#PTonICE Podcast

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses how healthcare providers can learn to assess patients' readiness to change when becoming more active, barriers they perceive to exercise and confidence in implementing a regular exercise program. Alex challenges providers to become a "guide to self-efficacy" with patients to increase their regular physical activity.

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 INTRO

What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're sure to use the code ICEPT1MO when you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.

01:33 ALEX GERMANO

Good morning, Instagram. 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 Jerry on ICE. My name is Alex Germano. I'm a member within the older adult division. We are going to talk about a recent article that came out talking about how to address inadequate physical activity in our patients, especially older adults. The older adult division continues to charge across the country this fall with courses in Charlotte, North Carolina, Fort Collins, Colorado. That's happening this weekend. You can catch us in Oklahoma City, Bellevue, Washington and Falls Church, Virginia to round out September. Head to the PT on ICE.com website to learn more about our current course offerings. It does not seem like we're slowing down coming into the end of this year.

02:31 INCREASING PATIENT'S PHYSICAL ACTIVITY

I know it seems a little lame to come on the podcast and talk about increasing our patients' physical activity clinically. I mean, I say this is a little lame because I think it's something like we're like, duh, we all know. We need to get our patients more physically active. And so it doesn't seem like the coolest thing we can talk about if it's a problem we all know about. But I thought this article added a lot of value to this conversation. Clinically I've really gotten to this point as a therapist where I believe that most of my patients' ailments, their balance concerns, the unsteadiness they have, the lack of endurance they have, the lack of strength could all really be fixed by joining a gym or performing some type of meaningful fitness in their lives. I have really begun to embrace and step into this role of being a guide to their land of fitness for my patients. And I do care about the reason I'm there and trying to work through that with them. But really the ultimate goal in the back of my mind the whole time is how can I lead this person to meaningful fitness for longer durations? Because I know that my physical interventions are not going to stick around too long if the only thing that they're doing for physical activity is physical therapy or occupational therapy. Now because this is the way I approach my patient care and sometimes I'm all by myself out there in the world doing home visit, I really thought that every physical therapist out there was trying to increase their patient's physical activity. And I think I'm a little blinded by the community that I'm a part of, ICE, and that we're probably all trying to do this. So I just thought every physical therapist is out there really trying to do this thing and everyone's going to be super bored by this conversation until I saw the statistic in this paper that despite 91% of older adults over the age of 65 not performing recommended activity guidelines, 91%, which is costing the world $53.8 billion a year, 50 to 75% of healthcare providers are not assessing and addressing inadequate physical activity in their patients. 50 to 75% are not addressing physical inactivity. And I thought to myself, oh well let me look at the studies that they're citing for these statistics because clearly physical therapists or occupational therapists are definitely addressing this. They probably lump together all these healthcare providers. No, most of the studies they cited for the statistic were involving physical therapists or other rehab providers. Yikes, mind blown. This is significant. And I think a lot of us are trying. We're probably trying. We are making some of these light suggestions for home exercise program. We tell people to break up sedentary behavior and sedentary time. But how often is that really working? How often does that patient go off to join a gym? How often do they start seeing the personal trainer? Do they start telling you every time you come, I am doing all of my home exercise? Honestly, not very often. So it's not maybe our lack of trying, but rather the way we're trying to approach this conversation is what's off about how we're trying to solve this problem. So this article that I am referencing, which will be in the links on this Instagram page, suggests that we might not be advocating for physical activity well due to a few factors. It could be our lack of knowledge or confidence on how to assess and address inadequate physical activity. It could be an uncertainty on how to use behavioral change techniques in clinical practice.

04:05 LACK OF PHYSICAL ACTIVITY AWARENESS

So the first part, how do we get more comfortable and confident in assessing and giving our patients physical activity recommendations? At the Institute of Clinical Excellence, you've heard it a million times. We do it ourselves. We walk the walk. We be about it. We can't say this enough, right? By having a solid foundation of our own exercise program, you're going to be much more convincing, much more inspirational to your patient whom you're trying to get to the land of fitness. Now I will admit sometimes though, I'm going to be and not worry about this. I don't think that this is, I think this is important that we're this way, but it's also important that we remember what it was like to not be fitness forward at all because having this strong personal practice and exercise can be detrimental. I am on vacation and I, when I'm on vacation, I love to exercise. Like love it. I got out there for a run this morning because we're coming up to our marathon and I wanted to get out there, got a good run in. I love to work out because on vacation I have extra time. I'm not in a rush to be in the gym early and get out of there early. So I love it.

07:21 EXERCISE AS A CORNERSTONE

A lot of my patients though report that exercising on a vacation is like absolutely not going to happen, right? It's like, it's so easy they're not going to be able to do it. And like I was thinking about like, why do I exercise on vacations? Because it means so much to me and I really know and appreciate exercise in my life, right? This is the curse of knowledge that I have. I know how good exercise is going to make me feel for the rest of my days. My patients do not feel that way. Dustin Jones talked about this actually a number of years ago talking about the curse of knowledge. I know how good it feels, how easy I can fit it into my life even in exceptionally busy times. We don't remember what it's like to be that newbie. And it's a huge excuse I see for my patients and I almost want to laugh when I make patients tell me they don't have enough time to exercise, especially knowing they're retired. They're not really having much to do around the house. Like most of their chores are kind of outsourced to other people and like as a new, like a newer mom, right? Like I have a one and a half year old and I've worked multiple jobs. Like sometimes I feel like I'm barely hanging on. Exercise remains a staple in my life. I could sit on my high horse and tell them I'm so busy and I still can fit in five days of exercise during the week. How many hours of TV a day are you watching? Don't you think you could sub in one of those hours for exercise instead? That conversation has never worked in clinical practice to elicit change in my patients. Okay? When I hear my patients don't have time, that really tells me something more. It tells me a lot about their readiness to change their lifestyle. And this might be really the missing piece around some of our education surrounding physical activity. So after you ask your patients about their current activity levels and compare these to the traditional guidelines set out by the ACSM, those ACSM guidelines, you can start to assess their stage of change. I think that's the most important thing we answer first. How ready is my patient to change? How ready are they to change? So an important question could be, do you intend to change your physical activity in the next month or in the next six months? I'm trying to determine a timeline. Now you can decide based on the answer if they kind of fall into these different categories. Are they in the pre-contemplation phase? Meaning they're not interested in really changing their physical activity at all. Or are they in the contemplation phase? Do they intend to increase their physical activity in the next month or the next six months? And do they have a plan in place to make that change? Most of my patients really land in the pre-contemplative phase where they're not considering changing really anything. They're not coming to me for an exercise program. They just have a problem they want me to fix. Now if there's some, you might even meet somebody who's in a preparation phase, who's actually made a plan to change some of their physical activity. They've reached out to a local gym, something like that. And if they're in that preparation phase, you're going to want to follow up on what's their action plan to increase their physical activity levels. If someone is in the pre-contemplative stage of change, we want to validate their current perspective. We don't want to convince them to switch sides. Not yet. It's our turn to show them what physical activity can do in their lives and wait for them to be interested in doing more. This is a call to action to make sure our patients really see the value of rehab that we provide. They should see a super clear connection between their goals and the exercises we select. If our patients are in that contemplative phase without a plan, so they're thinking about it in the next six months, they don't really have a plan to get there, it's our job to develop specific goals for them and an action plan while assessing their confidence to committing the plan. I think that's what we miss is that confidence piece. We usually miss it and we only kind of set out a goal or action saying you're going to do this exercise five days a week, sounds good, I'll check back in on that later.

11:20 ASSESSING CONFIDENCE WITH EXERCISE

The confidence assessment is key. You can ask your patient how confident they feel on executing a plan. Ask them on a zero to 10 scale, how confident are you that you're going to be able to do this exercise program five days a week? If the patient says anything less than a seven out of 10, we need to reevaluate the goals and the action plan. We probably should drop that down. Do you think you're going to be able to get three days of exercise in a week? Assess confidence, super important. Now if the patient already has a plan going, it's worth it to stop and talk about barriers. The article mentions using the 27 item inventory of physical activity barriers, which works through a patient through eight domains of barriers that could impact physical activity. That is a super thorough assessment. 27 items is a lot. So this could be appropriate for some, maybe not for all. The simpler one would be the self-efficacy for exercise scale. That's a bit simpler. It's a far fewer items. I'm sorry, I don't remember the exact number, but it's far fewer items than 27. But if you're really interested in figuring out what's going to cause your patient to stop being physically active, these are assessments you definitely want to do. Now as your patient begins to execute their plan, it is our job to constantly check in. In the article they say, recognizing success is essential because it increases self-efficacy. And I couldn't agree more. I am all about and in the business of improving my patient's self-efficacy. Honestly, I wonder if that is the job of the physical therapist for the older adult at this point. Bringing our patients back in control of their lives and giving them this feeling and sensation of self-efficacy. So I'm a guide to that land of self-efficacy. Now how do we do that is we check in constantly with our patients about their program, their physical activity program. And we cheerlead and recognize and give kudos to every little step that our patient makes towards these goals and especially when they work around barriers to completing the activity. So make sure if you have physical activity goals for your patient that these are things you're asking about every session. We're not giving them the plan and then not checking back in. It's really our job to continue to check back in. It's why we are different than medical doctors who see our patients once every six months and you know six months to a year. At that six months to year visit our MDs are usually telling people, hey you have to be more active and that's all they're doing. No, we get to do the hard work and really check in with our patients how this plan is going.

14:00 AGE-FRIENDLY HEALTHCARE

Now this article also describes age-friendly healthcare which helps to foster a person-centered care. So for older adults in particular you kind of have to determine what matters. They call this the four M's but what matters, M matters, knowing what our patient's mentation state is which I love, taking this consideration towards dementia and delirium that we need to understand before giving these guidelines. Talking about mobility optimization that making sure our patients maintain high levels of mobility and safety is critically important to the population and optimizing medication. So there's a lot that goes inside of this, there's a lot that goes into this conversation rather of physical activity and addressing inadequate physical activity in older adults. This article was really lovely, I really recommend a look because in the back of the article there's a resource guide of all the different physical activity related measures that you can compare and contrast to see if you can find some that are appropriate for your patient population. It's at the very end of the article. So I'll link it in the Instagram page but just remember first and foremost we are in the business of addressing physical activity, absolutely. We have to recognize that we have a bias towards exercise that our patients do not have so we need to come back to that newbie state of mind and really address physical activity from that place and not from our high horse of exercise. By doing this we have to first assess my patient's readiness to change. How often are they thinking about implementing a physical activity program in their day to day life? Think about those things first before you start giving recommendations because if they're in the pre-contemplative phase of behavior change they are not ready to hear from us that they need to be doing a physical activity program. Not yet. Think about the barriers that our patients are going to encounter and potentially use some scales like the physical activity barrier scale or the self-efficacy for exercise scale to address these barriers that are going to inevitably pop up when we start engaging in a physical activity program. Think about some older adult specific techniques such as thinking about mentation, thinking about medication in order to optimize our recommendations. Alright, so you guys are in the business of increasing physical activity for older adults. It's actually probably one of the bigger parts of our job. 91% of older adults are not meeting physical activity guidelines so get out there, let's start attacking these numbers. Have a good Wednesday.

16:29 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. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses how encouragement and support are crucial factors in helping patients overcome challenges and develop resilience. This episode emphasizes the significance of being there for patients and showing them that a healthier and stronger version of themselves is achievable, despite the short-term suffering they may experience. Lindsey acknowledges that this aspect of patient care cannot be measured on standardized scales or assessments, but it plays a vital role in the patient's journey towards better health.

Additionally, the episode highlights the importance of providing encouragement to patients when they face setbacks or failures. It is essential to support them and let them know that it is okay to struggle. By reframing these setbacks as part of the process and emphasizing that it is better than not taking any action at all, healthcare providers can help patients maintain their motivation and continue working towards their goals.

Furthermore, the episode emphasizes that patients should not be defined by their diagnosis or label. It is crucial to help patients understand that they have the power to make choices that can improve their well-being. Healthcare providers should assist patients in reframing their experiences and show them a different way to approach suffering. This involves forging connections, offering hope, and helping patients gain a new perspective on their situation.

In addition to encouragement and support, the episode also mentions the importance of accountability. Patients may need someone to hold them accountable for their actions and help them stay on track with their goals. This can be achieved through forming new connections, such as involving family members or enlisting the support of a healthcare provider. By creating a sense of accountability, patients can stay motivated and make positive changes in their lives.

Overall, the episode emphasizes that encouragement, support, and accountability are essential components of helping patients overcome challenges and build resilience. By providing these elements of care, healthcare providers can help patients navigate their journey towards better health and well-being. Lindsey emphasizes that simply modulating pain symptoms is not enough. They want to open up opportunities for patients to maximize their fitness, both physically and psychologically.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 LINDSEY HUGHEY Good morning, PT on ICE Daily Show. How's it going? I am Dr. Lindsay Hughey, one of our lead faculty for extremity management, along with Dr. Mark Gallant and Cody Gingrich. It's nice to see you all this morning. I am coming to you from Manitou Springs, Colorado. There are some mountains peeking in the background. This Clinical Tuesday, I am going to be chatting with you all about the stimulus of suffering and how in our folks in particular with knee and HIPAA can transform their current suffering to a strength. But I'll tell you it's not by giving up suffering, it's by transforming it. So we will take on this challenging subject today and consider how the suffering stimulus produces growth and satisfaction. But before we do, I would love to tell you about some upcoming courses that Mark and Cody and I have in the extremity division because there's only a handful of courses to catch us in 2023. So coming up is we are in Amarillo, Texas, September 9th and 10th. Mark will be there, so there are still spots left. Join him. And then September 16th, 17th, we'll also be in Cincinnati, Ohio. Moving into the fall, in October, October 7th and 8th, Cody will be in Rochester, Minnesota. So that'll be his first lead course. Join him. He is going to crush that. He has been on the extremity management team and ice team for so long. He brings such a wealth of knowledge. So that is going to be a blast of a course if you are nearby. And then Ridgefield, Connecticut, I added that course about three to four months ago. I'll be there with Melissa Reed. It's a really rad CrossFit gym, CrossFit 203. Lots of spots there, so join us. And then just a couple more opportunities in November and December. So check us out on ptlonice.com. But to the topic at hand. So I've come on here the last few months really chatting a lot about Hip OA and Knee OA and kind of that underlying systemic struggle that they have. And so in particular, we're going to talk about the mental physical struggle that they go through. So those folks with Hip OA and Knee OA, they often start to really identify with that bone on bone label, right? Osteoarthritis becomes who they are. It's how they plan their day. They plan their outings, their weekends, their shopping trips. It's all planned around how long a distance to walk, their energy level, the amount of steps that might be on board, wherever they're headed, how much pain they might be in, how much medicine they might have to take to get through that, or how much they'll pay for it later. So they are considering all of these factors. And it all comes back to like that label that diagnosis of, Oh, I have osteoarthritis. And this starts to really dictate their whole life. And it starts to creating quite a bit of disability limiting their interaction socially. It monopolizes their mental and emotional capacity a bit. And they're struggling. They are suffering. And this is on top of their pain, right in their knee or hip joints and in other areas in their body, because they're walking with the intelligent gait patterns. It's not just the physical impairments, right? Range of motion and strength. They are suffering physically and psychosocially. And we have to recognize this if we want to make an impact. And what's strange is that this suffering becomes a sort of comfort for them, because it's familiar, right? This is now their identity. 04:42 WHEN SUFFERING BECOMES COMFORT We often associate comfort in our society with happiness and well-being. But there's really this intriguing paradox that you start to become comfortable in your current suffering because it is familiar. And this happens to our folks with hip and knee OA in particular, their suffering becomes their comfort. It's what they rely on to dictate their life. Their whole identity is around the suffering. So the reason they don't go to the grocery store anymore, that they have their cousin do their shopping for them, the reason they ride the motorized car and don't walk through the store, the reason they don't take that flight to see their daughter because they can't help bear the thought of walking to that plane and the pain that will cause, or maybe the embarrassment of being pushed in a wheelchair, they're missing their bingo nights, birthday parties of family members, their church Bible studies. They're not able to mow the lawn anymore. They need their nephew or their grandson to do it. They're not doing their exercises because they hurt. They don't want to do them. They'd rather watch their shows. They're not going outside and enjoying the weather. This is suffering and it becomes this holding pattern of inactivity and excuse, which leads to what? It leads to more suffering. The familiarity of that routine to stay home, to not exercise, to eat out, maybe because it's convenient, because they no longer can stand to make a whole meal. This becomes comfortable. Folks are suffering though in another way with these choices, right? They're missing out on socializing. Their joints become more immobile the less they move. They become more painful with less activity and then plus that sequelae of untangible systemic inflammatory changes that are happening when you stop moving, right? Physically and then we can't even put a, you know, a tangible thing on the mental emotional changes that are happening internally and possibly affecting their ecosystems. They will not only stay in these patterns, think about your patients with HIP and NEOA or really anyone really suffering in any diagnosis. Folks tend to find solace in it. We are creatures of habit humans, right? And we stay in these holding patterns of suffering. Our job, we need to create a novel suffering stimulus for these folks. We have to help them see there's this opportunity challenge before them and guess what? They're going to continue to suffer, right? But in a different more productive way, right? And what I mean by that, it's doing your exercises regularly, getting 30 to 60 minutes of physical activity regularly, these things, planning a meal so you don't eat out or having someone come over, help you prepare that meal, things that are outside of comfort zone. Our job is we have to show them the dividends of adapting and learning and evolving lifestyle behaviors. They can change their activity level little by little. They can change their diet and nutrition, their fueling. They can change their hydration. This will all be hard. It will cause some suffering shifts, right? Because of the planning and the change associated with changing those behaviors, like waking up early to do exercises, right? If there's someone that works full time and they just say, I don't have any time to do my exercises for my hip and knee. It might be helping them develop a routine to take their vitamins or hydrate. It might just be asking for help, right? To have an exercise buddy in the morning to walk with. But these all take effort and it takes getting out of that comfortable routine of sitting, right? And doing less. It will definitely take failing, right? Patients, it's hard when you make lifestyle changes. Think about yourself, right? It's hard to make diet and lifestyle changes and nutrition, like eating more protein, drinking half your body weight in ounces. But if you're there, encouraging them, they'll continue to go back at it despite these failures. All of this causes some amount of suffering, right? This change out of normal routine to shift to more healthy lifestyle behaviors. It's one that involves sacrifice, but they have to be novel. It has to be something different, not their comfortable suffering. 09:17 PATIENT AUTONOMY & RESILIENCE We have to try to challenge and force adaption and learning and evolution surrounding their ecosystem, not just in their home program. And this ultimately leads to the patient's autonomy, right? Showing them that a healthier, stronger version of themselves is more resilient despite some short-term suffering. If you can be there to encourage them, right? When they do fail, this helps produce fortitude and resilience. And this can't be measured on an MPRS or KOS. I can't tell you an MCID of encouraging someone and the dividends associated with this. But if we can be there, right, to help them get back up on the saddle, maybe they take off doing their, they're doing great for a week with their physical activity and then they hit three days in a row where they don't, and they just don't feel like it. We have to be there to encourage them. When you fail, right, patients, this causes mental suffering. So as they shift behaviors, lifestyle behaviors, and maybe fail at them, we have to let them know that that's okay and that that's normal and that you're going to be with them. But this is better than sitting on the couch, not going out with your friends, planning your life around your osteoarthritis diagnosis. Our patients are not their diagnosis. They are not their label and they have to believe that. We have to help reframe that and I've talked about that in previous episodes you can check out. But the patients, they are, the some are their choices and we have to let them know that. We have to make them make better suffering choices. It is not okay if they miss doing their exercises, right, those three days. I'm not going to tell Nancy or Marilyn, it's okay. I'm going to say we need to get back at it, Marilyn. We need to get back up on that saddle. They need someone to tell them it's not okay. Along the way to the suffering and accountability, there's healthy byproducts, right, like forming new connection as your PT, right, as their healthcare provider. Maybe it's a family member that they're eliciting to help them be accountable to eat a little bit healthier diet or to drink that extra glass of water. We all need help and accountability to get through hard things and so help them realize that this is also an opportunity for connection to change their outlook and how they even connect with others around them. 12:21 THE SUFFERING STIMULUS The suffering stimulus creates change. Your values of the patient priority start to shift. I keep saying suffering stimulus and that's because in our course we talk a lot about dosage stimulus. In particular, we talk about it in the physical realm, right, like when we talk about strength, we say this is for functional confidence and competence or performance dominance. We work at this at five reps, five sets, greater than 80% one rep max intensity. We're working some sets, greater than 80% one rep max intensity. We're working so hard we need a three-minute rest break. We are doing this three to four days a week. In the rehab dose, it's eight to 20 reps, three to four sets, 30 to 80% intensity. This is for dysfunctional tissue issue, local issues, right, we might rest 60 to 90 seconds and then powers three reps, 10 sets, right, requiring a three-minute rest break because we're taxing the CNS to use strength quickly, right, power is force times velocity, right, these all have standard definitions and reps and set schemes and frequency. The suffering stimulus is a little bit different, right, this is an intangible dose but this is a dose that pushes a human outside of their mental and emotional comfort zone. It shifts their values and their priorities in their time choices, their nutrition choices, their exercise choices, lifestyle choices, even your friend choices. Some friends have to go, right, if they're the ones you're drinking with on the regular and that tell you to eat that extra piece of cake and those cheese fries, right, we might need to change our circle and that might even involve some family ties, right, our activity choices will change and there is a certain amount of suffering associated with that. The suffering stimulus frequency, it's a daily commitment, it's reps and sets, they are boundless but this yields in unmeasurable dividends of hope, resilience, confidence, and maybe a dash of fun if we do our job well to elicit and show them the power of doing exercise and how that changes life and how lifestyle behaviors enhances that even more. The suffering stimulus, it's a life-altering dose that we don't talk about enough. It's our job to show our patient that they can do this and support them in this journey and we do have to be honest that some folks are not going to really lean in to suffering, right, they find finding comfort in suffering. It really is a deeply personal journey, right. I want you to know this isn't about glorifying pain. I hate the saying no pain no gain, we don't say that but this is about recognizing that resilience and growth emerge from life's difficulties, from one's sufferings. We have to reframe that experience for the patient, show them a different way to suffer. It is a delicate balance. We have the privilege of serving humans on the regular, right, in their most vulnerable moments when they're in pain and they're hurting and they are suffering but let's forge connection, hope, and perspective change. Let's help them redirect to control the controllables. Let's help them find their why, paint that picture of what is most important to them, right, playing with grandkids, picking up their kids, running, it's always usually family, right, being able to keep running with their kiddos. Maybe it's running a marathon, maybe it's doing chores without restriction or mowing the lawn again, going to bingo. Let's give them the resources that hold them accountable to achieving these goals like gym access, community classes, connecting them with others with the same struggles. We know this if you've been to an ICE course and you've been part of our tribe for a while but we don't just want to change your hip or knee, shoulder pain, back pain, pelvic pain, right, we want to change your life. We want to modulate your pain symptoms to open the opportunity to maximize fitness but not just physically and not just through fitness-forward lifestyle behavior. We want to build and challenge your psychological fitness. We have to help our humans break their routine suffering for a novel suffering stimulus that challenges them not only physically but mentally to lean into hard-think mindset, lifestyle shifting behavior that yields a more healthy human. 15:47 PRODUCTIVE SUFFERING I want you to not only think about humoring suffering with hip and knee OA patients but even consider yourself, is there some comfortable suffering that you're currently taking part in that you maybe need to shift in to more productive suffering? Maybe it's tracking your food, maybe it's getting in zone two work more, maybe it's actually taking a rest day if you're a work outaholic, right, and allowing yourself dessert once a week. Consider how you can shift your patient to a suffering stimulus that changes their life and think about in your own life as well. Thank you for joining me this clinical Tuesday and if you feel so inclined share with me some ways that you have helped invoke the suffering stimulus personally or in your patients. The suffering stimulus is always a catalyst for change if you let it be. Happy Tuesday folks.

16:20 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 CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Rachel Moore discusses reintroducing exercise early to the postpartum athlete, including modified CrossFit workouts, gymnastics, core training, and impact training.

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 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at sign up to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show.

01:22 RACHEL MOORE

Good morning PT on ICE Daily Show. My name is Dr. Rachel Moore. I am on faculty with the pelvic division here at ICE, and I am coming at you live from a different space than I normally am today. I was in San Antonio this weekend with Christina Prevot at a pelvic course, and it was a blast. It was so much fun. We met so many amazing people. We always love our weekends out on the road. So if you are interested in jumping into one of our upcoming live cohorts, we've got Scottsdale, Arizona coming up September 23rd and 24th. That is our live course. It'll be myself and Alexis Morgan. And then September 30th and October 1st, we actually have a course in Canada. Christina Prevot will be leading that one. So if you are north of the border and you're interested in jumping into one of our live pelvic courses, great opportunity to do that coming up. We also have our pregnancy and postpartum newsletter. If you're interested in learning about all things pelvic, staying up to date on everything pelvic, it's a great way to get resources sent directly to your inbox. And you can find that link on the website. So you might hear my baby screaming in the background because he's eating. My mother-in-law is feeding him, so just ignore the baby.

02:46 MODIFYING CROSSFIT WORKOUTS

I'm here to talk to you guys this morning about modifying workouts for the postpartum athlete, particularly in that early stage. So what I wanted to do is kind of break down one workout and talk about how somebody at four weeks, eight weeks or 12 weeks for the same athlete, maybe we would modify that workout. Modifying workouts can be confusing because there's no set standard of at this point you do this, at this point you do this. So kind of across the board, it's going to be very individualized depending on the athlete in front of you. This is something we dive into a ton in our online cohort and we have an entire assignment where we break down different types or the programming and talk about ways to modify it for a particular athlete. But just to kind of give you a little glimpse of what that looks like and just chit chat about it this morning, there are a few factors that we're going to really heavily consider when we're trying to decide what we want to do for a postpartum athlete. And before we dive into those, I want to talk about why.

04:09 GETTING ATHLETES BACK INTO THE GYM

Why do we care about getting an athlete back in the gym, maybe at that three to four week mark rather than waiting until six weeks or even later? Why are we really emphasizing and why do we promote here at ICE getting our athletes back? For a lot of women, the gym is their community and it is their mental health support system. And so postpartum in and of itself can be an incredibly lonely time, especially if you don't have a village around you and especially if you feel like you're isolated from a village that you maybe have. So if we can find ways to get these women into their boxes back at the gym, maybe bringing baby along in their car seat or stroller or if there's child care, great. But bringing baby along, finding ways to modify the stimulus appropriate for somebody that's at that three, four week postpartum mark, we feel that that is incredibly advantageous for mom from both a physical health standpoint. So what are the factors we're going to look at when we're deciding what workouts need to be modified and how to modify them? For one, we want to know what mom did before she was postpartum. So did she work out in pregnancy? What did she do prior to getting pregnant? Had she been a CrossFitter for years when she found out she was pregnant? What was her previous level of strength and did that maintain throughout pregnancy or did she take a long time off and see this big deconditioning response? Method of delivery is another thing that matters really heavily. Some issues with their anterior core wall, but we typically expect to see that somebody who's had a vaginal delivery is going to have potentially more struggles with pelvic floor dysfunction with things like heavy lifting and running and that are going to challenge that anterior core wall. Again, that's not a hard and fast rule. That's not saying it's the only way. We see that overlap, but that's kind of the things that we can expect to see based on the type of delivery. We also need to know about the type of delivery that we expect to see. Especially if they're breastfeeding, we need to make sure we're having the discussion with them about making sure that they're getting enough calories in to support their body and help that not only postpartum healing that is occurring naturally, but also that recovery from being in the gym. We also really want to think about mirroring the stimulus of the workout. So we're not going to do the same things that somebody who is not postpartum, four weeks postpartum is doing, but we want to think about what the intended stimulus of that workout is and try to find ways that we can match that intended stimulus, whether that's muscle groups that are being hit, whether it's cardiovascular versus more muscular strength or what kind of factors we're shooting for and prioritizing in that workout. We want to preserve that with our modifications. So let's break down an athlete and a workout and let's talk about how we would how I would scale this athlete at four weeks postpartum, eight weeks postpartum and 12 weeks postpartum. So our athlete, we're going to call her Suzy. Suzy is a CrossFitter. She's been doing CrossFit for seven years. She just had her first baby. She exercised during her pregnancy until 38 weeks and then she just kind of felt like she wanted to rush. She was feeling like, meh, I'm not really wanting to push fitness right now. I'm just going to kind of take it easy. Her previous lifts, her one rep max back squat was 215 pounds pre-pregnancy. Her one rep max deadlift was 275 pounds pre-pregnancy. Her strict press pre-pregnancy was 95 pounds. And from a gymnastics standpoint, she was able to do kipping pull-ups, bar muscle-ups, chest to bars, and she was able to do double-enders and workouts. So an athlete that has pretty decent experience in CrossFit. It isn't brand new to this and continued to exercise during her pregnancy, had a vaginal delivery. How would we modify a workout for her at four weeks? So we're going to take a workout. It's going to be the same throughout just for the sake of not being confusing. And it's hard to kind of conceptualize and listen. So our workout, the RX version of this workout is five rounds for time, 40 double-enders, three wall walks, 15 toes to bar, and 20 double kettlebell deadlifts. At four weeks postpartum, how are we going to modify for Suzy? So we're going to maybe keep that same stimulus of five rounds. We could also decrease that, but for this exercise, we'll keep that same stimulus of five rounds for time. Instead of 40 double-enders, four weeks postpartum is pretty dang early to start doing that impact. So instead of just doing something like calf raises that would work her calves, but maybe not tax her cardiovascular system, I'm going to have Suzy do a 30 second either bike, row or ski, whatever feels the most comfortable at a comfortable pace. So she's not going breakneck. She's not going to like an eight, nine out of 10 RPE. She's just moving and getting her heart rate up for 30 seconds. Instead of wall walks, we're going to do a 30 second, 30 second, 30 second workout. So swapping the three wall walks out for 12 elevated plank shoulder taps, really focusing on that core connection piece. So focusing on that hollow body, maintaining that core brace, making sure that she's not pushing down into the basement and doing plank shoulder taps to an elevated surface that is challenging for her, but does not feel uncomfortable in any way. Instead of toes to bar, thinking about what the components of that toes to bar are with that lap pressed down and core component piece. I'm going to have her hook a band up to the rig and face away from it. She's going to hold a isometric lap pressed down. So she's going to engage her lats. If you're watching, you can see, but facing away from the rig, hands are in the van, pressing down, standing in that hollow body position, focusing on maintaining that core brace. Focusing on maintaining that core engagement. And I'm going to have her do knee marches. So we're going to swap out those 15 toes to bar for 15 standing knee marches with isometric lap pressed down to mimic that pressing with the knee raise. We could also, if we're thinking about flipping this, preserving grip or reintroducing grip, have her hold an active hang for 30 seconds as well. Those are two options for the same athlete. And you could also alternate from round to round. So maybe one round, we're doing that lap pressed down knee raise. And then that second round, we're doing that active hang and we're alternating between those two. And then finally, instead of the 20 double kettlebell deadlifts, we can even just take bodyweight good mornings. These get sneaky on you if you haven't worked your hammies in a while. So putting hands behind the neck, nice flat neutral spine, hinging forward and coming back up. So her workout again, five rounds for time, 30 seconds on a cardio machine bike rower ski, 12 elevated plank shoulder taps focusing on maintaining that core engagement, either 15 standing marches with isometric lap press downs or 30 seconds of an active hang or whatever amount of time she was able to maintain. And then 20 bodyweight good mornings. That would be the workout for somebody who is four weeks postpartum. She's showing up to the gym. She's hitting a similar intended stimulus. She's moving. She's in class with her friends and she's getting a workout in. Let's take this same athlete, same workout and pretend we have fast forwarded for whatever reason she's now eight weeks postpartum. At eight weeks post, five rounds for time, 40 toe taps or line hops. So we are introducing impact at this point. We can absolutely have maybe began this earlier at about that six week point. So introducing that impact 45 times is a high volume. So if this was something where we wanted to work on single unders, we could maybe cut that rep scheme to 15 or 20 and then still have her do those five rounds focusing on that less volume as we're introducing impact. So two options there from that impact standpoint instead of three full wall walks, maybe we're having her do three modified wall walks. So if you've done the crossfit open and you did a scale division with the wall walk, you start out on the floor, press up on your hands, feet go on the wall and you go hand behind, hand behind, hand forward, hand forward, come all the way back down. The chest hits the floor again. to start working on that core engagement, that active shoulder and getting up on the wall. Alternatively, she can work on a wall walk as high as she can go. So two options there as well. Instead of toes to bar, we're going to say that she's been working on her hangs, she's building that grip strength, she's got that hip swing down. We're going to swap that out for hanging knee raises and maybe 15 is too high volume so we can do 10 hanging knee raises, working on that good kip swing, pressing down as she brings her knees up and really pulling through the bar to get into that arch position. And then finally for the double kettlebell deadlift, we're going to let her send that and she's just going to choose a weight that she's able to hang on to that is an appropriate stimulus for her that she's not feeling any heaviness, pain or leakage. So for this athlete at eight weeks postpartum, five rounds for time, either 40 toe taps or line hops or decreasing that rep scheme and adding in single unders to work on that impact with the rope swing. Three modified wall walks or walking up as high as she can. Ten hanging knee raises and 20 double kettlebell deadlifts at a lighter weight. Let's take this athlete, hit the fast forward button and now we're 12 weeks postpartum. Same workout, same athlete. Five rounds for time. We're going to let her play with double unders.

12:27 INTRODUCING IMPACT

So these 12 weeks postpartum, let's say we've been working on impact. Eight weeks we did some single unders or some line hops. That's four weeks of time to have built up the stimulus of maintaining or responding to that impact. So instead of setting a set number for her, I'm going to give her a time domain. I want you to spend about 30 seconds of effort working on your double under. Doesn't mean it has to be breakneck speed. Maybe she's getting two to three, getting into that pelvic recovery position, resting and then picking the rope back up. This is giving her time within that workout to work on the skills that we are hoping to get back to while progressing along in that impact. We're going to swap out wall walks. Maybe not three wall walks, maybe just two. She may be able to do three, but if not, then we are going to drop that number down to two. We can always scale volume with movements. Same thing for toes to bar. So maybe she's back to toes to bar. She's able to hang on to four or five and then she starts feeling some fatigue, hops down from the bar, jumps back up for that second set. Again, this is five rounds, so that cumulative volume does add up. So instead of 15 toes to bar, maybe we're dropping her down to eight toes to bar instead. And then finally, that double kettlebell deadlift, we're going to let her send it and we're going to think, okay, at eight weeks she may have done a certain weight. She's probably at a little bit heavier weight at this point. Maintaining able to breathe, not having leakage, not having heaviness, not having pain, but choosing a weight that feels great for her. Double kettlebell deadlifts are an incredibly functional thing if you're a mom, constantly picking up diaper bags and car seats and kiddos and all the things. So one workout, one person, three different timelines. There are options even within each timeline for this athlete. There is no one right answer when it comes to modifying a workout for an athlete. We need to consider the stimulus of the workout. We need to consider this athlete's history. We need to consider this athlete's recovery and we need to consider the athlete's goals. So when we take all of these things into account, this is kind of a day by day process starting out, but eventually we want to get to the point where our athletes understand how to make these modifications themselves and they feel comfortable. Okay, I can press the gas on this or maybe I need to take a step back on this. At the end of the day, our job is to help them figure this out as we are actively working towards getting back to doing all the things that it is that they want to do. I hope that makes sense. I know it's kind of hard without like, I'm a whiteboard person. So I hope you guys learned something this morning. This is an area that we cover in our online cohort. So if you are looking to learn more about modifying workouts for the postpartum athletes from a programming standpoint especially, hop into our online cohorts, come hang out with us live on the road. We've got tons of courses coming up between September to December and hopefully we'll see you guys soon. Bye!

18:02 OUTRO

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

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses using curved, self-powered treadmills for running & gait analysis, including the differences between metabolic output on overground running, motorized treadmills, and curved treadmills. In addition, she talks about pros & cons of using curved treadmills for gait analysis.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money-saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show.

01:26 RACHEL SELINA Alright, good morning everyone. Welcome to the PT on ICE Daily Show. My name is Rachel Selina and I am with our Endurance Athlete Division, so both our rehabilitation of the injured runner live and online. So first, sorry that this is a little bit later. I'm in Southeast Michigan and we had some crazy storms come through last night, so I have no power, I have no internet. So I am currently at my sister's house, so a little bit of a travel today to do this, but I'm glad to be here. So today we're going to dive into using curved treadmills for gait analysis. It's a question that comes up a lot in our live and online courses, which if you're hoping to get into the live course this year, we have only one more course for 2023. So the next or the last chance for this year to do rehabilitation of the injured runner live would be in Knoxville, Tennessee, November 4th and 5th. Like I said, that's our last course for the year. And then we have another online cohort coming up as well. That one is September 12th. It starts so you can jump into either one of those or both of those at PTonice.com. 02:38 CURVED TREADMILLS FOR GAIT ANALYSIS So like I said, we get asked this question a lot as to whether or not you can use a curved treadmill for gait analysis. And so by curved we mean like the non-motorized curved treadmills, which are common now in a lot of CrossFit gyms. So they're self-propelled. Probably the most common one is the Woodway Curve, and that's the one that's become more common in CrossFit too. There's a Rogue branded one. That's kind of the official treadmill of CrossFit and CrossFit Games. And then there's also like the Assault Fitness brand has a Assault runner. In true form is one that has another or another brand that has the same like type of treadmill. So there's some different ones out there, but they're all essentially the same. Like it's not motorized, so it's powered by the athlete. And it has that kind of curved surface instead of the flat belt that we would be used to seeing on a treadmill. So the claim by kind of manufacturers about these treadmills is that they better reflect over ground running, mostly in terms of the self pacing. So when you're outside and you're running, you can just kind of spontaneously decide, hey, I'm going to speed up and start speeding up or kind of not consciously. Decide to do that and you speed up or slow down. So you can do that on the curved treadmills because they're not motorized or you don't have to like push a button to tell it to speed up or slow down. You can just kind of naturally do what your body would do. So they're marketed as being more reflective of over ground running. They're also purported to decrease impact and therefore reduce your risk of injury. Right. Claim that they promote good running form, good running technique, and then also that they cause more posterior chain muscle activation during running. So that's kind of all like if you were to jump on any one of those websites for those brands of treadmills and kind of read about what they say the purpose of this treadmill is, that's what you would find. When we take it to the research, though, one, there's not that much yet of just good solid research as far as like how running on this type of treadmill actually does change your running form or how it causes muscles to activate or definitely not yet. Like, does it reduce risk of injuries? We don't have that yet. 05:16 GREATER METABOLIC DEMAND ON CURBED TREADMILLS What we do see kind of consistently in the research is that there is a greater metabolic demand from using these treadmills. So like for the same, you know, if you were to do a 5K and you did that outside, you did it on a standard treadmill, like with a motor and a flat belt, or you did it on a curved treadmill, it would it would be harder in terms of there'd be more oxygen uptake. You'd have a higher heart rate and higher RPE for like the same pace on the curved treadmill versus the other ones. And so that's consistent. Like that has maybe not great quality evidence, but there is that evidence out there from the research. We also see on the curved treadmills that we do get a little bit of a reduced ground contact time. So that's the like the amount of time your foot is actually in contact supporting your body on the treadmill. And we tend to see a shift or just like a, I don't know, not not in everybody, but we see that trend to take pressure off of the rear foot, especially when we're striking and go to a more mid foot or forefoot strike when we're using a curved treadmill. So that's really all like, and not even super conclusively, but that's all that consistently we see in the research about using a treadmill like that. Inconsistently is the muscle activation piece. Like there's there's not solid research to support that you have more posterior chain activation. One of the studies that looked at that was actually not using a curved treadmill. It was just using a flat treadmill that was self powered. So in that one, they saw like a little bit more soleus activation and a little bit more rectus femoris activation. But like I said, we can't necessarily apply that to the curved treadmill because it wasn't on a curved treadmill. Like that just might be something about being self powered, but can't say for sure. It also happens when we're on that curve. So some inconsistent stuff like maybe they don't quite do what we what we think they do, but we're not just not quite sure on that yet. In terms of how we use them in the clinic or in the gym, right, like if you want to do a running analysis, is this a viable option to do so? Can you use this treadmill and still get good data? So I'd say you can get good data. We just kind of have to take it in stride with what else we know is going on. So just like on a normal treadmill, we want someone to have a period of being able to adapt to that treadmill if they're not already comfortable running on a treadmill. So what we mean by that is if someone's coming in for a gait analysis, we want them to at least have had exposure to running on a treadmill before we assess the mechanics on a treadmill. Otherwise, you're going to get a lot of inconsistencies because they're just not comfortable running on that surface. So the same thing applies here. We definitely would want someone to have exposure to running on this curve type of treadmill if that's where we're going to then assess the mechanics. Otherwise, we're just not going to see a gait pattern that really is consistent with how they would typically run. So you could use it to make sure they have that period to be able to adapt. So usually that's like three sessions on the treadmill. It doesn't have to be full like you run for five miles three times. It can just be like 15 minutes, three separate times of getting used to that treadmill before you try to do the analysis. The other thing is that we have research for motorized treadmills. 09:45 RUNNING MECHANICS & TREADMILLS We have that research showing that someone's gait on a motorized treadmill, a standard one, is consistent with what their pattern would be over ground. So we can take what we see on that treadmill and assume that that's what we also would see if they're running outside. And we just don't have that yet for these curved treadmills. So we can't 100% assume that the pattern that someone would be showing us on that curved treadmill would be what they would go out and run like over ground. The claim, and I wasn't really able to find where this was coming from, but the claim is that running on that curved treadmill is actually more similar to running uphill. So the one kind of caveat there would be if someone runs uphill a lot, like they're doing a ton of maybe trail or just like big ascents, then it might be more accurate because you can't really on a standard run. You could run on an incline, but that's the one case where it might be more similar to their over ground running if they're running uphill. But that's not like the majority of our people, especially kind of in that more traditional gym or clinic setting. So we have to kind of take it with a grain of salt. What we're seeing on the treadmill might not be 100% reflective of what we would see over ground. The other thing though would be if someone, say you're in that gym setting, if someone is only going to really be running on this type of treadmill, by all means then assess their gait on that treadmill because that's how they're going to be running. So if someone only runs during CrossFit classes when running is programmed and that's where they'll do their run is on that treadmill, then that's fine because that's the type of running that they're going to be doing. Otherwise, if you're going to use that curved type of treadmill for someone that's just kind of running on a treadmill, then that's fine because that's the type of running that they're going to be doing. Otherwise, if you're going to use that curved type of treadmill for someone that's just kind of normal, maybe recreational runner, I don't think it's pointless. I think we can get some good data. We'll probably be able to pick up on big, just like big faults going on. We'll still be able to see from that coronal plane if they're, you know, from Dellenberg, how their knee separation is, all of that we still could see. We just need to keep in the back of our mind that this type of treadmill might reduce their tendency to overstride, like to have their foot land far in front of their center of mass. It might reduce that, and it might also make them run a little bit more biased towards their forefoot or midfoot, which we might not really see, like they might overground be more of a heel striker. So I think we just have to kind of keep those in mind. The one other kind of big, big picture thing to keep in mind is if we're going to use that type of treadmill for gait retraining, like we want to start changing someone's mechanics, there's going to be a few gait retraining drills. There's going to be a few gait retraining drills that are really challenging to do on that type of treadmill. So the main one would be retraining cadence. When we're retraining cadence, it's really important initially that the runner keep a consistent pace. So usually that's why like a standard treadmill is super useful because we can set their pace, right, say we're going to set it, their comfortable running pace is a 10 minute mile. So we can set that treadmill to 6.0 and we know the belt's going to stay at the same speed. So if we're encouraging them to increase their cadence, right, to listen to that metronome, to turn over their feet faster, we know that they can do that without speeding up. Because otherwise the tendency, if you just increase cadence without being able to control that belt speed, is just to go faster. All right, so if we're trying to retrain cadence on a curved treadmill, you can see the speed, but you would have to consciously like work to keep that speed the same while you're also trying to consciously pay attention to a cadence. So it would just be a really challenging setup to kind of internalize that cadence and learn that really well. 14:04 CURVED TREADMILLS & OVERSTRIDING For some of the other tools, though, like the curved treadmill might actually be a good way to help someone who does over stride to start to learn what it feels like to keep their foot closer. So the curved treadmill would almost force them to not over stride because they keep over striding, right, that they're going to be landing higher up on that curve. They're going to just make the belt go faster, which is why that treadmill causes you to kind of keep your foot closer. So it could be a good tool for someone who does over stride to get on that type of curved treadmill and start to feel, OK, this is what it's like to keep my foot closer to kind of find that that more centered spot. But we would also need to make sure as they learn that that we make sure that transitions for them back to over ground running. And I think that's just the big thing, right? Like, I'm excited to see more research that comes out on these treadmills to kind of show us, hopefully, where where the usefulness of them is and how it actually does really change our mechanics. So we know best how to use that. But I think as long as we keep in mind that, you know, some of the things we see might not be 100 percent reflective of over ground. If we can also get a little bit of an over ground sense of what this runner is doing, we can use both of those together to make this still a really good tool for assessing and for retraining. So that's it. I'd love to hear your thoughts. If you typically use this type of treadmill, whether from like you personally run on it a lot or you do a lot of assessment on it. I'd be curious your thoughts. So definitely put those in the comments. And then, like I said, if you are hoping to catch one of our live courses, our last one is coming up in November. So feel free to jump into that. We'd love to see you there. All right. Perfect. Have a great weekend, everyone, and thanks for being here!

15:43 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 PT on Ice dot 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 PT on Ice dot com and scroll to the bottom of the page to sign up. And we'll see you there.

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses being wrong about dogmatic approaches to physical therapy, the harmful influence of technology on daily life, and long-term changes to the American healthcare system.

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

00:00 ALAN FREDENDALL

Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a fantastic start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at the Institute of Clinical Excellence and a faculty member in our fitness athlete division. We're here on Leadership Thursday. We talk all things practice management, small business ownership. Leadership Thursday means it is Gut Check Thursday as well. This week's Gut Check Thursday is a little test, Cooper's test in fact. This was a test created way back in 1968 by an Air Force Lieutenant Colonel Kenneth Cooper. He was a doctor in the Air Force and he wanted to figure out how to start to objectively assess the aerobic fitness of our military personnel, the Army and the Air Force, way back in 1968. This test is great. It has been studied a lot. It has a lot of normative data behind it. Very kind of similar to the six minute walk test that we use in the clinic with a lot of our patients to assess aerobic capacity. This is a 12 minute max distance run. Basically how far can you run in 12 minutes? So set a timer. The idea behind this test is that you would run it on a track or you would otherwise just basically run 12 minutes in a straight line. You don't want to end up running maybe in the CrossFit parking lot or the neighborhood where you have to turn and stop a lot. You really want to be able to pick up speed and stay at speed as long as possible. So make sure you're on a track. Make sure you're doing maybe six minutes out, six minutes back, or maybe 12 minutes straight out and then come on back with a walk. And then if you're on a treadmill, make sure you have the grade at 1% to imitate kind of the uneven nature of outdoor pavement. And then that's it. Figure out how far you ran in either meters or miles. There's some equations in the Instagram post to calculate, predict your VO2 max based on how far you ran. And then we've posted some normative tables as well. So this is a great test for ourselves. This is a great test for our athletes or patients as well to see how we stack up. So figure out Cooper's test. Yes, you can row it. You can bike it. Just be mindful that those are unloaded assessments of aerobic fitness so they don't quite translate directly to running. But as long as you retest under the same parameters, have at it with a biker row as well. Courses coming your way related directly to Leadership Thursday. Brick by brick, our practice management startup course starts again September 12th. That course just has one seat left. That's taught by yours truly. We cover everything you'll need to know about starting your physical therapy practice literally from step one of all the legal paperwork you'll need to figure out and file to get started. And then we get a little bit more into what it actually looks like to open and begin your practice. So that starts September 12th, one seat left. And then live courses I want to focus today on total spine thrust manipulation taught by our instructors Justin Dunaway, Jesse Witherington and Britt Lotteman. We have a couple courses coming your way through the end of the year. September 9th and 10th you can join Jesse down in Clearwater, Florida. September 16th and 17th you can join Britt out in Chicago. September 23rd and 24th Jesse again will be on the road this time in St. Mary's, Georgia kind of down in the southeast corner of Georgia by Savannah. October 7th and 8th, two chances to catch total spine thrust either in Columbia, South Carolina with Jesse or in Hendersonville, Tennessee right outside of Nashville with Justin Dunaway. November 4th and 5th Jesse will be out on the west coast, Simi Valley, California. And then two chances again in November before the end of the year November 18th and 19th. Britt will be on the road in Santa Rosa, California this time Northern California and Jesse will be in Albuquerque, New Mexico. So total spine thrusts coming your way. Today let's talk about this topic. So I do have some research to share with you regarding this topic but I really want to talk about the top three things I think I've been wrong about so far in my career. So we're going to talk about what it looks like to treat a comprehensive plan of care with a patient. We're going to talk about technology and we're going to talk about long-term changes to the health care system.

04:08 BEING WRONG ABOUT DOGMATIC APPROACHES TO PATIENT CARE

So I want to start with talking about the kind of back and forth dogmatic guru battles that we see all day long on social media of manual therapy sucks, it doesn't do anything, you shouldn't do any manual therapy, if you do manual therapy you're committing malpractice. And then the far other side of that same continuum of if that's exercise only then the belief that manual therapy is the only thing we do that matters that we can somehow cure or fix patients with our hands, with our dry needling, our cupping, our spinal manipulation, whatever stuff we do with our hands. So two different kind of camps fighting and barking at each other on social media and then talking about the research supporting one side or the other or both or neither. So what I've realized and keep in mind I'm coming from a point where I have sat in both of these camps at different points in my career of coming into school as a background as an exercise physiologist, of having no way and no knowledge of how to put my hands on people because I was an exercise physiologist so my intervention, the only intervention allowed to me was exercise. So coming into grad school with a belief that exercise is medicine as taught by the American College of Sports Medicine and that exercise is the way that creates the long-term fix and that manual therapy has no value. So I certainly sat in that camp in the beginning of my PT school career and then I've sat in the other side of the campus while getting into PT school learning more about manual therapy residencies and fellowships and diving really deep into the weeds especially behind spinal manipulation and dry needling and going to the other side of manual therapy is one of the most robust tools we can offer and a little bit of exercise maybe at the end for the patient to keep up their progress in between but being very heavily in the manual therapy camp and holding the the previous belief that maybe folks who are in the exercise only camp are there just because they're not that good at manual therapy so I certainly held that belief for a while. Now I would say I'm in in neither camp and maybe not even in the middle of coming to the belief of the unfortunate belief that we just can't talk or exercise patients into better lifestyle choices no matter how much we have the answer of some sort of combination of both maybe one more than the other is needed for our patients depending on who they are and where they're at in kind of their health and fitness journey and this can be maybe I think the most frustrating part of being a physical therapist and being a health care provider in general of knowing the answer right of knowing that exercise and a solid nutrition plan go a very long way into helping you become and stay a healthy fit individual but that from time to time some hands-on treatment is needed so knowing knowing the answer walking the path but really unfortunately not being able to just give that to another person especially maybe a patient that at the beginning of their plan of care has no formal relationship with us yet. I myself have an unshakable belief that I will continue to probably encounter some minor musculoskeletal injuries within lines of statistical norms due to the impossible ability to balance a lot of different things essentially balancing workload versus recovery of there's going to be days where I don't sleep enough there's going to be days where I don't eat enough there's going to be days where maybe my training volume is higher than I wanted to be my overall life volume is going to be higher than I wanted to and otherwise I put myself at a greater risk for an injury and sometimes we'll actually encounter an injury so I believe that is just part of the journey of health and fitness. I also have an equally unshakable belief that the current meat suit that my brain sits in has been evolving and adapting to stress for over two million years and that it's a naturally resilient structure that's capable of healing itself from most injuries maybe not a car accident or getting hit by a bus but certainly encountering some shoulder pain or knee pain in the gym or out on the run or something like that so that's what I believe but it is hard to transfer that to another person that my third unshakable belief is that it does not matter how much I trust my own body how much I believe that the body can heal itself I can't just take that belief from my brain and put it into somebody else's brain no matter how much I want that to happen no matter how much I talk to that patient in front of me we just can't talk people better we can't talk people into better lifestyle choices we kind of have to show them and that can come from a couple of different angles that can come from having them do some manual therapy techniques maybe even self-manual therapy techniques that helps alleviate your own symptoms to help connect that stress recovery adaptation cycle maybe some exercises or maybe both but otherwise we we do need to show people that this this thing that I've been wrong about is that seeing is believing and 99 percent of people can't be talked better the interesting thing is we have more and more research supporting this now we have some fantastic articles coming out of the pain neuroscience education space that support this that we cannot just talk people better we cannot talk people out of pain we cannot talk people into being healthier we have to show them both by our own example but also by them seeing the success as well and part of that comes from showing them some sort of change manual therapy exercise based doesn't matter whatever you think the patient needs so they begin to buy in to I'm not broken I'm resilient my body can fix itself I don't need surgery I don't need an MRI I don't need pills but that we can't just talk that person better really fantastic article if you have not read it yet by shala and colleagues 2021 the journal of manual and manipulative therapy saying that same thing literally the title of the paper is can we talk patients better and the conclusion is no we can't that we need to combine these things and that the most successful interventions for pain are multimodal they involve yes education discussion of sleep and diet but they do also involve manual therapy and they do also involve exercise it's everything together it's and not or most physical therapy studies if you read the methodology if you read the inclusion and exclusion criteria and if you read and find out in these papers why they initially studied a thousand people but only 760 people completed the study what happened to those other people well yes people get busy yes people get injured or whatever else they drop out of the study but in a lot of these studies folks drop out because they're not getting better they are maybe even going to get care somewhere else outside of the research study which you can imagine creates a lot of confounding variables that makes us need to exclude that person's data from the study there's a lot of really cool research now looking at that of that if we do not offer hands-on care there seems to be a sub-population of people who will leave our care and go get it somewhere else that if you try to talk somebody better and you say i am not going to do anything hands-on because i'm going to make you addicted to manual therapy there are people who will leave your clinic and immediately go get a massage or go see a chiropractor or maybe go see another physical therapist they will go get the care they think they need somewhere else sometimes immediately after your appointment and we need to to be cognizant of that likewise there are people who believe that if there's nothing hands-on as far as doing exercise of them being hands-on that the therapy has less value and likewise they will leave your clinic and go get extra care somewhere else so we need to be cognizant of that as well i think often of i get my hair cut every three weeks on thursday afternoon i see the same stylist i've seen her for years now she has had what i believe to be a pretty gnarly case of achilles tendonopathy from overdoing it increasing run volume i see her i've seen her progression of having a soft brace on to having a walking boot to now having a full cast on of chasing down what she thinks is going to help her in the health care system even though she talks to me for about an hour every three weeks and i try to talk about anything i can to get her to try literally anything else except pills and casting and surgery and imaging and she still won't come down to my clinic to see me even though i've offered to treat her for free of i cannot take the beliefs in my mind and put them in somebody else's mind they have to come unfortunately to that conclusion on their own so being wrong about being able to talk people better about being able to exercise people better and more understanding and recognition as my career has gone on that i need to recognize that every single person who comes into the clinic is different they have different beliefs and i need to recognize what those are and address them accordingly some people may need to start with a bunch of front-loaded physical therapy some people may not like to be touched at all they don't want to do any manual therapy they only want to do exercise and maybe some sort of blend for folks in between.

04:08 THE DANGERS OF TOO MUCH TECHNOLOGY

The second thing I've been wrong about is technology if you know me you probably have the belief in your mind that i am the biggest nerd you've ever met and i'm okay with that i grew up playing world of warcraft you can find me in my limited spare time probably trying to sneak in a video game or two every now and again so i'm certainly a giant fan of technology but as my career has gone on as i've gotten older i now have the belief that i think technology creates more problems than it solves the previous point was a great example of we would probably not have these dogmatic arguments and be so fervent in these different camps if we did not have technology to use to yell at each other from across the planet that the computer the internet the mobile device the whatever you're using has revolutionized humanity maybe for the better but i think nowadays more bad than good that having access to all the combined knowledge of our species is amazing but also being a button push or click away from constant contact with friends family frenemies work whatever can be really bad for us especially our mental health of you maybe you're this person maybe you are the spouse of this person or a friend of this person of that person who says did you see what so and so just posted this person is is my wife in our relationship of getting really upset at what other people put on social media and kind of letting it ruin your day and i think that happens a lot in modern society i think back to a question that i was asked very very early on and again i used to have the belief that more technology was better that we could talk other practitioners into better practice habits if we just argued with them on social media if we yelled at them on twitter and about nine years ago jeff moore saw me in an argument on twitter and just sent me a simple message that said hey do you think this is the best use of your time to advance the profession of physical therapy and obviously probably most things in our our life if we ask ourselves that question is this the best use of my time the answer is probably no but definitely to that question the answer was no definitely not and so i often ask myself that question a lot and what i've found over the years is that question and that answer that question takes me further and further away from engaging a lot on social media if you follow my social media now you see pictures of my son in my workouts and that's pretty much it right if far by far and large disengaged from physical therapy social media as a whole i don't listen to any podcasts anymore i listen to the news in the car and music when i work out and that's pretty much it so i've pushed technology away as i've gone through my career as i've gone through my life and i think i'm the better for it and i think having access to all of the gadgets that come along with technology is really doing us a disservice as well of i used to be a big proponent of whoop if you've listened to us here before if you've come to our fitness athlete classes you've heard us talk about whoop and other devices like that and likewise i think those cause more harm and good that having a constant stream of data letting us know you're not moving enough hey you need to move you need to exercise you're not eating enough you're not eating right you're not eating enough you're not sleeping enough you're drinking too much you're overeating this specific type of food i think those constant technological inputs into our life really set us up for a lot of unhappiness of folks who look at a whoop and think what if my resting heart rate is high because i had a beer last night what if it's low because i underate what if my respiratory rate is high because i'm sick what if i have coven 19 what if i have cove 23 what if i put strawberries up my butt would my fart smell better like we can what if this stuff to death and we i think we are doing that with our technology that i do think there is a sub-population of people who have to see that data that have to see whoop say hey every time you report drinking two or more beers you have an 18 reduction in your sleep quality i do think there is a group of people who need to be smacked in the face with that realization of again they can't be told that by somebody else a friend or a family member they have to be showing that objective empirical data but i also think there's an equal sub-population of people who will go completely insane festering about that stuff of worrying themselves to death about what does this data mean i shouldn't exercise today uh maybe i ate so wrong my resting heart rate my hrv is messed up i'm just gonna fast today or i'm not gonna work out for a week and they literally what if themselves to death about this stuff until probably the end result is that most of those people just ditch the gadgets i no longer wear a whoop i haven't wore one for many many years i have a pretty neat cassio g-shock this is a solar powered watch its only thing it does is tell time and then i have a fitbit which tracks my steps i try to hit 25 000 steps a day and that's it right i have no access to any sort of heart rate data or sleep data and i think i'm all the better for it so i think technology is really doing a disservice and i think the more we can intentionally disconnect from some of these data streams and communication streams we will find that we're a lot happier for doing so.

20:07 LONG-TERM CHANGES TO THE AMERICAN HEALTHCARE SYSTEM

My third belief is maybe a little bit pessimistic that i think unless something considerable changes with the american health care system i think the way that our health care system currently works is not going to alter significantly at least in our lifetimes that when we step back and zoom out and look at how a lot of stuff in our life is run they're run by for-profit companies the power company is a for-profit company the internet company is a for-profit company the health care clinic company is a for-profit company the insurance company is a for-profit company so we need to ask ourselves are we just victims of people trying to maximize profit and that's why we can't really seem to get ahead in a lot of big system changes and i think the answer that question is yes that's 70 percent of all americans still get their health insurance through their employer so they receive health insurance insurance from a for-profit employer that's run by a for-profit agency the insurance company that uses that insurance at a for-profit health care company so it's no wonder that we are trying to keep margins really narrow high profit low expense and at the end result the person that suffers is usually the health care provider and the patient while the overarching organizations post record profit after record profit year after year after year that both the input and output sides of the system have a vested interest in minimizing costs and maximizing profit and at some point we need to acknowledge and recognize that we also need to recognize acknowledge that with some exception health care providers are really uninvolved or minimally involved with the ownership and management usually of the business that they work for insurance companies are led by led by corporate executives and large health care systems are also led by corporate executives and if we look who sits in the leadership positions of a lot of these companies they're not health care providers they are investment bankers venture capitalists that sort of thing they're interested in profit it really starts to explain and i hope that this doesn't come off as a conspiracy theorist of why our outcomes are so poor despite how expensive our health care system is and that we really need to see big system changes if we're really going to make a dent in the issues that we have which is 90 of humans are sedentary 70 of of americans have chronic pain and we seem to be going backwards despite how hard we get up and go to work ourselves individually every day what do those changes need to look like i don't know i'm not i'm not a big picture person i'm kind of a logistics person but i think that's kind of the frustration that we all experience day to day of yes our individual patients are getting better but why are we still seeing people who got a knee replacement two days after going to see a provider about knee pain why have they not tried physical therapy first why have they not tried literally anything else first except getting booked right into surgery we feel those frustrations we wonder where those are coming from and it's no surprise i think it comes from our giant for-profit health care system as a whole so three things i've been wrong about been wrong about being on one side of the fence or the other the belief that we can talk or fix somebody with our hands or just help them with exercise only that we can take the beliefs in our mind about our bodies and the proper plan of care at least in our mind and put that into somebody else's brain been wrong about leveraging maybe too much technology especially both in personal and professional life and been wrong about the belief of really creating long-term systemic change in the health care system so i'd love to hear what you've been wrong about i'd love to hear questions comments discussion about this topic as well i hope you all have a fantastic thursday have fun with with cooper's tests if you're going to be at a live course this weekend enjoy yourself other than that have a great thursday bye everybody.

21:41 OUTRO

Hey, thanks for tuning into 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 pt on ice.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 pt on ice.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 recent changes to the Modern Management of the Older Adult Division and its mission to help clinicians provide the best possible care to older adults in their community as the provider of choice.

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 INTRO

What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're make sure to use the code ICEPT1MO when you sign up as that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.

01:33 DUSTIN JONES

We are live on Instagram. We are live on YouTube. Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the faculty members within the older adult division. This is Older Adult Wednesday. Today we are going to be talking about what is MMOA? What is this division? What are we about and what are we trying to achieve? We are going to spend some time diving into this because we have so many new folks that are new to the ICE community. We want to make sure that you're crystal clear on what MMOA is about and if you'd want to join forces with us. Before we go into the goods, I want to mention a few courses we have. We have a few live courses coming up in the next couple of weeks. We're going to be in Southern California this upcoming weekend with Alex Germano. I'm going to be in Windsor, Colorado outside of Fort Collins on the 9th, so the weekend after Labor Day. I believe Julie Brower is going to be down in Fort Mill, South Carolina, so you can catch MMOA live on the road the next couple of weeks.

02:43 MODERN MANAGEMENT OF THE OLDER ADULT

What is MMOA? Modern Management of the Older Adult. Our division, we just went through our big live revamp, so our MMOA live course is all new material and we're spending a lot of time reflecting on what we are about as a division. What are our goals? What is our mission? How can we get to that mission and what traits do we want our MMOA team to really demonstrate? I want to share this publicly just so you all are very clear of what we're about, so our goals and where we're headed and to propose that you join forces with us to achieve that mission of really changing the game for physical therapists, occupational therapists, fitness professionals that are working with older adults. So MMOA, Modern Management of the Older Adult, it really grew out of a big problem that we still see that we're still fighting. That older adults by and large in our society are underserved in so many areas, but in the context of rehabilitation, in the context of fitness as well, that most individuals, most professionals that are working with older adults will look at a date of birth. They'll look at medical diagnoses. They'll look at the medications that they're on and make assumptions about what that person is able to do. And when those assumptions don't line up with reality, we have a very, very unfortunate situation where people are not being served appropriately. They're being underdosed. They're being handled with kid gloves and we're not getting the results with these folks, the life changing results with these folks that we can get. That is a huge issue that pains every single MMOA faculty to see and we are on mission to try and solve that problem. How do we solve that problem? It is you. It is you that is watching this on Instagram, on YouTube, that is listening to this on the podcast. It is you, the rehab or fitness professional that has, we believe, has the most qualified skills to influence this population compared to any other healthcare provider. And we mean that. When we look at the research of how we can really influence older adults, it continually points back to that fitness forward approach. That exercise, that movement is such a big lever that we can pull to change these people's And you all watching and listening to this are the best professionals in the context of healthcare to administer this to this population that we love so dearly. Another big problem that we see that we're trying to solve is we have so many clinicians, so many fitness professionals, especially coming up in their training that they think, man, I want to work with the athletes. I want to work with the sports teams. I want to do the fun, sexy outpatient ortho clinic. And we go through our training and our training talks about a lot of things, but by and large, not a lot about older adults and how to best serve these individuals. And then we get out into the real world and what happens? You wanted to work with the sports team. You wanted to work with athletes, you know, from 8 a.m. to 5 p.m. or whatever. And who are you working with? By and large, on average, over half of your all's caseload, everybody watching this or listening to this, over half of your caseload is likely someone that is on Medicare, someone that is over 65 years old. And are you equipped to serve that person? And what happens when you're not equipped and yet you have these folks as the majority of your caseload, there becomes a big mismatch, right? It can be frustrating. It can be challenging and could lead to a lack of fulfillment and enjoyment in your work. And we're trying to absolutely crush that, to show you, the clinician, the fitness professional, of the life-changing impact you can have on these folks. When you use your skill set and you embrace that old-not-weak mindset, that you give interventions that actually meet that person where they're at to drive change, that it can be some of the most fulfilling work that you can do in the context of rehab and fitness, that you can change someone's life in a matter of weeks in certain situations with this population. And that has really driven a lot of the MMOA faculty. And we just want to spread that and share that just far and wide, as much as we can through many different means. So those are the big problems. The solution that we are trying to provide is we're trying to create an army. We're trying to create a community of like-minded clinicians that are locking shields to really fight ageism, to fight the under-dosage in our profession, and to show people what is possible when we serve these folks with an evidence-informed, fitness-forward approach. We do that through many different avenues. We'll do that through this podcast that you're watching or listening to, the PT on Ice Daily Show. We also have an MMOA podcast that's specifically older adult material. We have a Facebook group of about 5,000 clinicians from across the world that serves as a resource for so many individuals in terms of certain research cases. So much good conversation is going on in that group. We have our MMOA Digest. It's a bi-weekly email where we're sending out all the relevant information related to geriatrics. And then we have our courses, our certification.

07:49 CERT-MMOA

Cert MMOA. This is the certification that is our promise to clinicians. That if you go through our certifications, three courses, MMOA Live, our two online courses, Essential Foundations and Advanced Concepts, that you will confidently be able to serve that person, that older adult that walks through your door, or you walk into their home, or you walk into their hospital room. It's also a promise that when you see those letters behind someone's name, you can trust them. Our goal is that cert MMOA means I am 100% confident that my mother, that my father, that my grandmother could go to you and you are going to deliver an evidence informed and a fitness forward approach to my family member. That is what we're trying to do, selfishly trying to do to ensure that that cert MMOA holds some weight and you've got the goods. And so there's a group of 10 individuals from across the country that are working towards trying to solve these problems and providing the solution through those different means. We absolutely love what we do and it is such an honor to serve you all and to interact with all the students when we're out on the weekends and live courses and the online courses as well. And this team, this team of 10 all-stars of folks that really embrace that old not weak mindset that have been through our curriculum are spreading this information far and wide to try and equip you, the rehab and fitness professional, to better serve your older adult patients or clients. And each member is going to demonstrate three main traits. We call this our DNA. And what we're going to do over the course of the next couple of weeks on our MMOA channel or Instagram account, we're going to go live and really dive into what these DNA traits are and the specifics of them and how we may see that play out whenever you come to a live course, whenever you interact with us online as well in essential foundations or advanced concepts. These three DNA traits that we're all going to embody is that we're all leaders. Regardless of your role on the team, we're all leading someone and there are certain characteristics and traits of leaders that we embody. We're also teachers. We understand this material, but we're also methodical in how we relay that information to our students so you can use that come Monday. And then last but not least, we're performers. We are performing. We're trying to entertain you so to continue to engage and learn. And whenever we're having fun and you're having fun, we know learning goes up across the board. You will never come to an MMOA course and see someone read off of a PowerPoint presentation for three straight hours while you're sitting in your butt getting a pressure ulcer. That ain't happening, right? We're going to have fun. We're going to get the music cranking. We're going to be moving. It's going to be an absolute blast. So over the next couple of weeks, we're going to dive in. What does it mean to be a leader? What does it mean to be a teacher? What does it mean to be a performer? And how are you going to see that within the MMOA division? So tune in there. We'll be posting over there, but I just want to take this opportunity just with all the folks on here now, I just want to say a big thank you. We've had a lot of change as a division, a lot of growth as well. We're interacting with so many of you all in person on Instagram, you know, in our courses as well. And it is an absolute honor to get to do this, to get to share our passion with you all through these means. And you all just really fill our cup up. When you share, when you execute, you know, that particular tip or intervention, or you just share, man, I got to use this on Monday after this course, that makes it all worth it for us. So we're just incredibly grateful for you. All right. If you have any thoughts on that, or if you've experienced some of this in our course, we'd love to hear in the comments, but just wanted to share this, put it out into the world, and we're going to continue to break down our DNA leaders, teachers, performers over on the MMOA account. We're grateful for y'all. You have a lovely rest of your Wednesday. Talk to you soon.

11:46 Outro

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant debunks common myths surrounding the IT band. Mark emphasizes the importance of exercise in enhancing function. He mentions two types of exercises: local tissue exercises and functional activities. Local tissue exercises are designed to respect the irritability and stress levels of the tissues. These exercises may include variations of hinge movements, knee bends, or squats that are unloaded enough for the individual to handle. They provide a healthy stimulus to the tissues and help build strength and capacity.

Functional activities, such as step downs, squats, and deadlifts, are also incorporated into the treatment plan. Mark explains that coaching these functional movements is crucial in helping the individual return to their normal activities. By gradually increasing the training volume and appropriately dosing the force, they can both manage symptoms and provide a beneficial stimulus to the tissues.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 INTRODUCTION Alright, what is up PT on ice crew? Hope you're doing well on this Tuesday morning. I'm Dr. Mark Gallant coming at you here on clinical Tuesday. Lead faculty of the extremity management division alongside Lindsey Huey and Eric Chaconis. Want to talk to you today about IT band syndrome and some common myths. Before we get into that, we've got a few upcoming courses. So I'll be in Amarillo, Texas, September 9th and 10th. So a lot of tickets flying off the shelves for that one. So make sure if you're in Texas and want to check us out on for extremity management, that you get some seats to that. And then the following weekend, I'll be in Cincinnati, Ohio at Onward Cincinnati. So love to see you out there for that one as well. Again, for any of the ice courses, if you have not already signed up for the ice course that you want for the fall of 2023, the courses that are on the website are the only courses that are going to be added for this year. So make sure make sure you hop on there and sign up as soon as you can. 02:38 COMMON ITB BANDS So IT band myth. So IT band syndrome is one of those syndromes that we had a lot of ideas that came out of research from the 70s, 60s, even early 80s that for whatever reason or another have stood the test of time and stayed in our profession for over 50 years. And that's influenced a lot of the way that we treat a lot of the common manual therapy we see, the interventions we see. And we've got a lot better research that's come out in the last 10, 15 years to direct us how to treat these these IT band patients. And so we want to look at that. This is not to bash the researchers that have come before us. So Renee and Ober and those folks that did a lot of the research in the 1970s. We owe everything we know now to them. And I sincerely hope in five years, six years, a lot of you are looking back at these podcasts and go, man, like all all the stuff that Mark was saying or his colleagues at ICE, it seems kind of silly now. That's what we want to happen. We want you all to take everything we're we're looking at now and make it way better over the next five or six years. So so thanks to Ober. Thanks for Renee. And now we can stand on their shoulders and really move forward. So what were some of the common myths that came out of that research in the 70s? Well, the first one is that the IT band, the iliotibial band track starts at the proximal hip with the TFL and glute. And then it has a very simple unidimensional insertion point at Gertie's tubercle. So one single insertional point for that big, massive iliotibial band structure. What we now know is that the the iliotibial band insertion point is actually quite more complex than that. It attaches at the tibia. It attaches at the lateral femoral condyle. It attaches to the patella. And not only does it attach at multiple sites, these attachments are firm. So so that that distal IT band is not really moving very much at all. The second myth is that the IT band is tight. That that iliotibial band is going to get tight and it's going to limit that person's hip adduction. What we now know is that the structures that are most commonly going to limit someone's adduction are the glute medius, the glute men and the joint capsule. So the IT band is rarely going to be the primary driver of limited adduction. And the TFL, the glute max, the structures that it attaches to are also not typically going to be the primary driver of adduction. What we then see is the third big myth that that iliotibial band syndrome is a pain dominant syndrome being caused by a friction of that iliotibial band rubbing along the lateral structures of the knee because it has a unit dimensional insertion point. Because that thing is tight that it's starting to rub. And that makes a lot of sense going after those those old ideas. Right. If you've got a certain kind of problem, you can go to the doctor's office and you can get a prescription. If you've got a single insertion point and there's extra force causing that that to be tight and it starts to rub, certainly we can see tissues being irritated because we now know that it's got a complex insertion that's really firm, that the IT band is rarely tight. What we now know is that the typical pain presentation is often being caused by repeated force due to an increase in volume change in that person's activity and the lack of frontal plane control. So the most common thing you're going to see is someone really picks up their volume of running. They've got they've got poor control over the hip, knee and ankle. And that knee starts to ping in when you get that at a really, really high volume, the opportunity for the lateral structures structures of the knee to become sensitized gets significantly increased. Another one we see it in is as folks who do a lot of downhill running, they increase their trail running their downhill running by by high volume. So you're getting a ton more load into those those structures and you're getting that lack of frontal plane control and those tissues are going to get irritated. So what are we going to do about that tissue irritation? So so like any other pathology that we're going to treat, our first step is to calm things down. We want to put out that fire initially.

05:30 CALMING DOWN TISSUE IRRITATION

So with IT band syndrome, the primary thing that you're going to do to put out their fire is you're going to you're going to get control of their volume. All right, Chris, you were running 10 miles a day, five days a week. We're going to cut that down to five miles a day for three days and see if we can calm that tissue down. So it's rarely full on abstinence. Where we like to start is can we find that sweet spot where your symptoms are starting to calm down and we're still keeping you involved in your functional activity? So whether it's running Olympic lifting, whatever the activity may be, can we control the amount of load, the volume of force that's going into that system and get those symptoms to calm down? In addition, using using our manual therapy techniques to modulate pain. So you're dry needling, your myofascial decompression, your soft tissue mobilization. You're going to base these off irritability. If that person's high on their irritability, then we're often going to needle massage and cup tissues that are a little more distal to where the pain is at that lateral knee. So looking a lot at the glutes, maybe lower down on the ankle. And then as symptoms calm down, we can get at the tissues more more close to that knee, that tibialis anterior, the distal vastus lateralis, the short head of the biceps and really try to modulate people's our patient symptoms and and get those tissues a little healthier. From there at the same time, so we're not waiting until the pain modulation comes down, we're going to start doing some therapeutic exercise to get those tissues to tolerate load better. So we've got to strike that balance of we're trying to lower their symptoms and we want some healthy, good force to go into their tissues. So oftentimes that can be open chain exercises. So they're going to have typically a little less load on the tissue because you're not dealing with so many structures. You're not dealing with ground reaction forces. So keeping that that low to improve the overall tissue health and then progressing them into more closed chain exercises that are going to stimulate those tissues in a little bit closer environment to their typical activity. So things like hip hikes, closed chain clamshells, your side steps, all those sort of things. Then we want to get into some functional exercise. Can we get compound movements that are going to be close to the activity that that person is typically doing with those compound movements for IT band? We're looking at things like step downs, single leg squats, all of those type of activities. Kickstand deadlifts are another good one. 08:25 PT 1.0 & MOVING FORWARD Now we're PT 1.0. A thing that we did in our profession that we would like to move on from now is we said, OK, we're going to do our local tissue stuff. And when you get good enough at the local tissue stuff, then we're going to graduate you into doing these functional components. What we what we know now is we want to get all of this involved as early as possible so that we can influence the nervous system better and make that person less fearful of doing these these more challenging activities. So you're going to hit your local tissue exercises, respecting their irritability, respecting the amount of stress that that tissue can handle. And you're going to start doing variations of functional activities that they can tolerate again with their pain level, their irritability and their stress. So finding a hinge variation that's unloaded enough that the person can perform, finding a knee bend variation or squat variation, single leg squat variation that's unloaded enough that that individual can handle. So that's two components, local tissue with three components, pain modulation with our manual therapy, local tissue exercises to get some healthy stimulus into those tissues. Looking at a functional activity, squats, deadlifts, all those sort of things. All these are happening relatively at the same time. And then the fourth piece is looking at the activity that caused the problem. Was it running? Can we get them on the treadmill and do do a run a run gate analysis? Shout out to Jason, Megan and Rachel in the in the injured runner division. Can we look at their their Olympic lifting? Are they getting IT band syndrome because they started doing split jerks all the time and that position of their knees a little bit irritating? You know, the whole CMFA crew, can you really look at and coach well through a video analysis what that person is doing on their their Olympic lifting and start moving them forward there? So we're going to modulate the pain by controlling their volume. We're going to modulate the pain by using some manual therapy to influence the central nervous system to calm those tissues down. We're going to start exercising, getting good healthy stimulus while respecting irritability into the tissues through open chain and closed chain local tissue exercises. We're going to get a big functional movement, step down, squat, deadlift to start building robustness and capacity overall. And we're going to coach them on the functional activity that may have been the aggravating, whether that's running, downhill running or or their Olympic weightlifting. Now, what this does that's really cool is it positions you as a wildly unique provider to this individual. We are the only profession or one of few professions that are able to control that entire experience for that person. We've got the education where we can control their training volume. We can say, hey, look, I looked at your programming. Looks like you had a huge jump here and all of a sudden you're doing like three times the volume. Let's see if we can cut that back a bit. You can poke them with some needles. You can do massage. You can do myofascial decompression. You can do joint manipulation to calm that lateral knee down. You're the expert in local tissue exercise. You know, if I put this amount of force into this tissue and dose it appropriately, we can both keep symptoms calm down and give a good healthy stimulus to that tissue. You got to know how to coach the step down, the squat, the deadlift to get them back to their functional movements. And we've got to start getting better at being able to do those run gate analysis, video analysis for the big lifts, the Olympic lift, the squat, all those that we can really coach those well. And that will uniquely put you in a position to take that person through a whole plan of care and get them back to the things they love. That will really position you as the best possible guide. So again, to recap, IT band syndrome, we no longer believe that this is a friction based component because we now know that the IT band is firmly anchored to that lateral knee at the tibia, the femur and the patella. We know it's more of a volume increase and a lack of frontal plane control that's really irritating the system. If we can get that frontal plane control by getting a better step down, a better squat, better functional movement, use our local exercise to get better healthy stimulus into that lateral knee so those tissues can tolerate increased stress and improving our efficiency with the movements that we want to do, our running, our Olympic lifting, those sort of movements. Hope this helps. Love to discuss this more in the chat bar. Can't wait to see you all on the road in a few weeks. Hope you have a great rest of your Tuesday.

13:01 OUTRO Hey, thanks for tuning in to the P.T. 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 P.T. on Ice dot 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 P.T. on Ice dot 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 breaks down two recent studies, one that is VERY new to challenge beliefs on prolapse, the pelvic floor and strength training.

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 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back, with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show.

01:22 CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the team within our pelvic health division. If you are interested in learning more about our pelvic health division, we have a online newsletter that goes out every two weeks that focuses on the research, which I'm going to talk about today, in pelvic health. One of the things that is so exciting, but maybe a little bit overwhelming about being in public health and being in this area of exercise and rehab in the pelvic health space is that it is constantly changing. The research is coming out at a very fast pace, fast being relative because research is very slow, but we try and focus in on getting that research to your inboxes every two weeks. You can go to PTonICE.com slash resources and sign up for that newsletter. I am writing it this week and it goes out on Thursday. Also all of our online content, our next online cohort, and all of our upcoming live courses, our two-day live course is in that email newsletter. I hope that you all sign up to get all that research straight to your inbox. 02:48 ACUTE EFFECTS OF RESISTANCE TRAINING Today I'm going to be talking about a new study that came out of Carrie Bowes' lab, talking about the acute effects of resistance training on the pelvic floor. And so before I do that, I kind of want to set the stage for you all around some of the thoughts in pelvic health around heavy strength training. Where we have started this journey was that one of the risk factors for pelvic organ prolapse or descent of one or more of the vaginal walls towards the vaginal opening is that occupational heavy lifting. So individuals who lift heavy weights for their job, consistently lifting heavy weights, were shown to be at risk for more objective descent of one or more of those walls compared to those that didn't. And that because we didn't have any research on resistance training was extrapolated and said, well, maybe we shouldn't do any strenuous heavy lifting as females in order to mitigate or prevent the risk of pelvic organ prolapse from occurring. That was kind of the thought. Since then, we have really pushed back against that narrative and said, well, that doesn't really make a lot of sense because it's very different to go in for eight hours a day doing lifting versus, you know, the 30 to 90 minutes that individuals are doing. In your job, you can't control if you're feeling bad or feeling weak and just take a rest day or modify the way that you're doing your exercise. So again, there isn't really that comparison. 04:24 ACUTE CHANGES TO THE PELVIC FLOOR And now we're starting to get more and more research come out that's talking about kind of this acute change to the pelvic floor that we're seeing with different amounts of strength training or different types of strength training. So Carrie Bo came out with a study and what she was doing was she was taking individuals who were resistance trained. So on average, these were individuals who had never had kids. They were Nellie Parris. And so I never had a delivery and were trained resistance trained athletes. So they had on average about two years of experience. They were then put into a crossover design. So what that means was they took half the individuals and got them to strength train first and then took half the individuals and got them to rest first and then kind of compared. So what they were trying to look at was after a high load resistance training session, what was the impact on the pelvic floor? The thoughts were one of two camps. There's two camps in this space. One is that individuals who strenuously lift are going to have bigger pelvic floor muscles, stronger pelvic floor muscles. And the other is that it may actually create damage over time that they're going to see a big change in symptoms or change in vaginal descent. So you kind of have individuals in both of these camps and we're trying to figure out which hypothesis is correct. And so they took, they did a one rep max or a perceived or rate of perceived exertion that was very high in the squat and the deadlift on one day. And then they got them to come back the next day. So after that one rep max test, they kind of flushed out, let the body recover, came back in. Half the group started with a rest window. So took pelvic floor muscle strength measures at the beginning pre, then half of them rested and did a post and then half of them did a four by four strength training session between 75 and 85% of their one rep max on the squat and the deadlift with reps in reserve between one and three and then did a post assessment and then they flipped, they flipped them. So what they saw was that there was no big differences, no statistically significant differences between the rest pre post, but then also the resistance training pre post. And I think that's really interesting because one of the things that we kind of explain around our, our thoughts around heaviness or prolapse are things like that it's a fatigue issue or so maybe it isn't fatigue or maybe it is, but doing a supine assessment, which is our traditional way of conceptualizing pelvic floor muscle strengthening, isn't sufficient to look at this type of, of fatigue, like to really evaluate this type of fatigue in individuals who are experiencing these symptoms. So that was really interesting. The other thing was that, you know, they did see some individuals who complained of urinary incontinence in this sample around 28%, I believe. And so those individuals, the study wasn't powered enough to be able to subgroup those that experienced incontinence versus those that didn't, but there, what it was not just on individuals who were symptom free. I think that's a pro to this study because we can say, well, of course there isn't any fatigue or any downstream effects of individuals who've never experienced pelvic floor dysfunction, but that's not the case in this study. There was a significant cohort of these individuals who did experience leaking with lifting and the study just wasn't powered enough to subgroup this out. So the first step was to kind of take a full circle approach and say, was there any differences? And then the next step is going to say, is there any differences for individuals who do experience pelvic floor dysfunction versus those that don't? And then the next step is those that are multiparous or multiparous, like multiparous, we kind of, tomato, tomato, those who have had vaginal deliveries before or have given birth before vaginally versus those that haven't. And so this is kind of setting up this conversation around the way that we message things. So another study was done in 2016 and I just found it because it was in the discussion section of this paper around vaginal descent. So Carrie said the Bowe study was looking at pelvic floor muscle strengthening, pelvic floor muscle strength and assessment. 09:23 VAGINAL DESCENT AND EXERCISE The next question is around vaginal descent and are you more likely to experience symptoms of prolapse or heaviness post resistance training? And so this study was done in 2016, I believe it was published out of Janet Shaw and Ingrid lab that was looking at CrossFit athletes, those who experience, sorry, those who participate in strenuous exercise. So they got CrossFitters and they got them to do pre-post on the pop cue versus those that participate in non-strenuous exercise. So let's kind of break this study down too, because I think it's important. So in this second, this, I guess it was the first study, what the group from Nygaard and Shaw's lab did was they took individuals who were CrossFitters, got to check their pelvic floor muscle strength and the pop cues. The pop cue is an objective assessment of prolapse that has good reliability that looks at the different segments of the different walls of the vagina. And then as they do a strain maneuver, they see what the range of motion or the amount of each segment of each component of the wall are, and then create a grade based on the most amount of movement in whichever section of the vaginal wall that may be. So they took individuals who were CrossFitters and then they took individuals who participated in non-strenuous, non-high impact exercise and got them to come into the lab. And then the strenuous group was, they did a pelvic floor muscle strength exam and then the pop cue and then in the non-strenuous group, they did the same thing. And then they got the CrossFit group, the strenuous group to do a 20 minute AMRAP of sit-ups, heavy deadlifts. There was an impact movement in there and kind of went for 20 minutes. And then they got the non-strenuous group to do 20 minutes of an exercise of their choice at a self-selected pace. And then they did the pop cue again. Here's something that's really interesting. So the strenuous group was participating in CrossFit for over two years. They had an extensive history of strenuous exercise versus the non-strenuous group. And they kind of conceptualized this based on looking at what they did for exercise and the amount of loading in their bones to try and get some sort of measure of impact, which I thought was kind of brilliant. And they compared them. Strenuous group had done a lot more loading of their bones and musculature and therefore loading of their pelvic floor compared to the other group. And what they saw was that before their pre-exercise, descent in pelvic floor muscle strength was not different. Was not different. So this created preliminary research that the strength, individuals who are participating in strength training for several years, so it was like on average 22 months plus or minus, and they had to have at least, I think, a year of doing CrossFit regularly, three to four times per week to be able to get into the study in the first place, that there was no difference in vaginal descent. They had, there was no differences between the two. So that kind of goes against this argument that resistance training is going to cause a prolapse, resistance training in general for individuals who haven't had a vaginal birth yet. So I think that's interesting. And then post-partum, or post-exercise rather, they did see differences in descent in both groups. So both groups saw a difference in descent immediately post-exercise, which again, I think is really interesting because this does not support that resistance training and high impact is going to lead to prolapse down the line. Now again, we have a lot of work to do within this space. This was one study. I'm not going to just start shouting from the rooftops that all of a sudden, you know, we know all of the things that we need to know. I'm not saying that, but the fear focused language that is coming into this space around resistance training and avoiding Valsalva and all these types of things isn't founded objectively. So the other interesting thing was that there was only one individual, even though there was a change in descent, right? There was some changes pre-post-exercise and they didn't re, they didn't kind of follow them further and further forward. I would have loved to see them do multiple time points to see how long it took before that changed or kind of returned to baseline. There wasn't anything that, that was looking at what, what that change of symptoms were. 12:57 RESISTANCE TRAINING & PROLAPSE And there was only one person with subjective symptoms of prolapse. So again, we're, we're seeing this disconnect between objective signs and subjective experiences, which I think again is really interesting because we are focusing a lot on the grade, like what grade do you have? What grade do you have? And the evidence isn't really supporting that we, that should be our focus. If you are thinking surgical routes, if it is coming past the level of the Hymen, absolutely, because then we're going to say, is this impacting your quality of life? Is there sufficient imaging data to see that a surgery, for example, would be warranted? For individuals in the conservative space, again, we're, we're, we're questioning, does the objective signs matter? And, you know, we can't answer that question, but it is an interesting thought experiment and we're starting to have more evidence accumulate that, you know, there is a big disconnect. And yes, our body is going to change and show signs of fatigue with things like impact, but what's the cost benefit? What is the risk of telling people that they shouldn't be getting strong for their 60-year-old self, for their 70-year-old self, for their 85-year-old self, when we know that strength is such a huge, huge component of independence in later life? So it is so exciting, kind of going through Carrie Bowes where she didn't see any change in pelvic floor muscle strength to some of the research coming out of the Nygaard and Shaw lab that are talking about changes in pelvic organ support with heavy lifting and long-term heavy lifting. I think we're starting to get more and more data that the fear-focused messages aren't warranted, that we're going to start treating the symptoms and that we can expect changes to the pelvic floor when the pelvic floor gets a workout. Again, I don't think for anybody in the ice fitness forward community that that is necessarily a surprising finding, but it is definitely pushing some of the narratives in pelvic health and I think pushing them in a really necessary direction to try and change this narrative around the fear-focused language of resistance training in the pelvic floor. If you are interested in those studies, I'll post their DOIs below in the comment section. I am so excited to be talking about this research. Again, if you are a research nerd like me and you want to see the new studies that are coming out in this space, which these two studies are going to be in our newsletter this next week, I encourage you to go to ptonice.com slash resources to look for the pelvic newsletter. I am really excited to see some of the changes happening within our course and I just can't wait to continue connecting with you all about research in the pelvic health space. All right. Have a great day, everyone, and I will talk to you soon.

16:40 OUTRO Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses three postpartum physical scars that are often invisible to rehab providers. She explores how these scars can impact exercise prescription for clients in the early postpartum period.

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.

EPISODE TRANSCRIPTION

00:00 INTRO

What's up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today's show.

01:27 APRIL DOMINICK

Welcome to the PT on ICE Daily Show. Dr. April Dominic here. I am your host representing the ICE Pelvic Division. Today we'll focus on three postpartum physical scars that are often invisible to the rehab provider. We'll talk about how these scars can affect exercise prescription when it comes to working with a client who is early postpartum. But before we dive into that, let's chat about all things, updates and course offerings for the ICE Pelvic Division. If you're looking for a virtual option to learn all things fitness, athlete, pregnancy Our next Level 1 online cohorts starts September 5th. Otherwise, you can catch us on the road. We've got tons of courses coming up for this fall. And our next one is September 23rd and 24th in Scottsdale, Arizona. This is going to be with the lovely Dr. Alexis Morgan and Dr. Rachel Moore. This course is chock full of literature outlining the ins and outs of pelvic floor basics, pelvic floor dysfunction, the assessment for the pregnant or postpartum fitness athlete that includes an external exam or an internal exam option. We also have a lot of super fun labs that are going to cover core and c-section management. We also have tons of labs on reintroducing or continuing to use the barbell, do rig work and endurance exercise. Please go hop on PTONICE.com. Get yourself in one of our courses. We would love to see you there virtually or in person.

03:23 PHYSICAL SCARS POSTPARTUM

Today I wanted to hop on and shed some light on physical scars that a postpartum body endures early on. These scars aren't always visible or front of mind for the rehab provider. So think about it like this. You may have someone who is coming in very early postpartum due to some sort of orthopedic injury like for their hip, their shoulder, maybe their back, or they may be coming in for core and pelvic floor work. So it's important for all of us to be aware of these scars as they heal and the role that they play early postpartum with movement and exercise prescription. So when someone is pregnant, there is usually some sort of baby bump or something that is a visible reminder to others of their condition that they are pregnant. Enter the postpartum period. For many postpartum folks, those visible reminders of pregnancy fade and the physical impact the labor and delivery on the body are invisible to others. When someone is postpartum, there's no physical sign that they and their body have gone through this incredibly challenging feat. There's no cast for like when we have for a broken bone. There's no crutches for that ankle sprain. There's no sling to support the wounds. Unless maybe they have their newborn with them, there's really no obvious physical sign that someone is recovering postpartum. So three invisible scars that we'll chat about today are the uterine scar, the perineal scar, and the lower abdominal scar from a cesarean section. Let's circle back to wound care from school. Remember for our healing stages, our tissue healing goes through four major stages. Starting with the first couple, the hemostasis and inflammatory stages. This is going to be a period of local swelling. Next, the proliferative stage. And that's going to be the stage focusing on covering and filling the wound. And then the remodeling stage is characterized by scar tissue formation, which this can last for a year or two, if not. So let's unpack those three major postpartum scars. The first, the uterine scar. I feel like this is the most invisible. It's as the name indicates, a wound on the uterus. And in terms of time to heal, the uterus typically involutes or returns back to its pre-pregnancy size that's smaller by six weeks. And muscles that may be impacted by this scar, by this wound on the uterus, would be indirectly the pelvic floor and the abdominals. In terms of considerations to return to movement when we're thinking about uterine healing, if someone does some physical activity and there is an increase in vaginal bleeding, then that is going to be a sign for regression that the uterus and body may not be ready for that specific intensity level of physical activity or the duration of physical activity.

07:33 PERINEAL SCARRING

Our second scar is the perineal scar. In terms of where it is, it is on the perineum. And the perineum is the tissue that's between the vaginal opening and the anal opening. A perineal scar or injury may occur due to a large stretch on the tissue at the vaginal canal as the baby exits through that vaginal canal. In terms of time to heal, a majority of the stitches are dissolved by about two to four weeks. So there are two ways to tear the perineum. And that's either naturally or via an episiotomy. And that's going to be when the provider actually makes a cut in that perineal tissue. In terms of levels of severity of the perineal tear, there are four. The first degree is the licevier. It's small, skin deep. The second degree is going to involve the muscles of the perineum. The third degree is going to be a tear of the external anal sphincter. And that is what we use to keep poo in or keep poop out, like allow for defecation. And then the fourth degree tear is going to be the most severe. And that's going to be a tear that likely involves the internal anal sphincter, the external anal sphincter, and the rectal mucosa. One time I was talking to a group of OBs and one of them said, you know, we were talking about perineal tears. And one of them said, you know, the vagina is just simply remarkable. It gets to heal in real quick and nobody F's with that vaginal tissue. So that is the one good thing about perineal tears is that the vagina takes care of business. So muscles that are impacted by the perineal tear, the pelvic floor. And then when we're thinking about return to movement with someone with a perineal scar, movements that are wide-legged, like maybe a sumo squat or lateral lunge or really deep squat, there may be some discomfort at that perineum due to that stretch on the tissue in those wide positions.

09:01 C-SECTION SCARRING

And then we have our C-section scar. So where is it? I'll talk about the most common cut that is done is called the bikini cut. And then it's about four to five inches long and it's stretched across the lower abdominals. In terms of time to heal, that's going to depend on various factors. But some scars start to close at the skin level as early as two weeks. And then we know by six weeks, generally speaking, the scar is fully healed if there are no complications. And that's about the same timeline that someone is likely returning back to their provider. Some complications with scarring may be hypertrophic scarring or keloid scarring. And the keloid scar is going to be when the body over heals and the scar tissue extends beyond the original boundaries of the wound. So we want to make sure that we are referring them back to their provider if that is the case, if we happen to see that scar on the client. We know that around six weeks, abdominal tissue has only regained about 50 percent of its tensile strength. And by six to seven months, it's approximately in the 75 percent range of its tensile strength pre-incision. And muscles that are impacted by this scar, the C-section scar, are going to be our abdominal group. So the rectus abdominis, internal-external obliques, and the transverse abdominis.

14:01 CORE-CENTRIC MOVEMENTS & EXERCISE

In terms of considerations for return back to exercise specifically for a C-section scar, we're thinking we got to watch for that core heavy work, any sort of rig or gymnastics-based movements, or any lifting that may involve some sort of contact at the lower abdomen. So those are the scars. Now let's talk about two movement categories more in depth that may be affected by those scars. We have the return to exercise and then return to intimacy, which we'll dive into. So in terms of movement early postpartum, when dosed appropriately, it can assist in so many areas of recovery. We're talking reduction in postpartum depression risk or reduction in risk of blood clot, promoting tissue healing, promoting getting better sleep. That's just to name a few of why movement is important early postpartum. But when it comes to exercise, variables such as sleep and fuel not only influence the risk of injury and recovery, but they also directly relate to the energy status needed to participate in exercise. So sleep, we should be getting nosy and ask about sleep status. Be realistic and recognize that you're talking to a person with a newborn. So their sleep is going to look a little different given the newborn schedule. But we do want to make sure that the client in front of us is optimizing their sleep. Are they creating the best environment? Is it a cool environment? Can they make everything dark? Can they talk with our partner and be like, hey, I need this chunk of time for sleeping. Can you handle the baby while I do this? And then maybe they switch. In terms of fueling, are they able to nourish themselves with nutrient dense packed meals that are full of protein, packed with plants, reduced processed sugars that have sufficient calories, especially caloric intake is important, especially if someone is breastfeeding. They'll need about 400 to 500 extra calories. Okay, let's talk about return to exercise. Generally speaking, when we're talking about return to exercise for someone who's early postpartum, it's a great idea to start somewhere close to where they left off at the end of pregnancy and then build tolerance from there. Early postpartum, that's a time to determine the body's capacity for tolerating exercise. As a provider, it's helpful to have a conversation with our clients about ways we can manipulate exercise dosage to meet their current needs of their current physical status. These modifications are temporary. This is something that we want to communicate with them. We want to educate them on signs for regression with, hey, they did a certain workout or did certain exercise and then, hey, they experienced some leakage of urine or fecal matter. They had some pain or increased abdominal discomfort or vaginal heaviness. So we want them to communicate this to us so that we can then show them how we can alter a workout if needed through load, through adding rest intervals, maybe modifying the intensity or changing the volume and duration. That way they can still continue exercise without symptoms. So now let's talk about scar types and different types of exercise such as core, impact, or lifting. So during the early days and weeks postpartum, walking, reconnection with the core, the pelvic floor, and breathing is a really great place to start. This is going to be when we are starting to add in a little bit more after the first early days or a couple weeks. So with core-centric movements, as we move towards adding more intensity or load, we want to ensure that that abdominal incision is healed to avoid dehiscence. We can begin to experiment with its tolerance, with the anterior abdominal core walls tolerance to stretch in all planes, specifically going into extension, flexion, side bending both ways, rotation, a combination of all those movements. We want to be mindful of tolerance to pressure on the scar, whether that's pressure from simply just the workout clothes, or maybe they are baby wearing while they work out and they have some irritation there at the abdomen. Or maybe it's increased pressure at the abdomen from a set of dumbbells when they're doing a hip thruster, or when they slam down onto the floor with a burpee, or the rig or barbell making contact with the abdomen during gymnastics movements or lifts. With return to impact exercise, such as walking, running, or jumping, we want to be mindful that someone with a vaginal delivery and significant perineal tearing could experience an increase in their pelvic floor symptoms. Remember symptoms reported may be heaviness, vaginal bleeding from the uterine scar, or irritation of their perineum. And someone with a C-section could also experience these as well, but we're thinking that it may be more common with someone with a vaginal delivery or more likely to happen. So with return to impact, we're going to find their guidepost in terms of how much impact their body can tolerate, whether it's starting with a walk around the block, then adding a few more blocks each day, or if it is explosive calf raises, single unders, or step ups. And then for return to lifting, maybe we start with a PVC pipe, or a light kettlebell, or a barbell only movement. This is going to allow the client to re-familiarize themselves with the movement pattern, say of a clean or any sort of overhead press, and then they will be simultaneously building tolerance and in ranges of motion and load at their perineum and abdomen, where some of their scars may be. So return to any exercise will be person dependent, but knowing their history, mode of delivery, current symptoms, and scar status can help you guide them. And bonus, maybe this is a time that they slow down and dial in on foundational pieces of complex lifts or impact training.

18:07 PAIN WITH INTERCOURSE

Besides return to exercise, we also have a different return to movement, and that is return to intimacy, specifically penetrative intercourse. Once cleared by their providers, return to penetrative intercourse, the postpartum person may run into difficulty tolerating that vaginal penetration. This could be from a finger, a toy, or a partner student, Natalia. So it's estimated that 43% of women report pain with intercourse in that first six months early postpartum. And this is something major that we should be thinking about when someone is maybe sharing with us things that are going on with penetrative intercourse for them. A C-section or perineal tear can contribute to painful intercourse. There's a greater risk associated with pain with intercourse with an episiotomy versus a natural perineal tear. Just as we would practice scar desensitization in any other part of the body, we're going to do the same here at the vagina. And a pelvic PT is going to be really great in assisting and making recommendations for internal massage, stretching, or using a dilator set. So let's recap. Today we talked about three main scars that a postpartum person may have. A uterine scar, a perineal scar, or an abdominal scar from a C-section. Remember to respect these healing timelines. They will be unique to each person. The next time you have a client who's early postpartum on your schedule, encourage them to start small. Go slow for returning to exercise and intimacy. Educate them on progressive overload and how that may not be a straight line for them. Maybe a series of peaks and valleys that are impacted by external factors such as sleep, fuel their body's current physical capacity. Communicate with them. Get curious about their invisible physical scars as they may not feel comfortable telling you and offering you that information that, Oh, they have pain at their vagina at the bottom of a deep squat or their abdominal incision site is really bothering them when they're doing a hollow hold or hanging from the bar. So they will no doubt be thankful if their provider considers these scars, asks about them, and because they're not often discussed. So thanks for tuning in, everyone. I hope you gain some awareness of these physical invisible scars that a postpartum person may be dealing with. Next episode, I'll be discussing the emotional invisible scars in the postpartum period. Cheers y'all.

20:28 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 CU's 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 faculty member Mitch Babcock discusses that consistency in the gym, combined with attention to lifestyle factors, can lead to significant rewards in terms of fitness and overall health. By being present and dedicated to regular training, individuals can see improvements in strength, conditioning, and cognitive function. Additionally, by addressing lifestyle habits such as sleep, nutrition, and alcohol consumption, individuals can further enhance their fitness journey and ultimately live longer, healthier lives.

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

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EPISODE TRANSCRIPTION

00:00 INTRO

Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show.

01:26 MITCH BABCOCK

Hey, welcome everybody. Welcome to the PT on ICE Daily Show. Welcome to Friday. Welcome to Fitness Athlete Friday. I'll be your host today. Mitch Babcock, lead faculty in the fitness athlete division, all things online and live course. And it's been a minute since I've been on the podcast. So I'm excited to be back joining all of you this morning. So thank you. First of all, if you're downloading us, listening to us on your way to work, if you're on live with us on Instagram or YouTube, thanks so much for making this part of your morning or your evening, whatever it is for you. And thanks for downloading wherever you download your podcast from. We always appreciate it. Don't forget we're the only daily physical therapy show on the market. So thank you for subscribing and liking and signing up for those automatic downloads. It really means a lot to the whole team here at ICE. Before we jump into today's topic, which is post CrossFit Games for the rest of us. Okay, I want to talk a little bit about some of the courses that we have coming up for the live division. We have a very busy September in October and even leading into November and a couple courses in December. So looking at Q3, Q4, we've got quite a bit on the books. The fitness athlete team as a whole was a little quiet through the summer. As our team, many of us on the lead faculty, not us, but others on the lead faculty, welcomed some new additions to their family or kind of spending some time at home. So the summer months were a little quiet and we're excited to ramp up on the road here in Q3 and Q4. So you can find us all over. Zach's going to be out in the Bay Area here in September. The end of September you can find him out in California. I'm going to be out in Seattle, just north of Seattle in Linwood with Joe as well. We got a course in British Columbia coming up, Alabama, San Antonio, Florida, New Orleans, Colorado Springs. We're hitting some big cities and covering a large part of the map this fall. So if I just named off any cities, your cities or near you, please check those out on the PTA On Ice website. We'd love to see you at one of the live courses.

02:16 POST CROSSFIT GAMES

All right, let's get into today's show, shall we? If you didn't tune in last week to Kelly Benfey's episode on her post CrossFit Games Reflections, you should definitely do that. CrossFit fan or not, whether you train this stuff or not, you need to understand the level at which Kelly is at in humbly speaking herself. She's not going to give as much credit as she deserves. Making it to the CrossFit Games is a feat 99.9% of people that participate in CrossFit will never achieve. You can be pretty good at CrossFit. You know, you could be pretty good at pickup basketball, but you're not going to make the squad and play with the Lakers. You know, like that's kind of the comparison of which we're dealing with now in the CrossFit sector. And so for us to have someone like Kelly, who's went there, who's done that, who's trained at the highest level, who's rubbed elbows with the best of the best in the game and to get some reflections from her, it's worth the 10 or 15 minutes about what it's like behind the scenes. So great episode, Kelly. But today I want to talk about after the games, what about the rest of us that just train this stuff because we like it? We want to stay healthy and fit. We enjoy getting stronger, but we also have nine to five jobs. We also have families, husbands, wives, kids. We got to shuttle kids off to soccer practice. Maybe I coach the soccer team, right? What is what does it look like setting and reframing goals after the CrossFit Games for the rest of us? Because we still want to be motivated. We still want to be inspired. We watch the games and we see what's out there and we see what people are capable of and and all of that is fun and it's all a great part of the sport. But when it's our time to take the floor, it's important to reframe those goals and context and the things that matter to us and are achievable to what we can set our sights for over the next six, nine or 12 months. And that's really what I want to focus today on.

04:35 SETTING & REFRAMING GOALS

What can you reasonably achieve in the next six to nine months or even set your sights on before the next open rolls around? Because we know we're going to throw the hat in the ring and do the open. You know, what are some realistic goals, realistic goals that are going to turn into real change in your health and fitness and overall well-being? And that's ultimately what we're doing this for. We're not most of us aren't going to make the games. Hat tip to Kelly for putting in a ton of work over the last five to 10 years, probably to get to that point where she was able to make the games. But for the rest of us, we're looking to check that box. We're looking to do it safely and effectively and making sure that when we come out the other end, we come out unharmed and we come out healthier and a better person after doing the training than when we started. So here's some goals that I have for you today for post CrossFit Games goals for the rest of us. What part of your training really behooves you to spend time training?

06:30 INVESTING IN FOUNDATIONAL STRENGTH

And what I mean by that is strength and monostructural conditioning work. It's really going to benefit you long term to invest hours weekly daily into getting stronger. So I want you to set a goal to try to put 30 pounds on your deadlift over the next year, to try to put 20 pounds on your back squat and to try to put five to 10 pounds on your strict overhead press. Those are realistic goals that are going to require you to train those movements consistently. And because you're training the foundational strength movements, the squat, the deadlift, all of your other movements will then reap a reward from having done so. Your clean and jerk, your front squat are going to benefit from your back squat being trained regularly. All your Olympic lifts and all your other movements are going to benefit from you training your deadlift frequently. Your shoulders are going to be healthier from having done more strict press. So set some realistic goals. I'm going to put 30 pounds on my deadlift, 20 on my back squat, 10 on my overhead press And that's going to require me to make sure that I'm hitting those boxes week in and week out over the next handful of weeks, months, and the better part of the next year. So it really is helpful that you spend time working on the foundational strength. The other thing that's going to benefit you for your gymnastics movements. So spend time benefiting or getting increased reps or getting your first rep of a strict pull up. Many of you in the CrossFit space are still gung ho about your kipping pull ups, your toes to bar technique, all these other things. I want to bar muscle up, but you haven't laid the foundation with the strict pull up yet. You need to stay there. Over the next six or nine months, can you add one or two reps on your max strict pull up? Can you get your first strict pull up by going through a beginning strict pull up progression and over the next six months, get your first strict pull up. Those are going to be big rewards for your long term health in fitness training. The same thing with your push ups. We in the CrossFit space, those of us that coach a bunch, boy, we're used to seeing a lot of crappy push ups, right? Poor midline stability, we can't hold a good plank position, we don't have a strong shoulder position to be able to press out of the end range of extension, and we have athletes wanting to bang out a lot of reps and not even one of them looks solid. So spend time mastering your strict pull up and your strict push up. You're going to be a better athlete and your fitness will reflect that if you do. Master a skill over the next six to nine months. Get better at double unders. Figure out how to climb a rope, right? Finally take some coaching advice from your team at your gym and figure out how to put down a new skill. There's a lot of reward that goes into the neural motor, the coordination, all of the things that come together to allow you to build and develop a new skill. And if there's one that you've been putting off, because let's face it, your ego is kind of getting in the way, you don't like to look like you can't do the thing so you just scale out of it a lot, spend time over the next six months and learn that skill. Just one, pick one. I want to get better at double unders, I want to be able to do 20 unbroken double unders. Cool. Over the next six months you're going to attack that and that's going to be a goal that's going to elevate your fitness long term. You're going to have that skill for a long time and you're going to be able to use that skill in a lot of workouts coming up. So spend a couple of weeks, a couple of months and develop a new skill. And then your model structural work.

10:06 LONG DURATION ZONE TWO WORK

Add in one day a week where you're adding in some longer duration zone two, you know, longer duration stuff on the bike or the rower going out for a long paced run. Like we don't do enough of that. And every single expert in the space says from a longevity standpoint, it is so key from a health standpoint, from a fitness standpoint, it is so key that we get more long duration zone two work in. And now some of the research, some of the leading experts are saying 60 to 90 minutes, 120 minutes a week. Look just start easy with one day a week where you stretch it out more than 20 minutes. I mean low hanging fruit one day a week. I need to do a long duration piece that's more than 20 minutes. If we can check that, then we'll start talking about increasing the model structural workload and be able to increase that more. But that's a foundational component to your fitness. That's on the base of the CrossFit hierarchy pyramid that says, hey, we need to be really good at metabolic conditioning. And when we have a better aerobic base, everything else steps up above that. So build that aerobic base. Add in one day a week of model structural work zone two on a bike, on an erg, on a runner and stretch it out more than 20 minutes. So you're prioritizing strength. You're working on a skill. You're getting better at your foundational gymnastics movements and you're adding in some longer aerobic work. 20 minutes one day a week.

13:21 MORE CONSISTENCY IN THE GYM

From a class perspective, I would just say it ain't volume. It's not loading that's going to make the difference for you. You don't need to be lifting heavier weights and metcons. You just need to be present more frequently. Just be more consistent. If you normally make it three days a week, try to make it four. If you normally make it four, can you make it five? Can you just add one more day a week making it to the gym? Can you slide in that little Saturday morning class that you typically skip out on? Because you're going to see big rewards coming by just simply the consistency in the gym. You don't have to do anything heroic. You're just more consistent. You're getting five sessions instead of four. And week after week, that aggregates into a lot more training sessions at the end of the year. So bump it one day a week. If you have other skills that are going to make you a much better athlete six, nine, 12 months from now, set a bedtime and actually stick to it. Get the water intake that you need and try to reduce the alcohol. Can we go 30 days with no alcohol and just see what that does for your overall health? See what it does for your sleep, your concentration, see what it does for your overall training, your fitness in the gym? How much sharper am I cognitively when I'm at work? Measure all those things after 30 days of no alcohol. If you make it 30, can you make it 60 days no alcohol? 60, can I go 90 days no alcohol? And just start aggregating these days of optimizing all the little details that you can. And you're going to see such big rewards on your fitness. They're little challenges. They're hard ones. They're not easy, but they're ones that we can bite off and actually stick to for a month, make one month into two months, make two months into three months. The majority of us don't need a new competitors program. We finished watching the CrossFit Games and everybody's selling their hard work pays off, their Matt Frazier program, the new Mayhem Rich Froning style stuff. And while all those are great programs, for most of us, that's not what we need. We don't need additional loading. We don't need more volume or longer duration workouts. What we really need is more consistency in the gym. We need to get stronger at the things that matter and we need a better conditioning, a better engine to be able to do more things. And then the lifestyle stuff comes along with that. We're going to be one hour in the gym and the 23 hours out of the gym. What are we doing with the 23 hours out of the gym? Can I set a bedtime? Can I get better sleep quality? Can I eat better? Can I reduce my alcohol consumption? All of those little details that will stack up and aggregate over a year or six months or nine months into a much fitter version of yourself. The stronger and healthier you get, the longer you're going to live. And ultimately that needs to be all of our game plan. Why are we doing this? The oldest, not the oldest member, the most tenured member of my gym, we call him the Godfather just for that reason, says all the time, I'm just trying to still be doing CrossFit when I'm 70. Like every decision he makes in the gym day by day, he keeps that greater focus. He's not coming into the gym saying this is the year I make it to the games. He's coming into the gym every day saying, I need to make a decision that's right today so that I can still be doing CrossFit when I'm 70. Because I know that if I'm still doing CrossFit when I'm 70, I can be doing all the things in my retirement that I want to be doing. So keep the long term vision in play. We're looking to be able to do this over a lifespan. Stretch out and increase your lifespan, the number of healthy, good years you're living. That's what ultimately this is all about for us. So here's some small actionable goals that people like you and me can really bite off and really set our sights on over the next six or 12 months. Throw our hat in the ring when the Open comes around next year and say, hey, you know what, because I put that work in starting in August, I'm really a much better version of myself now in February. Comment below if one of these, if you've got a goal that we listed off and you're like, look, I need to jump on that. Drop a comment below whether that's YouTube, whether that's Instagram, whether that's on a podcast format. Let us know. Reach out to us. And then as always, if you need help with any of these things, that's what we're here for. So talking about all things lifestyle related in our live course as well. Excited to see those of you that are going to make it for your first time out at one of those courses. We're hitting the road heavy this fall. So looking to see you guys out there. In the meantime, if you're training today, have a great session. Get some caffeine in you and ramp it up. I will see you guys out on the road very soon. Have a great day, everyone.

15:56 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 PT on Ice dot 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 PT on Ice dot com and scroll to the bottom of the page to sign up.