and income. And then the highest happiness group had an exponential increase with income beyond $100,000. They could not seem to get enough money. Money on the opposite side of the least happy group, these folks seemed to be almost entirely intrinsically motivated by accumulating wealth, right? So these are our oil barons and our real estate moguls, our Warren Buffets maybe, folks who have a high value on money and its worth in their life. And then most of us are probably in that medium happy group. As we continue to make more money, we're able to buy nicer things, but it doesn't necessarily define us, but we do like to have that money. All that being said, there is a direct relationship between money and happiness. It's really important we recognize that paying people well, of feeling like the work that you do is rewarded with the amount of money that you place value on, is recognized both yourself personally, but also when you're leading others. What I found over my career Keep in mind, I've been working full time since I was 12 years old for about 25 years, is that the folks who tell you there isn't money for a raise, there isn't money for bonuses, or even that they maybe need to take money away from you, are telling you that because they don't want to give you more of the company's money, right? There is always more money, especially in the context of physical therapy, for an increase in your wages. We all have what we would refer to as a revenue-neutral position, which means the revenue you generate from the work you do is creating more wealth than what you are taking back from the company. I can't imagine a situation where a physical therapist would be getting paid more than what the clinic is collecting in revenue for those patients being seen. So it's really tough to talk about. I recognize that it can be awkward. It can be weird. It can be upsetting to personal and professional relationships, but I promise you when you draw a firmer line than the sand around what you're paid, when your comparative analysis engine is telling you, you're not being rewarded for the time you're putting in. That can be a pain point for dissatisfaction and the research would support that you are not wrong in believing that the money you're currently being paid and the money you think you would like to be paid is creating a happiness gap. It literally is, right? Killing's worth 2023. Messing with people's money on the leadership side is a recipe for disaster. It is never okay to cut someone's pay, to inflict some sort of monetary penalty aside from something catastrophic, right? Dave accidentally drove his car into the clinic and destroyed the clinic. Okay, Dave, you got to pay for that, right, man? But aside from really rare, unbelievable, catastrophic stuff like that. There's no reason to inflict a monetary penalty on someone or to take their benefits away. An example I have of this is my time in the army where if you messed up, if you were late to duty, If you didn't shave, you could be punished monetarily for that, right? It was called in Article 15, it is non-judicial punishment. That means usually you have to work extra duty and it usually means that they cut your pay that month. And that really puts a strain on people, especially in the context of the military where they're not already making a lot of money. And I fondly remember watching people have half their paycheck, all their paycheck taken away, and just instantly how it ruined that person, it ruined their career trajectory. So without a doubt, as a leader, that's something you do not want to mess with. We saw that mess with a lot during COVID-19. We saw pay being cut, and we saw benefits being removed, and then not returned. And it's no surprise that now, several years removed, we have the era of time that we now live in, what we call the Great Resignation, where folks are more than happy to say, give me a raise or I'm leaving, and they will literally leave, right? And for us as practice managers and owners, that's devastating. Attrition is one of the highest costs you can encounter, and you need to avoid it at all costs. When someone leaves, it's going to cost you $3,500 for every $10,000 that person makes. That's money you won't get back on maybe trading you did with them, time you spent with them, money and time you're now going to need to spend trading somebody else. And then of course lost revenue because that person is no longer working for you generating revenue. So keep that in mind when you're thinking, I'm going to withhold raises, I'm going to withhold bonuses, I'm going to otherwise inflict some sort of monetary penalty. It never goes well. And again, it's okay if money is a pain point for you personally, and if it's a pain point for the people underneath you that you're leading. Pay should always increase over time to match inflation at the minimum. I have said this a thousand times and I will say it a thousand times more. Every year you do not get a raise, you are taking a pay cut because everything in your life now costs more money to buy. So keep that in mind. I will beat that dead horse until we're all on the same page about that. And finally, I think this is something no one wants to hear. Both those of you who are maybe unsatisfied with your position because of the money and those of us leading others it is okay for people to leave a position if it's not working out for them financially, right? You cannot feed your kids with the promises of potential future money. Your landlord will not accept the ambitious dreams of your clinic owner and payment for your mortgage. and you cannot get any sort of retirement return on zero dollars invested. So it is okay to move on if this is a pain point that doesn't seem to be addressed. So money is the first part of our golden triangle. TIME The second part is time. Time is a finite resource that we're all running out of. I think every day now the moment I turn 37, I am statistically halfway dead. And statistically, every day beyond that point is that much time left I have on Earth. Time is interesting. Some folks don't feel the value at all. Some folks tend to place a great emphasis on it, maybe even more so than anything else. Humans are the only creatures that can perceive time, so I think it's unique that we're able to perceive the flow of time, and we're kind of aware of moments where we have maybe too much time that we might call boredom, and moments where we feel pressed for time. A lot of us, the majority of the human race, will spend most of our lives using our time to generate money and then trying to use some of that money to buy some of our time back. And that's the way it is, even if it is a little bit sad. But I think recognizing that that's how most of us are going to move through life is important. For some people, time will always be more valuable than money. It does not matter how much you offer someone, how much you may offer them for overtime, whatever, their time doing other stuff is important. There are those people, the clock strikes five, they're out of there and we need to understand and respect that that is one of their values and work around that in whatever way we can. Very few people though, even folks who maybe don't seem to value their time a lot, very few people do not like to have their time wasted for no reason. And this happens a lot in life. It happens a lot in day-to-day life. It happens a lot in the workplace. Think of every situation where you've shown up early or stayed late for a meeting or some other event that was canceled delayed or rescheduled even without notifying the people currently sitting and waiting there for that to happen. Every time someone schedules a meeting with me and doesn't show up, that's a strike in my mind against that person. Very few of us have the tolerance to have our time completely wasted in that manner. but it happens a lot and it happens a lot in the context of the physical therapy workforce. Think about how many times you've come to work and the first two patients on your schedule have canceled or rescheduled, right? And you're thinking, what the heck? Why didn't anybody text me or call me, right? I could have gone to the bank or I could have sat and had breakfast with my kids at home or any, literally anything else would have been a more valuable use of your time. We also, are often asked to work in situations where we know it's not a good use of our time, right? I think of every time I have been asked in the past to work on Christmas Eve, right? Especially in the context of patient care. I know as soon as I'm asked to work on Christmas Eve that no one is going to come to their appointment on Christmas Eve. I remember it's burned in my brain, I spent one Christmas Eve with a completely wiped-out schedule, laying on a treatment table, and I watched all six Rocky movies in a row, right? I watched like eight hours of Rocky movies and did not see a single patient. What a monstrous waste of my time, and the clinic's money, just a bad situation for everybody. The Japanese have a term for that. It's called "Isogaghii" is the act of pretending to be busy. Even when you have nothing to do, we hate that. That is not something that we should encourage. If you don't currently have something to do, don't be here. I live my life by that model. When I catch people sitting in the clinic and they're just kind of pushing buttons on a computer, I always ask, what are you doing here? Oh, you know, I'm, you know, final, I'm like, okay, go, go home, right? Go away. No "Isogashii". We do not need you to sit at your computer doing nothing until 9 pm just to appear busy. So that's money. That's time. AUTONOMY The last part of the triangle is autonomy and independence. It's important to know that we developed this very early, and we all have a strong sense of it, even if we don't voice that it's one of our values, right? I think of my son, he's about to be 11 months old. A couple of months ago, we were hand-feeding him, already he has that sense of autonomy. Now when I go to feed him, he slaps the food out of my hand, and then he grabs it and feeds himself, right? He's already expressing, hey, I'm not a baby. I don't need you to hand-feed me. I can feed myself, right? And that's already present in very, very small children, right? Those of you with toddlers, you know, that independent streak starts and doesn't stop. Those of you, especially with teenagers, you know, it gets more aggressive. And then obviously all of us as adults, have a very strong sense of autonomy. Again, even if we don't express it explicitly as one of our values. Just like time, autonomy is violated on a very regular basis in very unfortunate manners. This happens a lot in the workplace. A lot of you work for employers who control how you're allowed to dress. how you're allowed to speak and talk with your patients, how and when you're allowed to perform very basic physiological functions about when you can eat food. Some of you work for employers that don't let you eat or drink at work. You have to leave the building and eat outside by the dumpster like an animal because you're not allowed to eat in the building because the owner or the manager doesn't like the possibility of crumbs. That is a huge autonomy violation. We also see this in our workflow as well. A lot of us are performing unnecessary documentation so that someone can check our work, right? So that someone can audit our notes just for the purposes of having a checklist where they audit our notes, right? It serves no actual purpose as it relates to helping the patient by documenting what we did with the patient. And for those of us who take insurance, create a claim that goes to the insurance company. There is no point where it's required that all of these extra processes that we add to our workday are mandated. Nonetheless, many of us work for an employer who has all of this extra work, all of these extra checks on our autonomy just to have extra checks. That's very insulting and it creates a lot of redundant work that also simultaneously affects our time. So we are getting a one-two punch of time and autonomy when we're doing a bunch of busy work that doesn't respect our time. It doesn't respect that we're independent clinicians who have often been working a while with a bunch of advanced education. The final thing I'll say here is that what you'll unfortunately find is that leaders who micromanage more, and who place more limitations on autonomy are often the same leaders who have minimal or no restrictions on their own autonomy, right? The person who is a stickler about a dress code is often the person in the office in shorts and a t-shirt and sandals working on the computer, right? So be mindful of those things. As you are maybe seeking out a new position or evaluating your current position, there's no double standard on autonomy. THE GOLDEN TRIANGLE AS A ROBUST BASE FOR SATISFACTION So the golden triangle, the interdependence between these three things builds a very robust base personally and professionally. However, I think it's very important to note that if we take our comparative analysis engine in our brain and compare it to Maslow's hierarchy of needs, What some of us are doing is trying to aim for the very top of the pyramid, aiming for esteem, aiming for self-actualization, and trying to become the best physical therapist that can be when those other bases of the pyramid are not being met, right? We don't have our basic needs met because we don't have enough money coming in. We don't have control over our time. We don't have control over our autonomy. We talked last week about the pitfalls of social media, trying to make you think that the reason that you're unhappy is you're not buying enough stuff or consuming enough content. With that stuff in that content, mainly being focused on trying to push you to the top of the hierarchy of the needs when really what you need to do is address the base, meet those basic physiological needs, safety, security, love, Make sure that time, money, autonomy are on board before you consider purchasing that $10,000 self-help retreat or the mentorship program or the mindset program. I think a lot of our perceptions of concepts like burnout or imposter syndrome are really just the result of our comparative analysis engine and our skull recognizing differences and asymmetries between what we're doing every day and the results we're either achieving or not achieving compared to other people. And when we look and step back and look at this golden triangle, we see, okay, I am not making the money I think I should, especially compared to my peers. My time is not being respected. I'm working more than I think I should to make the money I'm making. And oh, by the way, I'm being treated Like an infant at work by having a dress code and having all of these extra redundant Processes at work that I need to do that consume more of my time and we are always again It is part of our survival. It's hardwired in our brains to make these comparisons. We're always consciously aware of the time and the work and the money and the autonomy compared especially to other people and kind of comparing again back to that hierarchy of needs. And that if we allow one or two or all sides of this triangle to be violated, that's where we find a lot of frustration, and trying to jump your way to the top is not going to get you there. You need to address that base. When folks reached out and they described their appointment situation, I used to be a lot more polite with my thoughts when people emailed us and said, what do you think? I'm seeing 20 patients a day. I'm making $62,000 a year. And every month that I see more than 250 patients, I get a $500 productivity bonus. What do you think? I used to be a lot more polite when answering those emails. I am not polite anymore, right? A lot of the dissatisfaction, a lot of the burnout, I hate that term, a lot of the burnout, though, can probably be addressed if we're a little bit more firm and reinforcing and adhering to our values of Again, money, time, autonomy, are all of those things in place? Okay, now we can begin to look more up that hierarchy, begin to pursue maybe specialization, become the best physical therapist we can be, or even if that's not something you value, the best whatever you see yourself becoming. But again, we can't get there if we don't address the base. Doing anything else is just addressing the symptoms. It's not addressing the root cause, right? We need to address the root cause first. We can't just keep treating the symptoms by buying stuff and taking vacations and that sort of thing to try to solve the unhappiness that we're perceiving. We need to know that it's all related and that we need to address it first before we can begin to kind of reach beyond the top of that pyramid. So I hope this was helpful. I would love to hear any feedback or comments you all have. I hope you have a wonderful Thanksgiving and we'll see you all tomorrow. We're gonna talk about rowing.

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

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses how to balance infusing patient care with hope with the reality of their recovery. Take a listen or check out the full transcript with show notes on our blog (www.ptonice.com/blog) or on your favorite podcast app.

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.

JEFF MUSGRAVE Welcome to the PT on ICE Daily Show, my name is Jeff Musgrave, Doctor of Physical Therapy. Super excited to be here on a Geri Wednesday. Geri on ICE is what we like to call Wednesdays, all things older adults. So today's topic is going to be all about a question I got this weekend while on a live course. So I had a student raise her hand, the reality of clinical practice here, and ask, how do we balance providing hope for our patients while still setting realistic expectations? How do we balance providing hope while setting realistic expectations? This is a reality of clinical practice for older adults when treating older adults. Lots of factors, and lots of things to dig in there. Before we get into that, if you're looking to see us on the road in 2023, your last opportunity is on December 2nd. That will be in Candler, North Carolina. Our other December offering already sold out. So that's your last shot in 2023 to see us on the road. Otherwise, we're coming out strong in January, team. We're going to be all over the map. We're going to be in Florida, California, Missouri, Ohio, and South Carolina in 2024. So we'll be coming in strong if you're hoping to see us live on the road. L1, previously called Essential Foundations, the next cohort is going to be on January 10th. then advanced concepts will be on January 11th. BALANCING PROVIDING HOPE WITH SETTING REALISTIC EXPECTATIONS Okay, so the question at hand is, how do we balance providing hope while still setting realistic expectations? important that we get this right. This is especially crucial for older adults. I want you to think about their history, and what their interactions are typically like in the medical system. A lot of people don't really give them the time of day. Their visits are rushed. People are throwing $10 words like idiopathic non-diabetic peripheral neuropathy that's what's wrong with you all right get out of my get out of my office kind of thing but we have a lot more time with our patients in comparison to a lot of other providers in the medical system and want to really leverage that time well. So as I've been chewing on this question, I gave the short answer during the live course, but I'm doing this podcast to give you the long answer for those that are interested. So it's like trying to find the narrow path, walking down a tightrope. We think about this journey with our patients from beginning to end. And the two factors that we're trying to balance here, if you can kind of imagine someone walking across a tightrope, they usually have this big pole that they use to balance. HOPE VS. HARD FACTS I want you to imagine on one end of this pole, we've got hope and this positive outlook, Because we know as physical therapists treating older adults, there's a lot we can do. A lot of people leave things like fitness and strength training, and power training. They have not incorporated any of those things. They need us. We can give them a lot of value. We can really do a lot of things to change their life. So we've got hope on this one end. And then we've got the hard facts. the realities of what's coming if they don't change, the reality of what is going to happen to them if they continue down this path. And we're trying to balance these two factors as we're walking with our patients down this path to recovery. So, long story short, the balancing act we're trying to do is we want to give a crap, make it clear that we care, we want to help, and we can help, without going so far that it sounds like we're full of crap. It's like, yeah, that's not possible, and exaggerate too much. But we want to be very clear that words matter. And if we go too far, too far on the hard facts, we can really shoot ourselves in the foot when it comes to recovery for older adults. You know, just a quick overview of some of the research. So Rebecca Levy, a researcher out of Yale, has done a lot of really interesting studies where she's looked at the power of positive beliefs in our belief systems, what we believe about aging, whether that's negative or positive, and how that may change our health outcomes. HOPE AS A POSITIVE TREATMENT FACTOR So she has done multiple studies looking at things like recovery from injury, like people that are hospitalized, if they are able to recover fully or not and she's found that people that are 50% more likely to recover to prior level function if they have a positive outlook on aging, talking about older adults here specifically. She did another study where she looked at people who had a predisposition for dementia if they had a positive outlook, even though they should have had an exponential increase in risk that should have led to them going on to have dementia if instead, they had a positive outlook on aging, they did not go on to get dementia as much as the rest of the cohort that all had that same predisposition. So there was an isolating factor of hope. And we think about when we have hope, we're gonna make different choices. If we believe we're in control and we are the ones charting our course in life versus life is happening to us. So hope is a very powerful tool. To summarize this, there's a great quote from Dr. Justin Dunaway out of our persistent pain course. And he says beliefs and expectations are the foundations on which outcomes are built. beliefs and expectations are the foundations on which outcomes are built. I love that. There was another really interesting study that came out of Harvard in 2007 and what they did, was they had several females, it was I believe it was about 45, don't quote me on that. It was somewhere around 45 to 50 females who had a very active job. They all worked in a hotel system where they were the people who were cleaning and turning over rooms. So they're moving all day. and we would say that they were physically active, they weren't getting fitness in, they weren't hitting ACSM guidelines, they weren't hitting Surgeon General's guidelines for fitness and lifting heavy things and hitting high intensity like we would recommend to truly be healthy. So they split this group to figure out if half of them were told that they were meeting the Surgeon General's guidelines and half were told they weren't, would there be any changes to their actual health measures? So they measured things like the hip-to-waist ratio. They also measured their BMI, their blood pressure, their body fat, and their overall weight. So they told one group, hey, the work you're doing, it hits the Surgeon General's guidelines. You're doing everything you need to do to be healthy. You don't need to exercise. And they told the other half, you're not meeting the Surgeon General's guidelines. You really need to exercise. This is not enough for you to be healthy. And what they did is they met back in four weeks and repeated all their health measures. They found that the placebo group had physical changes. They improved their weight, they reduced their body fat, their BMI was better, their blood pressure was better, and their hip-to-waist ratio was better. The power of words was tremendous for this group. None of them changed their behaviors. They were just told by a trusted source they're doing what they need to be doing and you should expect good things. Really incredible stuff. So we want to keep in mind providing hope is very important, especially to our older adults. They don't typically get a message of hope and we need to provide that because we have valuable tools. There are mountains of evidence showing that resistance training can help people get stronger in the early and late stages of sarcopenia. It's very important to provide someone with some hope. We don't want to take that too far and be completely full of crap, right? We don't want to tell our patients, oh yeah, you know, you can do these adductor ball squeezes, these leg kicks, and you're gonna be fine. You're gonna be prepared and protected for what life has coming at you. We know that is not true, and we're not suggesting that you grossly exaggerate, but we do need to give a healthy dose of hope. CONTENDING WITH REALITY So on the other end of the spectrum, we still have to contend with reality. What is a reality for our patients? What's the reality of the recovery going to look like? How much time should they expect the recovery process to take? And then we need to take a really honest look at what part of the journey we're going to be able to take them through. If you are an ICU clinician, if you're in an acute care setting, you may only see someone once or twice. You're going to give them hope and hopefully help them chart a path. Like, hey, this is going to go from here to home health. You need to find a good outpatient clinician. I know this great team. As soon as you're safe to get there, you need to get there. They will get you hooked up with a gym. And if you really want to change your life and stop coming back to the hospital, you can do that. You have every ability to do that. People have done it before. I've seen them change their lives. If you want to be another person to do that, you're going to have to commit for the next year. But then the decades to come are going to be way different than how your life has been the last month. Those adventures, those fun things you are planning to do, those can happen. That can be a reality for you. And that 45-second conversation could change someone's life. It may not always be, okay? We're not going to wear the rose-colored glasses, but your job is to plant those seeds. You still have to plant those seeds and let them know. Throw them a rope. They're still going to have to climb out of that hole, okay? So, we've covered the hope piece. We've talked a little bit about that scaffolding, but you need to create some scaffolding with reality in mind, okay? We know that there are tissue healing timeframes. that are on a range. We need to scaffold this up, that we need to know that we can get better but it's going to take X number of months and then inject yourself as to how far you're going to be able to take that journey. And day one, plant the seeds for what happens after. What happens after PT, after acute care, subacute, or if you're an outpatient clinician? What are their fitness options? You need to have these people on speed dial so you can bridge the gap, okay? And let them know. Just give them the whole story. Our older adults can handle it. They're used to getting tons of bad news. This is probably, even with a healthy dose of reality, some of the best news they're going to get because it's clear you care. There's hope. There's a path for them. But they need to know the realities and be prepared. What's coming ahead? So use science. Use the realities of tissue healing time frames to help them know, hey, this is how long this journey is going to take. Let's start thinking about these transitions moving along. Team, if we give too much reality and not enough hope, we're going to crush them. We're going to be kicking them while they're down. They're already maybe at a really pivotal point in their life. We give them no hope in all reality. They're going to quit. before it's time to get started before the real work begins. So based on the research that I just covered, based on the realities of being a human being, I would give a healthy dose of hope, and get them started, but we gotta balance that out just like you're walking that tightrope. You go too far either way, you're gonna fall off the path. We're gonna lose therapeutic alliance with our patients. They need enough hope to be ready that they're gonna have to struggle, they're gonna have to work hard, and it's gonna take a while. But there is hope they can truly change, that you've got the skills that you can provide, you know the people to make the transitions, and I think that is what's gonna lead to the most success for our patients, is balancing out science realities with tissue healing timeframes, knowing the person in front of you, and giving them a scale based on how much buy-in they're gonna give you. Are they willing to come into the clinic twice a week? Do they have a plan that supports that? Do they have the financial resources to support that? Or do we need a completely different plan where they're now motivated to do it at home and we need to spread this out and stay connected because we don't have good resources in the area? Alright team, I wish you the best of luck with your older adults managing those two factors, balancing hope and reality to get the best outcomes possible for our patients. I'd love to hear your thoughts in the comments. Have a happy Wednesday and I will catch you next time.

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

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses the concept of "DUDS" and "STUDS" when working with patellofemoral pain syndrome. Mark describes three outdated treatment paradigms or "DUDS" including an overemphasis on imaging, patellofemoral tracking, and VMO specific-strengthening. Mark encourages listeners instead to focus on the four "STUDS" of patellofemoral pain treatment: assessing current work demands on the knee vs. current tissue capacity, addressing power & not just strength of the knee, working in motor coordination & skill training especially when reintroducing functional movements like jumping, running, or squatting, and finally, ensuring load distribution across tissues is as equal as possible by working on range of motion.

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 All right, what is up PT on Ice Daily Crew? Dr. Mark Gallant here, Clinical Tuesday, coming at you the Tuesday before Thanksgiving in 2023. So first off, I want to say super grateful to have the opportunity to be on this podcast, rapping to you all and going around the country talking about these topics. So thank you all very much to anyone who's listened to this podcast or anyone that's caught us on the road. But before we dive into today's topic, last couple opportunities to catch the extremity crew crew on the road for 2023, we've got Cody is going to be in Newark, California on December 2nd and 3rd. So so a nice West Coast opportunity. And then Lindsey is going to be in Windsor, Colorado, December 9th and 10th. So those will be the last two for the year before we we take a little break and then we will kick off the second weekend of January for a full slate in 2024. So if you're trying to catch us on the road this year, those are your last two opportunities. And then make sure you grab those seats for 2024, because courses are selling out now and hitting max capacity. So make sure that you get those sooner than later. In addition, tonight on our Vice, so if you're signed up for the Vice program, our virtual ICE, Paul Killoren is gonna be on talking about peripheral dry needling. If there's any topic that pairs well with what the extremity crew is typically saying, it would be the ICE dry needling department talking about peripheral dry needling. So definitely catch that one tonight around 8.30 Eastern Standard Time. DUDS & STUDS FOR PATELLOFEMORAL PAIN SYNDROME All right, for today's topic, what we wanna talk about is duds and studs when it comes to patellofemoral pain syndrome, or what I would prefer calling kneecap pain. So what are the things that we've known over the years or we've tried over the years with kneecap pain that the research really does not shake out very favorably for? And what are the things with kneecap pain where it's like, Ooh, that that's something that we definitely want to pay more attention to. So I'm going to list all the duds and all the studs off, and then we'll break each one of those down individually. So for the duds, we've got imaging to the kneecap as a dud specifically for chondromalacia patella, patellar tracking and trying to impact patellar tracking would also be a dud, and then specific strengthening or specific loading or an attempt at specific loading to the VMO or the oblique fibers of the vastus medialis. So those are our duds and our studs are going to be building work volume capacity or looking at that person's work volume compared to their current capacity and making adjustments in their training. We have specific strengthening or building capacity to that anterior knee with both strength, endurance, and power. We have skill training or motor coordination, and then we have mobility towards the anterior knee and surrounding structures. So those would be the three duds, the four studs. DUD #1 - IMAGING OF THE PATELLA Now let's break each one of those down individually. So for most body parts, We now know that when we take asymptomatic folks and we image that region of the body, we're going to find as many tissue changes as we would for those folks that are symptomatic. Historically, we've called these abnormal tissue findings. Again, these are fairly normal findings for asymptomatic individuals, again, in every single region of the body. What we see with chondromalacia patella, so softening of the cartilage of the posterior patella, What we see when we look at that is if we take a bunch of asymptomatic individuals and symptomatic individuals, run them all through the MRI tube and say, who's got signs of tissue softening to that cartilage of the back of the knee, that number is equal or close to equal for both the symptomatic group and the asymptomatic group. So it would be hard to say that the finding on the image of chondromalacia patella is driving kneecap pain in any considerable way. DUD #2 - PATELLOFEMORAL TRACKING The second dud is patella femoral tracking. So there was this theory for a long time that the lateral structures of the patella or the structures that attach laterally to the patella are pulling that patella off track or creating some level of tilt or compression to the patella that is driving that anterior knee pain. What we now know is that this is not the case typically. The other thing with that was that the VMO was weak and not allowing that even force. We now have studies, it's a pretty cool study, where they took a group of 14-year-old women, they asked them all about their knee pain, how much pain are you in, and then they used imaging to track how their, to look at how their patella was tracking. So they got all that data at 14 when those individuals were at their peak symptom level. They then followed up with those individuals four to five years later, so now they're 18 to 19 years old, All of these individuals had significantly reduced pain. So the patella femoral pain or the kneecap pain had relatively worked itself out. And then they re-imaged and retracked how that patella was tracking. What was interesting is most all of them had a full reduction of symptoms. the knee was tracking the exact same way. So they found no difference in how the knee was tracking, yet that person had significantly reduced symptoms, which again, hard to say that that knee tracking is one, are we even able to intervene on it? And two, does it mean anything if all of the symptoms become reduced despite that knee tracking changing? DUD #3 - SPECIFIC TRAINING TO THE VMO And along those lines, the third dud, is specific training to the vastus medialis oblique fibers. What we now know is it's incredibly hard to isolate those fibers. When we activate the quads, we're getting the whole quad, all of the heads of the quad. And even if we did attempt it, we have no proof of correlation that those specific fibers are driving the symptoms. So our three duds, looking at imaging to drive treatment, specifically with Chondromalacia patella, being overly concerned with with patella tracking and trying to impact that patella tracking with the one thing that we've shown the good research that impacts patella that that would be theoretically impacting patella tracking is that medial knee taping mcconnell taping what we now know is that is much more of a symptom modulator and has no long-term impact on that patella tracking. And then VMO, specifically training the oblique fibers of the quad. What we now know is getting the quads more robust and resilient is the way to go, being far less concerned about those very specific fibers that are very hard to isolate anyway. So those are our three duds. STUD #1 - WORK VOLUME VS. TISSUE CAPACITY Our four studs are going to be looking at that person's overall work volume compared to their capacity. So this weekend is a prime time example. We're going to have tons of folks going out for turkey trots. We're going to have a lot of folks going out and playing backyard football with their family on Thanksgiving. They may not have been doing any training over the last four to six months to prepare their anterior knee. for that capacity. Family members might say, hey, I'm jumping into this turkey trot, and then Bill says, you know what, I'm gonna jump in with you, even though I haven't run since 1968 when I was training for Vietnam. That individual may encounter some anterior knee pain because the capacity of their anterior knee is not matched to the work that it's about to do. So anytime we've got one of these pain symptoms, syndromes, kneecap pain, looking at, okay, what is it you're doing? and what is the capacity of the knee currently, and trying to figure out where those gaps are. STUD #2 - TRAIN POWER, NOT JUST STRENGTH Along those lines, the second stud is can we increase the load capacity, the capacity to handle speed or power, and the capacity of that anterior knee to handle endurance. What is your ability to produce load or to tolerate load in knee extension or squat? What's your ability to sustain that over long periods of time for high repetitions or high time intervals? What is your ability to generate power with those things? Dustin Jones came on here a couple weeks ago and talked about how we may have named the wrong enemy when it comes to deconditioned older adults that it may be more power instead of strength is the problem that a lot of folks actually have load capacity tolerance to their tissue. What they lack is the ability to handle that load while generating high speeds or force. We see the same thing when it comes to kneecap pain. We're getting better at getting people stronger to build that load capacity. We also need to make sure they can handle that at fast speeds. Our box jumps, our broad jumps, our cleans, our snatches, or sprinting, those sort of activities, we need the same sort of intention to build the tolerance. So building the local strength capacity or building the local tissue capacity of the knee. STUDF #3 - MOTOR COORDINATION & SKILL The third stud is skill or motor coordination. The law of specificity has reigned true in strength and conditioning since it was looked at. If you want someone to get better at running, train them in running. If you want to get them better at squatting, they need to train the squat. If you want their step up to look better, they need to be working on step up variations. So this has a very much skill component like any other skill in life. It takes repetition, It takes breaking it into chunks, it takes slowing it down, speeding it up. If we want their step up, or their step down, or their running, or their squatting to look better, making sure that we break those things down individually and look at it in addition to the first two components. STUD #4 - RANGE OF MOTION And then the fourth piece that's a stud is range of motion. What is the range of the tissue surrounding the anterior knee that's gonna dictate how much force is going through that knee? So a couple of the big ones are, what is ankle dorsiflexion like? If that person significantly lacks ankle dorsiflexion, we know those forces are going to go up the chain, often landing on that anterior knee. So attempting to impact or offload dorsiflexion will help with that anterior knee pain. What is the length of the rectus femoris? What is that quad length like? If that tissue is super gummed up and tonic, we may want to work some eccentrics to improve the mobility of that tissue overall. And along those same lines, what is that individual's hip extension looking like? If that person lacks significant hip extension, again, they may encounter more force to the anterior knee. DUDS & STUDS FOR PATELLOFEMORAL PAIN So again, for our studs or duds, looking at the three duds, looking at imaging or being overly concerned with imaging, specifically chondromalacia patella, being overly concerned with patella tracking and trying to impact it, and being overly concerned with the VMO. Those would be our three DUDs that we want to spend less time addressing or no time at all. Our four DUDs are going to be looking with the patient at what is their overall work volume compared to their current capacity. What is the ability of the anterior knee to tolerate loads from a load capacity or strength perspective, from an endurance and from a powers perspective. What is their skill in the movement that they're trying to perform? Do they need to become a better runner? Do they need to get better at squatting? Do they need to get better at step ups? Looking at that specific motion. And then finally, looking at any range of motion deficits of the lower quarter. Specifically, what is that quad length like? What is their ankle dorsiflexion? And what is their ability to extend their hip? Hope this helps. Hope you all have a wonderful Thanksgiving and get some good relaxation and time with your families. Lindsay and Cody will see you on the road in early December. I'll see you on the road in 2024. Hope you have a great 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 CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the anatomy & physiology of phonation, the mechanics of breathing, and the relationship between the pelvic floor & the demands of speaking/singing. In addition, April covers unique considerations for professional singers & speakers and implications for physical therapy treatment.

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 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.APRIL DOMINICK What's up PT on Ice fam? This is Dr. April Dominick from the Ice Pelvic Faculty Division here today to talk about the pelvic floor and its role in breathing and voicing today. I have a feeling it'll take your breath away. But first, some updates from our pelvic division. First, we have our last live course offering of 2023. It is happening December 2nd and 3rd. with Christina Prevett, and that is gonna be in Halifax, Nova Scotia. And let's not forget about not one, but two of our online eight-week course offerings. Level one is going to kick off next year on January 9th, and the brand new level two advanced concepts are going to get rolling on April 30th. So head over to ptonice.com and secure your seat in one or all three of those offerings. So we wanted to hop on today to outline what we know about the pelvic floor and its essential tasks and things that you've probably already done today like breathing and talking.

THE PELVIC FLOOR & PHONATION I'll discuss the essential anatomy and then the structures that are involved and then we'll unpack the complex physiology of breathing and voicing with a special focus on what the literature supports right now in terms of what the pelvic floor's role is in phonation. Spoiler alert, there's not a ton. And when I say phonation or voicing, all those terms mean talking. So we need to understand what normal function is in order to identify dysfunction during pelvic floor assessment, especially when it comes to an individual complaining of any bladder issues or bowel dysfunction, leakage, pelvic heaviness, or pain during tasks like breathing and talking, or yelling and singing, This can happen to anyone. Think about the last time you were in a really loud bar or at a concert and you're yelling at someone or trying to talk to people and your voice gets a little fatigued. Maybe there's some fatigue in the pelvic floor as well. This can also happen with other occupations that primarily use their voices. So I'm thinking about teachers, maybe chefs in a busy kitchen or coaches, professional singers even. Another point to bring up is breathing and more recently phonation have been used in the clinic by physical therapists to treat pelvic floor dysfunction. Yet we lack robust evidence to support these clinical practices. So when it comes to breathing and voicing, I want you right now to think of some body parts or structures that are involved. I'll give you three seconds or you can pause.

THE ANATOMY OF PHONATION Most of us probably thought of the obvious structures like the nose, the mouth, the lungs, and maybe even the diaphragm. And those are great starts. And we're going to run through the other important players for breathing and voicing. Breathing and voicing work in a closed system, which involves the interplay of three regions. with different diaphragms. So the cervicothoracic diaphragm, the respiratory diaphragm, that's the diaphragm that you think of when we talk about the diaphragm, the dome shape, and then the pelvic diaphragm. So when it comes to the cervicothoracic diaphragm, the major surrounding structures of interest are the oral and nasal cavity, the larynx, which is also known as the voice box, and that houses the vocal folds, the trachea, and then there's supporting musculature. There's paralangeal musculature like the SEM and scalenes, as well as the intercostal muscles. From a nerve standpoint, we cannot talk about the pelvic floor or voicing or breathing even without talking about the vagus nerve, as well as the phrenic nerve that runs along this area. The vagus nerve innervates the vocal folds and the phrenic nerve innervates the diaphragm. So that's the cervicothoracic region and diaphragm. Then we've got the respiratory diaphragm. That's going to separate the thoracic cavity from the abdominal cavity. And the diaphragm at rest, it's that dome-shaped muscle And it's got many origins, the xiphoid process, some of the lower ribs, the lumbar spine. Indirectly, it also attaches to the psoas and QL or quadratus lumborum. And then in that same region, we have the abdominals and they aid in power production for respiration or phonation. We're talking the internal and the external obliques, the rectus, and then the transverse. Then we have the pelvic diaphragm, our third area. The pelvic floor muscles are actually the floor of this entire closed-core canister system. Its three layers involving the levator ani, the coccygeus, piriformis, optorenus, and ternus are all muscles that span from the pubic bone back to the coccyx, and then from the ischial tuberosity to the other ischial tuberosity. Functionally, the pelvic floor is involved in so many things, abdominal and pelvic support, modulation of intra-abdominal pressure, postural and respiratory support, bowel, bladder, sexual function and arousal, and reproductive function. When those pelvic floor muscles contract, they close off the urethral, vaginal and anal openings. When they relax, they open those openings so that if we need to, we can urinate or poop or do any of those things. So that's the anatomy piece.

THE PHYSIOLOGY OF PHONATION Now I want to go into the relevant physiology when it comes to pressure generation and management. So breathing is the transmission of air into and out of the lungs. Sounds simple. Right? No, not so much. We're going to go through how each region that we just discussed supports respiration in two forms, inhalation and exhalation. For the cervicothoracic diaphragm, the vocal folds are there and they march their own drums. So during inhalation and exhalation, those vocal folds stay open, and that's to allow airflow in and out. In terms of the intercostals, during inhalation, the external intercostals are going to elevate the ribs and go upwards and outwards, which expands the thoracic cavity, and then they'll relax on exhalation. The SEM and scalenes are going to assist in the inhalation portion as well as provide some postural support for the head and neck. So that was a cervicothoracic diaphragm.

THE MECHANICS OF BREATHING Now we're going to go into the respiratory diaphragm physiology and mechanics of breathing. So during inhalation, that dome-shaped muscle contracts and changes from dome-shaped and then flattens as it descends towards the abdominal cavity. This is going to create a vacuum that pulls air in. And then during exhalation, that flat diaphragm passively relaxes and returns back to its dome shape. Then we have the abdominal muscles. They are a little more straightforward. On inhale, they're going to relax and expand outward. On exhalation, they're going to contract and draw inward. Then we have the pelvic diaphragm. So during inhalation, the pelvic floor muscles relax and elongate. Then on exhalation, in the presence of now increased intra-abdominal pressure, the pelvic floor should contract and lift, which closes those openings, preventing any unwanted leakage or prolapse symptoms. And we have a few confirmations of this happening in the literature. In 2011, there was a group Telus et al, and they confirmed that these pelvic floor movements are happening with respiration during real-time dynamic MRI. We love some of that research. We also have other studies that show, hey, via EMG activity, there's actually some pelvic floor activity prior to resisted expiration. And this is cool because it demonstrates that maybe the pelvic floor has some sort of neural pre-planning during the expiration phase. So I know that was a lot of information, so I'm going to put it all together for you in terms of respiration, what's happening from head to floor. During inhalation, the vocal folds are open to allow the air to flow in. The external intercostals are going to elevate the ribs up and out. The SCM lifts the sternum. and clavicles, the diaphragm contracts and descends downward, the abdominals expand outwardly in response to the displaced organs, and then the pelvic floor elongates inferiorly. Whereas exhalation is more of a passive process of the muscles relaxing. But it can be a forced process as well, like during exercise or playing an instrument, or if we're under any stress, So now I'll run through the muscle responses during passive expiration, which is essentially inhalation in reverse. The respiratory diaphragm and inspiratory muscles relax, the pelvic floor and abdominals, synergistically contract, and there's this beautiful parallel lift of the pelvic diaphragm and the respiratory diaphragm upon exhalation. And then finally, those vocal folds, remember they stay open. so that air can exit the body. So that is respiration. It is the foundation and the power source when it comes to phonation or talking. As far as phonation goes, the entire body is a vocal organ. So the next time someone asks you at a party, hey, do you play any instruments? Be sure and tell them, heck yeah, I play this little thing, the voice. So next I'm going to detail the symptoms or systems involved in voice production. And I'll point out the differences in function of the two major muscles between respiration and phonation. As I said, the voice is a highly complex instrument involving many different body parts.

THE FOUR SYSTEMS OF PHONATION And so we're gonna think of phonation as comprised of four major systems. And these systems are like a four-legged stool. When they're all working in sync, that stool or the voice is nice and stable. When one leg of the stool is a little off, then your whole stool is wobbly and your voice is a little wobbly. Another key thing to remember is that phonation occurs during the exhalation portion of respiration. So the first of the four systems is the air pressure system. It's going to manage pressure and flow. It sets vibration in motion. We can liken that air pressure system to a musician's breath as they are playing the saxophone. In the human body, the structures that are involved in the air pressure system are the trachea, the chest wall, the lungs, diaphragm. Then we move on to the second of the four systems, the vibratory system. It's made up of material that can vibrate when activated. So if we're thinking about the saxophone, we're thinking about the reed as the vibratory system. This creates pitch. In the human body, the vocal folds, are what create pitch. They open and close, and that lets short puffs of air come through the glottis at high speeds. And the number of vibrations per unit of time is what creates pitch. Low pitch is the result of the vocal folds shortening and vibrating more slowly. Whereas high pitch is created by lengthening the vocal folds and vibrating more quickly. Loudness is determined by the subglottal pressure which is generated by the abdominals and modulated by the pelvic floor. And then we have our third system, the resonators. They are going to amplify the vibrating sound. It's the actual physical saxophone itself. They affect the richness of the vocal tone. In the human body, that's going to be the throat, the oral and nasal cavities. This is what is going to create someone's recognizable voice. Then the final and fourth system is the articulators. They are unique to the human voice. So there is no analogy for an instrument here. Articulars add quality and timbre. They modify sound shapes as they leave the mouth, which creates recognizable words. And these are the tongue and the soft palate, the lips. So in summary, for phonation or voicing, the voice is produced via the interaction of those four systems. Subglottal pressure creates sound pressure and intensity, via rapid oscillations, the vocal folds produce sound pitch. Via the vocal tract, the glottal sound is articulated, adding in someone's unique voice timbre. And then intra-abdominal pressure is controlled and generated with the rest of the core canister. And that's going to be mostly the pelvic floor and abdominals helping out with that piece. So during phonation, the primary muscles and their actions involved in the inhalation portion remain the same. So prior to speaking, we usually inhale and then we talk, talk, talk. The exhalation portion of respiration is like I said, when we phonate.

COMPARING EXHALATION TO ACTIVE SPEAKING So I'm going to talk about the two differences between quiet exhalation and actual phonation or speaking. One is that the vocal folds don't stay open like they do in quiet exhalation. During phonation, they are doing the vibration, opening, and closing through the different frequencies to produce pitch. Second, when it comes to the pelvic floor, there's very little research on what it's actually doing when we are phonating. Aliza Rudofsky is paving the way in these uncharted waters when it comes to research on the pelvic floor, phonation, and the voice, A study she published in 2020 looked at the glottis and the pelvic floor via bladder displacement. So they used 2D ultrasound imaging and folks without pelvic floor dysfunction. She had participants in a standing position. We love that because most singers stand or most people when we're talking, going about life, we're either sitting in an upright position or likely standing. And she had participants, she cued them to do a pelvic floor contraction, to do a pelvic floor strain, as if they had to go to the bathroom. And she also gave them some cued phonation tasks, like saying, ah, for three seconds at different pitches. She also had them take a note and go from low to high. And then she had them do some grunting. She found that during the pelvic floor contraction, the bladder moved cranially, or upwards, and during straining, the bladder moved caudally, or downwards. This is what we would expect. Interestingly, for the phonation tasks, she found that the bladder displacement was significantly different than that that she saw with the pelvic floor contraction. And remember, with pelvic floor contraction, we tend to see more of a cranial displacement, but with these glottal tasks, she found there was more of a caudal displacement towards the feet. And again, that's different from what we normally see with expiration. So this was some novel information about what's happening with the pelvic floor during phonation. She also recently did, and Aliza did an interview in August 2023, and she talked about some of the research she's currently conducting, still doing data collection, but she's having folks without pelvic floor dysfunction say on one exhale, one, two, three, four. And what she's finding is there again is a tendency towards pelvic floor lengthening that's happening and there's also this buoyant nature of the pelvic floor with a specific up and down response to each of those numbers. So again, that's early data collection, but really cool to hear about what could be happening that's a little different than what we would likely hypothesize with the pelvic floor and phonation. And to me, that buoyancy kind of likens to running. So in running, we know that with repeated impact, the pelvic floor is responding like a trampoline. It's going up and down. It's automatically doing this. And so this sounds to me very similar to that. Quiet respiration requires much lower subglottal pressure than phonation. So per Aliza's work, in those without pelvic floor dysfunction, as subglottal pressure demand increases, with the task of voicing, the pelvic floor has an overall tendency towards lengthening and then potentially going up and down with each voicing. Clinically, we can use these results to coach and educate patients, maybe those who are pre-abdominal or pelvic surgery or during pregnancy. We can talk to them about what may happen to the pelvic floor if it's unable to support those higher subglottal pressures that occur with certain phonation, like yelling or even singing. The pelvic floor system may give way in the form of urinary or fecal incontinence, pelvic pain, and feelings of heaviness. especially in that immediate phase, postpartum, vaginal delivery, or cesarean section because we just don't quite have those muscles or that muscular support to help with managing the intraabdominal pressure. And now I want to wrap everything up because that was a lot of information. So in terms of respiration and phonation, We can agree that those are both very complex systems of the body that use a number of body structures that start from the glottis and make their way down to the pelvic floor. Respiration is the process of inhalation and exhalation. During inhalation, the vocal folds, stay open, the SEM and external intercostals lift, the diaphragm contracts, and descends down, the abdominal slightly expands, pelvic floor elongates. Exhalation is either passive or forced, and generally the reverse process. When it comes to phonation, there are four main pressure systems in place. The air pressure system, the vibratory system, the resonators, and the articulators. They all work together to create unique vocalization. During the exhalation portion of phonation, everything stays the same with the exception of those vocal folds, moving back and forth, opening and closing, and then the pelvic floor showing a tendency towards lengthening with a potential buoyant response to each individual vocalization. The inability to support the intrabdominal pressure generated by these tasks with higher sub throttle pressure, such as phonation, may result in pelvic floor dysfunction. Clinicians can use this data as a preliminary sounding board for blending the intricacies of the vocal respiratory and pelvic floor systems, especially when they're treating someone who's coming in for pelvic floor and or vocal dysfunction, as we eagerly await even more research for these systems. Thank you so much for listening. And if you all celebrate Thanksgiving, have a wonderful 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 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 Selina // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel introduces the concept of an off-season for runners in order to focus on physical recovery, mental recovery, strengthening, and rehab. Rachel lays out a structured off-season approach for clinicians to use when working with runners.

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

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

EPISODE TRANSCRIPTION

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

RACHEL SELINA Good morning, everyone, and welcome to the PT on Ice Daily Show. Okay, I'm happy to be here as your host today. My name is Rachel Selina, and I'm a TA within our Endurance Athlete Division. So I TA for our Rehabilitation of the Injured Runner, both our live and our online courses. Our online course starts again on January 2nd, so if you're hoping to get into the next cohort of that, registration is open now, you can jump in online. It'd be a great way to kick off your new year Um, so we'd love to have you there again, January 2nd is when we start that next cohort. Um, so today, today we are going to dive into some running related topics.

THE RUNNING OFF-SEASON I want to talk about the running off season and kind of what it is, how it could be structured and really at the end of everything, like why we should take one or why we should encourage our runners to be doing an actual off season and what that could look like. Why do we need this? It's a big missed opportunity. I don't think many of our runners are taking an actual off-season, even though in almost any other sport, we see an off-season that has a particular structure that looks different than our typical in-season, pre-season kind of training. But we don't often see that in running. And here I'm mainly talking about our recreational runners. So not our elite, elite, highly competitive, like they're getting paid to run. Um, but our everyday person that has goals has things they're trying to achieve with their running. Um, but again, not quite that high end elite athlete. Um, and it's really not what I see people doing. Okay. So what I often see. And I live in Michigan, so this is a bit skewed for kind of our timeline, but the same kind of like concept applies. I live in Michigan, so most people end up having like a fall goal race. And that might be a like a marathon or a half marathon. But they train a lot over the summer, building up to that race. It happened in the fall. And maybe they're using that race as a like a they're going for a goal. They're going for a PR or they're using a lot of people are trying to qualify for Boston. OK, so either way, that that fall event is something that someone is really training for, has a specific time goal, and is pushing, usually pushing their limits to get there. After that, right, event happens, and then people usually take one to two weeks off totally, like no running. And then usually I see it as people kind of taking that totally off of like anything. And then after that two week period, I kind of jump back into running, back into training, maybe slightly less volume, right? Long runs aren't going to be quite as long, but I typically see people kind of jumping back into the same type of schedule, like training five to six days a week. I'm still usually working in some like sprints or hill work, track work, something like that. Um, so really not a, apart from those two weeks immediately after not a clear, like differentiation from what their training was prior to that race. On the flip side, I see some people where they do the race and then they're just done running. Like I don't want to run in the winter. Um, so I'm, I'm not going to run it all after my goal race until spring. Can I argue both of those probably are not our ideal situation. So I think, like I said, it's a missed opportunity and I think it's missed because there's a lot of benefit in doing an off season. Primarily four reasons we're going to cover. So I'm going to take this down a little bit.

PHYSICAL RECOVERY I think the first one is physical recovery, right? Someone typically, if they're building up to a goal race, has just spent the last three or four months, like progressively overloading every single week, building, building, building mileage, right? It's a continuous training cycle that adds up to a lot of fatigue. Some runners, right, we can encourage to take recovery weeks during their training, which can be helpful to like mitigate a little bit of that fatigue. But for the most part, people are constantly building their mileage, increasing their mileage and intensity over that three to four month period. So by the end of it, right, that's been a big stressor on the body, whether someone feels like recovered after their one to two weeks off of running, right? There's probably a little more going on underneath that the body is not actually fully recovered where they could jump back into full-on training and expect to do well. Okay.

MENTAL RECOVERY So physical recovery and then also mental recovery. Training to that extent, having to put in that amount of mileage and time into running to train well, right? Means we have to say no to a lot of other things during that time. We maybe have to say no to some family obligations or time with friends or just other activities that we like doing that aren't running, kind of everything takes the back burner. So it can also be really just mentally fatiguing and draining. So coming off of that, being able to have a period of time where we can be a little bit more flexible, be able to do different activities, not have to say no, and also be able to prioritize sleep. or like how many people are trying to fit in their running around a work schedule, family schedule, right? So often we compromise on sleep to be able to make that happen. So having a period of time where we can really build back some of those recovery practices is huge. And I think what we miss. And then it also gives us kind of that third point.

STRENGTHENING It gives us an opportunity to really help our runners do a full on strength training cycle, like intentionally trying to build strength. Um, we talk about this in the running, our live running course about trying to have runners incorporate strength training into their train, like into their endurance training, um, separate sessions, but concurrently meaning they're, they're doing aerobic training and then they're also in a separate session doing strength training. And we want that because it can help reduce the risk of injuries, but it can also help improve their performance. However, in that in-season cycle, that preparing for competition, most people aren't able to load to the intensities needed to really build strength. And it kind of takes second place to the running training. So having a two to three month period, where we can switch that narrative and make strength training the focus can be super helpful to actually help someone build the capacity in their tissues, right? Here's a two to three month period where strength training is going to be kind of our priority. We can actually build the capacity of your Achilles tendons, your quads, right? Your glutes. And make sure that when you go into that next training cycle, you're actually coming in more resilient, ready to train. Your tissues can tolerate more load.

ADDRESING REHAB & PREHAB NEEDS Sweet, and then our final thing I think that we could use off season for is really having a period of time where we address nagging injuries, right? Oftentimes we're seeing people come in, they're in the middle of training, their goal is to do this race. So we might let some things go or people might avoid addressing some issues because they want to finish their race. So having, again, having a period of time where we can fully address that injury, not just kind of do what we need to do to reduce symptoms and get someone to the starting line, um, could be a really helpful thing so that it doesn't become this chronic, um, you know, it goes away when I stopped training a little bit, but then it comes right back because I've never actually addressed it. It's also a good time to address our running mechanics, right? Sometimes when we're in the middle of like a really high volume training, We might want to make some changes to mechanics, but those mechanics, when we change them even a little bit, can have a big impact, which can be good, but it's also hard when the volume is so high. So having a period of time where our volume is lower lets us adapt to that new running pattern, whatever the changes that we're making in the gate mechanics, without it being such an overload because the volume's lower. Right. So we can kind of ease into that new pattern when we go back to our like building cycles for running, we're able to kind of already have that, um, but like internalized and have our body adapted to it. So it's kind of the, like the, the big pillars of what it could be, but then what that would actually look like, like, okay, that's great.

STRUCTURING THE OFF-SEASON How do I actually help my runner to structure an off season? If we go back to that initial goal race, race happens. And then we do want to encourage people to take that next one to two weeks off of running, but that doesn't have to mean off of all activity. So I'd encourage runners to focus more on active recovery, not running, but maybe they're doing some light cycling, swimming, yoga, anything else that kind of helps them to recover. But then also really focusing on refueling, right? Making sure we're sleeping enough in that time, just kind of replenishing the body after everything we depleted it from, from that baby vent. So that would be like one to two weeks. And then having another one to two weeks of a reverse taper, which is where we go from not running in those two weeks off and kind of gradually build the running volume back up, um, to kind of just a moderate level. So if we think of an actual taper before a race is the opposite where we're, we're at a higher volume, we kind of drop over one to two weeks. Um, and that purpose is to allow the body to be fully rested going into a race. So that would put us about a month out from a goal race, a month after it. And then I would encourage you to ask your runners to take two to three months after that of an off season. Okay. And that would look like keeping the volume at like no more than 60 to 70% of what they were previously running. Like as their, like their top training weeks or kind of their, their average volume week over week. So if someone was training 40 miles a week in preparation for, say, a marathon or half marathon, having them drop down to where they're not doing more than 24 to 28 miles a week. And that might look like going from training five to six days a week, running training, to dropping that down, running only three or four days a week. And that extra time, again, it doesn't have to be Like you just have to rest. Um, but filling it in with other activities that someone likes to do strength training, maybe it's CrossFit or swimming or yoga or climbing. Okay. And then finally, the intensity of this time should also be dropped down. Okay. We don't want, this isn't the time to like be working on our hills, our hill repeats, our sprints, our interval work, our track work, right. Keep the pace. low enough that it's like easy running. Okay. And then when the body is actually fully recovered, we can enter into that next cycle, ready to go, ready to push again and actually see benefit because the body's recovered and able to adapt to that new training stimulus. So the, the only other, um, It's kind of different situation here. Like what I've been talking about is someone who running is their main thing. Like they like to run year round, they're maybe doing a couple of different races in a year. If we have someone who's a true like multi-sport athlete, where they'll run during say like summer and fall, but then in the winter they switch, maybe they switch to skiing. Okay, that person's going to maintain their aerobic training, from the skiing, and they might not really wanna run at all, which I think we also need to have a bit of caution there, using that other sport as the off season, because running has such a different training load, right? It has that impact that differentiates it from any other activity. So we don't want someone's tendons and tissues to become unadapted to that stimulus of loading and running. So even if someone is taking their off season to pursue a different sport, still encouraging them to get like two to three, at least exposures to running or plyometric training. And it doesn't have to be long, right? Maybe it's asking your runner to do like, can you give me two 20 to 30 minute runs a week, right? Even with your other like skiing training. If they're like, nope, I don't want to run at all. Can we at least get some plyometric training? Can we work a little bit of jump rope in there? Can we work some just other kinds of jumps, box jumps, drop jumps, anything like that to still get exposure to impact loading? And I think like a lot of that can be more coming from a coaching perspective, but I think it's also important in the clinic, especially if we think that most people, when they have a running injury, they don't come to us until it's a big deal. That's kind of our typical pattern, which usually can look like someone coming to us shortly before a race, right? So our focus there to help them meet their goal has to be a little more on kind of like putting out the fire, helping them get to the starting line for their race. But if we can set patients up with the expectation, hey, this is going to help you get to your race. But then afterwards, like I want you to come back and see me. so that we can really address what's going on, right? I want you to take, especially if someone's dealing with an injury, I want you to take this off season afterwards. We're going to work through to make sure you're 100%. We're gonna drop your running down a little bit, make sure you recover so that when you go back to that next cycle, you are actually ready to go. This issue is no longer nagging you, you're stronger, you've had adequate recovery. So I think it's a big point for in the clinic, just the same as it can be outside as we're thinking about maybe our non-injured athletes. Perfect, I would love to know your thoughts, so you can throw them in the comments. Let me know if you're taking it off season, if you encourage your runners to do so, or just any kind of thoughts you have around the topic would be great. So thank you for tuning in, have a great weekend, and we'll see you next time.

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

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Office Alan Fredendall discusses how and why behind more carefully curating the digital & social media content you consume on the internet.

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.

ALAN FREDENDALL Team, what's up? Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day's off to a great start. Glad to have you here on the PT on ICE Daily Show. My name is Alan. I'm happy to be your host. Currently, I have the pleasure of serving as the Chief Operating Officer here at ICE and a lead faculty member in our Fitness Athlete Division. Leadership Thursdays, we talk all things practice management, small business ownership, and general leadership tips for all of you out there who are leaders in your own way. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday couldn't be more challenging but also simpler than getting out there and hitting a 5k run or if you can't run hit a 5k row. Great aerobic test. As I get more into endurance running, I would argue I've been learning to hate 5Ks the most if it's a really uncomfortable distance to settle into kind of a longer, slower pace of, you know, you're setting a good pace on the first mile. Dang, I'm almost a third of the way done. Second mile, third mile. can be quite an aggressive distance. It's the most commonly programmed CrossFit workout if that surprises you. I've posted some benchmark times as far as percentiles for both the 5k row and the 5k run to kind of compare yourself to where I stack up against the general population. So have fun with that one. It's good to test that at least once a year and see how your 5k has changed, especially if it's a goal for you to get your aerobic, your longer energy system a little bit more efficient, and specifically to get better at maybe 5k runs. Some courses coming your way. Before we talk about these courses coming up before the end of the year, I want to challenge you that if you are in the market for an ice course, and you're able to purchase a course before the end of this year, you should do that. Wink, wink, wink, right? There might be a change being announced soon that would make you regret not purchasing now. So you'll see that maybe an announcement coming soon. courses before the end of the year we're almost done we have some courses this weekend but that's probably too late for you we'll be off next weekend for Thanksgiving and then we have just three weekends left of live courses in 2023 December 1st through the 3rd that weekend you can catch Paul up in Bellingham Washington for dry needling upper body You can catch Zach down at his home base at Onward Tennessee for cervical management. Christina will be up in Halifax, Nova Scotia, A for Pelvic Live. Ellison will be down in Tampa, Florida for dry needling lower body. Cody will be on the road for extremity management out in California in the Bay Area in Newark, California. Brian Melrose will be in Helena, Montana for lumbar management. and Julie Brower will be on the road in Candler, North Carolina for Older Adult Live. That's right outside of Asheville. The weekend of December 9th and 10th, we have Fitness Athlete Live. That's your last chance to catch that course this year. That'll be with Mitch Babcock out in Colorado Springs, Colorado. You can catch Extremity on the road again, this time with Lindsey Huey in Fort Collins, Colorado. And Older Adult Live, your last chance this year will be in Portland, Maine with Alex Germano. And then our very last course of the year, of course, we expect nothing less than a person of Paul's caliber to be the last person working this year. He will be in Salt Lake City for dry needling his upper body. That'll be the weekend of December 15th, 16th and 17th. That's a three-day course. So if you're in a state that needs a lot of hours like Washington, or Maryland, that'll be a chance to catch a three-day version of that course. A course is coming your way from us here at ICE.

YOUR TRIBE DICTATES YOUR VIBE Okay, let's talk about today's topic. Your tribe dictates your vibe. You've often maybe heard the other way around. Your vibe attracts your tribe. How you carry yourself, your personality, your values, kind of attract the people around you that are maybe in your friend group, your colleagues at work, that sort of thing. I want to talk about it from the other angle your tribe dictates your vibe, of the people you choose to follow, whether they're actual in-person people or specifically today's topic, of the people you follow on social media can really dictate not only how you feel about yourself, care yourself, but of what you might begin to spend your time and money on for the worse or for the better. So I really, really, really want to stress that social media, I think, is destroying our society for the worse. Certainly, it has value in things like this and sharing information and education. from one person to a large group of people. But I think overall, we can begin to follow people who appear really relevant to our lives. But actually, if we do a really deep dive, we understand they actually have very little in common with us. And then ultimately, at the end of the day, we're in charge of who we follow. Many of us are not on social media against our will. And so that the emails you subscribe to, the social media accounts you follow, all of this digital content that you consume can have positive or negative effects on you. And to really stress, if you take nothing else away from this episode, to be really diligent in the streams and feeds that you begin to curate as you begin to follow email newsletters, social media accounts, and the like.

THE PITFALLS OF THE INTERNET: TALKING TOUGH & SOUNDING SMART The first point I want to make today is The pitfall of the internet, as it's always been since its inception of consumer-based communication, is that it's super easy to talk tough and sound smart on social media. We live in a very impatient, rapid-fire, fire-and-forget type of world now. You may not know, but certainly, if you work at all in customer service, you experience, that the average expected response time to an email or social media message is now 10 minutes or less by the average customer. That's a study from Forbes from this year in 2023. I could say a whole bunch of crazy stuff right now on this podcast. I could say it in a social media post and I would have almost no side effects come to me because our society now is so rapid-fire, so fast, so consumable that you would consume this. Maybe what I'd say you would resonate with, maybe it would make you upset. It doesn't matter because you will forget about it in three minutes when you scroll on to the next piece of content. on your social media feed or the next podcast episode that you queue up. The only regulation on what we say is from you all, from the consumers. What's noticeable on social media is that the people who tend to be the most aggressive and make the largest blanket statements are often those who do so without any sort of evidence or support. They're also not the people who tend to engage in the stuff that they create, right? They're very aggressive. They fire something out there. They know it might make you upset. You might actually make a comment. And that's kind of their goal, right? That drives their engagement up. That shows their post to more people. Maybe it further upsets people. It gets more comments. And what we need to realize is that cycle is kind of what fuels those people to have large follower bases, to be able to advertise different things to you. Hashtag, you know, ice barrel, try out your hashtag toe spacers, right? Those people are trying to strike a nerve on purpose to get more engagement, more followers, more followers, engagement equals I can make more money selling sponsored things to you. So we need to be aware of that trap that is out there for us on social media and be aware of the pitfall of the internet and social media itself of this very consumable temporary transient content and recognize if you're falling for that trap of if you are getting upset and making comment or if you're following people who make kind of outlandish, unsupported statements. If that makes you upset, again, the whole theme of this episode is why are you following accounts like that.

YOU HAVE NOTHING IN COMMON WITH THE MAJORITY OF PEOPLE YOU FOLLOW The second point I want to make of why are you following accounts like that is that you have nothing in common with the majority of people that you follow and obtain content from. You're making less money than you want to. You're working more hours than you want to. You're not feeling as physically well or as fit as you want to. You're not happy with how your body looks. Maybe you're not happy with how your marriage is going how you're raising your kids how your sex life is going, and how your postpartum recovery is going. You name it, you're being told that whatever is wrong with you, X is Y with you. Y is the solution, right? You are not having a good life because you don't wake up at 4 a.m. and do a 6-hour morning routine. You're not having a good life because you don't wake up and do a gratitude journal, use toe spacers, do yoga, meditate, do a cold plunge, or a sauna, or any of these other things that you're told are the difference between this apparently very successful person and you. But often when you do your research, when you look behind who are these social media influencers, you're often being sold solutions by people that are usually millionaires and who are usually millionaires, not because of the stuff they're telling you that they do, but because they're convincing people like you to buy the stuff that they're selling. And that's how either they are making their money or they're maintaining the level of income that they already have, right? Or maybe they started out in life and mom and dad footed the bill for college and for grad school and for their first house and they don't have a lot of debt and so they have a lot of extra time, they don't need to work as much to become this social media influencer and begin to sell you supplements and Toast Facers and all this kind of stuff. And the more you listen to those folks about what's wrong with you is that you're not consuming this stuff, the more money they actually make and the bigger that asymmetry actually comes. What's not said is that a lot of those folks have made their money by living what they're doing right now, which is a very imbalanced life of working more than you want to in order to try to pull yourself up the socioeconomic ladder. You're told that you're burned out or whatever and really the cause of their success is doing what you're doing right now and eventually getting to the point where their success comes to a level where they no longer need to work as much and maybe now they have more time to show you a video of them working out on the beach in Bali. And by the way, use my promo code Stephen10 for 10% off, whatever. And again, the more you consume that, the richer that person becomes. But at the end of the day, you do not have a lot in common with that person, yet you are trying to model your life after them, even though that's not how they currently live their life. And maybe that's not how they ever lived your life. These people are happy, healthy, and fit because they don't have to go to work anymore. Or maybe they never had to go to work. They can wake up and do their morning routine and go surfing because they're able to afford a full-time nanny to take care of their kids. Or maybe they don't even have kids and they get 12 hours of sleep because they have a night nurse. Or again, maybe they don't even have kids. And you get my point that they are living a very different life than you and maybe they never lived the life that you did. So it doesn't make sense for you to spend a lot of your time consuming their content and buying the stuff they're selling to somehow try to fix your life. Follow people who represent you, who represent your values, who are honest about where they made their money or how they got to the level they are at. I tend to follow people who are very upfront about how they got where they're at by pulling themselves up from being very, very, very, very poor, working a ton, and pulling themselves up the socioeconomic ladder. Is that ideal? No, but sometimes that is life, as true as it can be. And I resonate a lot more with those people who say like, look like this was the way that worked for me. It may not work for you. And I appreciate those people who are honest that look, it was a lot of years of 100-hour work weeks, working multiple jobs to pay off my debt to afford a house, to raise kids, and kind of get to where I'm at now. And I really, really appreciate that transparency, especially more as life goes on. So, what can we do about this of recognizing that Social media is meant to be fire and forget, instantaneous, consumable? It's meant to sell you things. It's meant to show people who maybe have nothing in common with you that you want to see yourself become only if you buy these products. If that's the way it's designed, what is the solution?

CUT THE CORD The solution is to cut that cord, right? Take a serious examination of the accounts you're following, of the newsletters you subscribe to, of in general the content you consume digitally via social media, email, whatever, and stop following stuff from people who make it seem like the only reason you're not obtaining the fulfillment you want is that you aren't buying enough of the stuff that they're selling. Stop following accounts that tend to speak on best practices, but speak so dogmatically. Manual therapy sucks, it has no value. On the other side of the continuum, manual therapy cures diabetes, right? Stop following that stuff if you don't actually believe that stuff. Some of us follow that stuff just to watch the comments and watch people argue, or maybe you're even that person, spending your time that could be spent better elsewhere, arguing with people on the internet. I'll be very honest, I used to be that person. If you knew me a decade ago, I was that person. I was that person yelling at people on Twitter. and Instagram and all the other social media platforms, and I've talked about this before, one of the biggest shifts in my life was meeting Jeff Moore, our CEO, who one day sent me a screenshot of all these comments I was making, all this time I was spending on the internet, on social media, and just said, is this the best use of your time to advance the field of physical therapy? And of course, if you really ask yourself that question, then the answer truly is no. So stop following that stuff. Stop following those accounts. Stop following people who tell you that the way you're treating patients is wrong. If they are people who maybe don't currently treat patients or have not treated patients in a long time, five years, 10 years, 20 years, or maybe people who have never treated a patient ever, right, that person who went from PT school, maybe right to a Ph.D., or a consulting job, or to work for an insurance company as an adjuster, and has no actual real-world experience. Why are you following content like that? Knock that off. Follow people who are in the clinic every day, who are trying to make it all happen, who are trying to blend manual therapy, patient expectations and beliefs, and fitness-forward lifestyle, getting people loaded, getting people addressing their sleep and diet. Follow people who put out content like that, not content that maybe just makes you upset at the end of the day. Follow accounts that make your life easier. Follow accounts that give you resources that you can provide your patients so you don't have to work as much making that stuff yourself, right? Follow, obviously, I'm biased. I can't not have any bias here. Follow us, right? Go to PTonICE.com, click the resources tab, and look at literally an endless list of ebooks, workshops, of patient resources already created for you to make your job in the clinic easier so that hopefully you don't have to spend as much time making the money that you're currently doing. You don't have to work as hard doing it. Follow people in a manner that sees you working less and making more and not just buying more gadgets and $10,000 mentorship programs.

THERE'S NOTHING WRONG WITH YOU And I think finally, what I want you to resonate from today's episode is to recognize deep down that there's nothing wrong with you. If you work more than you want to and get paid less than you think you should, you are not damaged. You are a normal American, right? 77% of Americans live paycheck to paycheck. Half of all Americans work two or more jobs. It is totally common to work more than you want to, to try to get ahead. Again, some of us are trying to pull ourselves up a huge deficit, right? We're trying to close a large asymmetry. We're trying to go from the poor person who grew up in a trailer park to maybe the first person in your family to finish middle school or high school or undergrad and grad school and be the first person to own your own home and be the first person to maybe have a retirement account and actually be able to think about retiring. We're trying to pull ourselves up multiple rungs. And I think for most of us, we believe that working a bunch is not how we get there. And I think when, again, we follow people who are more transparent in how they have their success. You'll find that's how they also got there, right? They didn't toe space and cold plunge their way from the trailer park to owning their own home starting a family paying off their debt and being comfortable in retirement. So recognize that there's nothing wrong with you.

CHALLENGE YOURSELF TO CURATE BETTER CONTENT Okay, challenge you. If you look at my social media account, if you look at my Instagram, you'll see I have tens of thousands of followers. I don't know who most of those people are or why they follow me. Yet, look at that ratio. When you look at the ratio of people who follow to followers, it is my belief that you should only follow people that you want to see content from. What you'll see when you look at my account is that I only follow a couple hundred people, right? I follow close friends and family members. and people that I want to see content from. Again, my goal with social media is to curate a feed that makes my life easier with different tips and tricks about physical therapy, coaching, leadership, business, about all the different spheres I'm involved in. That's how I curate my social media feed. I don't follow people back who follow me if I don't think they post any content, that's certainly possible, or content directly relevant to me. And I think it's okay if you have to unfollow those people. Some people may think that means they follow you. Well, hopefully, they follow me because they find value in what I post and I think it's okay to not reciprocate if you don't feel the same way. I'm sure the people who follow me that I don't follow are nice upstanding people who treat their spouses and their children well hold the door for people to pay their taxes on time and leave a nice tip at the restaurant for the waitstaff, right? Not saying there's anything wrong with them. It's just I don't believe that the content they create is beneficial to me, and otherwise, it just becomes an endless blob of noise that maybe as you start to follow and compare yourselves to, you start to feel bad about yourself. So take a step back. Why am I following these people? Is it beneficial to me? It's okay to unfollow people, I promise you. I'm giving you permission, I'm giving you the blessing to do so. Cut that cord, recognize that you don't have as much in common with most of the people that you follow, as you think you do, and recognize that a lot of those people are relying on showing you this grandiose awesome life in order to sell you stuff so that they can continue to live that awesome life of working out on the beach in the Caribbean and living in their mansion in Costa Rica and using dye-free detergent and eating organ meat and all the stuff you're told is the reason that you're not doing as well as you need to. Consider, that your tribe dictates your vibe. Who you follow can really make your day or ruin your day. It can make you feel bad about yourself. You could get caught comparing yourself. So just knock it off. Cut that cord. Hope you have a fantastic Thursday. Have fun with Gut Check Thursday. We're going to be at a live course this weekend. Enjoy yourselves. I'll be back here on Thanksgiving Day. So I'll see you all on Thanksgiving Day. If you won't be joining us, I hope you have a wonderful Thanksgiving. Have a great Thursday. 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. 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 as she discusses that the problem with patient education lies in the tendency of healthcare professionals to overwhelm patients with excessive recommendations, mistakenly believing that this approach is effective. They often act like a "fire hose," bombarding patients with information without considering whether it is truly understood or has a positive impact. This ineffective method of simply talking at patients, providing detailed explanations, or presenting long to-do lists is often learned from clinical instructors and perpetuated without recognizing its limitations. To enhance patient education, healthcare professionals should adopt a three-step framework. This framework involves "show and tell" by combining education with action and intervention, clarifying and recapitulating information to ensure comprehension, and following up and following through with patients to establish mutual accountability. By implementing this framework, healthcare professionals can avoid overwhelming patients and ensure the effectiveness of their education.

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. JULIE BRAUER Welcome to the Geri on Ice segment of the PT on Ice Daily Show. My name is Julie Brauer. I am a member of the older adult division. Excited to be here with you all on Wednesday where we jam on all things older adults. Excited to be talking to you all this morning about patient education. Our topic specifically is patient education finish the drill. All right, so what we are going to talk about this morning is the problem with what many clinicians perceive to be effective patient education. And then I'm going to unpack a three-step framework that you all can use to level up your patient education interventions. And I'm going to then share a few really detailed examples of how you can implement this going forward using clinical scenarios that many of you all experience pretty frequently. The goal here is that we just walk into the rest of our week doing 1% better, okay? THE PROBLEM WITH PATIENT EDUCATION: THE FIRE HOSE All right, so what is the problem with patient education? The standard. Too often, we act like a fire hose. We flood our patients with too many recommendations, and we think that it's effective patient education. Team, we cannot fool ourselves. that simply talking at our patients, right? So explaining the very detailed pathophysiology of their condition or explaining their fall risk profile after running your outcome measures or giving them a 10 item to-do list of safety and lifestyle recommendations that they have never heard before and assume that we are making a positive impact. Many times I think this comes from the fact that we didn't really learn in school how to be effective at communicating to our patients and providing education. And then we just kind of followed what our CIs did, right? I am so guilty of this. I remember as a new grad going into a patient and you're so excited because you want to tell them everything in your brain that you know, you want to share your knowledge. And I remember I would just fire hose, fire hose for 10 to 15 minutes and I would walk out of that room and be like, man, I crushed it with Dolores. Like she just learned so much. I just did an awesome job. And then I would sit down and write literally a paragraph of all the things that I educated my patient on. And for some reason, because I wrote an entire paragraph of my educational interventions, that must make it good, right? Like I perceived that I did this awesome thing. So I think that's a scenario that we find a lot. The other scenario, which I've also been here, and many of you have probably been here too, is that you constantly have this productivity being shoved down your throat, or you are just so freaking burnout and so exhausted, you look at your clock and you're like, I gotta get this last patient in. I gotta get this last patient in. I'm exhausted. I don't have a ton of time. I don't know if I'm going to get a second set of hands to get them up to do any exercise interventions. So what am I going to do? I'm going to go into this room and I'm going to sit there and I'm going to educate. I don't even know if I can stand up to do it. So I'm going to just stay in my chair, educate and type as I'm there. I know a lot of us had been there, right? I know a lot of us have been there, but are we really helping our patient? Do we really think that just by sitting there and telling them a bunch of stuff, it's going to cause any positive impact? We have to really start to dig in there. So I want to offer you all a solution. I'm going to explain this three-step framework. So what does finish the drill mean? It means one, we're going to show and tell, Two, we are going to clarify and recap. And then three, we are going to follow up and follow through. So let me unpack each of those. SHOW AND TELL, CLARIFY & RECAP, AND FOLLOW-UP & FOLLOW-THROUGH Show and tell. Are we pairing our education with action on our part, an intervention, a demonstration? Are we facilitating action on our patient's part? Show and tell. Next, clarify and recap. Are we ensuring that the education that we are giving, the literal words, the process, the steps that are coming out of our mouths is actually being understood? Are we ensuring that the message we are sending is being received in the way that we intend? Are we asking the patient to recap what they heard? Are we asking questions to clarify misunderstandings or gaps in knowledge transfer? And then lastly, follow up and follow through. Are we following up with the patient after we make those recommendations? Are we following through with a caregiver or the next provider? Are we holding ourselves accountable and the patient accountable? That is what it means to finish the drill. Show and tell, clarify and recap, follow up and follow through. Okay, let's go through a few scenarios to give you guys a very detailed, clear example of how you can implement. I have a massive list of these, but I'm just gonna give you three here this morning, okay? All right, for you acute care clinicians, You have Dolores on your caseload. She has just had a lumbar fusion surgery, and you go in to evaluate her. Instead of just telling her, Dolores, you have movement restrictions. No bending, lifting, or twisting, right? We all know the BLT restrictions. What we know is that restrictions can cause a lot of fear. A lot of patients never discharge them and they walk around like they're in straitjackets for a really long time. So instead of just telling Dolores what she can't do, let's show and tell. Let's show Dolores how to hip hinge safely. and distinguish that from actually bending and flexing at the spine. So how do we do that? If many of all have been following ice for a long time, you know this awesome hack. You can take the toiletry bucket that is in Doris's room. You can go take some towels, roll them up, soak them in water and put them in the toiletry bucket. You can put that toiletry bucket on an elevated surface like the bed or the chair, and you can show Dolores how to safely hinge. Let's clarify and recap. Let's ask Dolores, hey, Dolores, do you have any questions about moving your back safely and rebuilding its strength? Let's have Dolores recap the points of performance of that hinge motion and demonstrate it for us. Lastly, let's follow up and let's follow through. If you are lucky enough in acute care to see your patient twice, let's say it's the very next day, or maybe it's later in the day, on the same day, you can ask, Dolores to set the environment up. Show me how to pick this up. We are checking for Dolores's ability to have those points of performance and be able to form that hinge movement. Let's follow through, which is very hard to do as an acute care clinician because many times you have no communication with the next provider. You don't ever get to see Dolores again. How can we do it to the best of our ability? We can follow through by talking to Dolores, maybe putting it on her phone or on a piece of paper. I need you to show this to your outpatient PT. And what does it say? Can you please teach me how to deadlift? Right? We are planting a seed, passing the baton, trying to make sure she stays in that fitness forward lane because we don't want her back on our caseload. Maybe we even take it a step further and we actually recommend to Dolores a specific fitness forward PT in the outpatient setting who we are going to want Dolores to go to. Finish the drill. Okay. Let's talk about a home health example here. So let's say you have Dolores in home health. We know that her visual acuity is impaired, right? Maybe you have done an acuity test. You know that her prescription on her glasses are really outdated. Let's not just tell Dolores about the importance of vision, helping her balance to prevent a fall. Let's not just tell her to make that eye appointment with her doctor and then walk out the door and hope that she does it. Let's show her how to send a message via MyChart. Guys, systems are starting to charge patients for MyChart messages. Let's start to show them how to send appropriate messages via MyChart, right? Let's make this actionable. What if we call the doctor, put them on speakerphone with Doris, guide Doris how to schedule her own appointment to increase her self-efficacy? Let's clarify with Dolores by asking, are there any barriers that you can perceive getting to this eye appointment? Let's follow through by contacting a caregiver to schedule with them. Hey, this appointment, Dolores has a eye appointment this day, this time. Are you going to be able to take her? Let's make sure it's on both of your all's calendars, right? Or maybe we plan ahead with a service like Go Go Grandparent so that we know that the transportation piece that was a barrier is now something that is facilitated and that we have taken care of that. Okay. Lastly, let's talk about an outpatient example. All right. You're working with Dolores, an outpatient. She lives with her partner at home. She's got some balance issues. She has had a fall. So you are treating her. Let's not just tell Dolores to take up her rugs and put nightlights around her house. How often do we give that cookie cutter recommendation of let's remove all your rugs, right? Instead, How about this? How about we make this actionable and we get Dolores or Dolores' partner or a caregiver to get a video walkthrough of the pathway from Dolores' from the edge of her bed into the hallway, into the bathroom, into the living room, out her front door, whatever her normal pathway is for the day. What if we get a video so that we can actually see what her home environment looks like? And then we can say, okay, Dolores, that rug, that one, the one with the tassels that you know she's probably gonna trip over or she has tripped over. Can we get rid of that rug, Dolores? Why don't we clarify by asking, Dolores, are you willing to get rid of that rug? She may, older adults, we know this guys, right? It's really hard to tell them to get rid of rugs. They may be really resistant to that. So Dolores, are you willing to get rid of that one rug? Because you have gone through and you've triaged out of all of the rugs, that's the one that's gonna cause us the most problem. What if we ask Dolores, what are your feelings surrounding getting rid of your rubs? And you dig a little deeper there. Let's follow through with talking about how we're going to actually get this done. Because maybe Dolores may not have the capability to get down on the ground and remove her rubs. So what if our follow through is calling nephew Johnny to ask him, Hey, will you, within this week, come over to Dolores's home and help her take up her rubs? Right? What if, We don't just tell Dolores to have those lights throughout the home. Now that we have the video, we say, Dolores, the lights would be most helpful if you put them here, here and there. Here is the Amazon link of some cheap but effective ones to buy. Let's put it in your cart right now. That is how we follow up and follow through and make this actionable, right? Then we can say, Dolores, here's your follow-up. Bring in a video in the next week and show me what your pathways look like now. So you are able to see that we have followed through with this recommendation. The nightlights are where they're supposed to be and the rugs are taken out. Guys, this is what it means to finish the drill with our educational interventions. Show and tell, clarify and recap, follow up and follow through. I would love to hear you all take this framework into the rest of the week. And while you're with your patients and you're starting to just fire hose and spew out those recommendations, I would love for you to pause take the pause and really think how you're going to finish the Drew. How are you going to show and tell, clarify and recap, follow up and follow through? All right, team, that's all I got for you today. Lastly, let's talk to you all about our courses that are coming up. We have some sold out courses, which is wild to have at the end of the year. November, we have a sold out course in Illinois. In December, we are sold out or we're very near sold out in Portland, Maine. And then we have another chance for you all to catch us on the road in Asheville, North Carolina. In January 1st of the year, we are going to have both of our online courses, our Level 1 and Level 2, formerly known as Central Foundations and Advanced Concepts, that are going to be starting up on January 10th and 11th. You know where all that info lives, ptinex.com, mmoa.online. Hit us up if you have any questions. Go out there and start to make those educational interventions. Just 1% better team. All right, y'all.

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. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses various approaches to promote system-wide healing. One key aspect highlighted is the importance of education in the healing process. Lindsey emphasizes the need to educate patients about their condition and what to expect during their recovery journey. This includes providing information about tissue healing timeframes and milestones for progress. By equipping patients with this knowledge, healthcare professionals can help them understand their recovery process and make informed decisions.

Mindfulness is another approach mentioned in promoting system-wide healing. Lindsey suggests that practicing mindfulness techniques can help reduce stress and promote a calm mind. This can be achieved through activities such as breathing exercises, journaling, or spending time outdoors. By incorporating mindfulness practices into their daily routine, patients can support their overall healing process.

Exercise is highlighted as a crucial component of system-wide healing. Lindsey emphasizes that exercise should not be limited to traditional rehabilitation exercises but should also include activities like walking programs. For instance, in the case of total knee surgery, she suggests starting with a 10-minute daily walking routine and gradually increasing it to reach the recommended 30 minutes per day. Engaging in regular physical activity can improve overall fitness and support the healing process.

Diet is also mentioned as a factor that can promote healing, especially after a trauma such as surgery. Lindsey emphasizes the importance of nutrition in supporting tissue healing. Specific dietary recommendations may vary depending on the type of surgery and individual patient needs. However, healthcare professionals are encouraged to promote a healing-focused diet that provides the necessary nutrients for recovery.

Lastly, sleep is highlighted as a crucial element in promoting system-wide healing. Lindsey acknowledges that getting enough sleep can be challenging during the early stages of healing. However, they suggest providing patients with sleep hygiene tips, such as turning off electronic devices before bed or maintaining a cooler room temperature. By facilitating good quality sleep, patients can support their body's healing processes.

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.

LINDSEY HUGHEYGood morning, PT on ICE daily show. How is it going? It is clinical Tuesday. I am Dr. Lindsay Hughey from Extremity Management. I led that along with Dr. Cody Gingrich, Dr. Mark Gallant, and Dr. Eric Chaconas. So happy to be with you all on a clinical Tuesday. It's been a little while. Today I'm gonna talk with you about fitness forward post-op considerations for extremity management. It's a topic that often gets asked about on our weekends and our weekends don't actually have the bandwidth to hold those questions. So I'm gonna start sharing on PT on ice a little bit more here. So I'm excited to talk with you about that. But before I do, I want to share some upcoming courses that Mark, Cody, and I have because there are only a couple more opportunities left to catch us this year. And for those courses, we are getting close to 30 for each. And so spots will run out. So if you're on the fence, consider purchasing that in the next couple of weeks. So Fremont, California, Cody will be there on December 2nd and 3rd. And then the final opportunity this year is at CrossFit Endure in Fort Collins, Colorado, on December 9th and 10th. And that one's going to be a blast and numbers are growing. So please sign up now. If you miss those two opportunities just because family stuff's going on, know that we have offerings early in January as well. So Mark in Richmond, Virginia, on January 13th, and 14th, that same weekend, we're also offering a course with me in Louisiana. So please check out our calendar. We hope to see you on the road soon.

A FITNESS-FORWARD APPROACH TO POST-OP EXTREMITY CARE So today's topic at hand, we're going to dive into what a fitness-forward approach looks like when we are managing extremities post-operatively. So I want to first just talk about the framework generally, and then use an example. And the example today we'll talk about is total knee replacement. But there are five underlying pillars that I see that are required if we really want to have an all-inclusive approach that is fitness forward for these folks. So number one, we have to be really familiar with tissue healing timeframes of that condition and what to expect and not expect for that patient along their healing journey. So we have to be intimately acquainted with what's normal and what's not, and then be willing to educate the patient about that. So that second pillar is really education. So letting the patient know in whatever surgery they have, whether upper or lower quarter, what's really gonna facilitate healing? What are the expectations for recovery in regards to milestones that they need to hit by certain times and what milestones allow them to progress? There are certain timelines that we can't violate and range of motion precautions based on that specific surgeon. So really make sure we educate the patient and they are fully aware of those precautions. As Zach Morgan said in one of his podcasts recently, we have to catastrophize rest. I'm really letting someone know that rest will never be the thing here post-operatively. Yes, we might have to rest that directed limb, at times, but our body needs movement. It needs blood flow. And so really getting that message early that just because you just have surgery doesn't mean you'll just be sitting and laying around. We actually need to move to promote blood flow and healing to that extremity. Number third pillar is the protocol. Really being intimately aware of whatever protocol the surgeon gives knowing the timelines and actually reviewing them with your patient. Not all surgeons will have a protocol, right? Every surgeon's a little different, but find an evidence-based one based on that surgery and compare a couple of them if the surgeon isn't giving you one. It is really important to kind of sit down with the patient and briefly review that so they really understand, again, what's normal and what's not, knowing what safety precautions are on board from a range of motion and active range of motion versus passive range of motion perspective, and then again, those milestones. Pillar four, system healing. How do we promote system-wide healing? Well, I already mentioned a little bit about our education, about how we're going to catastrophize rest, right? We are going to keep our humans moving, but here's where meds will come in again. And if you've heard me on the podcast, you know, or even seeing my reels, you know, meds is something I'm really passionate about. Mindfulness, exercise, diet, and sleep. And really unpacking what each one of those is for your patient, right? So mindfulness, something that kind of soothes their stress and mind or soothes their soul, helping that connect them with that, exercise, keeping that human moving in whatever way possible, diet, promoting nutrition that promotes healing, especially after a trauma, even though it's a controlled trauma, surgery is traumatic on all of our tissues. So make sure the diet matches that, and I'll unpack some of those things that promote healing as we talk about our total knee example. And then sleep, really helping facilitate ways to help a good deep sleep, that seven to nine hours, and it's so hard in those early healing stages, but giving the tips that you think will help. And it could be as small as turning your phone off an hour before bed, right? Or keep the room a little bit cooler, around like 65 degrees to help them sleep, just giving them those sleep hygiene tips. more on that as we talk about the total knee example. And then the final pillar when we're thinking about fitness forward postoperative care is capacity rebuilding. And what I mean by that is considering all tissues involved in the surgery. So think muscle, think tendon, Think ligament if that's on board. Think skin integrity, right? Because there's an incision on board. And think bone. All of these are challenged. Their capacity is challenged because there is a period where there needs to be some precautions and rest on board. And there needs to then be a period where we gradually build up that capacity as it's going down. And it is our job to prevent loss of capacity as much as possible, and then also build it up as efficiently and safely as we can. And so there are three subsets in this capacity rebuilding phase. So consider when we're thinking about like the muscle, intend and think working locally, but then also think globally right. We don't want to be just so focused if it's a shoulder surgery just on the shoulder right. We also want to be thinking about scapulothoracic muscles. So local and global considerations are key. The second subset is nervous system offense. I think unless someone complains of numbness, tingling, and vague pain sensations, we kind of ignore the nervous system. But consider the nervous system is extensive, and our muscles, ligaments, bones, and tendons are all mechanical interfaces of the nervous system. So we can use the nervous system to promote intraneural healing and blood flow offensively. So consider using your nerve glides early more for tissue healing blood flow and intraneural nutrition. So thinking about it offensively prevention. In addition, consider central sensitization prevention, right? Again, this is a controlled trauma. And we know that folks who have surgeries or injuries are more predisposed to getting injured again. So consider that things like two-point discrimination training, laterality training, and pain pressure threshold are something we should both check on and possibly train if we see impairment side to side. And I'll tell you, in those initial early stages, that four to six weeks, there is definite nociceptive pain damage on board, but consider as we get towards the end, halfway through to the end of our care, we have to make sure central sensitization hasn't occurred in those tissues or become widespread. So check and then train if necessary. And then finally, the third subset of capacity rebuilding is functional pattern training. So consider we want healthy full body patterns. And what I mean by that is initially thinking of getting someone independent in their ADLs and IADL functions. Initially, they might need some assistance, but then eventually we want to normalize those patterns so they don't need any kind of assistance, whether that be a brace or an assistive device. And then we want to prepare humans not just for daily living, normal daily living, but think of job and sports demands. ultimately functional patterns will train those good functional patterns without assistance but then think about preparing for the unknown as well because things in life and sports will happen right maybe our older adult after total knee prepare for falls right think about our person after a meniscal repair like pray prepare for unstable landing. So that's what I mean when I say prepare for the unknown, right? Prepare for real life, which we'll do in a multi-segmental compound way. So to summarize, The five things. Tissue healing time frames. Two, educate your patients. Three, know the protocol and review it with your patient. Fourth, give a meds education for system-wide healing. And then five, think about how you're going to build up capacity in muscle, tendon, ligament, bone, nervous system, and then full body capacity. I wanna briefly take you through a total knee example, how we'll apply these five pillars, just so you can consider how you can apply this really to any post-operative condition. So let's think about someone with a total knee replacement, uncomplicated.

TISSUE HEALING TIME FRAMES So tissue healing timeframes, considering just the timeline of care initially, it's gonna be anywhere from four to 12 weeks. And we're really usually seeing them right for those two to three months. letting the patient know, that that's a realistic timeframe. And that there are multiple things on board, right? We have an incision to heal, a muscle to heal, and then bone. And so that four to 12-week timeframe really encompasses that and lets that human know that this is just not a quick rehab process.

POST-OP EDUCATION In regards to our education for someone with a total knee replacement, considering our first education strategies really need to be about signs of infection, right? And anybody postoperatively, this needs to be on board, but specific to this total knee replacement, right? If there is red, hot, and warm redness that is spreading outside of that incision. Here's where we make that circle around, we see that redness, and if it spreads outside that, that becomes an emergent thing that they need immediate medical assistance for. Consider letting them know the systemic temperature. If they're running a fever greater than 101 Fahrenheit, they need to, again, get to their doctor quickly. These are things we don't wanna mess with when we think about infection associated with the prosthesis. If there are dramatic increases in pain that are debilitating, another coinciding sign of infection. So that needs to be a part of our initial early stages of education. And then obviously we're educating about our HEP and its importance, but then we need to get into some of that nitty gritty of what facilitates healing. And I can't keep echoing Zach Morgan enough that we need to catastrophize rest, that letting that patient know that they shouldn't be sitting or laying around more than 30 to 60 minutes at a time. They need to keep moving so that systemic healing can happen. Giving them specific movement HEP parameters about exercise, and we'll talk more about the specifics on this in the med section for holistic wellness, but walking, a walking program, or cardiovascular program is crucial with someone with total knee replacement because we know of the underlying metabolic disease that coincides those. that are getting a total knee replacement. And then again, in our education bucket, expectations for recovery, which includes the protocol, and then just specific functional milestones.

POST-OP PROTOCOLS That third pillar is protocol. When we think about our total knee replacement, there aren't the very hard and fast range of motion precautions we would have in like a meniscal repair. But there are some must-have range of motion milestones achieved, like in that first year to two weeks, things like there should be independent mobility and getting in and out of the home. That should be all independent or modified independent, right, where they're using an assistive device. In that two to six-week mark, they should be at zero degrees of knee extension, right, to promote that terminal knee extension in gait. Anywhere from zero to about 105 degrees of flexion is that goal in the first two to six weeks. around the five to eight-week mark, we should be progressing past 115 degrees of knee flexion. So using these as buoys and goals is something that we not only want to have in our mind but also help encourage the patient that these are like milestones we want to achieve to keep them progressing. And then when we're past that eight-week mark, we should really be close to within normal limits for range of motion. Now we know not every case goes perfectly like this, but these are overall goals. And by the end of our time in therapy, so think that 12-week mark and this is where you can really set up the patient, here's where we're headed, is a normal step through gait pattern, right? That doesn't require an assistive device ideally. Reciprocal stair climbing, step over step, unrestricted standing, and walking to complete life tasks. If this is an athlete, getting them back to their athletic demand because we do have some of our total knees are in fact, athletes. So don't hold them back if they are, but consider them for our everyday human that just wants to get back. Let's think about Betty getting back to her, taking care of her grandkids, and gardening. We need to make sure that she can get on and off the floor, that she can kneel on that prosthetic, and feel confident in that to get up and off the floor for her grandkids. So consider those timelines. when we think about system-wide healing for the person with a total knee. And this part also applies to anyone who's had a post-op or has had an operative condition.

TAKE YOUR MEDS (MINDFULNESS, EXERCISE, DIET, AND SLEEP) Mindfulness, I already mentioned, right? Some kind of stress relieving strategy, whether it's breathing, journaling, or maybe it's just sitting or walking outside, but giving them something that kind of soothes the soul and the brain. Exercise. This is not just the HEP, right, working on specific impairments. It's not just about quad sets and straight leg raises. This is actually working through a walking program for someone with a total knee. You know, in the beginning stages, it might just be in phase one, working on a 10-minute walking daily. But then we want to eke our way to that 30-minute mark, right? Because we want to meet that minimum of 150 minutes a week of daily activity. Again, think about underlying metabolic disease. The person with a total knee replacement has to build up to this to help fight systemic implications. And so whether that is, ideally it is walking, getting their walking tolerance up to that, but it could also be biking. Think cycling and or swimming. Nutrition. So when we think about diet, that D in meds, we're thinking about nutrition that promotes healing. Make sure they're eating enough protein to heal that incision and help heal the trauma associated with the surgery. They're getting hydrated enough, half their body weight in ounces. that they're eating foods rich in collagen. Think bone broth, sardines, and organ meats, because collagen has been associated with improving healing. Things that are vitamin C rich. Think of citrus fruits like oranges which are cruciferous. Veggies like broccoli Brussels sprouts and tomatoes are another good source of thinking about vitamin C. Bromelain, eat pineapples. This helps reduce pain and swelling. Assuming this is okay with their doctor and nutritionist and their pharmacist, right, not interacting with any meds, all of these natural foods will help boost healing. So just giving that general knowledge, can be really helpful in the healing process. And then I already mentioned sleep, the importance of seven to nine, hours of sleep, giving sleep hygiene. And you can see past podcasts that talk about sleep hygiene tips, or even just message me and I'll send you some. But in the person with total knee, it's not just about how to get them to sleep better, but it's giving them some education like, don't put a pillow under your knee so your knee is flexed all night. And then you're fighting to walk into that terminal knee extension we've been fighting for with the quad set multiple times a day. If you're going to put a pillow under the leg, make sure that the knee is straight, right? Think about maybe talking to them about a wedge pillow so that they're elevating that limb above the heart to help with the swelling that is ongoing in that total knee replacement, but that doesn't put that knee in a flexed position. So when we're thinking about sleep hygiene for the person with total knee, it matters how you sleep, those positions of rest. and don't fall asleep with the ice machine on. This is asking for ongoing stiffness. And if it's cold enough, possibly even does some damage to the local skin tissue. So we don't want that. So, your education on sleep is a little bit different from that person with total me.

REBUILDING TISSUE CAPACITY And then finally, because I'm running out of time, and this is a topic that is rich and I don't want to take any more, but capacity rebuilding after this last point. So think about, the muscle, tendon, bone, and nervous system. So when we think local, think about skin integrity and prescribing scar massage as soon as that incision is healed, really working on scar massage, think working along as a T and an X, and then specifically focusing on that distal one-third of the incision, it's going to be really paramount in care and getting that knee moving. For local exercise or local muscle, we're thinking of exercising the quads and hamstrings, right? For global, we're thinking above and below the knee. Think about working the glutes, glute max, glute med, but also your hip flexors and to work on your stairs, and then think below also your plantar flexors. For stair climbing and think ankle mobility for squats, When we think about nervous system offense, this is one where I think it's an untapped source, but for that intraneural healing and blood flow, think about using sciatic nerve glides for all that posterior tissue tightness and or those folks that actually have complaints, right, of pain going down the leg. Often it's a secondary result of just an antalgic gait pattern, but get them doing that early so that doesn't become a problem. Even some of our folks have some femoral nerve or saphenous issues. So think about doing some femoral nerve gliding if there are medial and lower leg issues, just that on-off pumping. And then in regards to preventing central sensitization, just consider checking and screening our two-point discrimination, our pain pressure threshold, and our laterality training as we get further out in our rehab and closer to discharge to make sure that this isn't impaired. And if it is, then we train it. And then finally our functional pattern retraining for someone with a total knee. We in the early stages will teach them in a modified way to be independent in their ADLs and IEDLs. But then we wean off of that, right? We want to normalize their gait pattern. Think we go rolling walker to cane to independent ambulation. Even in our sit-to-stands, initially, we'll allow that kick out, right, when someone's going to sit down, but eventually, we want them to use that knee flexion. So we'll have them keep that leg in place and no longer kick out that leg. So consider a functional pattern changes throughout the healing process, but eventually, no matter what, we build up. squat pattern, deadlifts, we prepare for falls by fall training and we prepare for that human to kneel as soon as that incision is healed and they feel comfortable. This is how we train in a multi-segmental way for life after total knee I have usurped my time on the PTL Night Show 21 minutes in. So this is just one small example of someone with a post-op extremity condition and how you can approach it in a fitness-forward way using the five-pillar framework. No, in a total knee, there are minimal precautions, but there are a little bit more precautions on board in other conditions. I appreciate how you can apply this in both the upper and lower quarters. Join me in a month, the day after Christmas actually, to talk about post-op incision management. I appreciate all your time to listen today about a fitness-forward approach to post-op care. Happy Clinical Tuesday, folks!

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 describes pelvic varicosities & varicoceles. Rachel breaks down the difference in how these present in both male and female pelvic physical therapy patients as well as how to conceptualize treatment in the clinic.

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 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. RACHEL MOORE All right, good morning PT on ICE Daily Show my name is Dr. Rachel Moore I am here this morning. It is Monday morning. That means it is our pelvic day here on this podcast So I'm here with the pelvic division and I am super excited to talk to you guys this morning We're gonna be kind of diving into varicoceles and varicosities, vulvar varicosities, and the way that those are actually incredibly similar in our treatment approach, whether we realize it or not. Before we dive into that though, if you missed it, we've officially rolled out all of our certifications here at ICE. So we have certifications, we've had them before in the clinical management of the fitness athlete division and an MMOA, but now we have new ones. So we have orthopedic, we've got dry needling, we've got an endurance athlete, and then what we are super excited about in the pelvic division is we have our pelvic cert as well. So this is three courses, two online, a level one and a level two, and then one live course. If you're looking to get in on that certification, our upcoming courses, we actually have one this weekend in Bear, Delaware. That's going to be with myself and Alexis Morgan. So super excited about that. Still, time to hop into that if you want to buy yourself a plane ticket and get out there. And then we also have one on December 2nd. If you are north of the US border in Canada and Halifax, Nova Scotia, Christina is bringing those live courses to Canada. So we're super excited about that. Our next L1 cohort kicks off January 9th, and then our L2 you can already sign up for. So if you want to be in that first cohort of that L2, it kicks off April 30th. So if you're interested in getting that cert, all of the options are out there. Hop into one of those courses. We're excited to see you in them.

VARICOSITIES AND VARICOCELES Let's dive into our topic for the day. So a lot of times those of us in the pelvic space if we are maybe majority see women a lot of us tend to maybe start there and then maybe branch off into seeing men but if we are in this kind of blinders-on situation where we're like no no I only see women sometimes we may be uncomfortable or unsure if somebody gives you a call and asks about a certain diagnosis or maybe you have a friend or somebody that you know that is struggling with something and asks for advice on the pelvic space and you're trying to figure out how to get them into your clinic. And so I wanted to draw a parallel this morning between two diagnoses that we see as fairly common that actually are very similar in the way that we treat them. So that is going to be varicoceles and varicosities. So in utero, the reproductive tissues of males and females begin developing similarly. If you guys remember that from PT school, when we were learning about the brief amount that we cover these types of topics, once testosterone starts being released, that's when the reproductive organs shift and either develop into male organs or continue on the path of female organs. And so if the testosterone is there, then the tissue that is becoming the scrotum becomes the scrotum. But if the testosterone is not there, then that tissue continues on to turn into the labia. So when we think about our tissues and our anatomy, we often talk about how male and female anatomy really aren't that different. It is similar parts arranged differently and maybe to different sizes and proportions. But when we look back all the way in utero, we can see that developmentally these things start the same and there's a certain point where things branch, but we have these kind of analogous, um, uh, tissues within males and females. So, We know that the tissues are similar between the scrotum and between labia. When we're talking about varicosities, this is important for us to know because these are two diagnoses that we tend to see come up fairly frequently.

VARICOSE VEINS IN THE PELVIS So before we dive into the specifics of varicose veins in the pelvic area, let's talk about what varicose veins are. Varicose veins, if you're not familiar with them, are enlarged twisted veins. So oftentimes this comes from damage to the valves in the veins. So our veins have one-way valves that help push blood up and prevent backflow back down. If there is damage to the inside of the vein and the valves are damaged somehow or maybe are not operating at the capacity that they need to be operating, we can see kind of a backlog of blood and that can lead to this kind of inflamed or swollen look to the veins and that blood just kind of pulls in there. The causes of the damage, quote-unquote, Inside of the vein can be known. So this can be something like high blood pressure or it can be unknown Things that increase your risk for developing varicosities are gonna be things like being female So that's always fun when gender is one of the top things can't control for that genetic predisposition so if you have a family history of varicosities then this might be something that you're really keeping an eye on and older age as we get older maybe those valves within the vein become a little bit less competent increased body mass and then in pregnancy we'll dive into that here in just a second and then also interestingly having a history of blood clot that's really important to kind of keep in mind on our radars not only in our post-surgical patients but we're starting to see blood clots kind of popping up more and more um and so if you have somebody who might be not hitting any of these other risk factors but has a history of blood clots it's still something that we want to kind of keep on our radar varicose veins aren't a medical emergency by any means but they can cause some like uncomfortable unpleasant symptoms like heaviness aching pain and then swelling.

VARICOSITIES Let's dive a little bit deeper into varicosities of the pelvic region so in our biologically female counterparts we see vulvar varicosities this is varicosity that develops on the vulva so anywhere along the outside of the vagina so that tissue of the vulva It can happen on labia majora, labia minora. It can be going towards the inner thigh, more into that groin area. Really just kind of depends on the area that is affected. The risk factor for this specifically is pregnancy. So we see this come up in pregnancy for a few different reasons. One reason is that we have an increase in blood volume during pregnancy in order to support the baby. So that increase in blood volume means that our veins have to work harder to push more blood up. we also know that we see relaxin circulating and that does have an effect on all tissues and then we have an increase in pressure so we have increased pressure from both the weight coming down of baby placenta amniotic fluid and all the things but then if we also think about like the anatomy of a pregnant belly as people progress through pregnancy get into this maybe anterior pelvic tilt their belly maybe drops low it can cause some congestion or some backup within that system which then leads to less efficient drainage. This is something that we see pretty often in the clinic really and you might be familiar with this if you're in the pelvic space. but what we tend to not really think about is how this parallels varicose seals. So a lot of times we're pretty confident and comfortable with vulvar varicosities, but then somebody comes in with a little bit different anatomy, and we kind of get thrown for a loop. So a varicose seal is a varicose vein that's located within the scrotal sac. This can actually develop during puberty because blood flow to the genitals increases during puberty. As those tissues are maturing things can just get a little thrown off, but it can also happen as a result of surgeries So think about vasectomies even though those are like minor office procedures surgeries vasectomies or trauma to the scrotum They're surprisingly common, especially in the adolescent puberty side of things. And just because you have a varicocele doesn't necessarily mean you'll even know it, aside from feeling it, potentially. So the biggest way or hallmark of this is called the bag of worms. because within the skirt sack that varicocele feels like a thick ropey worm and so as people are feeling around checking testicles for different things then you might feel that bag of worms type sensation or that that feeling with your fingers and other than that you may not have any idea However if you have a varicose seal that is causing problems We can see swelling pain and heaviness as I talked about earlier and if this is left alone and becomes severe it can actually impact fertility in men because it can lead to decreased sperm in the ejaculate and so it can be something that if it happens in adolescence and somebody is trying to conceive later on in life with their partner and they're struggling, it's an area to look at. Just like vulvar varicosities, we see an increase in symptoms when we're standing for prolonged periods, but uniquely to this population, we can see potential pain with ejaculation. So with vulvar varicosities, we might see pain with intercourse because of the pressure on the outside of the vulva during intercourse. But with this population, it's going to be more so during ejaculation that there is pain.

WHAT TO DO ABOUT VARICOSITIES AND VARICOCELES We have our person in front of us, male or female, who comes into your clinic, some varicosity of some sort going on. What are we supposed to do? Jess actually did a really fabulous episode on this topic. It's episode 1198, so if you want to go back and listen to that, she talks specifically about varicosities during pregnancy, and those same concepts can be applied to varicoceles in men. So I highly recommend giving that a listen. We're going to dive in just really briefly touch on some of those topics and then I'll let you guys really dive into justice. External support can be a game changer for these folks, especially those with varicose heels whose anatomy is already putting things in a gravity, um, disadvantageous position for drainage. So giving some type of support, whether that is like when you're getting up and moving using your hand to support or getting some type of support garment. There are specific support garments that are made both for males and females for varicosities. soft tissue massage and when we think about this we're really thinking like mimicking lymphatic drainage I talk about this all the time with breast tissue and engorgement but the same thing we're thinking about this like congestion within the pelvic region and so we want to think about clearing more proximally up Towards the iliac vein so that we can kind of promote that drainage and then work our way down Rather than coming down to the bottom and just shoving everything up and causing more congestion Superiorly, so we're starting closer to the midline Draining quote-unquote that area. So if you're watching on Instagram, we're saying we've got a guy in and he's got varicose heels maybe we're starting here and then we're working lower and then working lower and until we get to that most distal tissue. From an exercise intervention standpoint, the pelvic floor muscles, of their functions are a sump pump. So when they contract and relax, they push fluid out of areas. So teaching our patients how to do pelvic floor contractions, how to lift up and contract into the attic, relax down and go into the basement, get that pumping mechanism going, and then teaching them belly breathing on top of that to help facilitate that as well. Finally, from a positional standpoint, we can have our patients if at the end of the day, they're super symptomatic and they're feeling rough after being on their feet, laying on their back, propping their legs up on the couch, or on a wall to get some passive decrease in gravity pressure on the pelvic region, and we can even take that a step further, have them plant those feet on that surface and do some bridging where they're squeezing their glutes, maybe adding in that pelvic floor contraction, layering that in, so we've got gravity coming down, we've got our muscles contracting and relaxing, really everything helping to push that fluid up and out into the drainage system to go bring that blood back to the heart. So, if you have somebody come in your clinic tomorrow, and you are a pelvic floor PT who traditionally treats females, and a guy walks in and he's like, I have a varicose seal, I don't know what to do. I hope that you can put your cap on, thinking cap on, and realize like, you got this, you know what to do. At the end of the day, we have to remember that our males and our females, although the anatomy is arranged a little bit differently, and proportions are a little bit different, they are similar tissue. So keep that in mind. You guys are rocking it out there. Have a happy Monday. Thanks for having me. Bye.

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. Megan Peach // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses the importance of cadence in running, variables that may affect a runner's cadence, the relationship between cadence & speed, and finally the "optimal" running cadence.

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

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

EPISODE TRANSCRIPTION

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

MEGAN PEACH, PT, DPT, OCS, CSCS Alright, Instagram. Here we go again. YouTube, we're on. Okay, finally. Sorry about that a couple minutes ago. I think I actually got it to work this time. Okay, we are live on Insta. We are live on YouTube. I am Megan Peach, probably the most technologically challenged person next to Jason that we have in this community. So, I apologize for the previous live feed that didn't actually work. Again, I'm Megan Peach and this is PT on Ice, your daily show. I'll be your host today. I am one of the lead faculty for the endurance division and specifically in the injured runner course, both the live and the online courses. And although our courses have wrapped up for this year actually, We are super looking forward to next year. Over the next couple of months, Jason and Rachel and I are basically doing like a big revamp of Rehab of the Injured Runner online. And so that course is going to look entirely different come January than it does right now. If you haven't taken that course and you've taken the live course already, or even if you haven't taken the live course, this is going to be a great time to hop onto that course, just because the material is going to be really complimentary to the live course, even more so than it has been in the past. And then if you have taken Rehab of the Injured Runner online already, it will be a really good time just to check in because it's going to look entirely different in terms of the material and what's in there. Remember, if you've taken that course already, you have lifetime access for as long as that course exists. And so check in with us in January for a full revamp, full update. We're super excited about it.

RUNNING & CADENCE Okay, so to get to today's topic, I wanna talk about cadence. And cadence is something that I think if you treat injured runners at all, if you have in the past or you've taken one of the courses, This is a topic that's pretty familiar. It's a running gait retraining tool that we use probably more than any other tool that we have in our gait retraining toolbox. And it's used for a variety of different injuries. We could use it globally for injuries like patellofemoral pain or IT band syndrome. exertional compartment syndrome. There are even prospective studies that have looked at healthy runners and the risk factors for their injuries. And they've seen that low cadence is a risk factor for things like bone stress injuries, things like medial tibial stress syndrome. So we can use it not only to treat injuries, but then potentially as an injury prevention tool as well when somebody has a really low cadence. And then we can also use cadence retraining as a way to treat really specific gait abnormalities or mechanical faults after we've done a running gait analysis. And so typically when we are using cadence as a gait retraining tool, we're increasing the cadence by at least 10%, at least that's the goal typically. And when we increase somebody's cadence, what we typically see are first, changes at the knee joint. At least those are the most prominent changes that we would see in a runner. And the changes we see at the knee joint are things like increased knee flexion at initial contact. We see a decrease in stride length, or a decrease in foot to center of mass, in terms of where the foot falls in relation to the center of mass. We also see changes at the ankle joint, not as prominent as the knee, but we still see them there. We see with an increase in cadence, we see a relative increase in plantar flexion. So whereas we might see a lot of dorsiflexion with a very slow cadence, we see relatively less or more plantar flexion as that cadence increases. Or you could look at it as less angle of inclination as well. We also see changes at the hip. Again, not as prominent at the knee, but they're still there. With an increase in cadence, we will see increased hip flexion also at initial contact. Not only do we see kinematic changes, but we can see kinetic changes while somebody's running as well. And so some of the kinetic changes that we'll see are decreased vertical loading rate with an increased cadence, as well as decreased vertical center of mass, which can then translate to decreased overall loading for that runner with each foot strike. And so while some of those kinetic variables aren't always accessible to us in a clinical setting, typically they're just lab-based variables. we can still use cadence retraining and still make some of those assumptions that it is going to affect some of those kinematic variables as well. So we can not only use cadence as a gait retraining tool to treat specific injuries, we can use it to treat kinematic variables, but we can also use it to treat kinetic variables.

VARIABLES INFLUENCING HABITUAL CADENCE What I want to talk about and spend the rest of the time today talking about is some of the variables that might influence somebody's habitual cadence that we don't normally discuss or sometimes don't even consider when we are using cadence as a gait retraining tool. And so somebody's habitual cadence, it just means that the cadence that they're running at normally, without any outside influence, without anybody saying, you should run at this cadence, or you should run at this cadence, or you should increase your cadence. It's just their normal everyday cadence that feels good to their body. And so some of the variables that might influence that are leg length, running experience, BMI, as well as speed. So leg length plays a role in that somebody with a shorter leg length, typically has a faster cadence, and somebody with a longer leg length typically has a slower cadence. Okay, now there's obviously a very wide range of a spectrum there in terms of cadence and leg length, and so these variables are typically related to cadence only at, or I guess more strongly, at the ends of the spectrum. So somebody with either very short legs or very long legs their cadence is likely a little bit more related to their leg length than somebody whose leg length sits kind of right in the middle or maybe that like middle 50% range. And so none of these variables are going to apply to everyone, obviously. The next one, so running experience can play a part as well. Somebody who has less experience running, so like a novice runner, typically has a slower cadence. I've definitely found this to be true in clinic versus somebody who has a lot of experience running or who is a very high level runner, maybe even a professional runner, typically has a very high cadence, upwards of mid 180s, upper 180s, maybe even low 190s, depending on that runner. I've definitely found that variable to be true within clinic, but again, Take that with a bit of a grain of salt because the ends of that spectrum in terms of novice versus experience tend to ring more true with a relationship with cadence than the middle of that spectrum for experience. BMI can also play a role in that somebody with a greater BMI tends to have a slower cadence versus somebody who has a lower BMI tends to have a bit faster of a cadence. That one, clinically, I really can't speak to that one, but that's what's in the literature.

SPEED & CADENCE All right, and speed is the last variable that I wanna talk about because I think intuitively, we know that speed is related to cadence, and that's true to a certain respect. And intuitively, if we think of as somebody speeds up their pace, then their cadence is going to speed up as well. And that's true, but only to a certain extent and really only to higher speeds. And so for most people, their cadence is going to speed up only as they approach sprinting or a very, very fast run. And so when we think of speed and we think of running pace, We have two different strategies that we can use to increase our running pace or our speed. And one of those strategies is to increase the stride frequency or increase the cadence. So we increase the number of times our legs turn over, and that alone can increase the speed. The other strategy to increase speed is an increase in stride length. So rather than increase the stride frequency, we can also increase the stride length. And when we increase the stride length independent of any other changes, we can actually increase the speed even when we're maintaining the same stride frequency or cadence. So if we are using these variables independently and considering them independently, most humans are going to take the stride length strategy first up until they get to a point where they're almost sprinting. So a very fast run, a very high intensity run. And at that point, then they're going to employ more of a stride frequency or a cadence tactic to increase their running pace or running speed. So let's think about when you have an injured runner on a treadmill and you're choosing to use a cadence gait retraining tool to address either their running-related injury or certain gait mechanics, and you get them back on the treadmill, and you're having them run at their 6.0 mile per hour, whatever they did their running gait analysis at, and you say, okay, I want you to run at this new cadence, and you've increased their cadence, and now you have it on a metronome, and you put the metronome on the treadmill, and they hear that click, click, click, click, click when they're running, and the first thing they do I think you've all experienced this. If you have treated injured runners before, the first thing they do is that they increase the speed on their treadmill, right? So why we don't want them to do that is that if they increase that speed on the treadmill, chances are they're also going to employ this increased stride length strategy to increase the speed. They may also increase their cadence as well, but we have to remove some of those variables. If we keep them at the same speed that they did their running gait analysis, which should be a fairly comfortable speed for them, something they would run just an easy run, or even a moderate run, but let's say we have to keep them at that same speed that we use for the running gait analysis while we're using that increased cadence, then they have no choice but to increase the cadence rather than increase their stride length. We don't want them to do that. If they increase their stride length by increasing the speed on the treadmill, what's going to happen is that they're likely going to reach out further, meaning they're going to increase their over stride, which is definitely a variable we don't want to influence negatively. We want that over stride to reduce. They may get increased knee extension at initial contact, which again, not a gait mechanic that we want to encourage. We want to encourage more knee flexion at initial contact. We also want to encourage more or less dorsiflexion at initial contact, more plantar flexion, relatively speaking, which is likely also going to increase in the negative direction if we increase the stride length by increasing the speed on the treadmill. All of these variables are very much related in terms of the gait mechanics and the speed of the treadmill and which strategy they employ to actually increase that running gait speed. But if we take out the speed component and just leave that pace at the same pace on the treadmill, then they have no choice but to then change their cadence to match the cadence that you've chosen. And in turn, what we're hoping to see is a positive change in their gait mechanics.

"OPTIMAL" CADENCE" Now we often get a question in both courses of what's the optimal cadence for a recreational runner, and really there isn't like a set in stone, everybody's gotta run at this cadence. It's a range, anywhere from mid 170s to mid 180s is typically what we kind of range for for a recreational runner. It may go higher than that. For a more experienced runner, I find that they can tolerate higher cadences, for a very novice runner, generally sometimes they don't even tolerate like a mid 170s and so although it might be a goal, it's something that we may have to work up towards in the future and with different gait retraining strategies. Okay, so I hope that helps. I hope that clears things up for some cadence questions that we commonly get in both the rehab online and the rehab of the injured runner live. I hope you have an awesome Friday and a great weekend and we'll see you next time.

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