#PTonICE Podcast

Dr. Christina Prevett // #LeadershipThursday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, ICE faculty member Christina Prevett emphasizes the crucial role of understanding statistics in making clinically relevant decisions. While staying up to date with the literature and being evidence-based are often emphasized in healthcare, Christina points out that it is not enough if one lacks the ability to comprehend the meaning of statistics and their application in a clinical setting.

Christina acknowledges that interpreting statistics can be challenging, even for individuals with a PhD and experience in the field. This understanding leads the host to empathize with clinicians who may find statistics intimidating. It is recognized that being evidence-informed and evidence-based requires clinicians to possess the skills to understand and interpret the data they encounter.

To make statistics more clinically relevant, Christina suggests utilizing systematic reviews and meta-analyses as tools for interpretation. Specifically, she delves into the interpretation of a forest plot, which graphically represents the results of a meta-analysis. By understanding how to interpret and analyze the data presented in systematic reviews and meta-analyses, clinicians can determine if the findings are significant enough to drive changes in their practice.

Christina also highlights the importance of considering clinical relevance when interpreting statistical findings. The concept of the minimum clinically important difference (MCID) is introduced, which refers to the smallest change in an outcome measure that is considered clinically meaningful. An example is given of a statistically significant improvement in a timed up-and-go (TUG) test, but it is explained that it may not be clinically relevant if it does not meet the MCID for the TUG.

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.

CHRISTINA PREVETTGood morning everybody and welcome to the PT on ICE daily show. My name is Christina Prevett. I am one of the lead faculty in our geriatric and pelvic health divisions. So usually you're seeing me on Monday and Wednesday, but today I'm putting on my PhD research hat to talk a little bit about statistics, which I know sounds really boring, but I promise I'm gonna make it really exciting. But before we do that, we have a couple of courses that are coming up across our divisions. So MMOA is in Wappinger's Falls, NY this weekend. Extremity Management is on the road in Woodstock, Georgia. And Cervical Spine is heading to Bridgewater, Massachusetts. And so if you are looking to get in some Con Ed before the end of the year, we still have a couple of opportunities across all of our different divisions. And so I encourage you to go to ptinice.com and take a look at some of those opportunities. Okay, so a little bit about my kind of hat outside of working with ice is that I recently finished my PhD at McMaster University at the end of this year. I just announced that I'm doing a part-time postdoctoral fellowship at the University of Alberta looking at resistance training and its interaction with pregnancy and pelvic floor function.

BUMPING INTO STATISTICS What that means is that I am bumping into statistics all the time. And I'm going to like kind of start this off and say, I've been asked to do some webinars and things around statistics for the ice crew for a while. And to be honest, it's been really intimidating for me to do that, despite the fact that, you know, I have a PhD and I'm interacting with this stuff all the time. Um, statistics is hard and, you know, discussing statistics in a way that makes sense is also challenging. And when I reflect on that and the fact that you know, I feel uncomfortable sometimes with interpretation and you know, I did a part-time PhD for seven years and I'm in a postdoctoral position. I recognize how challenging it can be for clinicians. And, you know, we get told all the time, like, you know, stay evidence-informed, like it's important to be evidence-based. It's important to stay up to date with the literature. But your ability to stay up to date with the literature is only as good as your capacity to understand what it is trying to tell you. And I mean that in the best way possible, that it is so tough for us to gain insights from what the statistics mean into what is clinically relevant for us to understand and be able to bring into our clinics. So today I'm trying to take our statistics and make them clinically relevant to you.

SYSTEMATIC REVIEWS WITH META-ANALYSIS One of the first ways that I want to do that, and if you like this type of podcast please let me know, and I'll do more, is around the systematic review and meta-analysis and then trying to kind of deep dive into interpreting a forest plot. So when we're thinking about a systematic review, this is the highest level of evidence when we have a systematic review of intervention or prospective studies. When we take a systematic review, we ask a very specific question. And I'm going to use the example, I'm working on a systematic review right now on resistance training and pregnancy. And I'm going to take some of that to make this relevant to how this happens. This is where we're trying to get an idea of the state of the literature. So we use a PICO format, which is the population that we're trying to look at. So in this case, it's individuals who are pregnant. The intervention is what you are trying to see if there's a positive or negative benefit or whatever that exposure may be. And that for me is resistance training. The comparison group is to usual obstetrical care. And then the outcomes, we are looking at fetal delivery, pregnancy, and pelvic floor-related outcomes. So we're looking at the investigation of resistance training on incidents of gestational hypertension and preeclampsia, gestational diabetes, rights of cesarean section, the size of babies, and babies more likely to be too big or too small. What does their birth weight look like? How long are they pregnant? And then are they at increased risk for things like urinary incontinence, pelvic organ prolapse, diastasis recti, or pelvic girdle pain? So that's kind of the format of a systematic review we're trying to answer a very specific question. From there, we go to the literature and we want to make sure that we encompass as much literature as we can. in our search strategy. So that is usually why you'll see a list of PubMed and OVID, CINAHL, Sports Discus, like these types of different big searching platforms that are looked at. And then you're going to get a Prisma plot that you're going to see in the first figure. And that kind of describes a person's search strategy. So how many hits were given when this search was done? How many were excluded because of duplicates? How many were excluded from the title and abstract because they were done in rats instead of in humans? Or they were looking at an acute effect of resistance training versus being on a resistance training program like you're going to have a lot of those that are excluded. And then you're going to have kind of what is included in your systematic review, and then what is included in your meta-analysis if a meta-analysis is indicated or possible. When we're looking at a systematic review, we're looking at a qualitative synthesis. And what we mean by that is that we're trying to figure out, you know, where the state of the literature is. And when I'm reporting on something like the systematic review portion of a paper, You're seeing things like, you know, how many studies were done in resistance training in pregnancy? How long were those interventions? Were they done in the same cohort of individuals? What was, how many of them were statistically significant? What was the dosage of that intervention? Those are things that kind of come under the systematic review umbrella. But I would say really now the emphasis is being placed on the meta-analysis and that is the quantitative combination of these studies and that is what gives us this forest plot. So when we are going through and doing a meta-analysis, there are a couple of things that we need to make decisions on very early on. So the first thing is on a random or a fixed effects model. This is kind of getting into the weeds, but almost all papers are going to be a random effects model, which means that we're going to expect some variability in the population that we are working with, and we're going to account for that variability in the calculations that we're using for our forest plot.

PRIORI SUBGROUP ANALYSES The second thing that we are looking at is a priori subgroup analysis. And so I'm going to use my research study to describe this. Before going into this meta-analysis and putting this forest plot together, we have to brainstorm around where possible sources of skew or bias would come into a forest plot. For example, in the resistance training intervention, it would be very different when we have resistance training in isolation versus resistance training as a component of a multi-component program. And so one of our subgroups analyses a priori we discussed was that we were going to subgroup studies that were only resistance training compared to our big meta-analysis, which included our resistance training in isolation or as a multi-pronged program. Another example in our systematic review is that some of our studies were on individuals with low risk at inception into the papers versus those that were brought into the study because they were diagnosed with a complication like gestational diabetes. we could think that the influence of resistance training on a person who has not been diagnosed with gestational diabetes versus those who have could be different. And so we did a secondary subgroup analysis where we looked at the differences between studies that looked at only individuals with gestational diabetes versus those that didn't. And so when you are looking at a forest plot, you will see the big analysis at the top, including all of the different studies. And then after that, you will see different subgroups where there's a repeater of what was in the main group, but it's a subsection of the included studies. And that's what we see. And then we try to see, you know, is resistance training and isolation positively associated with a benefit? versus multi-component or is there no difference and that gives us a lot of information too? So that's that subgroup analysis. Then you go into the results of the paper and there is a forest plot that is there and this forest plot has a bunch of different names of studies It has the total number of incidences and the weight. It has a confidence interval with a number around it. And then on the right-hand side, there's like dots with lots of lines and then a big thick dot at the bottom. I'm trying to explain this to our podcast listeners so that you can kind of understand. And I hope you're kind of thinking of a study in your mind that you have seen in the past. But we're going to kind of explain each of these different things. Okay, so when we're looking at what we are trying to find, it is going to depend if we are looking at a dichotomous variable like did gestational hypertension get diagnosed or not? And if it is a dichotomous variable, what we're looking at is an odds ratio with a 95% confidence interval. So if we are thinking that no difference between usual care and resistance training is one, then a reduction in risk for gestational hypertension with resistance training would be an odds ratio that is less than one. When it is less than one, it becomes statistically significant when the 95% confidence interval encompasses all numbers less than one. When the confidence interval, say for example, our odds ratio is 0.8, we can say that there is a 20% reduction in risk, because a one minus 0.8, of getting gestational hypertension because of resistance training. I'm making these numbers up. But that is only statistically significant if the confidence interval is 0.7 to 0.9. then we can say there's a statistically significant reduction in risk for gestational hypertension with resistance training in this systematic review of this meta-analysis. Where we cannot say it's statistically significant is if the odds ratio is 0.8 and the 95% confidence interval is 0.6 to 1.2. That crossing of one means that there is a higher likelihood that there is that variation is because of chance and not because of a true difference. And so what you see is that when you're looking at the odds ratio, the combination of all of those odds ratios from the individual studies are then pooled in that bolded line at the bottom of the forest plot to give us the confidence that we have based on all of the studies combined, that there is a true effect of resistance training in this example on gestational hypertension.

I-SQUARED HETEROGENEITY The other kind of statistic that we're looking at is the I-squared statistic or the amount of heterogeneity. So when you're looking at that forest plot and you're seeing all the dots and those lines, the heterogeneity is basically saying how close are those dots? How much spread is there in those dots? And so if the heterogeneity is low, we can say that not only did we have a statistically significant result, but across all of the studies, we tended to see a trend in the same direction. So it allows us to have more strength and confidence in the results that we are getting. If we see a high amount of heterogeneity, so like there are some that are like really favoring control and saying that resistance training is bad for gestational hypertension, and then some are having really positive effects of gestational hypertension on resistance training, that I square statistic would be high, and then we would probably have to be doing more evaluation, and that's where we would rely really heavily on the subgroup and say, Well, is there certain subpopulations of this group that are skewing the data in one way or the other where their results may be different than the results of other individuals? And so that gives us a bit more information. So the odds ratio is when we're looking at the presence of an event and it's a binary variable of yes, this exposure exists or no, this exposure didn't. When we are looking at continuous variables, we are looking at like a time on an outcome measure, like the time to up and go, we are looking at a mean difference score between resistance training and a control. So the mean difference is going to be in the measurement of the outcome measure that we are looking at. So the target would be seconds. So then from the pool, it would be plus, Six seconds or mine I guess minus six seconds would be in favor of resistance training and that your tug score is six seconds less in a resistance training arm than a control arm or if it goes against resistance training it would be plus six and Again, we're looking at that 95% confidence interval. That average, that mean difference is also something that we would push against what our clinically relevant difference is. So we may see something that's statistically significant at a two-second improvement, but we know that the MCID for the TUG is four seconds. So while yes, it's statistically significant, it may not be a clinically relevant finding. So that's kind of where we build in clinical relevance. And then again, we look at that 95% confidence interval, see what that spread looks like, and look at that I squared statistic. Where it gets a little bit more complicated is when we have things that are measuring the same thing, but measuring it in a different way. So an example in the systematic review that I did on resistance training and lower extremity strength is that there are a lot of different ways for us to measure lower extremity strength. Some people may use an estimated one rep max, and Some people may use a five-time sit-to-stand as a conduit for functional strength training. Some people may use a dynamometer for knee extensor strength. There's a lot of different ways for us to do that. We can still do a meta-analysis on this, but what we have to do is transform all of those variables into one type of measure. And that's when we would see something called a standardized mean difference, an SMD. And in that SMD, we're essentially taking the impacts of all these different types of measurements that are telling us the same information and putting it into an effect size. And so the effect size gives us the amount of confidence that we can see in the influence of the intervention resistance training on the outcome of lower extremity strength. So an effect size using Cohen's d statistic would be that less than 2 is no effect, 2 to 5 is a moderate or minimal effect, 5 to 0.8 is a moderate effect, and 0.8 and above is a large effect. And so in my systematic review on lower extremity strength and resistance training in individuals with mobility disability, we saw a standardized mean difference of 3, which means that we can be really confident there was a large influence of resistance training on the development of lower extremity strength. So kind of pulling this all together, I know I threw a lot at you. When you were looking at the forest plot, you were looking at trends in the data that are pooling all of the different intervention studies, looking at the same construct and looking at the same outcome. When we are looking at the odds ratio, this is a binary variable. There's going to be a 95% confidence interval. And the pooled odds ratio that we look at with respect to making decisions is that bolded number at the bottom. Our I-squared statistic gives us an idea of the spread of the data and the results that we see. When we are looking at continuous variables, you're going to see either a mean difference or a standardized mean difference. The mean difference is reported in the measurement of the outcome measure that we're talking about. So it could be seconds, it could be points. A standardized mean difference is an effect size where we are transforming multiple different outcome measures into one output that's pooling these things together, but we have to do it in a standardized metric that looks at the magnitude of the effect of that outcome. So how do we think about this clinically? Well, the first thing is that we need to understand where these effect sizes are and if they are significant. And then we have to put it through the filter of, is this clinically relevant? When we have something that isn't statistically significant, the next thing to do is go into the methods and say, you know, was this dose appropriate? Was this done in the way that I would do this? And can I be confident that the interaction between what I would do in the clinic and what was done in these studies is significant enough for me to drive changes in my practice? All right, I hope you found that helpful. I'm at 18 minutes, I knew I would. But if you have any other questions about statistics and how to interpret them, please let me know. It's really important that we know how to understand the data that we're being presented with because that's how we're gonna change our clinical decisions based on what we are seeing. All right, have a wonderful afternoon, everyone. I promise hopefully I didn't stress your brain out by talking about math too much and hopefully, this was helpful and we can do it again sometime.

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

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses the new international guidelines for physical activity and exercise in the prevention and management of mild cognitive impairment and dementia. With the number of people with dementia projected to double by 2050, increasing levels of physical activity could potentially prevent 3% of these cases. Alex highlights the importance of understanding that dementia does not equal Alzheimer's disease.

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

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

EPISODE TRANSCRIPTION

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

ALEX GERMANO
Hello everyone and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today's segment of Geri on ICE. My name is Alex Germano, a member of the Older Adult Division.

ALZHEIMER'S DISEASE AWARENESS MONTH
It is Alzheimer's Disease Awareness Month so I thought it would be fitting to present some research in the cognitive space of Geri Rehab. So today we will be reviewing those new international guidelines that came out in September for physical activity and exercise, for the prevention and management of mild cognitive impairment and dementia. Now, the number of people with dementia is projected to reach 75.6 million by 2030. This is gonna double by 2050. It's estimated that 3% of these dementia cases could be prevented by increasing levels of physical activity. That could be millions of people. Now, let's recognize that dementia does not equal Alzheimer's disease. Dementia is a symptom, it's not technically a disease. However, 60 to 80% of dementia cases are thought to be caused by Alzheimer's. So, just important to note the distinction there.

UPCOMING COURSES
Now, before we dive into more, I want to give you just a heads-up of what we're up to in 2023. There are only a few months left here, And I wanted to highlight our upcoming courses. We have a live course in Wappingers Falls, New York, and Westmont, Illinois this upcoming weekend. And then in December, we will be in Chandler, North Carolina. And we will have our first ever MMOA Live in the state of Maine. So we will be in Portland. And there are only a few seats left for that course. It's already looking big, and wonderful. I'll have two TAs with me. It's going to be really high-energy, lots of fun course. So if that's what you're looking for, to kind of kick off your holiday season, we would love to have you join us.


INTERNATIONAL GUIDELINES FOR PHYSICAL ACTIVITY & EXERCISE FOR DEMENTIA
Now let's review this guideline. First, who collaborated on it, and who made it? It is a collaboration between Alzheimer's Europe, a neuropsychopharmacology group, the European Geriatric Medicine Society, the Council on Aging, osteoporosis, there's osteoporosis and Osteoarthritis Council, the International Association of Gerontology, the World Psychiatry Association, the European Academy of Neurology. So, This is a pretty stacked team who came together to look at all this research and literature in order to help us determine the strategy. Their goal was to create some type of evidence and expert-based guidelines on prevention and management strategies regarding physical activity, which they define as any type of bodily movement. Okay, so think like decreasing sedentary behavior. and they were looking to see if exercise which is planned structured or repetitive movement could be applicable to those who are healthy and to those with mild cognitive impairment and dementia. Now they were trying to answer three main questions so we'll dive into each and then let you know about the status of the literature in each section. The first question they were trying to answer was, in people without dementia or mild cognitive impairment, aka healthy older adults, is physical activity and exercise able to delay the onset of dementia and mild cognitive impairment? Could this be considered a preventative strategy? They based their recommendations on two studies, okay? One was this very big meta-analysis of over 250,000 people that in those with higher self-reported physical activity, remember these are not sedentary people, they had a significantly lower risk of dementia, Alzheimer's disease, vascular dementia, and there tended to be a dose gradient response, so those who were more physically active were at less of a risk. Now they did say that overall this study had a high risk of heterogeneity and it was not powered super well. So there's that to consider. Now they based their exercise recommendation around one large randomized control trial dealing with the outcome of interest. In this study there were 1,635 community-dwelling older adults who were either put in a moderate-intensity exercise program or within the control group was this health education program. They were supposed to go to these health seminars once or twice a week. Now in this This study, surprisingly, did not result in a lower incidence of mild cognitive impairment or dementia across the groups. So there was no difference in each group. So the guideline, this international guideline, does say that exercise could be comparable to a health education program. And I feel like for us, the Institute of Clinical Excellence, that can feel kind of like a gut punch. So let's think through why this is and let's put maybe a giant asterisk next to it. When you dig into the study that they're referencing, the intervention groups, did 30 minutes of walking, 10 minutes of lower extremity strengthening with ankle weights, and 10 minutes of balance training and flexibility. And what the authors of that paper recognize, and also in my mind, is probably not the best dosage of exercise for this population. And that could absolutely have been a limiting factor. The study group also recognizes that cognitive function, unfortunately, was more of this tertiary outcome. It wasn't really the main goal of the study. And due to that and the poor dosage and the length of the study and the Cohort, they selected being at just an inherently less risk of cognitive decline because they were like educated wealthy folks this is why health education and Physical exercise were kind of equated as they were being, they were told as being equals in this they could both benefit cognition Now there are some huge positives to the study that are that need to go recognize Particularly that participants that were in the physical exercise group and were over the age of 80 years old and those who had really low levels of physical function to begin with, they had very good benefits in terms of executive functioning as compared with the health education group. So people who were older and not doing as well benefited a ton from the exercise versus just health education. Now cognitive function also remained stable over two years for these participants, so that's also a huge win. Now this study also had very high retention rates, people really enjoyed it, and the physical activity levels in the intervention group remained, were much higher than the controls. And you know, like we understand the power of exercise, not only for cognitive health but for many other health outcomes and like non-health related outcomes. So we also recognize that exercise doesn't really have any negative side effects. So there's almost no reason that we shouldn't have people engage with exercise. And that's what the guideline, this international guideline came to the conclusion of. They say that without dementia or mild cognitive impairment, physical activity should be considered for the primary prevention of dementia. However, they recognize that health education may be equal to exercise in this space as well. So if you educate people about their health, they probably go do some health-promoting behaviors and that may help delay or attenuate the decline into mild cognitive impairment and dementia. All right. win for exercise.


CAN PHYSICAL ACTIVITY & EXERCISE DELAY THE ONSET OF DEMENTIA?
Now question two, are our physical activity and exercise able to delay the onset of dementia in people with mild cognitive impairment? This is a very important question for us. We really feel passionate about finding and identifying humans who have mild cognitive impairment because they are kind of in this window where treatment actually may be really effective. So this is what the study was trying to answer. Now currently, physical inactivity or sedentary behavior seems to be an independent risk factor for the conversion of mild cognitive impairment to dementia. However, they weren't able to find studies that specifically were out there to indicate if exercise or physical activity could directly reduce the risk of dementia. It's very difficult for studies to capture that exact question. However, they did find research in populations with mild cognitive impairment that did exercise, And that did improve cognitive outcomes. Exercise information in this population, unfortunately, is very heterogeneous, as are many exercise studies, in that the type, duration, frequency, or intensity of the exercise was very different across all the studies. They also recognize in some of the literature that resistance training and mixed aerobic and anaerobic programs have the capacity to improve global cognition. They also saw the benefits of mindfulness-type activities. However, there was no exercise program that came out as superior for preventing or delaying cognitive decline. So the general consensus statement is that 100% of experts agree that we should not discourage exercise in the population with mild cognitive impairment. I know sometimes these vague recommendations are really, hard to hear and if you feel like it doesn't give you the information you're looking for we should reframe that and think this actually gives me a ton of good information this means that I don't have to force Doris who loves to do tai chi to do resistance training that means actually her tai chi may work let's just get her to the appropriate dosage and intensity and frequency of that activity So this almost removes some of our bumpers and gives us like a lot of space to work with many different humans. And in this population, we're meeting so many different people who have so many feelings about exercises and histories with exercise and physical activity. So I love it when the bumpers get removed and we can say, hey, really anything is going to work at this point. So keep encouraging exercise in the population of people with mild cognitive impairment.

CAN EXERCISE IMPROVE COGNITION IN THOSE WITH DEMENTIA?
And then lastly, Can physical activity or exercise improve cognition and disability in those with dementia? So let's go a step further into the part of the population with even more significant cognitive decline. dementia, and let's see what the evidence says. Overall, in people with dementia, it came out with mixed physical activity and exercise at a frequency of two times a week for 40 minutes. That was effective in improving global cognition in moderate Alzheimer's disease. Home-based physical activity interventions in people with a moderate degree of dementia Also stabilized disability and activities of daily living. There were plenty of secondary benefits to exercise, outside of just what it's doing to cognition. It helps improve depressive symptoms, improve fall risks, and improve the number of falls. The evidence did not decrease the risk of hospitalization, mortality, or quality of life in the studies that they found. So it's important to know kind of what the benefits of exercise truly are here. And so the recommendation in the international guidelines is that in people with moderate dementia, physical activity and exercise could be considered for maintaining cognition. In people with moderate dementia, exercise could be considered for stabilizing disability. compared to usual care. Interestingly, this is the only time where it was not 100% of them, but 86% of the experts agreed that physical activity and exercise are important for maintaining cognitive reserve and function in people with dementia and that it may have beneficial effects on non-cognitive outcomes such as mood, but these potential benefits should be balanced with the potential side effects. I do not know, and they did not define what potential side effects of exercise and physical activity are, That is something I would love to understand more about because I almost see no downfall in increasing physical activity and exercise for this population. I agree that there are many barriers to doing that once we are in the throes of dementia. So I think that is going to be the biggest hurdle to get over and maybe the demand on what we're asking caregivers to do. But once again, we have another recommendation saying yes to exercise. Overall, you're seeing the trend exercise of or physical activity take the win on delaying potentially delaying even the development of mild cognitive impairment for delaying the onset of mild cognitive impairment to dementia and For those with dementia to help maintain a high quality of life now Unfortunately, the evidence is not perfect. It's not amazing in this space and this article does a really nice job at like a call to action for better quality studies, and more of them, more diverse studies in different populations of dementia. But, you know, there are many reasons why these recommendations kind of remain vague, and it's because mild cognitive impairment and dementia are multifactorial in nature, and it's not just due to physical inactivity and exercise, right? Like, these patients have many risk factors that cause them to develop these conditions, and we can't change that with physical activity and exercise. I can't exercise my way out of smoking. I cannot exercise my way out of not eating well, and smoking cessation and nutritional impacts are very big in this space. Also, the way that we're defining exercise and physical activity really is different across the literature. People are using different types of exercise interventions, and getting clear evidence can be difficult. but I really like that the study recognizes that and pushes for better recommendations for the use of exercise across stages of cognitive change. So, you know, don't feel frustrated by some vague guidelines. I think it's great to have guidelines like this out there just promoting the benefits of exercise overall for all stages of cognitive change. Think about it as letting the bumpers kind of go and that you can just start anywhere with this population and really just try to dial in dosage and keep increasing intensity That's what we know really works. Alright, so you guys get out there and start getting those patients moving. Have a really great rest of your week Wednesday. I will pop the link to this article and guidelines in the Instagram chat. Thanks, 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. Zac Morgan // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett delves into the need for a shift in the perinatal space, moving away from a fear-focused message and towards one of empowerment.

Christina emphasizes the significance of understanding and respecting individual risk tolerance when it comes to making decisions about exercise and healthcare during pregnancy and postpartum.

Christina argues that healthcare providers should not impose their own risk tolerance onto their patients, but rather support and empower them in making informed choices that align with their own comfort levels.

She also highlights the presence of unwarranted shame in the perinatal space and encourages listeners to critically evaluate their own risk tolerance zones, challenging any beliefs or practices that contribute to this shame.

Christina underscores the importance of evidence-informed practice and the facilitation of movement and exercise, rather than creating barriers based on fear.

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

CHRISTINA PREVETT

Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of our team within our pelvic health division. And if you have been catching all of the news coming out of the ice world, you know that we just announced our pelvic certification, CertPelvic. And we are so excited to bring this to you all. One of the missions that we have been kind of on this journey for over, you know, the last four or five years has been to try and flip the script in pelvic health and really create a fitness-forward approach to pelvic health, just like we are trying to do in the orthopedic spaces. And so our cert pelvic is our next Step in that trajectory. And so we are going to have three courses in our cert pelvic curriculum We have our two-day live course and then we're gonna have two eight-week online courses level one and level two if you have taken Our live course that is going to count as your cert pelvic The only additional piece is that there is going to be an added skills check to the end of our second day. If you are interested in becoming CertPelvic, you will have to find a time when we are near your area to be able to take that skills check for the end of day two. You don't need to take the course again. You do not need to pay a fee for the skills check. We just have to get that from you for individuals who have already taken our live course. And if you're interested in catching our live course one more time, or getting in before the end of 2023, we have two opportunities left. Alexis is gonna be in Bayer, Delaware on the 18th and 19th of November, so in two weeks. And then at the beginning of December, December 2nd, and 3rd, I am gonna be in Halifax. And that course you'll see is slightly less because we are making it equivalent to the Canadian dollar. So if you're wondering why that course is at a different price, it's because we're creating an equivalency to the Canadian dollar. And so if you're interested in catching us before the end of 2023, those are your last two opportunities.

EXERCISE IN THE PREGNANT & POSTPARTUM SPACE

Okay, let's talk about exercise in the perinatal space. You know that we have been on a huge journey to reframe the idea around Pregnant and postpartum exercise it is no surprise to any of you who are listening and have listened to our division that we are very pro pushing the boundaries and that we believe from a fitness perspective that the answer should be yes For health promoting behaviors instead of flipping to the no and proving it I did a podcast episode a little while ago where I said is it ethical, you know to remove resistance training in a pregnant individual and because we don't have an abundance of literature. And I made the argument that it isn't. Until we have safety data to take away a health-promoting behavior, we should start with the yes. And so this kind of goes into this reframe. I was talking to Sinead DeFore, who is a Ph.D. who's looking at diastasis recti and pelvic girdle pain literature, and she created this idea around risk tolerance within my brain and it has really helped me to solidify our thoughts and feelings about exercise our sparks notes a very first thing is that We are going to have individuals who are going to have their own Risk tolerance and I'm gonna give you a couple of different examples. So everyone is gonna have their own risk tolerance when it comes to exercise. Personally, when I got pregnant with my daughter five years ago, I was a national-level weightlifter. A barbell was an extension of my hand. I knew where it was going to go. I knew what it was going to do. I could make finite, tiny little details and I would be able to manipulate my technique. I felt extremely confident moving around a barbell during my pregnancy. Was not a runner. I had done CrossFit but I wasn't doing CrossFit at that time so my body was not used to the impact of running and So I didn't feel that good running after about 18 or 20 weeks of pregnancy And so I removed running from my exercise routine I was not running that much to be good with but I removed it and I kept Olympic weightlifting all the way up until delivery and That is my risk tolerance. I decided what felt good for my body and I made decisions within that. That does not mean that I do not have individuals that I have seen that were running right up until delivery and then a heavy squat or squatting below parallel just did not feel good for them. It didn't feel good on their pelvis. So many people have their own risk tolerance. we are starting to see people push the boundaries in almost every stretch from a pregnant and postpartum fitness perspective. We are seeing individuals, part of my postdoctoral work is some of our team members are talking about contact sports, for example, and contact sports are contraindicated during pregnancy. People are told to not do equestrian, for example, during their pregnancies. And then you have some equestrian riders who feel extremely confident with the horse that they are working with and may continue to ride. Even though right now our data says that maybe we shouldn't do that on the chance that somebody falls off a horse. I treated an individual who was snowboarding, 17 weeks pregnant, fell so hard she broke her collarbone, baby ended up being okay. Another one of these decisions would probably not have been within my risk tolerance, but individuals are starting to push the boundaries. We are starting to see changes in the military with respect to flying restrictions. We were being told that when you found out that you were pregnant you were grounded with respect to flying hours. Yeah, right. Someone says, I grew up showing horses and you couldn't get any of those ladies I knew at the barn to get off that horse. Absolutely, right? And that is, again, literature that we are basing off of a lack of understanding. I'm sure that there are so many examples exactly like that, where individuals feel so confident with their horse that they are not worried. We don't have any evidence to say that Riding a horse is bad, but we just don't want to minimize the risk of falling But here's the thing if we kind of take this back and talk about risk tolerance as grown-ups We can decide it for grown-ups or not But as grown-ups we are taking risk every single day every time we walk out of our house We are deciding if it is snowing and we decide to jump into a car. We are making a decision and we are calculating We are creating risk thresholds. When we are even talking about health-promoting behaviors, we are talking about stacking the deck in our favor or away from it, right? We are health-promoting or we are taking things that are going to increase the risk of an adverse event. But none of these things are guaranteed, and everybody is going to have their own risk tolerance zones.

BECOME A PRO AT PUSHING THE BOUNDARIES

As physical therapists who are working in the perinatal space, it is time for us to embrace that risk tolerance, embrace the fact that individuals' risk tolerance may be different than ours. And I'm talking about kind of pushing the extremes of exercise, but I'm also talking about allowing individuals who do not feel safe continuing to do certain exercises to be allowed to step that back if that pulls them within their risk tolerance zone. We do not have a movement problem in our society. We have a lack of movement problem. All of our divisions are screaming this from the rooftops. You're going to hear me say this in geriatrics. What that means though and what we see is that during pregnancy and postpartum exercise goes down and we see that fewer individuals are hitting the exercise guidelines despite the fact that our guidelines during pregnancy from an intensity and a Duration perspective mirror that of the general population what I mean by that is we are still trying to accumulate 150 minutes of moderate-intensity exercise during pregnancy and moderate intensity resistance training are Recommended but what we see is that during pregnancy for a whole slew of reasons Not just the fact that individuals are pregnant and getting scared away from exercise though. That is a component We are seeing that individuals are less active so Then we go into the postpartum period, and it's the same thing.

THE RISKS OF NOT EXERCISING DURING PREGNANCY

Our division is adamantly against the six-week blanket statement that we shouldn't be doing any exercise, and we are 100% against the five in the bed, five around the bed, five in the home type of rhetoric. The reason is that it's going to increase our risk for blood clots, and it is unrealistic for so many individuals who do not have a village that allows them to be able to do that. If you are trying to bond with the baby and that is something that you want to do, excellent, but I also think that it's important for us to be able to make informed decisions, which includes the fact that early movement, and I'm not talking exercise, I'm talking about getting out of bed, is really important for the management of postpartum complications. risk tolerance is going to be different. We see a lot of individuals who want to go to the gym two weeks postpartum. Are they jumping into a CrossFit workout? No, but are they becoming around their village because they feel really lonely and sad and their hormones are all over the place and somebody is going to take their baby and tell them and have an adult conversation and that's something that they want to do completely. their risk tolerance is going to be different. Do we have some individuals who adamantly want to wait until six, eight, 10, or 12 weeks, who do not have the mind to go in, who are struggling with sleep, who are having trouble with hormones? Absolutely. And so we are going to meet them where they're at.

REFRAMING RISK TOLERANCE

And so why is this reframe around risk tolerance so powerful? we don't have a movement problem, which means that we need to push our recommendations within a person's risk tolerance. And the message needs to be around facilitating movement, not creating barriers to exercise, right? As physical therapists, our job is to help facilitate movement. And when we create fear in the perinatal space, by moving or shifting a person's risk tolerance down beyond the level that they want to accept. We are not providing evidence-informed practice, right? One, we don't have the evidence to show that there are things that are adverse, and many of these things are mechanistic based on theory and are starting to be disproven. But the second thing is that we need to be taking our clients' wishes and hopes into perspective and that is an equal part of the triangle of evidence-informed practice and then obviously our clinical experience. Our clinical skilled care is where we can move those buoys, and give individuals ways for them to navigate exercise so that they know what they are listening to their bodies for, in order for us to be driving change in this space. When we accept this model of risk tolerance, we get to move from the no or I don't know to the yes within these kinds of buoys or navigational obstacles that we're going to be able to keep individuals within. We need to think that we want to move individuals away from being more sedentary out of fear in the perinatal space and move them to more empowered movement of their bodies in order for them to feel strong and empowered. We are starting to see over and over and over again that Individuals who maintain strength during their pregnancy have a much easier time postpartum from a muscular physical reserve perspective. We see this across everything in rehab. Our body needs to be strong enough to handle what we're asking it to do. It doesn't it breaks down. There are overuse injuries if the tensile strength of our bone does not match the force at which we hit the floor We have a fracture we see this in orthopedics the same is true in the perinatal space like our body needs to be able to respond to the stress is on their body in the pregnant and postpartum period and if we are deconditioning our pregnant individuals we are not setting them up for success and so we need to be able to have a shifting and moving risk tolerance to meet the risk tolerance of the person that is in front of us and then if there's obviously some big risks or red flags, we are going to educate on that. But most of the time, it's our own discomfort because their risk tolerance doesn't match our risk tolerance. And then we are making recommendations that are not serving them, but making us feel more comfortable. And so my call to action for you all today is to push your comfort zones. Really reflect, is there a discrepancy or difference between your risk tolerance and mine? And if there is, is that because of my own experience in this space? Is it because of my own lack of experience with somebody with this type of risk tolerance? And then how do I marry those two things to respect where the evidence is, but also where my client's perceived risk is? And then how can I bring my own clinical practice to help marry those two things together to serve the person that is in front of me? All right, I went off on a soapbox. I can't believe I'm already 14 minutes in. I hope that you found that helpful. This idea of risk tolerance and being able to see this as a moving target, I think is going to shift us away from a fear-focused message in the perinatal space towards more one of empowerment. And if your risk tolerance is less than your client's, that is not bad, but it is not our job to project our risk tolerance onto a patient, especially when we don't have any justification for that kind of shifting or that moving away from a person's own tolerance zone. And I really challenge individuals to not make individuals feel bad. There's a lot of shame in the perinatal space that is unfounded. And I think it's really important for us to really think critically about these risk tolerance zones and where ours exist. All right. If you have any other questions, if this is something that is a reflection point for you, I want to hear about it. If you want to see more of the research and get more of the news coming out of our pelvic division, cause geez, things have been moving really fast in our divisions. I encourage you to sign up for our ice pelvic newsletter. It's a research-focused newsletter that comes out every two weeks on Thursday. Our last one went out last week. If you have any other questions about our ice pelvic cert, please reach out to us. We've been fielding questions. We just love the interest that we've seen in our certification and we are so excited to show it all to you. Otherwise, I hope that Alexis sees some of you in Bayer or I will see some of you in Halifax. Have a wonderful rest of your Monday, everyone, and we will talk soon.

OUTRO

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

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett delves into the need for a shift in the perinatal space, moving away from a fear-focused message and towards one of empowerment. Christina emphasizes the significance of understanding and respecting individual risk tolerance when it comes to making decisions about exercise and healthcare during pregnancy and postpartum. Christina argues that healthcare providers should not impose their own risk tolerance onto their patients, but rather support and empower them in making informed choices that align with their own comfort levels. She also highlights the presence of unwarranted shame in the perinatal space and encourages listeners to critically evaluate their own risk tolerance zones, challenging any beliefs or practices that contribute to this shame. Christina underscores the importance of evidence-informed practice and the facilitation of movement and exercise, rather than creating barriers based on fear.

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 CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of our team within our pelvic health division. And if you have been catching all of the news coming out of the ice world, you know that we just announced our pelvic certification, CertPelvic. And we are so excited to bring this to you all. One of the missions that we have been kind of on this journey for over, you know, the last four or five years has been to try and flip the script in pelvic health and really create a fitness-forward approach to pelvic health, just like we are trying to do in the orthopedic spaces. And so our cert pelvic is our next Step in that trajectory. And so we are going to have three courses in our cert pelvic curriculum We have our two-day live course and then we're gonna have two eight-week online courses level one and level two if you have taken Our live course that is going to count as your cert pelvic The only additional piece is that there is going to be an added skills check to the end of our second day. If you are interested in becoming CertPelvic, you will have to find a time when we are near your area to be able to take that skills check for the end of day two. You don't need to take the course again. You do not need to pay a fee for the skills check. We just have to get that from you for individuals who have already taken our live course. And if you're interested in catching our live course one more time, or getting in before the end of 2023, we have two opportunities left. Alexis is gonna be in Bayer, Delaware on the 18th and 19th of November, so in two weeks. And then at the beginning of December, December 2nd, and 3rd, I am gonna be in Halifax. And that course you'll see is slightly less because we are making it equivalent to the Canadian dollar. So if you're wondering why that course is at a different price, it's because we're creating an equivalency to the Canadian dollar. And so if you're interested in catching us before the end of 2023, those are your last two opportunities. EXERCISE IN THE PREGNANT & POSTPARTUM SPACE Okay, let's talk about exercise in the perinatal space. You know that we have been on a huge journey to reframe the idea around Pregnant and postpartum exercise it is no surprise to any of you who are listening and have listened to our division that we are very pro pushing the boundaries and that we believe from a fitness perspective that the answer should be yes For health promoting behaviors instead of flipping to the no and proving it I did a podcast episode a little while ago where I said is it ethical, you know to remove resistance training in a pregnant individual and because we don't have an abundance of literature. And I made the argument that it isn't. Until we have safety data to take away a health-promoting behavior, we should start with the yes. And so this kind of goes into this reframe. I was talking to Sinead DeFore, who is a Ph.D. who's looking at diastasis recti and pelvic girdle pain literature, and she created this idea around risk tolerance within my brain and it has really helped me to solidify our thoughts and feelings about exercise our sparks notes a very first thing is that We are going to have individuals who are going to have their own Risk tolerance and I'm gonna give you a couple of different examples. So everyone is gonna have their own risk tolerance when it comes to exercise. Personally, when I got pregnant with my daughter five years ago, I was a national-level weightlifter. A barbell was an extension of my hand. I knew where it was going to go. I knew what it was going to do. I could make finite, tiny little details and I would be able to manipulate my technique. I felt extremely confident moving around a barbell during my pregnancy. Was not a runner. I had done CrossFit but I wasn't doing CrossFit at that time so my body was not used to the impact of running and So I didn't feel that good running after about 18 or 20 weeks of pregnancy And so I removed running from my exercise routine I was not running that much to be good with but I removed it and I kept Olympic weightlifting all the way up until delivery and That is my risk tolerance. I decided what felt good for my body and I made decisions within that. That does not mean that I do not have individuals that I have seen that were running right up until delivery and then a heavy squat or squatting below parallel just did not feel good for them. It didn't feel good on their pelvis. So many people have their own risk tolerance. we are starting to see people push the boundaries in almost every stretch from a pregnant and postpartum fitness perspective. We are seeing individuals, part of my postdoctoral work is some of our team members are talking about contact sports, for example, and contact sports are contraindicated during pregnancy. People are told to not do equestrian, for example, during their pregnancies. And then you have some equestrian riders who feel extremely confident with the horse that they are working with and may continue to ride. Even though right now our data says that maybe we shouldn't do that on the chance that somebody falls off a horse. I treated an individual who was snowboarding, 17 weeks pregnant, fell so hard she broke her collarbone, baby ended up being okay. Another one of these decisions would probably not have been within my risk tolerance, but individuals are starting to push the boundaries. We are starting to see changes in the military with respect to flying restrictions. We were being told that when you found out that you were pregnant you were grounded with respect to flying hours. Yeah, right. Someone says, I grew up showing horses and you couldn't get any of those ladies I knew at the barn to get off that horse. Absolutely, right? And that is, again, literature that we are basing off of a lack of understanding. I'm sure that there are so many examples exactly like that, where individuals feel so confident with their horse that they are not worried. We don't have any evidence to say that Riding a horse is bad, but we just don't want to minimize the risk of falling But here's the thing if we kind of take this back and talk about risk tolerance as grown-ups We can decide it for grown-ups or not But as grown-ups we are taking risk every single day every time we walk out of our house We are deciding if it is snowing and we decide to jump into a car. We are making a decision and we are calculating We are creating risk thresholds. When we are even talking about health-promoting behaviors, we are talking about stacking the deck in our favor or away from it, right? We are health-promoting or we are taking things that are going to increase the risk of an adverse event. But none of these things are guaranteed, and everybody is going to have their own risk tolerance zones. BECOME A PRO AT PUSHING THE BOUNDARIES As physical therapists who are working in the perinatal space, it is time for us to embrace that risk tolerance, embrace the fact that individuals' risk tolerance may be different than ours. And I'm talking about kind of pushing the extremes of exercise, but I'm also talking about allowing individuals who do not feel safe continuing to do certain exercises to be allowed to step that back if that pulls them within their risk tolerance zone. We do not have a movement problem in our society. We have a lack of movement problem. All of our divisions are screaming this from the rooftops. You're going to hear me say this in geriatrics. What that means though and what we see is that during pregnancy and postpartum exercise goes down and we see that fewer individuals are hitting the exercise guidelines despite the fact that our guidelines during pregnancy from an intensity and a Duration perspective mirror that of the general population what I mean by that is we are still trying to accumulate 150 minutes of moderate-intensity exercise during pregnancy and moderate intensity resistance training are Recommended but what we see is that during pregnancy for a whole slew of reasons Not just the fact that individuals are pregnant and getting scared away from exercise though. That is a component We are seeing that individuals are less active so Then we go into the postpartum period, and it's the same thing. THE RISKS OF NOT EXERCISING DURING PREGNANCY Our division is adamantly against the six-week blanket statement that we shouldn't be doing any exercise, and we are 100% against the five in the bed, five around the bed, five in the home type of rhetoric. The reason is that it's going to increase our risk for blood clots, and it is unrealistic for so many individuals who do not have a village that allows them to be able to do that. If you are trying to bond with the baby and that is something that you want to do, excellent, but I also think that it's important for us to be able to make informed decisions, which includes the fact that early movement, and I'm not talking exercise, I'm talking about getting out of bed, is really important for the management of postpartum complications. risk tolerance is going to be different. We see a lot of individuals who want to go to the gym two weeks postpartum. Are they jumping into a CrossFit workout? No, but are they becoming around their village because they feel really lonely and sad and their hormones are all over the place and somebody is going to take their baby and tell them and have an adult conversation and that's something that they want to do completely. their risk tolerance is going to be different. Do we have some individuals who adamantly want to wait until six, eight, 10, or 12 weeks, who do not have the mind to go in, who are struggling with sleep, who are having trouble with hormones? Absolutely. And so we are going to meet them where they're at. REFRAMING RISK TOLERANCE And so why is this reframe around risk tolerance so powerful? we don't have a movement problem, which means that we need to push our recommendations within a person's risk tolerance. And the message needs to be around facilitating movement, not creating barriers to exercise, right? As physical therapists, our job is to help facilitate movement. And when we create fear in the perinatal space, by moving or shifting a person's risk tolerance down beyond the level that they want to accept. We are not providing evidence-informed practice, right? One, we don't have the evidence to show that there are things that are adverse, and many of these things are mechanistic based on theory and are starting to be disproven. But the second thing is that we need to be taking our clients' wishes and hopes into perspective and that is an equal part of the triangle of evidence-informed practice and then obviously our clinical experience. Our clinical skilled care is where we can move those buoys, and give individuals ways for them to navigate exercise so that they know what they are listening to their bodies for, in order for us to be driving change in this space. When we accept this model of risk tolerance, we get to move from the no or I don't know to the yes within these kinds of buoys or navigational obstacles that we're going to be able to keep individuals within. We need to think that we want to move individuals away from being more sedentary out of fear in the perinatal space and move them to more empowered movement of their bodies in order for them to feel strong and empowered. We are starting to see over and over and over again that Individuals who maintain strength during their pregnancy have a much easier time postpartum from a muscular physical reserve perspective. We see this across everything in rehab. Our body needs to be strong enough to handle what we're asking it to do. It doesn't it breaks down. There are overuse injuries if the tensile strength of our bone does not match the force at which we hit the floor We have a fracture we see this in orthopedics the same is true in the perinatal space like our body needs to be able to respond to the stress is on their body in the pregnant and postpartum period and if we are deconditioning our pregnant individuals we are not setting them up for success and so we need to be able to have a shifting and moving risk tolerance to meet the risk tolerance of the person that is in front of us and then if there's obviously some big risks or red flags, we are going to educate on that. But most of the time, it's our own discomfort because their risk tolerance doesn't match our risk tolerance. And then we are making recommendations that are not serving them, but making us feel more comfortable. And so my call to action for you all today is to push your comfort zones. Really reflect, is there a discrepancy or difference between your risk tolerance and mine? And if there is, is that because of my own experience in this space? Is it because of my own lack of experience with somebody with this type of risk tolerance? And then how do I marry those two things to respect where the evidence is, but also where my client's perceived risk is? And then how can I bring my own clinical practice to help marry those two things together to serve the person that is in front of me? All right, I went off on a soapbox. I can't believe I'm already 14 minutes in. I hope that you found that helpful. This idea of risk tolerance and being able to see this as a moving target, I think is going to shift us away from a fear-focused message in the perinatal space towards more one of empowerment. And if your risk tolerance is less than your client's, that is not bad, but it is not our job to project our risk tolerance onto a patient, especially when we don't have any justification for that kind of shifting or that moving away from a person's own tolerance zone. And I really challenge individuals to not make individuals feel bad. There's a lot of shame in the perinatal space that is unfounded. And I think it's really important for us to really think critically about these risk tolerance zones and where ours exist. All right. If you have any other questions, if this is something that is a reflection point for you, I want to hear about it. If you want to see more of the research and get more of the news coming out of our pelvic division, cause geez, things have been moving really fast in our divisions. I encourage you to sign up for our ice pelvic newsletter. It's a research-focused newsletter that comes out every two weeks on Thursday. Our last one went out last week. If you have any other questions about our ice pelvic cert, please reach out to us. We've been fielding questions. We just love the interest that we've seen in our certification and we are so excited to show it all to you. Otherwise, I hope that Alexis sees some of you in Bayer or I will see some of you in Halifax. Have a wonderful rest of your Monday, everyone, and we will talk soon.

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad".

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

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

EPISODE TRANSCRIPTION ALAN FREDENDALL All right. Good morning, folks. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. We're here a little bit early in the garage. We're going to be talking about some double unders today. Welcome to Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at the company, as well as the Division Leader in our Fitness Athlete Division. We love Fitness Athlete Friday. We would argue it's the best day of the week. On Fitness Athlete Friday, we talk all things relevant to the CrossFit athlete, Olympic weightlifting, powerlifting, bodybuilding, anybody that's recreationally active in the gym. We also talk about our endurance athletes, whether you're running, rowing, biking, swimming, triathletes, If you have a person that's getting after on a regular basis, Fitness Athlete Friday has a topic for you. Some courses coming your way from the Fitness Athlete Division. We have a couple live courses before the end of the year as we get ready to close out 2023. This weekend, as in tomorrow and Sunday, November 4th and 5th, both Mitch Babcock and Zach Long will be on the road teaching. Mitch will be down in San Antonio, Texas, and Zach will be in Hoover, Alabama. Even though it's last minute, both of those courses still have some seats. And then your final chance to catch Fitness Athlete Live will be the weekend of December 9th and 10th. That's gonna be out in Colorado Springs, Colorado, and that will be with Mitch as well. Online from the Fitness Athlete Division, our entry-level course, Clinical Management Fitness Athlete Level 1 Online, previously called Essential Foundations. The next cohort of that class begins November 6th. We love that class. That is a great entry-level experience into all of this stuff if you have not taken it yet. We take you through the very basics, back squats, front squats, deadlifts, presses. We get into some basic gymnastics with the pull-up and introduce you to Olympic weightlifting with the overhead squat. Along the way, we have case studies relevant to athletes with those particular issues that we discuss with those movements. We talk a lot about loading and we get you introduced to basic programming, both for injured athletes and also how to recognize CrossFit style programming, strength style programming to better prepare you for those folks who want to continue on to our level two online course, previously called Advanced Concepts, who really want to drill down into programming, advanced gymnastics, advanced Olympic weightlifting, and truly become the provider of choice for athletes in their region through the clinical management fitness athlete certification. So that's what's coming your way course-wise from us in the CMFA division. WHAT ARE WE DOING WITH THE DOUBLE UNDER? Today we're going to talk about double-unders. This is personally an issue I've struggled with for a long time and probably maybe aside from pull-ups and handstand push-ups, one of the more basic movements we see in the gym that still a lot of your membership base will struggle with, maybe you personally struggle with, and I want to talk about what are we actually trying to do with the Double Wonder, some tips and tricks and cues to think inside your mind as you're going through them. I want to spend some time talking about the equipment involved in jumping rope because I think there's two sides of the equation, people with very basic equipment and people with maybe equipment that they don't need that's maybe too expensive, too advanced, And then I also just want to talk about how to begin to better practice double unders so that you can work towards achieving them and being able to complete them during a workout, in large sets, when the CrossFit Open comes up, or just in your regular workouts at the gym. So first things first, with double-unders. When I ask a lot of athletes in the gym when I'm coaching, when they say, oh my gosh, I just did five double-unders in a row, I say, great, great, what were you thinking about? And overwhelmingly, the majority of the people say, I don't know. I couldn't tell you what I was thinking about. And that strikes me as very different from a lot of stuff that we do in the gym. People usually have maybe one cue or maybe even a couple cues in their mind when they're setting up for a heavy deadlift, when they're setting up for a clean and jerk or a snatch or a handstand pushup. They often don't kick up upside down or go to max out their snatch and tell you that they had nothing going on in your brain. But something about the double under, people think it's just magic, how you learn these and how you get better at them. And unfortunately, it's not magic. Fortunately, it's just physics. So I want to talk about really at a base level, at a nerdy physics mathematical level, what are we doing with the double under? We are translating linear force. We are creating force across the lever that then transforms into rotational force where your jump rope handle meets the bearing. FIX THE SET-UP If your jump rope is nice enough to have a bearing. So a lot of times the setup, even with just the handles is wrong of looking at a jump rope. Again, it's quite a basic piece of equipment. It's got some handles. you to hang on to in a rope. Even a cheap moderate jump rope of $20 should have some sort of bearing set up so that it spins a little bit. We are trying to create force at the end of the handle that as we flip that jump rope it turns into rotation through the rope and that by doing it both hands at a time with that flicking motion we spin the jump rope. What we're not trying to do is physically spin the rope ourselves with our shoulders, right? We're trying to create rotational force through a flick. So the first thing is making sure that you are even handling your jump rope appropriately. If you are cinched down with a full grip, right where the handles meet the bearing, first of all, you can physically block the bearing if you're not careful. If you hold right here with a depth grip, that bearing cannot spin anymore, right? It's going to be extraordinarily difficult to easily create rotational force here and you're going to naturally be that person who has to spin your arms to spin the jump rope. That's exhausting. It's not a great way to do single unders and it's an even worse way to do double unders. So first things first, where are you grabbing the handle? You should be grabbing further down the handle, ideally with a loose grip, as low on the handle as you can get, right? The longer the lever, the more force amplification we have, right? The more force is going to be transferred and transformed into rotation down here versus the higher we grab up towards that bearing. So a nice loose grip, thinking about flicking, creating linear force at the bottom of the handle that creates a spinning force for me up at the bearing. So that's number one of making sure that you're even using the jump rope correctly. The next thing is making sure it's sized correctly. I always laugh when I see people in the gym who I know are taller than me, which is not very useful because most human beings are taller than me, but I know someone is a couple inches taller than me and I see them using a rope shorter than a rope I would use and I think What the heck, why are they using such a short rope? It makes sense why trying to do double unders, they're bringing their knees up to their chest and bending their knee to try to clear the rope because the rope is so short. How do we sign the jump rope? We take the jump rope, we hold both handles, we step one foot, we try to even it out as much as possible, bring it towards our body, and the length of that rope should be at our nipple or maybe a little bit higher. If it's down at our stomach, it's too short. You're gonna have to do some really unnatural jumping things, like piking your hip, or kicking your legs back, or both, just to be able to clear that short rope. Likewise, being a little bit longer is okay, but this thing up to my chin or above my head, I have a lot of slack behind me now. I'm moving a lot of extra weight I don't need to, and that's all the more drag factor on the rope that's gonna mess up my timing as I try to learn double unders. So making sure we're holding the handles in the appropriate place and making sure that we understand how to measure our jump rope. A really nice jump rope will have maybe a nut or a screw here to adjust. This is a typical, what we call a class rope. This is just a $20 rope from Rogue. You'll often see these in the wall at a gym for everybody in class to use. These can't be adjusted. They go based on your height. There should be a table or a chart or the coach should know what color you should be using based on your height, assuming that you know what your own height is, to make sure that you're using a jump rope that is long enough with maybe a little bit of extra slack, but is not extraordinarily short or long. So that's first things first, using linear force to create rotational force, making sure the rope is sized to us correctly, and making sure we're holding the handles in the right spot so that we're not hampering ourselves from creating that rotational force. SOMETIMES IT'S THE WRENCH We have a saying, with jump rope, with most things in life, it's usually not the wrench, right? It's not the equipment, it's the mechanic. But sometimes it is the wrench. A lot of folks start trying double-unders with maybe the class rope they have, and I think that's a great place to start. Now the issue is a lot of folks will start trying double-unders, they'll look at people in the gym who are really great at double-unders, and not recognize that that person probably started with the class rope, and they'll immediately go out and buy a $200 competitive CrossFit game speed rope. There's a couple issues with the wrench itself of making sure you have the right wrench. We've already talked about length. A really nice jump rope, again, will have a way to adjust the length that you can undo a screw or a nut and make it longer or shorter and get it really dialed in. These ropes, again, are a fixed length but making sure the length is exactly correct. The next thing that most people don't consider is that this jump rope has some weight. Yes, the handles have weight, but that's going to be relatively fixed based on the brand that you have. So not considering the weight of the handles, what is the weight of this rope? This is a class rope. This is about 2.5 ounces or so, which I would call a medium weight rope. When we are doing jump rope, In learning double-unders, the best thing you can do is use a rope that's a little bit heavier.

null: Why? Two reasons.

SPEAKER_01: When you spin a heavier rope, you can hear it slapping on the ground in the gym, even over the loud music. That helps your brain learn the timing. A heavier rope also forces you to develop wrist speed. When we're doing double-unders, it's not about how fast you jump, it's about wrists. And a really light rope doesn't force you to learn that speed because it costs you almost no energy to go through that movement pattern. So for a lot of folks, they're trying to purchase the most lightweight rope ever, and I'm going to show you some different ropes here in a second, when in reality they should probably be working with a heavier rope. Again, this is a class rope. This is maybe two and a half to three and a half ounces, somewhere in the middle. What's going to help a lot of folks Smartgear brand rope. You can buy this from Rogue or from RX Smartgear directly. You can see just by looking at these two ropes, significantly thicker, right? This is a 4.1 ounce rope. The handles are different. Yes, they spin a little bit better. They have a little bit better hand grips. You can see here different spots to put your thumb along the handle. But most importantly, the cable is heavier. This is going to teach hand speed, this is going to build up endurance with the double under, and it's also both the sound and the feeling of this rope is going to help learn timing a lot better for our jump rope. So making sure that we have the right rope. Again, almost everyone trying to get good at double unders immediately goes and buys the $200 speed rope, when in reality they should probably buy this. Now the nice thing about these ropes, as you can see, I'll bring it up really close, is this is just a keychain type carabiner. When I'm ready for a lighter rope, the most expensive part of a jump rope are the handles. The cable is usually cheap or sometimes even free if it gets frayed. If you fray your actual rope, you can email Rogue, you can email RxSmart here, they'll send you a new cable that you can reattach to your handles and you can use the same handles forever. So as you get better, you can detach, put a lighter cable on, make it easier and more energy efficient as you actually start to string together double-unders. But early on, you're going to want a heavier rope, something around four ounces. That's the biggest recommendation I can make to folks who are trying to learn double-unders, and especially to those folks who have 19 different speed ropes at home. They've got a second mortgage on their house full of jump ropes just to pay for them all. and they're going lighter, lighter, lighter, thinking they need a lighter rope, a faster rope, lighter handles, diamond grip handles, when in reality they just need a heavier cable. So when in doubt, go heavier. Again, four ounce rope compared to maybe a two and a half or three ounce rope. Once you can start to turn over bigger sets of double unders, 25, 30, 50, you're able to start doing them in workouts, your efficiency, your endurance with them improves, now you're ready for a cable itself is basically non-existent. This is aircraft grade aluminum. This is about eight tenths of an ounce. So almost 500% lighter than that heavy rope I just showed you. This weighs almost nothing. It is very hard to feel when you jump rope with this cable and it's very hard to hear as well, especially if you're in a CrossFit style gym in the middle of workout with loud music playing. What's different about this besides the cable weight? The handles are so much nicer. They are diamond grip. My thumbs can lock on. I can hold very low on the rope. Again, I want to have as much time for that force to build up and transfer along the length of the handle as I can. I can hold just my index finger and my thumb and really develop that flicking motion. What's also very nice is look at the spin on this handle. right? That thing spins forever. Very, very, very efficient for large sets of double-unders, but only once you can actually do them. So this is kind of the in-stage progression of somebody who looks at a workout that has a couple rounds of 30 or 50 or maybe even 100 double-unders and says, no problem, I got These ropes are about $200. And again, the most expensive part arguably is the handle. If the cable frays, you can replace it. But a very, very, very high quality jump rope intended for folks who have already learned how to do big sets of double unders, ideally using a heavier, cheaper rope. So that is what we would call a speed rope. So that's the wrench. BUT IT'S USUALLY THE MECHANIC Now let's talk about the mechanics. because there are a lot of things we can do, a lot of cues we can give that can very quickly make double unders a lot better. The first thing is understanding, again, in a double under, what changes is my hand speed. Jump, spin, spin, jump, spin, spin. It is a double spin of the rope. It is not an increase in my jump rate. A lot of folks, off the ball of their foot. Because in a single-under, we're only clearing the rope once, we can get away with a very small jump and just clear that rope once. We see a lot of boxers do this. You see a lot of people in the gym who have jumped rope a lot in the past do this with single-unders. They can crank out 150 single-unders in one minute with that very fast, low jump. That's not gonna cut it for a double-under. Why? The rope has to pass twice. A lot of athletes in the gym will ask me, I have no problem getting it over the first time, but it gets caught the second time. The answer is yes. The rope has to come back around again twice and you have to be in the air the whole time. That's why it's called a double under. You're trapping the rope on the second time through, which is why you're not getting your double under. How and why are we trapping the rope? Most commonly, is we do not increase our jump height, we just now try to jump even faster. All we're gonna do there is trap the second pass of the rope that much more quickly. We're just getting more efficient at bad double-unders. We need to consider a smaller, taller, slower jump. We should practice single-unders on the ball of our foot, and we should practice a little bit taller jump, but not try to pick up our legs not jump speed. If you correspondingly increase your jump speed, you're going to trip because you're now trying to basically get in rhythm and jump twice for two rope swings. That doesn't make sense. Keep your jump speed the same. Stay tall, vertical on the ball of your foot, and jump a little bit higher. Practice single-unders that way. When you can begin to turn over 50 or 100 single-unders like that, now you know you have the jump height, the jump speed, to be able to begin to turn over double unders. Remember, wrist speed, not jump speed, and stay on the ball of your foot. A lot of folks will do some really dramatic stuff to get that rope over twice, and they will land on their heel. Again, the rope has to pass twice. If you land on your heel, there is no physical way that rope can pass under your foot for its second time through. You're going to track the rope underneath your foot. So small, short, sorry, tall, vertical jump. PRACTICING & DRILLING DOUBLE-UNDERS Make sure we're practicing wrist speed. A penguin drill is a great drill to give people, to have them practice maybe what's a new jump height and cadence for them. And at the top of their jump, have them slap their thighs twice to imitate the double flick of the jump rope. You'll find a lot of athletes who think they should be able to do double-unders, struggle a lot with that drill. They're used to that short, very fast jump cadence for single-unders. Asking them to slow down and jump a little bit higher wrecks them. It also messes them up mentally when now they have to focus on actually doing something with their hands. You'll find they're probably not as ready for double-unders as they thought they were. So double-unders, not magic, just physics. We are creating force across a lever, the handle of the jump rope. We're holding it as low as possible. We're trying to create rotational force where the rope meets the handle at the bearing. We're holding it as low with as loose of a grip as we can. We're thinking about flicking the wrist, not spinning the shoulders. Sometimes it is the wrench. Make sure the rope is the correct length. Make sure newer athletes who are beginning to experiment with double unders use a heavier rope, something three, four, maybe five ounces, and that we reserve those speed ropes for once we're actually able to string together bigger sets of double unders with a heavier rope. PROGRESSIVELY OVERLOADING DOUBLE UNDERS The final thing is how to progress these. A lot of folks want to be able to do more unbroken sets, Can you just practice more sets of double unders? Yes. The key thing though is that we practice that. We don't try to do it in the middle of the workout under an extreme amount of cardiovascular fatigue and that we consider double unders no different than a back squat or a clean and jerk or a deadlift. That we take principles of progressive overload and we carry it over to our body weight, cardiovascular stuff, especially higher scale, like double unders. How do we do that? Things like a Zeus Rope. or a drag rope are great. A drag rope is literally climbing rope with handles. It has, you can see the same handles as some of the other jump ropes I've shown you. The only difference now, there is no handle spin. The only way I'm going to rotate this rope is by being really aggressive and really fast with my hands. This is a nine ounce, I guess you'd call it cable. Again, it's technically just a length of climbing rope. This is nine ounces. So this is 900% heavier than the speed rope. So if I want to get better at double unders where I can look at a workout that has a couple rounds of maybe a hundred double unders and it has some other stuff in there too that's also going to make me tired from a cardiovascular perspective, how do I know when that workout shows up that I can blast through those with my speed rope? Well, when I go back and take class workouts that maybe have small sets of double unders 20 or 30 at a time, I bring my drag rope to class. And I do smaller sets with a heavier, slower rope that continues to progressively overload my double-unders so that when big sets do show up in different workouts, I can handle those no problem with my speed rope. So it takes practice, intentional practice. Folks are always disappointed that they don't magically learn double-unders 18 minutes into a 20-minute AMRAP. That's not how it works. Sometimes it does, but it usually doesn't. Practicing this stuff at home with a cheap jump rope from Rogue that's 20 bucks, practicing 10 minutes a couple times a week is really going to go a long way. I always tell folks when they're practicing double-unders the same way I tell them when they're practicing things like pull-ups. When you're learning to kip, when you're learning that motion, forget about getting your head over the bar. Just learn the rhythm. That's the most important thing you can do. I say the same thing to folks who are going to be going home and practicing double-unders. Don't focus on actually getting the double under. Focus on doing the mechanics correctly. Use a timer so that you're not just in your garage for an hour and you're breaking stuff because you're so frustrated or the neighbors are worried because you threw your jump rope into the street. Set a timer, do as many as you can, and then take a break for two minutes and do a couple sets of that. Make sure that you aren't treating it as a workout, but that you're treating it as practice and that you use different methods once you actually can do double unders. to continue to progressively overload your double unders. So double unders, not magic, physics, make sure your wrench is set up, but make sure your mechanics are dialed in as well. And make sure if you want to get better at these, that you actually spend diligent time to practice and make sure that it's actually practiced and it doesn't turn into a second workout that day. I hope this was helpful. I hope you have a fantastic Friday. If you're going to be at a live course this weekend, we have 10 of them going on, I believe. So I hope you have a fantastic weekend. We'll see you all next time. Bye everybody.

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

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the idea that moving into a leadership role requires a shift in mindset from focusing on individual accomplishments and deliverables to prioritizing the building of culture and guiding the team. Jeff emphasizes that one of the hardest things about transitioning into a leadership role is separating your sense of worth from the tangible outcomes of projects. Instead, leaders need to concentrate on steering the team in the right direction and creating an environment that fosters productivity and engagement.

Jeff describes that a true leader's job is not to solve every problem or complete every project themselves. Instead, their role is to provide guidance and support to the team, ensuring that they stay on track and between the "buoys." This means constantly having touch points to build culture and considering where the team should go, as well as where they should not go.

Jeff also highlights the importance of reframing what being productive looks like in a leadership role. It suggests that leaders should focus their energy on three main areas: culture building, organizing and strategizing, and problem-solving. Culture building is described as the leader's top priority, as they need to create an environment that people want to be a part of. Organizing and strategizing involves evaluating when to intervene and when to let capable team members come to their own conclusions. And problem-solving requires knowing when to provide guidance, but not getting caught up in completing the task oneself.

Overall, Jeff suggests that moving into a leadership role requires a shift in mindset from individual achievement to team success.

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

JEFF MOORE All right team, what's up? Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Moore, currently serving as a CEO of ICE, and always thrilled to be here on Leadership Thursday, which is always Gut Check Thursday. Let's get right to brass tacks. What's the workout this week? It is ascending squats, but of decreasing challenge, and then the reverse for our gymnastics. So it's gonna look like this, kind of an interesting workout. So it is for time, You're gonna open up with nine overhead squats. That barbell prescribed weight's gonna be 135, 95, so scale accordingly. Paired with 21 pull-ups. Then you're gonna increase your squat number 15, but moving to front squat, same barbell weight. gymnastics going to 15 chest-to-bars and then 21 back squats and then 9 muscle-ups. So you got kind of this 9, 15, 21 climbing a number of a decreasing complexity on the squats and then the opposite 21, 15, 9 as your gymnastics get more challenging. So should be a very interesting workout. Just one time through that for time. All right, regarding upcoming courses, it is all about the certifications this week. So if you have not heard, we launched our entire brand new suite of new and renovated certifications over on ice. So we've got our brand new pelvic certification. We've got our dry needling certification now. The group has launched that advanced course. We have our brand new ortho certification, the endurance athlete certification. on top of a tremendous amount of renovation and facelift on all the other ones. So if you have not browsed our new certification offerings, go to PTOnIce.com. That certification tab is right on the top. Jump in there and look at all those different search. Remember, One thing that separates ice certs from everybody else is live testing is involved in every single one of them. So regardless of which one of those you jump into, there is live testing. We believe that is really what holds the standard. So just know that you will be examined in person to make sure you indeed have the goods before we throw that stamp of approval on your work. So that is what's basically, involving all of our worlds this week is getting all the certifications launched. Hope those really improve not only your skill set next year, but your ability to market effectively that you're a specialist in these areas and really take over your geography and serve your community. So enjoy those certifications, check them out. All right, it is Leadership Thursday. BREAKING UP WITH DELIVERABLES We are talking about breaking up with deliverables. A challenging but necessary conversation. Challenging because… There's very few things, especially for really high performers, that is more satisfying than completing a really big project, right? Something you've been working on and chipping away on, very few things feel better than putting a bow on something like that, crossing that off that to-do list that you've been looking at for months as you kind of worked your way through the project, not to mention just delivering a beautiful deliverable. Nothing feels better. The bigger leader you become, the better leader you become, the less you will get to experience this. If your leadership trajectory really takes off, you will literally never, again, get to experience that wonderful feeling of wrapping up a project. The reason for this is it almost never makes sense For you to finish anything, right? Once your job is getting the train on the tracks, your job is approving the project. Your job is saying, you know what? That makes sense to put resources towards that. Considering all the other options available, your job. is figuring out the right combination of people that will maximally effectively take over that job and really bring it to completion as fast as possible and be able to scale it. So is it the right gig? Who are the right people to do it? What resources do they need? How can I collect those in the most cost and time effective manner? Those are your jobs. But once that train is on the tracks, proper delegation should always bring it to the finish line. It would be very rare, very rare, that a task needs your personal involvement end to end. Just because you want it to, doesn't mean it does. In almost every case, your job is going to be saying, yep, that's the right thing that we should do with our resources. These are the right people to make that happen. And here are all the resources they need to be freed up and made available so they can execute properly. Those are all of your jobs. The actual doing of it, the execution, the part you want to do, right? Cause it just, again, feel so wonderful to be a part of creating and finishing something like that is something you should almost always hold yourself back from. Now, I know what you're saying. You're saying, but that's what makes it feel like I've accomplished something. Like getting something to the finish line is what feels rewarding. You have got to reframe if you're truly moving into a leadership role. Like you're going to be organizing and strategizing a number of people that are in your circle and your job is kind of commander in chief. If you're heading in that space in whatever your division might be, you've got to reframe what being productive looks and feels like. You gotta reframe this, and you gotta think about three big buckets where your energy is gonna be going, and none of them are gonna be about bringing a project to execution. CULTURE BUILDING The first one is culture building. Your number one job, right, is that glue that keeps everything together, that makes the energy of the organization feel like something that people who are a part of it want to be a part of. Number one is culture building. In every single touchpoint, with another individual in the group is culture building. It doesn't need to accomplish anything, right? These touch points, these little moments of interaction don't need to finish anything. They don't need to accomplish anything. What they accomplish is you understanding each other just a little bit better. What they accomplish is you seeing where the other person's coming from, is a little bit of trust building because you had that moment of connection. They accomplish that. No, it's not finishing anything. This is an infinite game. Culture never has an end point. You never win culture, right? You nurture culture. And it's with every single touch point that you do so. So one of your biggest buckets as a leader is gonna be culture building. And culture building has no conclusion. So you'll never get that feeling of finishing. INNOVATING Number two, energy bucket number two is innovation. Time spent pondering solutions is one of your most important jobs. And here's the rub, here's the really uncomfortable part. 90% of your time will be considering solutions that you don't move forward with. You certainly can't finish anything you never start. And 90% of your time is going to be exploring options that don't wind up being the right call. But that is a critical part of your job. There's no way that you can rule down where your resources should go if you don't consider all the options and say no to most of them. So because so much of your time is going to be spent evaluating possibilities that literally never get off the ground because you decide they shouldn't, obviously you won't have any sense of completion there. But yet, if you're not in that role, you will never allocate your resources properly in a way that allows the company to move forward efficiently. Innovation, and namely deciding what shouldn't get off the ground, is a huge spend of your time and has no completion. PROBLEM SOLVING And finally, number three is problem solving. One of your key roles as a leader is evaluating when should you intervene. Oftentimes, my number one recommendation there is to restrain yourself, right? To let very capable, high-performing people come to their own conclusions, but be evaluating it from a 30,000 foot view. But you do need to sometimes say, you know what? I'm gonna jump in here. A little bit of restraint is always a good thing, right? But knowing when to jump in is very important. Now, here's the key. When you jump in, you jump in with a couple pieces of information or a little bit of guidance, again, to get the train back on the tracks. What you don't do is follow the train. Right, that's falling right back into that temptation of wanting to get something to completion. That's not your job anymore. Your job is, ooh, this isn't going in the right direction. Watch it, study it, think about it, find your moment, and then jump in and say, team, can I ask that we look at one thing a little bit differently? What are your thoughts here? Okay, now you jump in, you change the energy of that environment, of that project, you get people chiming in as a group, you decide, Oh, this is the one change we've got to make. And then very importantly, you get back out because you've got to go do that somewhere else. If you stay on that ride, you're not getting back over and solving that same problem in seven other spots. The people can handle it. Your job is just to steer, just to get them back in between the buoys and then get out of there. One of the hardest things about truly moving into a leadership role is you've got to divorce your sense of perceived worth from deliverables that you're a part of. Your energy needs to be in constantly having touch points to build culture. Your energy needs to be spent thinking about where should we go and maybe more importantly, where should we not go? Your energy needs to be in and out of different projects when you see an area that your experience or wisdom can nudge people in the right direction and get their momentum built back up before you remove your energy from the scenario. These things never feel done because they never are done. None of those buckets even move closer to a perceived finish line. You just keep nurturing and spinning those plates at all times and never ride any of them to the end. DIVORCE YOURSELF FROM DELIVERABLES TO IMPROVE THE EFFICIENCY OF YOUR BUSINESS You have to divorce yourself from deliverables, otherwise you're never going to take the true position of an effective leader. Give that some thought. I know you're high performers. I know you love finishing projects. I know for many, many, many years that has filled your cup, but it's killing your team. Try to reframe it. Let me know if you have any thoughts. PTOnIce.com. Thanks for being your team. We'll see you next week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses the difference between sarcopenia (the loss of muscle mass) and potentiapenia (the loss of muscular power). Dustin reminds listeners that performing functional outcome measures & then creating a treatment plan based on functional deficits uncovered during assessment is the most important thing in ensuring patients receive the individualized care they need: "Assess, don't assume." Dustin also discusses the utility of using functional outcomes to assess & track progress so that insurers like Medicare will continue to pay for treatment.

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 00:00 - DUSTIN JONES All right, welcome y'all. This is the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division as we call MMOA. We're going to talk today about a really interesting topic. We're going to name the enemy and that is potentiopenia. We're going to name the enemy particularly when we're working with older adults and that is potentiopenia. This is brought to you by a listener question, a commentary that they wrote and I want to dive into the topic of power, strength, Sarcopenia as well. What should we really be focusing on? How can we screen? Before we get into the goods, I want to mention about some upcoming MMOA live courses. MMOA live is a part of the cert MMOA curriculum. Part of that curriculum is a live course. Also our MMOA level one online course, which was formerly called MMOA essential foundations. And then MMOA Level 2, which was formerly called Advanced Concepts. You complete all three, you get your cert MMOA. We have three upcoming weekends where you can go to that live course. We're gonna have Annapolis, Maryland and Central South Carolina. This upcoming weekend, November 11th, we're gonna be in Wappinger's Falls, New York. And then right before Thanksgiving, November 18th, that weekend, we're gonna be in Westmont, Illinois. So if you are looking to get some Con Ed before the end of the year, be sure to check us out. PTOnIce.com is where you can find all that. POTENTIAPENIA All right, so naming the enemy, potentiopenia. So this is a term you probably have never heard about because it's not been coined, it's not been researched, it's not been agreed upon in literature. This is a word that was made up by Dr. Ronald Michalak. So Dr. Michalak is an orthopedic surgeon that's been practicing for roughly 20 plus years that has quitting his surgical practice to go back and pursue his PhD in Rehabilitation Science. Dr. Michalak is an avid listener to the PT on ICE Daily Show, so I want to take the time to shout out to him, but also for all of y'all that listen to this show that aren't our typical physical therapy crowd, right? The OTs, the speech-language pathologists, the other healthcare providers. I know we have some PAs, some NPs in here, but we're really grateful for y'all tuning in because we're starting to see we have a fitness-forward army clinicians that are trying to solve the same problems. This is one example. So Dr. Mitchell like you know 20 plus years doing orthopedic surgery you start to see some patterns right? You start to see the issues with focusing on the tissue, right? Of focusing on, oh, that bone-on-bone, we should probably just go ahead and replace that whole joint, and that will solve all your problems, right? There's some issues to that, that when we focus so much on the anatomy, the structure, that we apply surgical interventions to non-surgical problems, that creates issues, right? And so over his career, he started to see, man, the biggest issue is not the quote-unquote bone-on-bone, it's the fact that these folks are deconditioned, they're weak, they're not able to do the things that they want to do and it leaves them susceptible to some of these medical situations that I'm often performing surgery on. What can I do to prevent them from even having surgery? And so we started to dig into the research and science and what he has come to the conclusion of is we are really missing the boat to where we're focusing on the wrong things and what we need to focus on particularly with this population is their lack of power. hence the term potentiopenia, the lack of muscular power. So, I want to give some context for this discussion because I think it's really interesting of how much progress has been made in this area, particularly in geriatrics and geriatric rehabilitation. SARCOPENIA So, sarcopenia, you've heard us talk about this so many times on the PT on ICE Daily Show. If you've taken any of the MMOA courses, you've heard this term. Sarcopenia was first coined in 1989 by Dr. Rosenberg, and at the time, the definition, the accepted definition of sarcopenia was age-related loss of muscle mass. That we thought, oh man, these folks are losing muscle mass, therefore, they are losing their strength, they are losing their ability to do what they need to do. This is a big issue. It's age-related, but we may be able to do something about it. As this was studied more and more, and just this whole concept, was being critically you know thought about that the term of sarcopenia or the definition of sarcopenia was missing a little bit right because you can have someone that is losing muscle mass but may still be really strong or you may have someone that does have a good bit of muscle mass that is rather weak or they're not able to produce their force quickly aka they have low power So, in 2008, Dr. Clark really started to push against this definition of sarcopenia and say, hey, this isn't the issue. The issue is the lack of strength, the age-related loss of muscular strength. And he coined the term dynopenia. That was a back and forth, back and forth. And now in terms of the term of sarcopenia, what we're seeing is that it's starting to incorporate some of the things that Dr. Clark really was pushing for. And now you're often going to see sarcopenia defined as the age-related loss of muscle mass and strength. That's what we speak to in the MMA course. And so a lot of the screens that you're seeing of being able to identify folks that have sarcopenia are mass related screens of actually measuring muscle mass and having cutoffs based on certain age groups and so on and so forth. But then there's also functional measures, right? Gait speed is one, grip strength is another one, the SPPB, the short physical performance battery test can indicate that someone is at risk of sarcopenia. Sarcopenia has changed a ton over the past few decades. Now, what's interesting is that the amount of research, which is so massive in this particular topic, that we have really good evidence to show, man, if this person scores below one meter per second, for example, on the gait speed, that this individual is at risk of sarcopenia, also a host of negative health outcomes. It's very predictive. We have a lot of data to show that poor performance on some of these outcome measures is a big issue and very predictive and warrants medical treatment or physical therapy, if you will, or occupational therapy, some of these rehabilitation-based services. Now, here's the issue. Here's what I think Dr. Michalak is going towards, is a lot of these screens that have been used to say, hey, this person has sarcopenia, age-related muscle mass and strength, that these screens may not actually be measuring what we think, right? If you think about gait speed, normal gait speed, for example, is that a measure of strength? Not really, right? Is it a measure of, let's say, power, the ability to produce that strength quickly? Potentially, right? Definitely, if it's a fast gait speed, or if we're looking at gait speed reserve, the difference between max gait speed and normal gait speed. Think about the 30 second sit to stand test, where we're standing up and sitting down 30 times. Is that a measure of strength? You can make a strong argument that, no, not necessarily, but it's more of a measure of how people can use that strength quickly to perform that transfer. Same thing could be said for the five times sit to stand. And so these outcome measures that are often tied to quote-unquote sarcopenia, the age-related loss of muscle mass and strength, isn't really measuring that. We can say that those tests are very predictive of some of these negative health outcomes. That's not what we're talking about. What we're talking about is do these tests actually measure, indicate what they're saying that they measure, right? Now, here's the, I think the important part about this is that if I am performing a five-time sit-to-stand test or a 30-second sit-to-stand test and think that, oh, this indicates that this person has impaired lower extremity strength and I focus on strength-based interventions, right, I'm just worried about getting them stronger, not necessarily trying to help them get stronger, produce force quicker, aka power. THE NEGLECT OF POWER-BASED TRAINING And so what Dr. Michalak is really proposing is that our focus on age-related loss of muscle mass and strength, the focus on strength has resulted in the neglect of power-based training. We need to really think differently about these terms and ultimately what they result in. I think we should have a new term, potentiapenia. That was his argument. This is all in a beautiful commentary that I loved reading that I'm going to link in the notes. So here's our take on this. I agree that… we have really dropped the ball on power-based training, right? That we often neglect that in this population for many reasons. One is just we haven't named the enemy as one. Two is that we often have ageist assumptions about what people can handle, right? That, oh, that's too intense for them or they will get hurt. It's not as well studied as strength-based training. There's a lot of reasons that go into that, but I do agree that we have really dropped the ball there. A new term, creating a new term, and everything that's associated with that, I don't know if that's the answer, but I do think we need to continue to be critical of the term sarcopenia and what that actually represents. It's already changed to age-related loss of muscle mass and strength, which is lovely, and I would love to see that conversation continue to include power as well. Clinically, here's what I think is really important for us when we think about some of these deficits that folks are undergoing and we're throwing around some of these terms. STRENGTH VS. POWER TRAINING I think the big thing that needs to be focused is we're diving into the weeds of strength versus power and you know reps and sets and volume and all that type of stuff that when first one is when we're working with individuals that are relatively sedentary or inactive and Movement is king. I don't care what they do. The fact that they are moving is ultimately important, right? We got to get people moving first and we need to be less picky of what that looks like, especially with sedentary and active individuals. That's the first thing. The second thing is we need to really think about our assessments and challenge our assumptions with this. This is why in our courses we always say assessments over assumptions. It's very easy for us as clinicians, when you're doing an assessment, you're doing the five-time sit-to-stand test, 30-second sit-to-stand test, to assume, oh, this person needs to do more lower extremity-based strength training, right? That's a very common thing for us to correlate. Now, that test may not be and probably isn't testing pure strength, right? There's other ways to do that. One rep max testing, estimated one rep max testing. We can use dynamometry as well. There's other methods to test strength. These functional and very practical outcome measures may be more a testament to someone's power ability. So when we use these tests, particularly the 30 seconds sit to stand, five times sit to stand, I think is a great example. that we need to be thinking probably about strength training, but we also need to be thinking about power training. Can they produce that force quickly? Because it ultimately is an indicator of power, the ability to produce that force quickly and do that transfer. So what your outcome measures tell you, we need to be very careful of how that informs the intervention, right? And ultimately what we're often going to find, I think this is not an or conversation, strength training or power training, in the realm of ice, you will hear this so often, it is and not or, right? Probably both, strength and power, we can do both. In reality, when we do get people stronger, you often see, especially in folks that are untrained, you are gonna see an improvement in power production. You could do specific power training, where you're doing force movements quickly, you're probably using lighter loads, and you're probably gonna see an improvement in strength, right? That's gonna happen with a lot of untrained individuals. But I think in the context of rehab, in the context especially of One Rep Max Living, that we probably want to do both. Heavy loads are really good. Heavy loads provide an amazing stimulus to promote muscle mass, our strength, but also the strength of our bones, also our soft tissue remodeling. It makes us more resilient individuals. But fast loads are really good too, right? They give us that type 2 muscle fiber stimulation to prevent some of that preferential decline. in those fibers. That quick speed is so practical for so many things that we do in the real world and also in high-risk situations. It's an and conversation. We want to do both. Now, Dr. Mitchell, I had two specific questions that I also wanted to hit on. Could referrals be written or phrased better from the physician end to encourage PTs to try to help get these individuals moving toward fitness? Now, I want everyone to listen here, and by and large, the PT on ICE Daily shows largely physical therapists, physical therapy assistants. Think about what this physician just asked. This physician is basically saying, where are my fitness forward clinicians, right? Where are my fitness forward clinicians? Where are the people that I can trust with my patients? I love this question. I think from our angle, from kind of the rehab fitness side of things, Let it be known. What are you about? Lock arms, lock shields with us, the ICE tribe, the ones that are really pushing this fitness forward message because there are healthcare providers looking for you. Now, Dr. Mitchell, from the physician's standpoint, I do think it is helpful to make it clear as a physician that you have that fitness forward approach. And oftentimes, we don't see that on referrals, right? It's the diagnosis and treat, which you love as a PT, to be honest, but if you do run a 30 second sit to stand and acknowledge that it is under or below a particular cutoff let it be known and let it be known what you are thinking about that it is a potential loss of power production potential right and let the PT do the job of assessing to determine is this a bigger power issue or a bigger issue of just producing force of strength. FUNCTION-FORWARD HEALTHCARE PROVIDERS But let it be known, I love it whenever I see another healthcare provider perform some type of screen, like a 30 second sit to stand, a timed up and go is another one, that tells me that this is a function focused healthcare provider. And we're speaking the same language, especially when we're coming from the MLA tribe. We speak function, we speak that fitness forward mindset, include some of that information and that's really going to get the point across particularly to the fitness for clinicians. I would also say Dr. Michalak is go to PTOnIce.com, look at the find an ice clinician map and build relationships with that person that is local. The second question that he asked was, are there any insights into Medicare billing or reimbursement that would allow them to do so and actually get paid for their expertise? So the question here is mainly looking at, he's interacted with some PTs where he sent the referral that was not pain based, where these clinicians said, I can't get this covered, right? I treat pain, I get paid to treat pain. That is not correct, right? So you can definitely get reimbursed to have the fitness forward approach when you use appropriate outcome measures. When you can demonstrate medical necessity through the performance of these validated outcome measures that we cover extensively in our MMOA level one online course, and a little bit as well in our MOA live course, when we're using those outcome measures to demonstrate, hey, this person has a score, which based on the literature is showing that they are at a higher risk of whatever, negative health outcome, usually it's a fall, that that warrants your services. It is medically necessary. So we can have fitness-forward physical therapy. This is what we often see in the context of home health. We treat more function than pain in the context of home health. Outpatient, not so much. It's more of a pain driver, but you can still have a fitness-forward approach in the context of outpatient. These outcome measures are absolutely key because they demonstrate medical necessity. Multiple outcome measures I should say great conversation. So what I want y'all to do if you like this topic I want you to come to Instagram and I'm gonna drop a couple links. You could also send me a direct message At Dustin Jones dot DPT and I'll send you the links as well because it's a really great conversation. I think by and large Yes, we need to get people stronger We're already really pushing forward with that and I love that but we may need to take it to the next level of power based training In terms of a new name, potentiopenia, I don't know. I'll let the really smart people debate that and discuss that, but I'm going to keep pushing the message that we need to build people's resilience. We need to end one rep max living and really show that people may be quote unquote old, but not weak. Also that they may be quote unquote old and not slow. Y'all have a good rest of your Wednesday. I'll talk to you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jordan Berry // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Jordan Berry as he discusses the reverse hyperextension exercise as the go-to exercise for the low back. The reverse hyperextension provides a decompressive effect on the spine, often reducing symptoms, while simultaneously allowing for strengthening & mobility through the full range of motion of spinal extension & flexion.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

JORDAN BERRY Good morning, PT on Ice Daily Show. This is Jordan Berry, Lead Faculty for Cervical and Lumbar Spine Management Courses. Coming at you on Clinical Tuesday, we are chatting today about why the reverse hyper is king. We love the reverse hyper when we're either building strength in the back, trying to modify symptoms and pain in the back, but we're gonna talk about today about all the different exercises and machines, equipment that we have in the clinic when we're talking about the lumbar spine, why the reverse hyper is king. Before we get into that, just a couple upcoming courses. We've got a few spine courses left before the end of the year. So if you're trying to catch cervical spine management, you've got two options left this year. You've got November 11 and 12 is going to be in Bridgewater, Massachusetts right outside of Boston. And then we also have December 2nd and 3rd out in Hendersonville, Tennessee. So two options left for cervical spine. If you're trying to catch lumbar before the end of the year, you've got three options. You've got Fort Worth, Texas coming up November 4th and 5th. And then two options, December 2nd and 3rd. We've got Charlotte, North Carolina, and then Helena, Montana. So a few options left before the end of the year. We've got a ton of dates on the books already for 2024. So hoping to see you at one of those live courses either before the end of the year or maybe sometime in 2024. So let's dive into the content today. THE REVERSE HYPEREXTENSION So again, chatting about the reverse hyper and why the reverse hyper is king. So let's define king to start with. So when I think about an exercise, ideally it would do three things. So it would do a combination of reducing someone's pain, improving the mobility in the lumbar spine, and then building strength and endurance in their back as well. Like if I had one exercise that could do those three things, that's what I would consider king. So reducing pain, improving mobility and building strength and endurance all at the same time. And so yes, there are multiple techniques and exercises that we have that are incredible for reducing low back pain. but they don't do an awesome job at improving someone's mobility or strength. And then we've got exercises that are awesome for range of motion. However, they don't do a good job at reducing pain. And then of course we have some awesome exercises for building capacity and building strength in the lumbar spine, but maybe they don't do a lot for improving range of motion. What I'm saying is the reverse hyper is the king of all three of those if you package that up into one exercise. And so to start with, If you're not familiar with the Reverse Hyper, I would say YouTube it or look it up or try to find one even better and test it out in person. But if you're not familiar with that machine, there's a, essentially you're laying on a platform. So it's elevated a few feet in the air, almost looks like a GHD machine, but you're laying across it and you're holding it with handles in the front. So your torso's laid out on the area. and then your legs are essentially hanging off the side of it. So the pad that you're laying on hits right around the hip crease, legs are laying off the machine, and then it's plate loaded. So you have this pendulum underneath that you can load with weight, load with plates, and then the strap goes around the lower leg. And the exercise is essentially just contracting the posterior chain. So you're lifting the legs up and down, And then it's taking your lumbar spine through full flexion and full extension. And again, hard to explain verbally, um, on the podcast, but look it up on YouTube, um, get out to a gym that has one and test it out. But I want to talk about the three reasons why I think this exercise is king. STRENGTHENING THROUGH THE FULL RANGE OF MOTION So the first one is it's strengthening through full range of motion. Now, if we're just talking about building capacity and strength in the lumbar spine, no argument, the deadlift is king. The deadlift is an incredible exercise for building strength and capacity in the posterior chain. However, the deadlift doesn't utilize a lot of range of motion in the lumbar spine. Like, when we coach the deadlift, what we want to see is essentially straight lines. Straight lines or strong lines. So, we coach it to have a neutral spine position throughout, so the lift is more efficient, right? But, we're not actually utilizing a lot of range of motion for the lumbar spine. And we would never treat another joint like this. So, you know, if you're only utilizing hip hinge type of movements, then you're missing a ton of range of motion. And think about treating an Achilles tendon or rotator cuff. We would never utilize just a very small amount of the range of motion. We always talk about strengthening through the full range of motion. So why is the spine any different? So the reverse hyper, as you kick those legs up and down, right, you're taking the lumbar spine through full flexion and full extension. and you know an exercise similar to the Jefferson Curl in a way where we're utilizing a lot of range of motion of the spine but Jefferson Curl is much easier to cheat on because if you have really good posterior chain mobility then you can essentially do one massive hip hinge on the way down. And it looks like you're really utilizing lumbar flexion, but you're not. The reverse hyper, because you're locked in laying on the pad, it's much harder to cheat. And so we love this exercise for strengthening through the entirety of the range of motion. DECOMPRESSIVE EFFECT Now, second, there's what we call a decompressive effect. So on the actual reverse hyper machine, not a variation on the actual machine, you have this pendulum weight underneath that is plate loaded. And as you lift the legs up and down, that plate swings pretty far under. And so as you're flexing the low back, because the weight is underneath and has some momentum to it, you almost get this decompressive traction like effect. Now, why this is so awesome is this exercise can work for someone who has almost any levels of irritability. So, for high levels of irritability, like when someone's back is really jacked up and they have a lot of pain, it can sometimes be challenging to find an exercise that relieves symptoms and feels really nice. And you'll be surprised to find that for those individuals that can't tolerate other forms of exercise, they will really like the Reverse Hyper. And even the heavier you go on it, the better it feels sometimes because it's more weight underneath that is almost tractioning the spine. And in my mind, what I think is happening here is we're essentially creating a pump. So when we have that pressure gradient that we're creating, when you contract and relax and contract and relax, And that pressure gradient is going to essentially pump fluid and water into the lumbar spine. And I think about the couple of research articles that we referenced in lumbar management, they're both from Paul Beatty, 2010 and 2014. And he's looking at diffusion weighted MRI. And in the first study, we're looking at interventions like prone press-ups and lumbar PA mobilization. Second study four years later, lumbar spine thrust manipulation. But what they found in both studies is the individuals that had a significant symptom reduction, so a massive pain reduction, following the intervention, we saw an increase in hydration, the diffusion coefficient, in the discs in the lumbar spine. So essentially the discs brought in fluid, brought in water content, and that matched up to who had a significant reduction in pain. What do I think is a massive, massive pump that we could utilize in the clinic? It is the reverse hyper. So I can't prove that there's no research for that, but I would love to see something like that in the future. But I really believe that's what's happening is one of the ways that we're reducing symptoms is the diffusion coefficients. We're creating that pressure gradient is drawing in fluid to the lumbar spine and helping to reduce pain. I think that's why some individuals they have pretty high levels of pain, pretty high severity, are able to tolerate that type of exercise. SCALING THE REVERSE HYPEREXTENSION And then lastly, the third reason why the reverse hyper is king is it's easily scalable. So yes, the actual reverse hyper machine, the official true reverse hyper machine is a bit harder to find in commercial gyms, but there's a scalable option for pretty much anyone. You know, you could regress it anything from a GHD machine where you're on the backside of it. So you're holding with your hands where the feet would go and lifting the legs up and down. You could throw a band around the bottom of it and have some banded resistance. We could utilize just a bench. We could either lie on the bench and so the end of the bench would hit the hip crease and have our legs hanging off. Or we could go on top of a physio ball on the bench to get more of the curve in the lumbar spine that mimics the true machine. Or something as simple as just holding something at home. Like sometimes in the clinic for my clients that don't have a lot of equipment at home, I'll have them just lay across our coffee table or a bed or some sort of table that they have where the edge of the table hits the hip crease and they can just lift their legs up and down in its simplest form. It's an awesome exercise for, again, not only increasing range of motion, reducing pain, but also building strength and endurance in the lumbar spine. So there's pretty much a variation for anyone where you can mimic this type of movement. CONS OF THE REVERSE HYPEREXTENSION The pushback with the reverse hyper over the last few years has really been two things. Number one is the cost. The traditional reverse hyper machines were a couple thousand dollars and they took up a significant amount of space. So if real estate is an issue in the clinic, a lot of the old reverse hyper machines took up the space of about a squat rack. And so because of that, not a lot of gyms and not a lot of physical therapy clinics utilize that. But thankfully, a lot of companies are solving that issue. A couple companies like Rogue and Titan and a couple smaller ones are now making reverse hypers that are not only significantly cheaper, but are more compact as well. Some of them even fold up. So they take up pretty much no real estate in the clinic. So because of that, That is why we think the Reverse Hyper is the king of exercises for the lumbar spine. So again, there are exercises that yes, might be best for pain, might be best for building range of motion, might be best for building strength for any N equals one. But I'm arguing if you gave me one exercise that could do all three, I'm taking the Reverse Hyper all day. That's what I've got team. Thanks so much for taking a few minutes to listen. I would love to hear some thoughts on this. So if you're utilizing the reverse hyper, either in your personal training, um, just from a performance standpoint, or if you're utilizing it, um, in the rehab setting, I would love to hear comments, how you're using it, what you think about it. Um, drop those in the comments and, uh, and we'll chat about it. But other than that team have an awesome Tuesday in the clinic. Um, if you're coming to a cervical or lumbar course in the future, I will see you soon. Thanks team. 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. Jessica Gingerich // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses simple, but often overlooked interventions for treating patients with symptoms of pelvic prolapse including the Kegel, unilateral hip strengthening, and proper breathing & bracing.

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 00:00 - JESSICA GINGERICH Welcome to PT on Ice Daily Show. My name is Dr. Jessica Gingerich and I am on faculty here at Ice with the Pelvic Division, which means that it is Monday again. We are getting super close to Halloween. I'm really excited. I'm definitely a Halloween girly. Today we are going to talk about what may be missing during the plan of care when it comes to prolapse. So this is another hot and relatively scary topic for a lot of mamas, but also for a lot of clinicians in this space. So we're going to talk about a few housekeeping items before we get started. We are currently in our last cohort of the year for the online course. This is something we are gonna put the pedal down come January. We've got a lot of exciting things coming up. So if you have not signed up for this course, head over to ptonice.com, just sign up. We also have a few more courses, live courses, to round out the year. So, if you're looking to dial in your internal assessment with that kind of higher level population, that athletic population, head over to PTOnIce to sign up there as well. My hope after this podcast is that you guys want that. You want to sign up for that live course. You want to dial in your internal assessment, dial in your interventions, and just guns a-blazin' out in this population. For those of you in the ICE Students Facebook group, you will hear more about the revamped certifications from Jeff tonight. Otherwise, stay tuned to Hump Day Hustlin' emails for details. So if you haven't signed up for Hump Day Hustlin' emails, again, that's all on the website. It's free. We just want to get out as much information to you guys as we possibly can. So we have some really fun new certifications coming up that Jeff is gonna dive into later tonight. So as we begin our PT careers, a lot of us prefer a specific population, right? We want to treat the older adult, the pregnant person, et cetera. We want to dial in our skills. And we love to see that, right? Like that, I love that. I want to get really good at that one thing. I want to go to the provider that is that provider. I am the person that you want to see if you are experiencing X, Y, and Z. We hear that a lot as faculty, especially in the pelvic space is, you know, well, I only want to kind of treat this type, this, the urinary incontinence or, you know, low back pain. And as a faculty, we've all kind of experienced those same thoughts and feelings. Again, it's intimidating when you get into this space. Well, we quickly learned that you can't just pick and choose. If you have someone that's experiencing urinary incontinence, they also are likely experiencing something else as well. If you are in the pelvic space, you're going to see all things. PELVIC PROLAPSE The ones that are at the top of the list, at least that we hear about as faculty, are the ones that are scary are pelvic pain and prolapse. So today we're going to focus on treating prolapse and specifically what we may be missing in our plan of care. It is going to be outside of the scope of this podcast to talk about the assessment of, um, like the subjective or objective assessment of prolapse. So if you are unfamiliar or you feel like you're just kind of shaky on this, again, that live course is waiting for you. Once we know the pelvic floor is strong or weak, or that it's a timing issue, or that they may or may not be tender to palpation internally or externally. And when I say externally, I mean hips as well. And that they may or may not have objective signs of prolapse. we then get to develop our plan of care. Now notice that I said may or may not because these clinical patterns are not identical. You will see so many different clinical patterns when it comes to symptoms of prolapse. So let's just say your patient comes in with feelings of heaviness, pressure, or dragging, and it feels like they may be sitting on something. That's something how they're describing it. When they're in the shower, they feel, as they're bathing, they may feel something physically. The heaviness gets worse after they have a bowel movement, void, go to the gym, or have been on their feet all day. So what's your next plan of action? Well, first and foremost, we wanna encourage you guys to stop focusing on the biomechanical components of a prolapse. Of course, there is that person or that type of prolapse. We're maybe talking about surgery. That does happen, but it doesn't happen without needing that pre-physical therapy, the stuff that they're doing beforehand, getting stronger, learning how to poop and pee. learning how to brace. So all of this stuff is still happening, even if surgery is part of the discussion. So first and foremost, let's stop focusing on the biomechanical components. Let's start focusing on the symptoms. So understanding what makes the pressure heaviness better, what makes it worse. Can we, part of their plan of care, ramp up the things that make it feel better and ramp down the things that make it feel worse? That has to be followed with this is not gonna be your forever. This is not gonna be you never doing that thing because it ramps up your symptoms and always having to like sit and be immobile because it ramps down your symptoms. We have to think about this on an irritability scale just like we do with pain. We have to be able to bring down their irritability, so then we can make them better by loading them. So now that we know that, I'm gonna give you four points to go home with today that are great points to start with. When you have that person come in with a script that says pelvic organ prolapse, or doesn't say that, it says pelvic pain, but then you start asking them questions and you're like, hmm, they may have symptoms of pelvic organ prolapse. REMEMBER THE KEGEL We have to remember the Kegel. This is number one, the Kegel. It has gotten so much hate over the past few years, especially on social media. I don't think that was anyone's intent to just say never do Kegels, but it matters. Teach your client how to do a Kegel. Lift and squeeze, shut off the holes, come to the attic. But we have to remember the relaxation component to the Kegel. Teach them how. to relax. Have them focus on this. A lot of times people feel like they can multitask a cubicle. If they are new to this and they don't know and they didn't even know they had a pelvic floor, they need to go in a room where it's quiet with no kiddos running around and focus on the up and the down component of a cubicle. Something that I love to say in the clinic is the relaxation component of a Kegel is sometimes more important than the contraction. Everyone always thinks we need to go up, up, up, up, up. And when I say everyone, I mean typically our clients. And they forget that this actually has to happen as well. Or, not that they didn't forget, but they think that they may be in that relaxed position and they're not. and that's where that internal palpation can be golden. Again, people tend to focus on the contraction, so being constantly contracted can also lead to symptoms of heaviness. So maybe their symptoms of heaviness are coming from this versus actually symptoms of prolapse. UNILATERAL HIP STRENGTHENING Number two, single-sided hip strengthening. get their hips stronger, always, but even here, get their hips stronger. And I don't mean with a TheraBand. Throw it out. If you want to warm them up with it, great. But we've got so many options. Step downs, step ups, we've got single leg RDLs, we've got variations of that. We have Core stuff that we can do, like the options are endless. We can do side planks, we can do hip thrusters. Don't forget about strengthening their hips. INSTRUCTING THE BRACE Number three, teach them how to brace. Symptoms of heaviness can happen due to faulty bracing strategies. Bracing is not only for lifting heavy either. We need to prepare mom for the demand of life. And mom is holding Johnny who has a runny nose and she's trying to wipe his nose and he's flinging his head back. She's going to be bracing her core and she's not even gonna think about it. So let's prepare her for that. Number four is find and encourage frequent rest positions that ease or make their symptoms go away. This could be lying on their back. This could be seated, this could be laying on their stomach, it could be leaning over the counter, anything that makes their symptoms ease. Again, follow this up with this is not forever, this is a for now, we wanna get those symptoms, the symptom irritability down. And once we get those symptoms down, what can we do? Everything that we just talked about in one through three. So to recap, find the symptom aggravators, find the things that make their symptoms go away or ease. There may be multiple clinical patterns to prolapse-related symptoms. Prolapse can be scary to a lot of women. It is, if they've Googled it, they are gonna come in wide-eyed, or if the doctors told them that, there might be tears. But it can also be really scary to clinicians if we don't know how to treat this. You have four places to start. The Kegel. Gets a lot of hate, but we need to start using it. Don't forget about the hip. The hip muscles are gonna be supporting structures to the pelvic floor. Bracing is not only used for heavy lifting, and using positions that ease symptoms to lower irritability, which will increase our loading capacity. That is it. Start there. So team, I hope this helps. I hope you have a great week and enjoy your Halloween 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.

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock discusses how to approach setting up at a competitive event, including looking the part, preparing to capture leads, and knowing what is possible in the context of a short session with a potential patient.

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

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

EPISODE TRANSCRIPTION

00:00 - MITCH BABCOCK All right, here we are. Good morning, everyone. Welcome to the PT on ICE Daily Show. I'm your host on Fitness Athlete Friday. I'm Mitch Babcock, lead faculty in the online Essential Foundations Level 1, Level 2 courses and our live Fitness Athlete course on the road where we do all things barbell in your hands all weekend long. I'm pleased to be joining you guys this beautiful Friday before Halloween here, October 27th. And my apologies for nine minutes behind the clock as our CrossFit hour this morning was jamming and ran a little bit long. Today's topic is something that we derived off the ICE Students page. So shout out to all of you that are active on the ICE Students Facebook page. We always appreciate the engagement, the questions, the comments, the thought. It spurs topics like these. You don't even know what kind of good info may come from a question that you pose on the ICE Students Facebook page. So thanks for being a part of that to everyone. 01:18 - THE ART OF THE 10 MINUTE EXPOSURE The topic today is the art of the 10 minute exposure. We're talking about, hey, someone posted a question of, I have an opportunity to set up at a local CrossFit gym or a CrossFit competition that's going on. And I want to know what should I do? Should I treat for free? What should I be doing? How long should I be doing it? And so we want to talk around that concept today of like, let's say you have 10 minutes with a free prospective client and you're trying to win them over in that fitness athlete space. What are some things that you need to be doing and doing well? And so that's going to be our topic of discussion today. And just before I dive into that, I do want to let you know that next weekend November 4th and 5th. Both Zach and myself are gonna be out on the road. Zach's gonna be in Hoover, Alabama, and I'm gonna be in San Antonio, Texas. Team, we are running out of dates to catch the live course at the end of 2023, so if you were hoping to wrap up that cert, or you wanted to hit that course and get dialed in on all your barbell dosage, treatment, refinement, everything, there's like a total of three weekends left at the end of the year. Anna Marie Island just sold out, so that one's off the map now in Florida. Shout out to everyone that's gonna be in Florida. We got Colorado Springs, we got Hoover, Alabama, and we got San Antonio, Texas. So if you want to catch us next weekend, we've got two dates. Check the PT Online's website and we will see you there at those courses. Okay, let's paint the picture. You are a newly minted business owner of your own. You've started your own practice, maybe in a CrossFit gym or near one. And you're looking to do this fitness athlete thing on the out of network side of things. And you want to anchor your ship tight to a CrossFit community in your town, which is smart. And you have an opportunity now to go to a CrossFit competition, market yourself, get your name out there, your business exposure, all of that. What should you focus on? I wanna start with looking the part. 05:07 - PHYSICALLY LOOKING THE PART Aesthetically, physically, from a business perspective, from a clothing perspective, all of the above. That if you're gonna go into this environment, that you need to pull up on the right horse. I don't want you showing up to a biker rally on a scooter and thinking like, I don't know why I didn't blend in with this culture, this community, right? Humans still operate on that first impression basis. That is still a key component. Those first three seconds that someone looks at you, sees you, makes all these internal assessments on what your business is like, what kind of information they can gather from you, what kind of expert you are. We have to respect that first impression and we have to bring our best foot forward. So let's start with your setup. your nice pop-up table, right? Whatever that is, they're cheap on Amazon, you can get a nice brand new table for 100 bucks, it's black top, looks good. Go on Vistaprint or Banner Buzz or one of these websites that will print out a nice custom fit tablecloth that will stretch over an eight foot pop-up table that has your business logo branded across the front of it. So you've got your treatment table and you've got a nice table up front that's going to hold all your brochures or anything else that you have on it. Marketing materials wise, that's a very nice printed stretch fit cover. You're going to invest a couple hundred dollars into having those things ready at any event you go to and market. 5k races, CrossFit events, whatever, right? Tent or not, really doesn't matter. Indoor comp, outdoor comp, you may wanna invest in a little pop-up tent, but let's just assume you're set up inside and you don't need to worry about that. You've got your treatment table, you've got a table up front. You need to personally look the part as well. And I don't just mean the clothes you wear, and yes, I do mean the clothes you wear, but I also mean physically. You need to physically look the part. If you're going in here and working with fitness-forward athletes, you should look the part like you train from a fitness-forward approach yourself. If you're not there yet, and you're trying to inject yourself into that community, anticipate a hard ramp up, right? You need to look like you work out, you train, you've exercised, you do CrossFit, you have some calluses on your hands, that you can speak to the expertise that these athletes are expecting you to have. That is just a cold truth that no one really wants to admit and talk about. If you can't tell the person in front of you how many burpees you do in seven minutes, you're probably not ready to set up at a CrossFit comp yet. Your personal expertise probably has some developmental work to be done on the back end prior to you setting up and going out there and being like, yeah, I can solve all your problems for you. I know exactly what you're going through. So get yourself dialed in from a physical perspective. Two, get your wardrobe updated, right? Do not roll into a CrossFit comp rocking that same polo that worked in the in-network setting and the khaki pants that you wore Monday through Friday. We're not in that setting anymore, right? So invest a few hundred bucks into a nice clinic wardrobe that looks good. Some nice athletic pants, joggers, whatever. Black always goes well. And get yourself a nice top and take it to your local screen printing place and have your business logo screened on the top of it. everyone's wearing the cotton freaking t-shirts with their low company logo on it but not everybody's wearing that that next level nice t-shirt whether that's lulu or whatever you go and you buy your stuff from you get that nice t-shirt you get your company logo on it it just stands out it just looks a little bit better a little bit more professional and a leg up on the competition you're going to business suspense that stuff anyways you might as well get a shirt you like you feel good you look good in and go get your company branded on the front of it So step one, looking the part. Both your setup, your table, your banner, your clothing, right? And physically looking like you train and you exercise and you know what you're talking about when it comes to this stuff. Two, Treat for free. Everyone's talking about should I charge people at these comps. I say that you're there to gain exposure. You're there to convert people back to your clinic. You want them to come to your operation. So you need to funnel everything through that filter. Everything needs to be geared around how do I get in front of people, show them I know what I'm talking about, and then get them to schedule an eval and come see me at my clinic. It's not about a transactional thing here. It's about giving things to the consumer in that environment where you're in front of hundreds of them, over delivering for free, and then converting on that at the end of the sale. 09:49 - CONVERTING LEADS And that's a key part. You need some way to capture leads and convert leads. The best way to do this is having some sort of QR code available. Everybody's scanning QR codes these days. Having a flyer printed out on a little plastic flyer holder that when they walk up and it says right there, free 10 minute session with Dr. So-and-so. Scan here. Boom, that's easy. Boom, pull out my phone, scan it. It takes them to something, a lead generation on your website. That could be sign up for my newsletter, name, email, phone number, city, whatever. That could be put in your contact information. We're going to reach out after today and kind of be in touch with you. Whatever that is, whatever lead funnel that you want people to go to, that's where that QR code directs them to on your website. So they scan the QR code. Boom. That holds their place in line. And then you're calling the next person up 10 minutes at a time. Hey, I got 10 minutes. What's going on here? In that 10 minutes, your goal is to address the areas that most need addressing, to over deliver the best you can, and then to convert that individual after the sale. Give, give, give, and then ask. Give, give, give in that 10 minutes. Here's what I think is going on. This is common. These get blown up. This gets overworked. This is out of position. This is stiff. We need to mobilize this. Here's some things that I like to do. Let's get some needles in that area. Let's do some cupping. And at the end of it, say, hey, I would love to earn your business. If you would, please take my card. I'd love to have you call and set up an appointment. I can actually get you scheduled right now. This looks like something that needs some work. Would you like to schedule right now while I got a few minutes? Don't be afraid of the ask. You're giving free content, you're giving free knowledge, you're giving free experience, and you're giving your time and service to that individual. Do not be afraid for the ask at the end of it, right? Can I earn your business? I'd love the opportunity to work with you, get you in the clinic. My e-mail rate is this. Can I get you scheduled for next week? Convert those leads. We stink at this as a profession and something we definitely have a lot of work to do on getting better when that conversion, that sales conversion process kicks in, right? 10:43 - TRIAGE & TREAT And then the last thing I have, if we're looking the part, if we are converting our leads is to know what works and deliver on that. Team, if they're at a CrossFit comp, they don't need pain science information right now. Okay? I'm not saying there's not a time and a place for that. What they need is something to help them recover. Their back is likely blown up. It feels like there's a hundred gallons of blood shoved right in their erectors right now. They want their back to loosen up and feel better. Their legs are probably imploded. They want their legs to feel better. Their shoulders are probably imploded. They want them to feel better. Right? Understand what these comps and these things are going to ask people to do. Lots of pull-ups, lots of squats, lots of deadlifts. Know what works for those things so that you're efficient in your clinical approach in those 10 minutes you have with someone. We're not trying to solve all their pain and all their problems in 10 minutes. We want to show them that we have tools that can help them. And if you give me more time, if you give me an eval, if you give me a couple sessions, I can get to the root of your problem. So you're having things at the disposal, ready to go for shoulder, like high-volume pull-ups, what am I gonna do to address the lats and the biceps? High-volume squats, what am I gonna do to address the legs and the quads? High-volume deadlifts, what am I gonna do to address the low back? Are you gonna bring needles and stim and hook people up and get them stimming? Cool, maybe get two treatment tables so you can get one person started on that and you get the other person on the table right after that. Are you gonna do some cupping on there, try to increase some blood flow? Great, get it set up, get it rocking, take a bunch of pictures. Another good thing to ask someone for is to have them take a picture and post about your company on social media. Remember, they're getting this for free. They're willing to do something in exchange. Scan your QR code? Sure. Post a picture? Sure, I can do that. Tag my business? I would really appreciate the exposure. We're just getting started. I love working in this community. I love working out in CrossFit. I'd love to be able to help athletes like you down the road. If you could post about my business, that would help me a ton. Thank you so much. They're thankful for your time, your service, and your free delivery of something to them, and they're willing to exchange that in terms of something else for your business. So there's some things for you guys to think about. The art of the 10-minute exposure. You've got 10 minutes in front of somebody. Treat them for free. Have some way of funneling and converting those leads. And don't forget to ask for the sale. Can I get your schedule? Can I get your book? Can I get your e-mail? Look the part. clothing, wardrobe, physically, and then your environment that you're set up, your tables, and your banners, and your marketing materials. And don't forget to ask for something on the tail end. Let's take a picture. Let's post about it on social media. Convert those leads, team. Get those people that you're there, you're giving your time for, for free. Convert those people into prospective clients that are on your books for the next week's following. I hope this was helpful. I hope you took something from it. that you know what works and that you're going to deliver on what works in that 10 minutes for that patient. Team, thank you so much. Shout out to anyone that's going to be at our courses to the end of the year. We're looking forward to wrapping up 2023 with a bang. Next weekend, we're in Hoover, Alabama and San Antonio, Texas. And still some spots for you to join us if you want to. And have a happy Halloween. I know we're rolling into it this weekend. Our gym has a Halloween WOD planned for tomorrow. So a costume WOD for tomorrow and then Halloween on Tuesday. So let me be the first to wish you a happy Halloween weekend, team. Thanks so much. Go kill it in clinic today. Have a great one, 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.