#PTonICE Podcast

Dr. Dave Finkelstein // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Spine Division faculty member Dave Finkelstein makes his debut on the podcast to discuss the importance of asking patients if there is anything important they want to cover or do in their session. This question is often overlooked by therapists, but it is seen as one of the most important questions they can ask. By asking this question, therapists are allowing their patients to take control of their care and be in the driver's seat. The aim is to promote a sense of self-efficacy in the patients' care and give them the opportunity to express what is truly important to them.

The episode highlights that therapists may be surprised by their patients' responses to this question. While some patients may be open to whatever the therapist suggests for the session, others may have specific concerns or topics they want to address. It is crucial for therapists to listen to these concerns and not dismiss them for their own predetermined plans. By addressing what is important to the patients, therapists can alleviate their fears and concerns and demonstrate that they are truly listening and invested in their well-being.

Furthermore, the episode emphasizes that asking this question helps to strengthen the therapeutic alliance between the therapist and the patient. By showing attentiveness to the patients' needs and concerns, it enhances the trust and rapport between them. This, in turn, can lead to better treatment outcomes and a more positive therapeutic experience for the patient.

In this episode, the host discusses the importance of asking specific questions to patients in order to determine the direction of their care. The host shares five specific questions that can be asked to gather important information from patients.

The first question is, "How did you feel after the last session?" This question allows healthcare providers to understand how their intervention or treatment has affected the patient's symptoms. By knowing how the patient felt after the previous session, healthcare providers can make informed decisions about the next steps in their care.

The second question is, "How are you progressing with your goal?" This question helps healthcare providers assess the patient's progress towards a specific goal. It allows them to gauge whether the current treatment plan is effective or if adjustments need to be made.

The third question is about the patient's adherence to their exercise program. The question is, "How often are you keeping up with your exercises?" This question helps healthcare providers identify any barriers the patient may be facing in following their exercise program. It also allows them to assess the effectiveness of the home exercise program.

The fourth question is, "How are you feeling today?" This question helps establish a baseline for the patient's current condition. By understanding how the patient is feeling at the start of the session, healthcare providers can evaluate the impact of their intervention or treatment.

The fifth and final question is, "Is there anything specific you would like to discuss or address today?" This question gives the patient an opportunity to express their concerns, priorities, or any specific topics they would like to discuss during the session. It allows the patient to take an active role in their care and helps build a sense of self-efficacy.

Overall, these five questions provide valuable information for healthcare providers to determine the direction of a patient's care. By asking these questions, healthcare providers can gather subjective information, assess progress, identify barriers, evaluate the effectiveness of interventions, and address the patient's priorities and concerns.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 DAVE FINKELSTEIN Alright, good morning to the PT on ICE Daily Show. I am your host today. My name is Dr. David Finkelstein and I have the pleasure of serving as a TA in the spine division. I am a TA in the cervical and lumbar spine management courses. The topic today is ask for directions. But before we jump into the topic for today, I wanted to highlight a few of the upcoming courses that we have in the spine management division. So on September 23rd, we actually have all three of our lead faculty leading courses that weekend. Zach is going to be in Henrico, Virginia at Onward Richmond. Jordan is going to be in Baton Rouge, Louisiana at Delta Physical Therapy. And Brian is going to be in Parker, Colorado at Onward Denver. So if you're looking to hop into a lumbar spine management courses, all three of those gentlemen are going to be running courses on September 23rd. If you're looking to jump into a cervical spine management course, Jordan is going to be in Brookfield, Wisconsin on July 22nd at Onward Milwaukee. Jordan will also be in Charlotte, North Carolina, August 26th at his home base of Onward Charlotte. And then Zach on September 9th is going to be in Roswell, Georgia at Onward Atlanta. So looking to jump into a cervical spine management course, those are going to be your next few opportunities in the coming months. All right, so let's jump in the topic today. The topic is called Ask for Directions. And the idea came from a conversation that I had with one of my coworkers. She was talking about one of her patients that seemed to plateau in their care, and she didn't know which direction to go in terms of directing her care. So when we're working with our patients, they're going to be giving us a lot of subjective information as the weeks go on. And my hope with today's podcast is to give you all some specific questions to ask your patients to know which direction that you want to go with their care. Right. So I have five questions that I want you to consider, and there were more prompts. So that way you can dive a little bit more into those questions as you ask them. All right. So question number one, how did you feel after last time? I love starting with this question because it helps us know how the patient felt with our intervention after our last session. Right. Usually our patients will say something along the lines of, I felt good. Don't accept that as your answer and then type into your documentation system and then move on. Right. We want to know how our intervention affected them. So you want to dive into that a little bit more. So when the patient says good, ask them, what does good mean? How good did you feel after last session? How long did that good feel for? Right. So that way we know how effective our intervention was. And if they did feel good after last time, that might be something along the lines of you want to increase the vigor, continue on with the dosage of, of what you did last time to help prolong that good sensation that they felt. Conversely, if they didn't feel good after last time, if they tell you, you know what, Dave, I actually didn't feel so hot after last time. I felt quite a bit worse. Don't panic. That's actually good news in a way because it helps you know that you were in the right place, but maybe your vigor was a little bit too much or maybe your dosage was a little bit too much. Right. Because if you weren't in the right place, their symptoms wouldn't have changed. Or conversely, they might've done something between the last session and your current session that also could have flared up their symptoms, unpacking it a bit more. Maybe John said, you know, I felt pretty good after last time, but then I mowed the lawn and then picked up a few boxes and then I did X, Y, Z. And then after that, I felt a little bit worse. So it helps you know exactly if it was your intervention or if it was something that they did afterwards. Right. It also helps you know if you establish their irritability correctly after the initial evaluation. So if you did your particular intervention, you thought they were low irritability and you intervene in an area and nothing really changed, you might want to consider going a little bit more vigorous into your examination or into your vigor to see if you can really elicit their symptoms. And then conversely, if they felt like really flared up after last time, maybe your vigor was a little bit too much and you overestimated their irritability. Right. So in both ways, that's a really good starting place when you ask the patient. So that first question is how did you feel after last time? Question number two, how did you progress towards X goal in our cervical and lumbar spine management courses? We talk about obtaining a subjective asterisk. Basically, that's something that the patient that's important to the patient that you want to measure, but you can't measure in the clinic. So what that looks like is how many times someone woke up in there in the night because of their pain or how long into their commute they're able to sit for before they have an onset of symptoms. Right. So if you ask them, John, how did you feel after or how are you progressing with your commute? And John tells you, you know what, Dave, actually, it's a little bit better because I was sitting for 30 minutes and then my symptoms came on and now I'm sitting for 45. So now you know that your intervention was effective because their commute increased. Right. Whereas conversely, if they say, you know what, Dave, after last time I was in my commute and I was only able to tolerate 15 minutes of sitting before my symptoms really started to act up a bit, then you know, once again, maybe it was that bigger or maybe it was that particular intervention that you did that was a little bit too much that that might have increased their symptoms a bit. So asking them how they felt with that specific goal, with their subjective asterisks that you obtained in the initial evaluation, seeing how they progressed with that. And also keeps those goals that are salient to the patient in the back of your mind that you continue to ask them in those follow up sessions. Right. So that's question number two. How are you progressing with X goal? Question number three, how often are you able to keep up with your exercises? I love asking this for a home exercise question as opposed to are you doing your home exercises? Because it's a little less judgmental. Right. If the patient didn't get to do their exercises, you're asking them from a place of curiosity as opposed to did you do your exercises? So when you ask the patient how often are they doing their exercises, it gives the patient opportunity to even tell you, you know what, Dave, I actually didn't. Wasn't able to keep up with those exercises. Don't judge them for not doing their exercises, but look at that as an opportunity to examine barriers to their adherence to their home exercise program. Right. So you can tell John, like John was up. How come you weren't able to do those banded external rotations? And they tell you, you know what, Dave, I just didn't have an opportunity to go out and buy the bands because I'm a little short on time and it did help after last time, but I just I wasn't able to go on by the band. So that way you now have the idea that the barrier was purchasing the bands. Right. So then you can change that exercise to a sidelined external rotation. We're holding a can of tomato sauce there. You're kind of taking out that barrier of buying a band. You got the stimulus that you wanted. And then you also taught John a way of creating a weight in his house using a can of tomato sauce. Right. So using that as an opportunity to identify a barrier. And then also, if your intervention was effective as far as a home exercise program. So take, for example, a patient with low back pain radiating down their leg. They say, you know, Dave, doing those prone press ups that you gave me, I felt pretty good for about an hour after you gave me that exercise. But then it kind of went back to baseline afterwards. And then you realize that you dose that out three times a day. You might consider asking John, hey, John, you know, you felt pretty good for about an hour after you did those exercises. What are your thoughts on maybe increasing that from three times a day to six times a day? You know, it might sound kind of aggressive, but in that way, you're increasing that dosage of that thing that was helping John. So now you're getting a good idea of how your home exercises are affecting your patient and then playing around with that dosage or that particular intervention. Right. So that question, once again, is how are you how often are you keeping up with those exercises? Question number four, how are you feeling today? Seems like a very basic question that we ask all of our patients. But I want you to think about why we're asking our patients that. We're asking that question to establish a baseline, how they feel right now. So that way, if we do some sort of intervention, that we know how it's changing their baseline symptoms. This is another opportunity that the patient might say, good, don't take that good as a as your answer. Tell them, like, can you unpack that for me a little bit? Tell me what what good means and then start to trace out their symptoms. See exactly where their symptoms are, how intense are their symptoms? So that way, when you establish that baseline, you feel really confident about the intervention that you did, whether or not it changed their symptoms for the better or it did. Right. Establishing that baseline. All right. So question number four, how are you feeling today? Question number five, I think, is one of the most important questions that we can ask our patients, but is often overlooked. So question number five is, is there anything you want to cover today? Talk about do that's really important to you. In that question, we're taking our hands off the steering wheel and allowing our patients to be in the driver's seat. We want our patients to feel a sense of self-efficacy in their care. And this is the best question to open that opportunity to know what's really important to them. Right. Maybe our patients will say, you know what, Dave, whatever you want to do today, I'm game for, which is fine. And then you continue on with that plan that you had. But your patients might surprise you and say something on the lines of, you know, Dave, I was actually thinking about it the other day that I don't really know how to get off the ground if I were to fall. And that's kind of in the back of my mind for a while. In that the patients opening up to being vulnerable and saying, hey, this thing is really important to me. What you don't want to do is ignore that and be like, well, sorry, John, you know, I had this other plan and I just want to proceed with it. We'll cover that in the next session. You want to cover the thing that's most important to your patient because it's going to help take that kind of fear, that concern out of the back of their mind. And then in addition to that, you're helping boost that therapeutic alliance by addressing that thing that's really important to them. Right. Nothing is going to tell your patient more that you're listening to them, that you're concerned about them than intervening in that thing that's really important to them that day. Right. So that question is, is there anything that you want to talk about or do today that's really important to cover in our session today? So those are the five questions I'm going to give you a quick recap. Question number one is, how did you feel after last time to know how your intervention affected their particular symptoms? Question number two is, how are you progressing with X goal? Recapping back to their subjective asterisk, making sure that you know exactly what's important to them and how that's progressing or not. Question number three is, how often are you keeping up with those exercises so that way you can identify barriers to their adherence to their exercise program in addition to knowing how effective your home exercise program actually is? Question number four is, how are you feeling today? Knowing the back of your mind that you want to establish a baseline so that way you know how your intervention is affecting the patient. And then question number five, once again, really important to ask our patient, is there anything important that you want to cover, talk about, do today that would be beneficial? Right. So give those questions a thought. Try that out. Keep in the back of your mind why you're asking these questions and then diving a little bit more. Let me know how it goes. Shoot me a message in the comments section. I love talking about this stuff. I love the conversational piece and the Therapeutic Alliance piece of patient care. If you're looking for more opportunities to jump to some courses or see some of our free resources, go to PTNICE.com. Check us out. Everyone, thanks for giving me some of your time and have a wonderful morning.

14:07 OUTROHey, 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 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.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the obturator internus muscle and its role in pelvic floor and hip conditions. She highlights the importance of understanding and addressing this muscle for effective treatment. Take a listen to learn how to better serve this population of patients & athletes.

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

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's 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 PT on ICE Daily Show.

01:29 APRIL DOMINICK Good morning PT on ICE Daily Show. Dr. April Dominick here. I am your host and I will be continuing our conversation on pain in the butt, this time with a spotlight on the obturator internus muscle. The obturator internus is a persnickety hip muscle that is housed inside the pelvis and it contributes to quite a few pelvic floor and hip conditions. So before we dive into that, I just want to give you all some updates from our ICE Pelvic Division. If you didn't catch our big news from our newsletter that we sent out last week, we week online course that is going to cover advanced pelvic health concepts and it's coming January 2024. So make sure you hop onto pdniice.com, check the resources page and get yourself signed up for our pelvic health newsletter for all things research oriented. And our next level one online cohort starts September 5th. So be sure and hop on to that course. And then you can catch us live for our two day course on the road next week and actually we will be here in Denver, Colorado. That's July 29th and 30th with Dr. Alexis Morgan and myself. We'll have a jam packed course for you. Our lecture will focus on all things pregnancy and postpartum. For the fitness athlete, labs will go over all internal external assessment of the pelvic floor with a option for video learning if that assessment does not sound like it is for you in terms of the internal piece. Other labs will cover management of C-section scar, diastasis recti, core work on and off functional barbell lifting, endurance including running, all sorts of fun fun stuff. So there are still a few seats available for that course if you want to come hang out with us and if you aren't able to make it to the Denver course we'll be in Sedona, Arizona and that's going to be September 23rd and 24th with Christina Prevot and Dr. Rachel Moore. So if you missed it two weeks ago we chatted about another kind of pain in the butt, one that was focusing on a bony structure, the tailbone. It's episode 1505 if you want to slide back and catch that. But today we're going to focus on the soft tissue muscle or cause of the pain in the butt, specifically the obturator internus or I love abbreviations so I may call it the OI during today's episode. So if you, the listener or if you have a client who has some sort of hip pain that seems difficult to pinpoint, they're having trouble telling you where it's at maybe because of where it's at they may be kind of pointing in the nether regions or they might be headed up near the and you're like, oh I don't deal with that stuff or they may point just at the ischial tuberosa and you're like, oh thank goodness, hamstring strains, I can deal with that for sure. But maybe you throw everything you have at it, your hip mobility exercises, your strengthening exercises and it's just not getting any better. Well I encourage you to consider my friend the mysterious obturator internus muscle as that may be influencing some of that hip pain that you or the client has. So we'll chat about the obturator internus' unique anatomy, its functions, other competing soft tissue contributors as well as certain conditions or maybe client reports to be on the lookout for that may be influenced by this muscle. I love history so the word obturator actually originates from the Latin word obturo which means to stop or block up. This lines up given that the obturator muscle actually covers the opening of the obturator for Raymond. So this, the location of the obturator, it's a big old hunk of hip muscle that lives on the front and side of the hip. So for those listening, I'm holding up my pelvic model, we're looking at the pubic bone and going just lateral to it and there's a, I like to think of it like they're two skull eyeballs, but anyways, there's a big old hunk of muscle that's in red here and that is the belly of the obturator internus. And then it has this really cool tail that actually whips out and takes a 90 degree turn to then connect onto the top of the femur or the top of the leg. Due to this unique deep parking spot within the pelvis, it can affect both the function of the pelvis and, or pelvic floor and the hips. So in terms of function, we'll go over three major functions of the obturator internus. Number one is it can externally rotate the hip when the hip is extended. So like when you're standing, it can abduct the hip when the hip is flexed or when your leg is raised up like you're marching. And then it also has a key role in stabilization of the femoral head or the leg into the acetabulum. So especially during weight bearing and propulsion. Based on a study in 2017 that looked at female cadavers, the, they, I love the phrase that they used in this article, they called it the architectural design of the obturator internus is affected by aging. In that, in their study, they found after the age of 60, both the force generation capacity and the fibrotic nature of the OI muscle is reduced. That's so interesting. And what they suggested in that article was maybe we should be focusing a little bit more on functional upright movements that have the leg and weight bearing as that tends to be when the obturator internus is more in a shortened position. So maybe we can generate some greater functional capacity and strength in that position versus our typical non-weight bearing exercises like maybe a clam. In terms of impairments, the OI will often step up to the plate and compensate to stabilize the pelvis when other muscles like the glutes or abdominals are a little on the weak side. You can also develop just like any other muscle, any sort of muscle banding, knots, and it rare if it's rarely lengthening or relaxing. And so all of that is definitely going to result also in some reduced range of motion and then reduce blood flow to this muscle, to this area and its surrounding nerves will definitely contribute to a cranky OI, which then may lead or lend towards hypersensitivity when that OI muscle is palpated. And we can palpate it externally near the ischial tuberosity as the obturator internus actually lies just on top of the ischial tuberosity, similarly to how the subscapularis lies on the underside of the scapula. So it has that similar kind of bony muscle contact. Or you can palpate this muscle intra-vaginally or interactively. And there are so many times during my sessions, if I'm doing a pelvic floor assessment and I roll over to the obturator internus that the shock and maybe relief of the person on the table is paramount. They're like, oh my goodness, that's the pain that I have during deep penetration. Or that actually just brought on some urgency for me, some urinary urgency. That's the feeling that I get randomly. Or that's the pain that I have when I'm sitting and it's been hard for me to describe it to you. So it's super powerful being able to palpate this muscle and just help bring some validation to your client who's like, I just don't know where this pain is coming from. And then due to its many functions and that unique anatomical location, the OI is capable of referring to lots of areas. So sometimes it'll kind of act like a chameleon. One day, you know, it's referring pain to the hip. Maybe one pain is referring pain if someone's pregnant to the round ligaments. So other soft tissue areas that you should be screening if you're looking at the obturator internus muscle would be the hamstrings like we talked about, the adductors, big, big relationship between obturator internus dysfunction and then the pelvic floor, specifically the levator anion muscle group, as well as the coccygeus. And then not to mention just muscle structures, but another nerve structure that would be super helpful to have on your hypothesis list that may be affected if the OI is cranky is one of its best mates, the pudendal nerve. So the pudendal nerves is going to support sensation in your urethral and anal sphincter function. So along its path, the pudendal nerve is actually surrounded by some obturator internus fascia. And that goes along alcox canal, which is on the border of the obturator internus. And it provides a really large opportunity for entrapment of that pudendal nerve, which then could lead to some possible pain and dysfunction. So the obturator internus, I like to think about it like a nosy aunt who has her nose in everybody's business and the family, all the hot goss. So because of that, it is involved in so many different conditions. And these are a few things that you may hear from your clients in terms of aggravating factors. So they may talk about, hey, I just have this ton of discomfort when I sit for a long time. Or I just got my peloton and I actually have a lot more discomfort now because I've been cycling quite a bit. And we're saying this, but maybe you will have already screened out the tailbone. deep penetration or sexual play like I chatted about. And painful or tight hips, urinary urgency, frequency leakage, SI joint tenderness, difficulty or difficulty with description or pinpointing some sort of pain or pressure that's deep within the pelvis, deep within the vagina. Or sometimes people will often say, I have pain that is, it just feels like I have a golf ball in my rectum. So these are all things that I want you to keep in your mind when maybe thinking about could this be the obturator internus muscle. From a trauma standpoint, the OI can be injured in posterior hip dislocations, again, just because of where it's at with from an anatomy standpoint. It can also be involved in acute or overuse strains from sports like kicking, tackling or falling. Falling, usually this is in young males. And then sometimes the obturator internus can be strained in conjunction with adductor longus strains. So in summary, if you have clients that are coming to you that are describing some pain up in that region where you may not be used to screening or palpating for in the nether regions and they point towards this yield tuberosity and you're like, just stay there, don't go higher. I want you to think about thinking outside of the hamstring adductor strain box and be sure to include the obturator internus in your hypothesis list. Due to its unique anatomy of living inside the pelvic bowl, but shooting a little leg out to the side or a little tail out to the side to attach to the femoral head, the obturator internus muscle is sneaky. It's involved in so many different pelvic and pelvic floor and hip conditions. We talked about pain with intimacy, prolonged sitting, bladder urgency, frequency, just to name a few. And if this is describing your hip pain or if you're dealing with a client who isn't responding to traditional PT, consider reaching out to your local pelvic health PT to help screen for pelvic floor dysfunction. I actually have a really close relationship with a lot of the ortho-PTs in my area who don't have an interest in treating the OI, but they've learned how to screen for it from me and they now refer out to me and nine times out of 10, they are spot on with calling that obturator internus as being a contributor to their client's pain. And then better yet, for the PTs out there, come on out to our live course so that you can learn how to palpate and master and learn techniques for external and internal palpation and treatment of the muscle. So learning how to screen for this muscle will be such a game changer for successfully your clients with this hip and pelvic pain without you needing to refer out. Thank you all so much for being here. We appreciate you. Hopefully you don't have any pain in the butts on the schedule, but if you do, at least you're armed now with which other sneaky muscle that could be contributing. Happy Monday and I'll see you next time.

17:02 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.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com https://pubmed.ncbi.nlm.nih.gov/34852731/ https://pubmed.ncbi.nlm.nih.gov/33630675/

https://pubmed.ncbi.nlm.nih.gov/32023545/

https://pubmed.ncbi.nlm.nih.gov/34770213/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4493260/ https://pubmed.ncbi.nlm.nih.gov/31869820/

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines heat-based recovery including hot tubs, whirlpools, and saunas. Take a listen to learn how to discuss cold plunging with your patients or athletes.

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

EPISODE TRANSCRIPTION

00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody. Enjoy the show.

01:32 ALAN FREDENDALL All right. Good morning, team. Welcome to the PT on ICE Daily Show. Happy Friday morning. Hope your Friday's off to a great start live here on YouTube and Instagram, everywhere you get your podcasts. 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 ICE and a lead faculty in our fitness athlete division here on Fitness Athlete Friday. We consider it the best start day of the week. We talk all things CrossFit, Power Lifting, Olympic Weightlifting, endurance athletes, running, swimming, cycling, all that sort of thing. So if you're interested in working with the recreationally active patient or client, Fridays are for you. We're going to talk all things heat based recovery today. We spent two weeks ago talking about cold based recovery. So it'll be a nice change of pace on the opposite side of the spectrum. Before we get started today, first of all, I want to say big thanks to our friends at FIRE, Foraging Youth Resilience for having Jeff, our CEO, and myself out this week to their annual camp outside of Boulder, Colorado. Huge fun getting to know a lot of the kids, the campers, as well as a great network of coaches, games athletes, all sorts of wonderful people from the CrossFit space coming together to help support FIRE. It was great to meet everybody out there. If you want to learn more about FIRE, you can read more on their website. We're big supporters of FIRE here at ICE. So you'll continue to see us have more opportunities to help get involved with FIRE and support FIRE as time goes on. Some courses coming your way from us in the fitness athlete division. If you're looking to catch us out on the road for clinical management in the fitness athlete live, that's our two day live seminar. Your next chance will be September 9th and 10th. That's going to be out in Bismarck, North Dakota with Mitch Babcock. And then you can catch the same month at the end of September, September 30th and October 1st out on the west coast. Zach Long, aka The Barbell Physio, will be out in Newark, California. That's in the Bay Area of California. And then online, our clinical management fitness athlete essential foundations, our eight week online entry level course into the clinical management fitness athlete curriculum. That will start September 11th. That's taught by myself, Mitch Babcock, Kelly Benfee and Guillermo Contreras. And then the next week after our level two online course, clinical management fitness athlete advanced concepts start September 17th. So you can learn all about that at ptenice.com. That's where everything lives that you want to know about ice. So today's topic, heat based recovery. We have talked about cold based recovery, specifically two weeks ago here on fitness athlete Friday. We talked everything regarding cold plunges and cold based recovery. We're going to go to the opposite side of the spectrum now and talk about heat based recovery. So the big summary from if you didn't catch us two weeks ago, the big summary from cold plunging is that we really want to avoid it after exercise. It seems to really have an effect on that post exercise inflammation effect that we want to build strength, build hypertrophy. It does have some benefits, but we mainly want to avoid it after exercise. You're going to see a recurring theme here with heat based recovery. But I do want to start by first of all, defining what is heat based recovery, talking about the differences between things like hot tub or whirlpool. Differences between you may have questions about infrared versus traditional sauna. And then I want to talk about some of the research supporting the use of heat based recovery, but also the application of it both in the clinic. And when you're discussing these topics in the clinic or the gym with your patients or athletes. So let's start first by defining it. What is heat based recovery? We have a couple different types. The first is what we'll call hot water immersion. This is basically the opposite of cold water immersion or cold plunging. This is where you get in a hot tub or a hot bath or a whirlpool machine, some sort of hot water immersion. Now defining temperatures here is really important. We did that two weeks ago with cold water immersion. Really important to note that at least from the research, we have specific temperature ranges that we're discussing with all of these modalities. And we're also assuming that you have your whole body immersed in something like a sauna. Or that if you're in hot water, for example, a hot tub or a hot bath, you're immersed at least up to the level of your neck. A lot of what we're going to talk about doesn't apply to you if you're somebody that just sticks your your foot in the hot tub. Or doesn't otherwise get fully immersed in whatever modality you're using. So two different types of hot water immersion, hot tub or hot bath. When we're at home and we run a bath, when we look at what is the temperature of what the average human being might consider quote-unquote hot. A hot bath is right around 100 degrees Fahrenheit. And that your average hot tub is not too different. A hot tub that you might get into is going to be somewhere between 100 to 110 degrees Fahrenheit. But now when we look at this from a research perspective, it's usually tightly controlled and it's usually tightly controlled a little bit hotter. So when they look at hot tub whirlpool type immersion in the research, they're looking specifically at a temperature range of about 110 to about 120 degrees Fahrenheit. So if you're somebody that really hates a hot bath, if you run a hot bath and you wait for it to cool down a lot, then just know this is going to be on the upper end of your temperature comfort. Why this matters is that when we add that that circulating bubble component to a whirlpool, to a hot tub, it seems with the water continuously moving that it makes that hot water immersion just a little bit more tolerable and therefore they bump the temperature up a little bit. Again, 110 to 120 degrees Fahrenheit. And again, immersion in a hot tub whirlpool up to the level of the neck. Now duration is really important. We talked about that with cold plunging. That if you're somebody that gets in for a minute, you probably don't have to worry about the positive or the negative effects because you're really not doing it. The same is true here. When we look at hot water immersion, when we talked two weeks ago, we talked about humans have a really great tolerance for heat at rest. We can sit outside 70, 80, 90, maybe even 100 degrees, especially if we're in some shade and we can be okay. We don't have a great tolerance for cold at rest. And we see this carry over into hot water immersion that because we're so much more tolerant to heat, we see duration for hot water immersion a lot higher. We often see duration 15 to 30 minutes in a whirlpool in a hot tub. Maybe you've been at a hotel or a resort or something. You've seen that sign. We've all seen that sign on the hot tub. You know, don't stay in here too long. Max time 20 minutes, 30 minutes. That tends to be our tolerance for hot water immersion. So somewhere between 15 to 30 minutes, but definitely longer than what we're used to seeing with cold water exposure where the general recommendation usually never exceeds 10 minutes. Now getting into sauna, temperatures are going to go up. We're no longer actually sitting in water. We're usually sitting in a room that is either steam heated or dry heated. Those also have different temperature parameters when we look specifically at how they're studied in the research. Traditional sauna, whether it's dry or a steam sauna, is a lot hotter. 150 to up to 220 degrees Fahrenheit. Infrared sauna is going to be lower, 120 to 140 degrees Fahrenheit. And again, the duration for sauna is going to be higher, a lot like hot water immersion. Somewhere between 30, maybe even to a 90 minute dose, and that's going to be mostly for infrared sauna. That would be really tough to do in a traditional sauna. So that's how we define hot water immersion and also what we would call just sauna, sauna protocol, traditional or infrared. Now the research. I want to share a couple of different papers with you as we get into talking about what does the research support? What does it not support? Talking back to hot water immersion. So again, our hot tub or our whirlpool protocols. A great paper from 2022, the Journal of Sports Science. More and more Gamino and colleagues, pardon me butchering that, looking at hot water immersion. They took folks and they had them sit in a whirlpool for 15 minutes at 110 degrees Fahrenheit. They also had another group sit in a cold plunge at 50 degrees Fahrenheit and they compared outcomes on the quadriceps muscle. They wanted to look at specifically the contractile properties of the muscle itself and found that the group sitting in the hot water after exercise had increased contract properties of the quadricep muscle compared to the folks who did cold water immersion and compared to the folks who did nothing, who sat at a room temperature room. So the the effects of hot water immersion appear to have a more beneficial effect on our muscle and we'll get more into that as we get more into the research. My next paper, really old. I love some of these old papers that just show how long we've been studying this stuff. Francisco and colleagues back from 1985, so before I was even alive, Journal of Applied Physiology. Looking at the use of hot water immersion and comparing it to basically an active recovery protocol. So two groups of subjects, one group exercising at 60% of their VO2 max. So essentially an active recovery spin on a cycle or a really really really low slow jog, something like that. To a group that did an hour in a whirlpool at 105 to 110 degrees Fahrenheit. And then they did a crossover here. So they took both groups and then flipped them a couple of days later and had them repeat the same thing. What they found in the group who sat in the hot tub for 60 minutes is they had an almost identical cardiovascular change. So they had an increase in their cardiovascular output and their mean arterial pressure, which just kind of tells us that there is a cardiovascular demand on the body when you are exposed to heat that mimics low-level active aerobic recovery type exercise. So what does that tell us? That tells us that first of all if we are looking for a recovery day that a longer hot water immersion or maybe a sauna can be a viable option in place of a recovery workout that we're going to get some increased cardiac output. Our heart rate is going to elevate. We know being exposed to heat we're definitely going to sweat. That's going to come on board no matter what. But we're going to see blood pressure changes as well. That tells us we're kind of getting a flushing pumping effect when we're exposed to heat specifically in this study hot water immersion compared to if we went to the gym and just spun on our bike or went for maybe a really long walk or a really slow jog or just some sort of active recovery exercise that they appear about equal. Which is great if that's what we want. If we're trying to limit cardiovascular load, if we're trying to limit volume on our body then we need to be mindful that a longer duration hot water experience can have that effect on us. So it appears to be about an equal effect, which is nice. The next study here, Borg and colleagues from 2020, the International Journal of Sports Physiology and Performance, looked at hot water immersion versus cold water immersion versus control. Specifically they had these folks do these modalities after cycling in what they called hot weather, 75 degrees Fahrenheit. So they went for a long bike ride in the heat and they came back. They threw one group in cold water immersion in the cold plunge. They threw one group in hot water immersion, a whirlpool, and one group just sat at room temperature. And they found that those exposed to the hot water immersion were more likely to report that the session they had just performed, the cycling session in the heat, was easier. And they also had a lower cardiovascular response to those who had a cold water immersion. So it seems like when we're cooling down we want to choose heat as it's easier on our body, easier on a cardiovascular system than finishing a hot workout in the heat. It sounds great. We've all had those workouts. I just had one two weeks ago where we literally want to stick our head in the sink, which is exactly what I just did, and just cool down our head. That seems like what we want to do, but we know that can have sort of a shocking effect on the body compared to if we ease ourselves out of the heat with maybe not exactly what we just did in the heat, but we choose something that's going to feel temperature neutral compared to what we just did, which was a really tough workout in the heat. Heat exposure after exercise, especially in the heat, seems to have a beneficial effect as we're trying to cool back down to baseline. Now switching gears and looking at the sauna research. So this is just as popular as everybody wants to know about cold plunges. Everybody wants to know about sauna protocols. If you listen to anything about Andrew Huberman, you have been blasted with more information than maybe you've ever wanted to know about the sauna. But I want to pick just a couple papers here looking at sauna exposure, specifically after exercise. So Bezoglav and colleagues 2021 International Journal of Environmental Research and Public Health. This is a great study. This doesn't actually research anything on sauna protocols itself. I love this study. This is basically a patient expectation, an athlete expectation of what athletes expect will help them recover and what they actually choose when they are performing their recovery. And it's just really important to know this paper in the back of your head. That 97% of athletes surveyed use sauna as their number one choice for recovery. So that's really important for us to know. We have to be able to speak intelligently about good, bad pros, cons about sauna with our athletes knowing that 97% of them are thinking I'm not feeling great. I'm feeling banged up. I am going to choose sauna as my number one recovery protocol. And we know this from physical therapy research. Massage is also popular. Not surprising. It's popular with athletes. 87% of athletes choose massage as their secondary recovery protocol. And then 80% choose taking a nap, third. So in that order, sauna, massage, and napping. So that's a really important paper to know. Miro and colleagues from 2015 in Springer Plus. This is an online open access journal. Looked at comparing folks doing infrared sauna, traditional sauna, after performing either hypertrophy focused resistance training for 60 minutes or endurance training. So they basically wanted to create a bunch of muscular damage and then have folks either get in an infrared sauna or traditional sauna. This study also had a crossover design. So the objective outcome here was a counter movement jump test and then also effects on the cardiovascular system. So that traditional sauna was performed at 122 degrees Fahrenheit for 30 minutes. The traditional sauna was performed at 70 degrees Fahrenheit for 30 minutes. And again, both groups exercise really hard for an hour. The traditional sauna group saw a reduction in performance on the counter movement jump after sauna protocol compared to the group using the infrared sauna. The traditional sauna group also had a significant spike in their heart rate. About 30 to 40 more beats per minute resting while sitting in the traditional sauna than the group sitting in the infrared sauna. So again, like we talked about a couple papers ago with environmental exposure, it seems like using sauna, specifically a really hot traditional sauna after exercise, seems to have a negative impact on our system. Of it's just too much heat load, it's too much cardiovascular load. It can lead to both negative performance outcomes, but also negative physiological outcomes. Supporting that, Skorsky and colleagues from 2019 International Journal of Sports Physiology and Performance. This group was looking specifically at performance. They had swimmers perform 4x50 meter sprints. I don't know anything about swimming. I assume that's a tough thing to do to do 4x50 sprints. Afterwards, the swimmers were either put in a group where they sat passively at room temperature. For 25 minutes or they did three eight minute rounds in the sauna, a traditional sauna at 185 degrees Fahrenheit. And then they had those athletes come in the next day and repeat the 4x50 swim performance. All of the subjects who used the traditional sauna after the sauna reported a stressful experience, both physically and mentally. And then the next day all of them had impaired performance when they went to repeat the 4x50 swims compared to the group that sat at control. They obviously did not report sitting at room temperature as a stressful experience. And they all performed better at the 4x50 than the sauna group. So it appears that longer duration, hotter traditional sauna seems to have a more negative impact on recovery. So what does this tell us? What does all this research tell us? How can we apply this with our patients, with our athletes, when they're asking questions about sauna? Maybe they're already using a sauna protocol. So as we talked about two weeks ago, cold water immersion, cold plunging appears to have a really negative impact on performance and recovery when used directly after exercise. Compared to hot water immersion, whirlpool, hot tub used after exercise. And it also really seems to affect our ability to adapt to the heat. So the takeaway here is that if we're just finishing exercise, maybe traditional sauna, especially for a longer duration, especially for a higher heat duration, is maybe not the modality of choice. Just like a cold plunge is maybe not the modality of choice. Which is not to say we can't use heat as recovery modality. But if we're thinking we just finished training, we should look towards that hot tub. We should look towards that whirlpool. We should maybe look towards that active recovery. And we should save a really long, hot traditional sauna or a cold plunge for maybe before training earlier in the day. Or what we don't have research on yet is what is that window? How much time difference between training and using a really hot sauna or using a cold plunge is still going to allow us to feel better recovery wise but not have those negative effects on performance. We don't know that yet. But for now what we can recommend is stay away from that cold plunge. Stay away from that really hot, long duration traditional sauna about right after training. Give yourself a gap. Again, we don't know how long. Or do it earlier in the day sometime before you actually start your exercise protocol. We do know that both hot water immersion and infrared sauna offer cardiovascular effects that are similar to active recovery. So if we really are not feeling like exercising today, if we're really feeling like we need a day off, we can still have some positive health benefits from going and getting in the sauna. Especially something like an infrared sauna or sitting in a hot tub for maybe 10 to 30 minutes. But we really need to consider avoiding that long duration traditional sauna. It appears to have a big effect on our cardiovascular system. It's adding a training load. It's adding a heat load to our body that's going to cause our body to need to adapt to that stress. So big term takeaways. There's no shortcut, right? What we're seeing in the research with both cold water immersion and hot water immersion, there's no shortcut here. We need to allow the body's natural inflammatory response to the exercise that we just did occur if we want to reap the benefits of that occurring. Yes, these things can help us feel less sore. Yes, they can help us feel less fatigued. But if we use them too much, they do seem to have a long-term detrimental effect on our performance. Which kind of defeats the purpose of going in and doing a hard workout, a long run, a long bike, a long CrossFit session, a long weightlifting session, whatever you're doing. If we chronically use these things, yes, we might feel better. But we need to be concerned that maybe we're leaving something on the table as far as strength, as far as hypertrophy when we use these kind of extreme temperature modalities, cold plunging, really really hot sauna. I could imagine that one study that showed a really detrimental effect was only 185 degrees. Some traditional sauna protocols in the 200s. I know Jeff Moore does the sauna at 205 degrees, I think for 15 minutes, which is even more of a heat load than 185 degrees. So just be aware of that and understand how to speak about these things with your patients and athletes because they're going to have questions about it. Remember that paper? 97% of people look to sauna is the first choice for a recovery modality and then massage and then taking a nap. So 97% of people could use probably more education on sauna because we know they're thinking about using it. So I hope this was helpful. We have an entire week in clinical management fitness athlete essential foundations dedicated to this now. We talk all things nutrition, sleep, we talk cold water immersion, hot water immersion. We also talk about compression therapy. So things like massage, massage guns, cupping, all that sort of thing. We discuss all of that research that your athletes, your patients want to know about when they come into the clinic and ask about recovering from exercise. So I hope you have a wonderful Friday. I hope you have a fantastic weekend. Thank you for joining us. Have a good day. Bye everybody.

22:33 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. Jeff Moore // #LeadershipThursday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses that the decision to innovate or imitate is a career-defining choice with long-term implications. The host emphasizes that while collaboration and sharing of ideas are common in any field, blatant imitation is detrimental to one's career. The host distinguishes between collaboration and imitation, stating that imitation involves repeatedly hijacking other people's logos, sayings, or content.

The episode provides three reasons why being an imitator ensures a mediocre and short-lived career. Firstly, the process of creation, coming up with something new and contributing in a unique way, is described as the most invigorating aspect of any career. The host emphasizes the satisfaction and impact that comes from thinking differently and having others benefit from one's novel ideas or techniques.

Secondly, the episode highlights the importance of authenticity in career success. The host suggests that imitators may experience imposter syndrome because their success levels do not match their actual contribution. They are described as grabbing ideas from others, recognizing what will resonate with their audience, and building their business without truly creating or going through the challenges that lead to breakthroughs. The more their success grows without a true contribution, the greater the asymmetry and imposter syndrome.

Lastly, the episode emphasizes the value of continuous creation and innovation for a long-lived and energetic career. The host encourages listeners to keep creating and strive for novelty and harmony in their careers. It is emphasized that the decision to innovate or imitate is a defining one, and individuals should aim to put forth their authentic selves rather than copying someone else's.

Overall, the episode argues that choosing to imitate instead of innovate can lead to a mediocre and short-lived career. On the other hand, embracing innovation and creating something new is described as invigorating, authentic, and essential for long-term success and fulfillment.

Take a listen to today's episode.

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 JEFF MOORE Alright team, what's up? Happy Thursday, welcome to the PT on ICE Daily Show. I am Dr. Jeff Moore, thrilled to be your host, currently serving in the role of CEO here at ICE. It is Thursday, which means it's Leadership Thursday, but it also means it's Gut Check Thursday. Let's talk about the workout. This is going to be familiar to a bunch of you. So this is the workout from the CMFA Essential Foundations Course 21-15-9 Deadlifts Bar Facing Burpees. Quick, painful. Go get some of that. Post your time, post ICE Physio, hashtag ICE Train, hashtag Gut Check Thursday. It's a classic workout, we've done it a lot. It's a really nice benchmark one to challenge yourself in that kind of middle distance, high intensity space to keep coming back to every year and see how your fitness is evolving. So give that a shot. 21-15-9 Deadlifts and Bar Facing Burpees. Upcoming courses, I want to highlight Modern Management of the Older Adult Live because we've got a ton of options. So if you're trying to become the fitness for provider for your older adults in your community, you've got to hit the MMOA Live course. This weekend, they are in Watertown, Connecticut. Next weekend, July 29th, 30th, they are in both, Waukonson's, Georgia and Meridian, Idaho. That'll be the first, that's in Boise. That'll be the first course, I believe, at Onward Boise. So go get some of that. And then August 5th, 6th, they are at Onward Physio in Frederick, Maryland. Important to note, August 12th, 13th, they are in Lexington, Kentucky, and that is at Stronger Life, and that is the MMOA Summit. So if you want to meet all the MMOA faculty, they're going to be at that one course, August 12th, 13th, and that's at Stronger Life. So if you want to see the Stronger Life operation that Dustin and Jeff and the crew have been building out in Lexington, that is a really, really cool opportunity to kind of see behind the curtain and meet a ton of faculty. So go check out those courses. That's Older Adult Live on the road everywhere. So go get some of that action. Innovation or imitation, the career-defining decision. That's what I'm calling this episode. And I am not saying that lightly. I think if you really zoom out, and if we're talking leadership here on Thursday and thinking about looking long, long term at your career, if you decide to innovate or if you decide to imitate is probably the great decider. I mean, let me tell you the three biggest reasons why. But let me first note that we're not talking about sharing ideas, building off of each other, sharing techniques. There is a very reasonable amount of collaboration that is not copying an imitation. We're talking about blatant imitation, right? Where you know who you are, that you're hijacking other people's logos or sayings or content on the regular, right? Over and over again. I mean, if you scroll your feed, it's like you're obviously doing this. You've probably been reached out to. And then on the other hand, many of you probably have your own imitators, right? Where you look and you're like, gosh, that person's always taking my stuff and trying to put a very lame or benign twist on it. But it's pretty obvious what's going on. That's what we're talking about. Being that person, being in a position where you've got that person tailing you, we're going to unpack both sides of it. There's only one line on being imitated, many lines on being the imitator. So three reasons why being an imitator ensures a mediocre and short lived career. Number one, creation. Coming up with something new. Feeling like you really contributed because you saw something a different way or said something a different way and other people legitimately benefited that would not have if you didn't create that process is the single most invigorating thing in any career. That process of thinking differently, of contributing something novel, of having somebody come up to you and say, Hey, because you said it that way, things have really gotten better for me. I hadn't heard it like that. I hadn't thought about it like that. I have not used that technique. And now because you did that, things are better off in my sphere. That process of creation is the single most rejuvenating thing in any area of business. When you look at entrepreneurs, you look at people who are constantly high energy, are constantly seem to be thriving. It is largely because they're tapping into that creation energy on the regular and it gives back three times what you give it. That process of doing things novel and useful is what extends careers. It's what makes careers exciting. It would make it so it makes you get up in the morning and be absolutely beside yourself to dive into that next project. It's what builds anticipation for the next year of business. It is all of the things that constantly give you energy back that make burnout sound like a ridiculous idea because you couldn't imagine ever wanting to stop riding that train of creation. Creation is invigorating. And if you're copying, you're not creating. So you're never getting that energy back. And there is simply a timeline for how long you can go without it. Number two, this is the one that people don't see when they feel like taking other people's ideas is a viable way to continue their business. It's not. And this is why you can't build on a foundation you didn't pour. I'm not saying you can't go take the idea and put it on your platform and get a few likes. You can do that. You can get a short term bump in your business. There'll be plenty of people who didn't know you did it. Like you can do that, but you can't build on it. One breakthrough and by breakthrough, I mean the process of the breakthrough. When you were thinking about a certain idea and you realize in the moment, hold on, there's a better way to do this. There's a better way to say this. There's a better way to build this. That process, that breakthrough, having that moment changes you. Like it really changes you because not only will everybody that you told think a little bit differently or be able to use it novelty, but you changed because your mind saw a different pathway. That change is what's required to make you different, to see the next thing. When you're going through the hard work of trying to make something better and having that breakthrough, that process of when it happens is what allows you to see the next one because you're now different for having had that breakthrough. If you're just hijacking ideas all the time that sound good or look good or think might get you some business, you're not actually changing. You're not developing. You're not going through those breakthroughs. So you're not going to have the next one or the next one. So pretty soon your only option is imitation because you're not doing the work of creation. You can't build on a foundation you didn't pour. Other people's ideas being on your platform does not make them yours from the sense of you are not different for having come to them. So there is no way now that you're going to be able to go from there because you didn't even really get there. So think about how hijacking that process prevents your ability to look even further. The final one, and I don't speak all that much on this topic because it kind of annoys me, but it's important to acknowledge this is where imposter syndrome I think actually comes from. The worst cases of what you would call imposter syndrome, a complete lack of authenticity in an individual in a certain position that maybe didn't earn it, you can kind of feel that, that case of imposter syndrome, the worst cases are when somebody's, and I'm those listening on the podcast, when somebody's success levels don't match their actual contribution, and this is the case of the imitator, right? So somebody who's grabbing ideas from other people and they're catchy ideas, right? They're good at recognizing what's going to resonate with their audience, grabbing ideas from other people, putting them out on their platform, never really creating, never really never going through kind of the trough of challenge that leads up to a breakthrough, never experiencing that, just hijacking ideas and quote unquote building their business. The more their success grows in the absence of a true contribution, the greater that asymmetry, the greater the imposter syndrome. And the problem is the momentum only goes in one direction because like I said, once you start imitating, you're no longer changing, so you can't make the next step forward, so you're never going to. So all you're going to wind up doing is put yourself in a position where people think that you know a lot of stuff or have done a lot of the work when you know you haven't. And the more quote unquote successful you get, a lot of people knowing of your work and maybe even financially benefiting from it, but the more deep down you know you haven't really done any of it, the greater that asymmetry, the more fragile your steadiness in that space because of the absence of authenticity. You know deep down you haven't earned that success and the more that asymmetry grows, the more other people can feel it. The phonier it feels, the more it lacks authenticity. And team, as we talked about over and over again on Leadership Thursday, authenticity realness is at the end of the day, what people really resonate with long term. And you will have less and less and less of that every year, the asymmetry of what it looks like, you know, and what you've actually contributed grows. That is an exhausting place to be. Nobody likes that feeling of I'm going to be exposed. Nobody likes that feeling when it's getting worse and worse and worse and worse every year. It will eventually overwhelm that person. And that's what brings me to the last point of this podcast. For those of you out there who are doing the hard work of creation, who feel like you're often being imitated by that person in town, by that person online, whatever, right? You feel like gosh, I really thought that, you know, I put a lot of effort into that and it kind of got hijacked, right? And you're feeling that chronically. You're not. Because those individuals always succumb to the above. They can't have longevity because creation isn't filling their cup. They can't jump from a foundation they haven't built. And every time they do that to you, their imposter syndrome grows. They know it was your work. They know they didn't and couldn't have thought of it. But they also know other people think they did. And the more that asymmetry grows, it has a breaking point. They never have longevity in the space. So stay in your lane and drive fast. We know how frustrating it can be, right? We know how exhausting it can seem at times. But understand that because of the above, every single one of those people's careers will be short lived and fizzled because all of the above are fixed equations. There's no getting out of that stuff. It's the wellspring of what a long lived energetic career can be. In the absence of those things, it simply can't be. So for those of you who feel like your work is being ripped off, let that be kind of a statement of confidence that I promise you because of all of the statements above, that will be a temporary discomfort for you. Keep creating. Team, innovation or imitation, it is the career defining decision. Do the work to try to come up with novel things that excite you, that excite others, that bring harmony into your career because you're actually putting forth your authentic self, not somebody else's authentic self. Do it right. You only get one shot at it. Cheers, team. I hope that helps on Leadership Thursday. I will see you over here next week. PT on ICE.com. It's where all the goods live. Have an awesome Thursday.

13:18 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.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.

Christina Prevett // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Christina Prevett discusses the significance of research in the field of physical therapy is along with the importance of translating that research into evidence-informed practice. She acknowledges the substantial nature of their research and highlights the necessity for clinicians on the front line to have access to this valuable information. Staying up to date with available evidence and combining it with clinical expertise and patients' experiences and desires is emphasized as crucial for clinicians. The episode also addresses several gaps in research that need attention, including the need for rehab research for individuals in sitting positions, outcome measures for wheelchair users, and managing conditions in neurological populations. The host expresses frustration at the lack of clinically relevant outcome measures for wheelchair users and emphasizes the need for research to support the role of rehab in enhancing quality of life and managing various conditions. Overall, the episode underscores the importance of research in informing and improving physical therapy practice.

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 omn 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 CHRISTINA PREVETT Hello everyone and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty in our geriatrics curriculum. So in our geriatrics curriculum, we have three courses in CertMMOA. We have our online eight-week essential foundations course, our online eight-week advanced concepts course and then we have our live course. We are on the road in the summer and into the end of 2023. So our books are closed for 2023. So we have all of the courses that are going to be on the 2023 calendar on the calendar. And so if you are looking to get into one of our courses, know that there isn't going to be an option for something closer until we're kind of booking for 2024. So this weekend, Julie is going to be in Watertown, Connecticut. And then the next weekend, 29th, I guess it will be two weekends, 29th, 30th, I'm in Watkinsville, Georgia. There's still some room in those courses. And so if you guys are interested, just let us know and come hang out with us for all of our geriatric research and all of our geriatric course material. Okay. In today's content, on Monday, I talked about gaps in pelvic health research. So I'm on our pelvic faculty as well. And so today I'm going to take the exact same approach and talk about gaps we see in the geriatric research. I am obviously in full blown research prep mode. I am defending my PhD on resistance training in older adults, at risk older adults at the end of July. So you're going to see me full blown in the research space. And so hence the topic of these podcast episodes. When we are comparing different areas of literature, and we're talking about geriatric rehab in particular, one of the things that I want to start out with is that the state of our research in geriatrics is actually pretty good. You know, we are pretty far ahead when it comes to comparing to other areas. Like when I compare to pelvic health research, there is no comparison. I can off the top of my head bring out 10 studies that have never actually even been done before in our pelvic health research, but I cannot say the same thing in geriatrics. I had to really, pardon me, I had to really think about where I thought our gaps were. And obviously I'm thinking about this around my contribution to the literature with respect to my PhD. So the first thing that I wanted to talk about is the fact that our research is pretty good. You know, we have a lot more in this space and now we're kind of going into the nuance of our rehab and how to translate the research that we do have so that clinicians who are on the front line have access to that research and can really truly embrace evidence informed practice where they are up to date with the evidence that is available. They're taking their clinical expertise, they're taking their patients experience and desires and kind of combining them together. So that's the first thing. So I'm going to be talking about four, three or four different gaps in the research that we have so far and what this means when we are making recommendations or we are thinking about them with respect to our plan of care for our older adults. So the first thing, and I'm on, this is my bias because this is where my PhD was, was we have very few studies that have looked at high load, low repetition weight schemas for resistance training with older adults. We have one that I can think of maybe two studies and the second study is kind of an ish because it had a descending rep scheme where they use less than five repetitions and higher loads. My PhD tried to change that. I did two pilot studies that looked at the safety and feasibility of a three sets of three to five repetition schema at an intensity of seven to eight out of 10. So that high vigorous intensity, high load, low repetition resistance training. And so it's important for us to know this, right? We don't have this research. And when it comes to the way that we work in geriatric literature is that we see what works in our younger or middle aged individuals. Then we push into our healthy older adults and then we push into pathology. Right. This is the story that we saw with high intensity interval training, for example. Right. We saw that it worked in athletic populations. We started pushing the intensity into HIIT training in middle age, healthy older adults. And now the state of the literature, we cannot even deny it because we have evidence for HIIT training in a variety of different pathologies, multimorbidity, obesity, different age groups, et cetera, which is great. We don't have that yet when it comes to geriatric literature in this high load schema. What we see from a muscle physiology perspective is that the magnitude of strength increase tends to bias heavily towards heavier weights. See the one that I did there versus lower weights, higher repetitions. When it comes to individuals who are doing nothing and they start doing something, of course, we're going to see improvements in strength at any set reps. But the magnitude of those differences tends to bias when our loads are heavier. Because we don't have anything in the under five repetition schema, we see this reflected in our exercise guidelines. Right. Why are our exercise guidelines the way they are? Right. Two to three sets, eight to twelve repetitions, 60. Now we're kind of pushing into that 70 to 79 percent of a person's one repetition maximum is the standard exercise prescription that we're seeing out of the American College of Sports Medicine. We saw it in the International Conference for Frality and Sarcopenia Research consensus statement. And this is because that is where the vast majority of the literature goes. And this is where this momentum can build around two to three sets of 10. Right. Because we've always done it this way. There's a good chunk of literature that's there and we don't have anything on the flanks. Right. We don't have anything in under five. We don't have a ton in the 20 plus. And when we get into the higher repetition ranges, now we have this interference that can happen between cardiovascular fitness and neuromuscular fatigue. And which one is the one that's breaking down first or is the limiting factor? All of this to say. When we don't have those discrepancies, we have to be mindful, one, about the strength of our recommendations, but number two, we have to be pushing towards trying to get studies that evaluate this type of loading schema so that we can take a big picture view and then really start to look at dose response data. So that's number one is that we don't really have a ton of studies that look at repetitions less than five and kind of my one B is that this influences things like our exercise guidelines and not in a good or bad way, just a we have to use what's available. And that's why things are the way that they are. The second one is going to kind of be a blend of pelvic health because we in advanced concepts, we go through in week five urinary incontinence and pelvic health issues and geriatrics. And I've talked about this a bunch on the podcast before. But we have very little evidence that's looking at conservative management of pelvic floor dysfunction for individuals over the age of 65. And we have almost nothing when we look at individuals over 75 or 80. Urinary incontinence is one of the leading causes of institutionalization. So where individuals need a higher level of care, end up in assisted living, end up in institutionalized setting is because of issues with urinary incontinence. That should be justification enough that that we need studies in this area and kind of this one B or two B to C type of step down is we don't really have a ton on pelvic floor muscle training in older adults. We have some. It's not a ton. Oftentimes, our older adults are giving are given medications that influence their urine flow rate, whether that's directly with medications being given to work towards helping with kidney function or things that are given as a consequence of having urinary incontinence that change urinary flow and urinary output. A big example that has nothing to do with either of those things, but is actually a side effect because this is the second classification is individuals are given a medication for one issue and side effects relate to urinary incontinence or other pelvic floor dysfunctions is Lasix or diuretics. Individuals who are on diuretics can have horrible, horrible problems with urinary urgency and urinary incontinence or both. And it has a huge impact on their quality of life. And right now, the only research we have is that it negatively impacts their quality of life. And the next step is to try and figure out what to do about it or what can we do about it conservatively? Can we change medication timing? Can we work on different things? Can we work on urge suppression techniques? Is that going to be relevant because urine outflow is higher because of the water pill? There are so many questions, but we have nothing like we have zero studies that have looked at how to help our clients with urinary urgency or urinary incontinence as a consequence of their medication regimens. This is important because the thing that happens is that people stop taking their meds because they literally cannot go out of their house or cannot be too far from a bathroom without not taking their pill. Because if they're on their pill, they're going to the bathroom all of the time for the five to six hours post taking their medication. And so this can essentially make a person homebound. That is important, right? In PT, that's a super big thing. In OT, it's a super big thing. In rehab in general, we are trying to discharge homebound status. And this is a big influence of that. Kind of in this urinary incontinence vein for the elderly, for our older adults, you know, we have conservative management in general. We have men management in combination with conservative management when there is a medical side effect because of the medication a person is on. And then the third one is some of the issues that we see post catheterization. So individuals who are placed with an indwelling catheter and then are removed from that get into this situation where they are in bed, they go to the bathroom whenever they need to because the catheter is there. And then once the catheter has been removed, sometimes there can be a disruption of pelvic floor musculature. There can potentially be damage to the urethral structures. And then you also have to try and work on those urge suppression techniques so that now you're not just going to the bathroom whenever you get the slightest urge to go to the bathroom, but you're holding it in order to go to the bathroom when it's convenient for your schedule or when you have the block of time within your day that you can go to the bathroom. We are now also seeing different types of catheters like periwicks, which are external catheters. And what do those do? All of these things that we're seeing hugely in acute care, we're seeing it in, you know, individuals going into home health. This kind of goes into neurological populations who may be doing self catheterization. All of these things and the role of rehab in managing these conditions to improve a person's function and quality of life really has been understudied and a big low hanging fruit that we could potentially be having huge impacts and potentially preventing transitions to institutionalized care is by being able to tackle some of these problems. But we need the research to back us up first. So that's number two and two A and two B. And then the third one that we're going to talk about, and I think this one is a frustration point for a lot of our clinicians, is clinically relevant outcome measures for our wheelchair users. So we have a ton of outcome measures in the geriatric space. One of the things that I think is actually really cool is that in our rehab space, our geriatric outcome measures are very strong. We have we have several options. We have good cutoff scores. We have reliability and validity data. We have minimally clinically important differences. All of these things. We have standardized protocols. We have different MCIDs, different reliability and validity data across different settings, which makes sense because our older adult population is extremely heterogeneous. All of that is good. You know, that is great. We touch on that a lot in MMOA about how we want to be leveraging our outcome measures and not just for the sake of doing outcome measures, but in order to guide our clinical reasoning and create risk stratification, which is what they're intended for. The problem becomes when we have a client who spends a good portion of their day in sitting. When it comes to our outcome measures, we have this Goldilocks type of scenario that we need to be mindful of. We are going to have a cohort of individuals who are going to experience a floor effect and a person who is a wheelchair user on a 30 second sit to stand test is a very good example of that. They are going to get zero and they are probably always going to get zero. And therefore using a 30 second sit to stand test for a person who spends the majority of their day in a wheelchair is not helpful. We also see that we're going to have some older adults who are going to have this ceiling effect where they are going to knock it out of the park and we're not getting any information. When I was working predominantly in outpatient, one of the first things that I would ask my older adults who walked in independently into my clinic was can you stand on one leg? I was not going to be wasting 15 minutes of my time doing a Berg on those individuals because it's a waste of their time. It's a waste of my time and it doesn't tell me anything. And so we have to kind of figure out we want this composite, we want these tools in our toolbox that we can pull and leverage based on our clinical impression after a person's subjective. But when we have individuals who are sitting, we have very, very few outcome measures. We have the function in sitting test, we have stuff like the FIM. We can maybe start using the Berg and look at some of their transfers, but our pool to try and fit this Goldilocks scenario is quite limited. And so we really do need to think about clinically relevant outcome measures for things like transfers or bed mobility or things that are relevant for them. And these things are starting to come out. We have some pilot research on different outcome measures. But what we try and leverage now with an MMOA is trying to get objective data for things like transfers. And what that can look like is instead of giving MinMondax assist, which is important, we're going to do that based on our clinical judgment, but also put a timer on it. And so if we can put a timer on it, then we can see the first time we did this sitting at the edge of the bed transfer, it took us five minutes from start to finish. And now it's taking you 30 seconds. Like that's a huge improvement or it's taking three minutes. That changes the flow of a person's day. It helps the caregiver a ton. It makes individuals feel more capable who are trying to help their caregivers with their care. And so we also need the research to back us up with that. And we need help to try and figure out how we can justify our rehab for individuals in sitting. If we can't use the outcome measures that are so commonly prescribed in different settings to try and see improvements over time. And we can make huge improvements in a person's function and a person's capacity who may not have the potential to get into standing and do more standing tasks, but still has an infinite amount of potential to improve their quality of life and the things that they're doing throughout their day. So those are kind of my big three areas in geriatric practice that I think we need to be focusing on that rep dose response data in resistance training, where we're looking at load under five repetitions and seeing, does that have any improvements or the magnitude of that improvement in strength with, with a direct influence on a person's physical function? When it comes to pelvic floor in the older adult space, we have a lot of work to do when it comes to just conservative management in general in our individuals over 75, anything with response to medication management, symptoms, side effect profiles of medications and their influence on the pelvic floor. And then post catheterization work, whether that's indwelling or external catheterization and what that does to things like urgent continents. And then our third is helping our individuals who are spending most of their day in sitting. How do we help our wheelchair users so that we can justify our care, have normative data and reliability and validity data of outcome measures to be able to speak to our insurance providers who are, you know, a lot of times we're trying to justify our treatment interventions and then make sure that we know when we're making clinically relevant changes in their quality of life, when the goal of getting them in standing is not the one that we're looking at. All right. I hope you found that helpful. If you have any other questions, just let me know. I'm going to be in the research space a lot in the next couple of weeks. I might be sick of it by the time I get to the end of the month with my defense. But let me know what your thoughts are. If you have any other questions, if you are not signed up for MMOA digest, that is our every two week newsletter where we bring all of that research to your inbox. So if we see any studies that are coming out that are filling in some of the gaps that we were talking about, you're going to know about it first. If you're signed up for MMOA digest, just head to ptnice.com slash resources. If you're looking for research in general, make sure you are following hump day hustling. All right. Have a great day everyone. And we'll talk soon.

20:07 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. Zac Morgan // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the importance of including lumbar flexion in a robust rehabilitation program. Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 ZAC MORGAN, PT Good morning PT on Ice. I am Dr. Zac Morgan. I am with our spine faculty, so I lead the spine division teaching lumbar and cervical spine courses. And this morning's episode is going to be a little bit on that topic of spine pain and specifically why low backs must flex. So we'll get to that, but before we do, let me just point you in the direction of a few courses that we have coming across the country over the next few months for both lumbar and cervical. So over in Richmond area, lumbar, the next offering will be September 23rd. We actually have several courses going, lumbar that weekend. So if you're anywhere in the country and you want to catch lumbar spine, September 23rd is a good one to have marked down. So it will be outside of Richmond, in Baton Rouge, and over in Parker, Colorado, right outside of Denver. So several good offerings spread all around the country. If you're looking for cervical management, we've got a few coming up as well. We've got Brookfield, Wisconsin, that's July 22nd, that weekend. And then August 26th and 27th will be over in Charlotte, North Carolina, and then September 9th over near Atlanta in Roswell, Georgia. So several good open offerings. If you're looking for one of those spine management courses, we'd love to see you out on the road. We'll have a bunch more throughout the year. So watch the website, watch the podcast, and you will know when we're going to be in your area. This idea for this episode came into my head this morning about, or not this morning, this idea came into my head over the last few weeks as I've seen more and more posts from, we'll just say Instagram influencers, people that are in this space of Instagram and perhaps are physical therapists and treating a lot. And I see a lot of vilifying of lumbar flexion, specifically a lot of pointing towards anatomy and the reasons why people shouldn't flex based on their anatomy. And the most common reason that you're going to see people vilify flexion in the low back is due to concerns of disc herniation. And we all know that there's some older studies that have pointed towards lumbar flexion, putting an increased pressure on the posterior annulus of the disc, and thereby making a lot of therapists for a long time very concerned about having their patients move into flexion because of the fear of every flexion weakens the posterior annulus of the disc. And with each flexion, you're actually weakening that tissue, eventually causing a problem. But I want to push back on that narrative a little bit. Now understand that at ICE, we think of back and neck pain in patterns. So there are some patterns of back pain where I will withhold flexion on my clients. I'll tell my client, hey, please, I need you to stop flexing. Sometimes I'll even utilize tape so that that way they're able to feel when their low back is moving into flexion. But that pattern is fairly obvious. And that one is what you classically think of as more of your lumbar radiculopathy or derangement presentation. And typically in that client's objective exam, when you ask that person to move into flexion, they're going to worsen. So each time you have them flex, they'll either lose range of motion in deflection, meaning their fingertips won't slide as far down their thighs as they did prior, and or they'll peripheralize. Their symptoms will exit the low back or maybe intensify in the low back and start to spread down the limb if they have some sort of sciatic related complaints as well. So if you're seeing a loss of forward flexion and or peripheralization of symptoms, that is the client where I would withhold flexion and not forever. I would tell that client on day one, Bill, right now, when you've been forward, your symptoms are getting worse. For the next couple of weeks, I need us to be really judicious and careful with forward bending. But understand that is a normal, healthy movement for your low back to make. And one day we're going to get back to it. So make sure you always prep them with that because we want that client to know we're coming back to flexion no matter what. Flexion is a normal part of the range of motion of the lumbar spine. It's really challenging to move through the world without flexing your low back. If you don't believe me, go ahead and throw some tape or have one of your coworkers throw some tape on your back and see how often you're pulling that tape top. Every time you put your shoes and socks on, when you sit on the toilet, putting your pants on, loads of things make your back into reflection. People recognize this when they hurt their back and they're flexion sensitive. All of a sudden they're like, wow, I didn't realize how much I use my back. What they're usually complaining about is that flexion. I didn't realize how often I flex my back. So let's get into it. There's a time and a place to withhold flexion, but it's certainly not everybody because for most people they need to be able to move. So one pattern in particular that pops into my head of people that really need to flex is the dysfunction patient. And if you're McKinsey trained, you've probably thought of this in terms of like, if a derangement doesn't clear up their end range flexion, they will become a dysfunction. But I like to think of that pattern as more all encompassing. Essentially a dysfunction patient is someone with soft tissue extensibility dysfunction across the posterior side of their spine. Meaning they don't have the elasticity in their muscles, in their paraspinals, and all the structures on the posterior side of their spine. They don't have the elasticity to move into flexion. And you'll hear this person say things in the subjective exam like, Zach, it's so tight. It feels very tight. It feels like I need to stretch. My back is always tight. When I wake up in the morning, my back is tight. If I've been standing for a long time, my back will get tight. If I have to sit for a while, my back will get tight. You'll hear them complain of things like tightness. And one thing that always stands out in this person's objective exam is you'll ask them to forward bend and they'll turn to the side and go to forward bend. And you'll see that they only access hip flexion. They actually don't reverse their lumbar curve at all. So you'll see that low back just stay flat as they move their fingertips down their thighs and their hip flexion will eat up all that motion. Often this person will have adapted pretty decent hip flexion. And sometimes I'll even see them put their palms on the floor. But if you look at their lumbar spine, there's no motion coming from them. So when we see that pattern, often flexion is part of the solution. Getting that person's low back to accept load and deflection can be part of what helps them solve this problem. So I always want to be really careful when it comes to vilifying any motion, because for some people that motion's the solution. While for other people that motion may really bother their symptoms. And this is the big overarching point is one solution is never going to work for all of back pain. If there was one solution, if the solution was to not flex, or if the solution was to only extend or spinal manipulation or dry needling or anything, we wouldn't see back and neck pain be this multi tens of billions of dollar problem year over year. If we had it figured out that well, this problem would be much easier to solve. So it seems clear that some people need it and other people's don't. And that's how back pain works. That's why you listening to this episode as the provider need to be confident in this space and understand that not one prescription works for all of back pain. So let's talk about why flection works a bit. And some of the things to think about moving forward, just to help push back again on that narrative of vilifying flection. First things first, with a lot of these people, they feel very tight and they feel very compressed. I don't have perfect proof for this, but if you think about the attachment site of the pair of spinals, I mean, from the base of the skull all the way down to sacrum, those big ropey muscles run parallel to one another on either side of the spine. If that person's tense, if they truly are tight, if their nervous system is just really heightened in the region, often that tone in those pair of spinals goes up. And what you see is a compressive type feel when they have it in the neck, they'll feel like somebody's got their hands on their head, just pushing down in the low back. They just hate sitting or hate compressive load. And one person that tends to do really well with flection based exercise is this one. So often, if you have that person start to put some length into that system by repetitively challenging flection, those muscles will relax a bit and the tone will drop some. And as that tone drops, the person will report a better feeling in their back. Hey, it feels like it's stretched out. That really feels like a good stretch, Zach. I love moving in that direction. Yeah. Now that I've done that, I feel better. Reminder the derangement patient who doesn't need to flex. They're going to feel worse each time that they do this. The dysfunction patient may feel bad while they're flexing, but they feel better after. So that's one of the key differences. And part of that is cause I think we're reducing some of the compressive load. That's just sort of statically sitting on this person's spine by getting them to move those muscles. So one thing that's nice is we get a reduction in that compressive load. This kind of goes hand in hand, but that subjective report that your patients give you of, man, my, my back feels so tight. It's so tight. I need a stretch. This addresses that feeling for whatever reason, their nervous system feels as if they're tight in that region. Sometimes people are, they truly have muscle extensibility dysfunction. Other times people are just tense and they have a hard time relaxing those muscles. Either way, repetitive flexion in my practice has been a really good way to sort of give those muscles some input or give them some actual stretch that allows them to lengthen out and allows that person to move with more, uh, fearless, thoughtless movement that allows them to kind of move about their day without feeling like a robot quite so much. So often getting rid of some of that tightness feel involves doing some stretching. And I realize I'm kind of going counterculture here because I feel like the pendulum is swung very far away from sweat stretching. But the most common question I get asked in the clinic is, can you show me a stretch for this? And I know a few of you are laughing and thinking, gosh, yes, people always think that's all we do is show stretches, but people see value in stretching. And if we believe in, in, um, patient expectations, then we should match those expectations to some degree. I'm not saying we're not going to load as well. We're off. We're going to do that. If the patient's impartial, my preference is certainly eccentric exercise because you get the added benefit of tissue durability alongside lengthening. But if we're just trying to get the person to buy in, I'm all for stretching and often stretching those pair of spinal makes this person's back feel way, way better. The next piece is just motion is lotion, right? Like our, our body is built to move. It is not built to be static. It has been adapted over years and years for movement, not for desk sitting, not for being really still. And so part of this is just motion is lotion, right? Like when we get a fluid exchange through those structures of the spine, through those muscles, the person's back feels significantly better. And there's no reason to run from that. We want that fluid exchange. We want that person moving around. And then the last piece team that I want to emphasize is why we should flex is that function is huge here. So if we were unable to flex our back, things like putting on our socks are completely a disaster. If you don't, if you've never experienced a derangement, I hope you never do, but spoken from someone who has that morning, you wake up and you can't flex. Everything's harder. You're considering asking your wife to help you get your pants on because it's so hard for you to move forward. We have to be able to flex. If we can't flex, all of those activities get way harder. And if we put forward the message that you need to be fearful of flexion because of your disc health, people are going to stop doing it. They're going to see those videos and they're going to say, you know what, that person's an expert. Let's be really careful with flexion. We don't want people being careful with flexion. Now I would never coach someone to lift a heavy load, a maximal deadlift with their back flexed. And that's partially due to, I do think end ranges are probably not the best for lifting, but a lot of it's performance, like straight lines or strong lines. I love when Mitch Babcock says that when we get the back flat, you can utilize your hips so much better and you can move more load. So from a performance standpoint, it makes sense to me to keep the back flat at heavy loads. When we're talking about putting our shoes and socks on, when we're talking about grabbing something off the floor, when we're talking about even doing things like ski, Yerg, GHD sit-ups, rowing, our backs are going to enter flexion. And if they don't, that will start to feel like movement dysfunction for the person. And if they try to stay perfectly flat through all of those things, it often drives this dysfunction pattern. So team, I really just kind of wanted to hit the high levels here of why our backs have to flex. And like I said, I see it over and over where there are different influencers who are vilifying lumbar flexion. And I think it's something that we as a PT community need to stand against. And it's not that we need to vilify those influencers. They are putting forth great information as well, but I do think it's a bit of an outdated narrative, outdated narrative for us to stop flexing the low back. Are there people who need to transiently limit their lumbar flexion? Absolutely. I see them all the time in the clinic. It is not rare for me to say, Hey, I need you to hold back on that motion for the short term. That said, do we need to drive a bunch of content towards making people fearful of that motion? No, much like knee flexion. We don't want people afraid of knee flexion. Same deal with the low back. It's just like everything else. It's a bunch of joints with a bunch of muscles surrounding it and a bunch of nerves giving it input and output from that region. That area needs to move. So let's not vilify it. The next time I'm on here, what I'm going to do is show you on a technique Tuesday. So we'll bring back technique Tuesday and I want to show you some mobilizations that I love to improve lumbar flexion in this person that we've been talking about. So that's all I've got for you today. Hope you have an awesome Tuesday and we will be back tomorrow morning. Same time. Thanks team.

14:56 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 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.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Christina Prevett discusses current gaps in pelvic floor physical therapy research. 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 INTROWhat'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 PT on ICE Daily Show.

01:27 CHRISTINA PREVETT, PT Hello, everyone, and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. I'm so excited to be on the podcast. I feel like it's been a hot minute since I have been on here because our other faculty have been doing such an amazing job sharing content with you. If you're looking to get started and join us within the pelvic health division, we have our eight week online course starting today. So eight weeks going from preconception all the way to postpartum return to sport. We're going to spend a ton of time going through different concepts, research, all that fun stuff and then you get to hang out with us for the next eight weeks. So if you're interested, make sure you go to PT on ICE.com and you should sign up while you're there for our pelvic newsletter. So we're going to be talking about research today. That is where we send out new research articles that the faculty sees and we have a pretty big announcement coming into the newsletter. So if you are not on the pelvic newsletter, you should go to the resources page on PT on ICE.com and join because there's fun stuff happening over there. All right. So today we're going to be talking about gaps in pelvic health research. We have done an incredible job over the last several years of starting to fill in gaps in our knowledge. And part of the reason why we do not have as much research in some of these areas is because the rise in popularity of some of these movements or these exercise trends has really changed over the last five to 10 years. And research takes time. It's important for us to know where the state of the research is so that we know how much confidence we can give to our recommendations and assessments. When it comes to evidence informed care, it is three pronged, right? We have our evidence base, what research says. We have our clinical expertise and we have our patients or clients lived experiences and their hopes and desires. And when we don't have the evidence base, we rely on the other two. However, there is bias that gets introduced there. There's bias that gets introduced in research as well. But I think it's important for us to know what we can confidently say from a research perspective and what we can't. So today I'm going to go through five big gaps that I have seen in the pelvic health research. If you are interested in doing a PhD from somebody who is about to defend their PhD at the end of the month, here's great topic areas because our research base is really small or completely non-existent. And the completely non-existent one that I'm going to start at the very beginning because it actually blows my mind is on C-section scar massage. Scar massage after a C-section is the gold standard for helping with the rehab process. It creates more movement and motility. It allows us to get into more stretched positions. Some individuals have seen potentially some association between adherence and scar tissue and low back pain. Alexis did a podcast episode on a case study with that. But we have no research in any type that has looked at C-section scar massage. And that blows my mind because we are so confidently talk about using C-section scar massage. And it's because clinically and with our patients right there lived experience, we see such a huge benefit. Because we don't have any research, why? We can't even say is this effective or not. But the second thing is that we have no idea around dosage. Do you need to start at six weeks? Can you start at six months? Is it the same effectiveness? Should you be doing two minutes or five minutes? We don't have any research that is looking at what is the most effective dosage or does this work at all or is it a placebo because we're starting to desensitize our body to that surgical site. We don't really know. And so it's really neat to see and really important for us to recognize that there is a huge gap there that should be getting filled. All right. The second one that we see a complete lack of research in and this became really relevant with some of our athletes is around coning during pregnancy and its impact postpartum. Really confidently people say online that you should avoid doming and coning during pregnancy within our pelvic health division. We do not create fear around doming or coning. We try to minimize it as much as possible by getting recruitment from other core muscles because we think that is going to keep the pregnant core stronger, not because we are trying to mitigate damage, not because we are trying not to ruin anything, not because we are trying to prevent diastasis recti postpartum. But we know, pardon me, that when we reduce that coning that usually that also means that individuals are stronger. Unfortunately the prevailing messaging online is that if you cone during your pregnancy, you're going to have diastasis recti postpartum. And we don't have research either way about that narrative despite how confident people are saying that. What we do have research for is that individuals with postpartum diastasis recti are weaker than those that aren't. And so by scaring individuals around avoiding coning during pregnancy, we may be unknowingly or unintentionally deconditioning that pregnant person and their core. And so we need to be doing research on this about, you know, what if we don't do any modifications to their core training? What is that going to do for them postpartum? You know, when I think about a late term pregnancy, that stretching of the linea alba, when a rectus contracts, it comes together and there's going to be almost like an air pocket that occurs because of that lengthening of that tissue. In my mind, like that, especially a little bit of that is not something that I see as quote unquote bad. But I know that I am not not everybody agrees with that narrative. So we just need to be sure that we're doing more research on this. So that's number two. Number one, C-section scar massage. Number two, avoiding coning during pregnancy and its influence on postpartum outcomes. Number three is any postpartum protocols for return to activity. We have maybe the beginning of research in the running space. And largely in the running space, it's helpful because a lot of people enjoy the sport of running. It's an easy barrier. There's no barrier to entry in terms of just putting on running shoes and going on to the pavement or onto the trail. And so we're starting to see more and more research. But when we're trying to look at things like risk factors for issues with postpartum return to running, we're seeing a huge amount of variability. And that is where us and the pelvic PT space and us in the PT space in general are like well done because everyone is going to have different experiences, different support systems. All of those other factors are going to influence. And so we see some people are waiting a full 12 weeks before they go back to running. We have other individuals like our elite level athletes who are starting with four to six weeks and are back to 80 percent of their running volume by 14 weeks plus or minus 11 weeks at standard deviation. So a huge swing in terms of how long they are going back or how long they are waiting before going back. And so we need to try and look at some of this early return to activity and try to figure out different protocols to try and minimize risk for not only pelvic health concerns, but we're seeing also a larger risk for musculoskeletal injuries. And so we're seeing individuals returning to postpartum impact, which is running and are having lower extremity issues. So we have so much work to do. And then when it comes to the resistance training space, oh my goodness, we have literally nothing. In the cross-sectional study that I designed with our collaborators, we tried to give some descriptive data of when individuals are returning. But again, that is just scratching the surface of what is possible or what we may be seeing in this space. So number three is any postpartum protocols for return to activity. Anything that people are utilizing now is based on physiology theory and clinical experience. We don't really have anything in the research right now to identify those things. All right. Number four is information on pelvic outcomes with interpregnancy windows. And this may seem a little bit off to right field from me, but hear me out. So when we think about family planning, individuals kind of have often an idea of how close together they want their pregnancies to be, what sometimes these pregnancies are a surprise. Sometimes there are things outside of our control that leads to when individuals are having pregnancies. What we do tend to see in the literature where we do have research is on fetal outcomes. And we always kind of start on fetal outcomes where risks to baby increase when a person has a subsequent pregnancy less than six months after delivery versus those that wait 18 months. What we see clinically is that sometimes rates of pelvic floor issues and diastasis recti can follow that same trend where when individuals get pregnant really close together, they didn't have that window of time where they were able to recover their pelvic floor and their core strength back. And therefore they have potentially a harder time recovering after a subsequent pregnancy. Some of these fetal outcomes like increased risk for miscarriage and stillborn birth that can happen in those close interpregnancy windows may be a result of things like pelvic floor insufficiency or just not getting the strength back in those structures in the pelvis between pregnancies. And so we don't have any research on this, but as a faculty, we are super interested to see is it the interpregnancy window or is it the amount of time it takes individuals to get back at least close to baseline with respect to core strength and pelvic floor strength after baby. And so information around interpregnancy windows with respect to mom's outcomes, I think are super important. So number one, C-section scar massage. Number two, postpartum or coding during pregnancy. Three postpartum return activity and four information on interpregnancy windows. My last one and I left it for last because this is like where my research brain is right now is on lifting during pregnancy and appropriately dose resistance training. So if you guys have been following the podcast or you follow me online, you know that I was projects that looked at cross-sectional data on individuals who lifted heavy during pregnancy, over 80% of their one rep max at least at some point. And we tried to describe individuals experiences, what their labor and delivery looked like and what some postpartum issues or complications may have been. Now right now I am working on a project that is a systematic review on what we know from resistance training and pregnancy literature. So I am doing a complete scour on the research that is looking at what the dosage, what outcomes individuals are looking at and trying to make some, see some gaps in the research and make some informed decisions. Y'all, what we have so far is all exercises in sitting one to two kilos max weights. So five pounds max, we have fair band exercises and these are what we are using to make decisions. Overwhelmingly the outcomes are related to the fetus, right? So we are looking at and that is super important. Do not get me wrong. That is super important. But I think at this point we can say especially under dose resistance training is not going to be bad for baby. That is where the gross majority of our research exists. We have nothing that is heavier really than a person's purse that they use to walk in here and it gave me an unbelievable understanding of where our conservative under dose recommendations come from because all of our research was on therapy and exercises, stuff done in sitting, pelvic tilt and abdominal breathing was a protocol for resistance training. When is breathing resistance training? But that's the state of our research right now. And so we get upset about the fact that these are recommendations and yet there's this huge gap that we are seeing in the literature that does not have anything. And so because pregnancy is such a protected time, we don't want to make recommendations that we don't really have anything to base off of. And so we have so much work to do. And so here are my five, right? We have C-section scar massage, coning during pregnancy and postpartum diastasis outcomes, any type of postpartum protocol for return to activity, especially in the lifting high intensity space, information on pelvic floor outcomes and core outcomes for interpregnancy windows and the influence on pelvic floor dysfunction. And then my personal, like one that I am spending a lot of time on is around lifting and appropriately dosed RT during pregnancy. Like you all know that I am in the geriatric faculty as well and it's like just as bad, if not a little bit worse with respect to some of the RT dosage that I'm seeing in this space based on, or as compared to systematic reviews that I've done in community dwelling older adults that are struggling with mobility. And so that is saying something. And it just shows that we have so much work to do. And so I want to kind of finish off this podcast. I'm going a little bit long winded and I knew that I would talk to you about research is that we have work to do, right? We need to one show that these are things that individuals are interested in. We need to try and help inform practice. And then we need to be patient. You know, there are researchers that are working on this. I was at female athlete conference in Boston and I saw and got to connect with so many PT PhDs and other medical providers who were doing research that were trying to bridge some of these gaps for individuals who love exercise at any capacity, at any stage, at any level. It just it takes time. You know, where I'm getting ready to hopefully ramp up for perspective data, which means that I'm going to follow people through their pregnancy. But a pregnancy is 10 months and it takes time to recruit people and it takes time to go through ethics. And then we got to do all the analysis and then we have to write the research paper up and then it has to go through peer review. And that takes time as well. And so we are getting there. This is my I am so excited. If you want to do a PhD and jump into this army of trying to create research, I am here for it. And hopefully we are going to continue to see individuals pushing into this space and we're going to be able to close some of these gaps. All right. That's all I got for you today. If you are interested in learning more or you want to talk about PhDs and all those types of things and doing research, make sure you reach out. I did an entire thread in our ICE students group. So if you have taken an ICE course and you were in that Facebook group, I talked about doing research and I hope you all have a wonderful Monday and I will actually see you on Wednesday for the geriatric podcast. All right. I will talk to you all soon. Have a great day.

19:00 OUTROHey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at PTonICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTonICE.com and scroll to the bottom of the page to sign up.

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

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discussed several strategies that can be employed to achieve intensity, which is crucial for cognitive changes. These strategies, including increasing load, decreasing rest, and increasing work time or volume, are part of physical training and can drive metabolic adaptation and enhance cognitive benefits. By challenging the muscles and cardiovascular system through increased load, individuals can experience improved cognitive function. Similarly, reducing rest periods allows for a more continuous and demanding workout, while increasing work time or volume extends the overall duration or amount of exercise performed. All of these strategies contribute to increasing the intensity of the workout, which is essential for promoting cognitive changes.

Incorporating a dual motor task and cognitive layer during exercise can further enhance cognition. This can be achieved by integrating activities that require both physical movement and cognitive engagement. For instance, one way to introduce a dual motor task is by having individuals hold two cups and transfer water from one cup to the other while walking. This adds complexity to the exercise and challenges both the motor and cognitive systems. Additionally, engaging in mental tasks like answering questions or performing mental math while exercising can also enhance cognition. Starting with simple preference questions and gradually progressing to more challenging cognitive tasks can create a cognitive load while individuals focus on the physical activity, leading to cognitive changes. It is crucial to control the intensity of physical training by adjusting factors such as load, rest, work time, or volume to ensure the desired cognitive benefits are achieved.

Shifting exercise sessions to a busy environment can introduce cognitive load and improve cognition. Instead of conducting sessions in a quiet one-on-one room, it can be beneficial to move to a busy clinic space, a bustling hospital hallway, or even an outdoor setting with unpredictable elements. Exposing individuals to a busier environment adds a cognitive challenge to their physical activities, such as skating or walking. This cognitive load stimulates cognitive changes and enhances the cognitive benefits of training. It effectively adds a cognitive layer to the exercise session and promotes neuroplasticity. Furthermore, incorporating a dual motor task, such as moving water back and forth, and asking cognitive questions like preference inquiries or mental math can further amplify the cognitive benefits of the exercise session. Overall, integrating a busy environment and cognitive tasks into exercise sessions can be a valuable strategy for improving cognition.

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 INTROWhat'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 DR. JEFF MUSGRAVE, PT, DPTAll right. PT on the ICE Daily Show. Welcome. This is Wednesday. This means it is Geri on ICE talking about all things, topics to help make your care for your older adults as good as possible to really set yourself apart as an expert with older adults. What we're going to be talking about today is exercise that improves cognition. There are a couple different types of exercise training that is really superior for improving cognition for older adults and we're going to talk about what those are and then how to incorporate them into your care. Before we get to that, just a quick rundown of what we've got going on in the older adult division. If you were hoping to catch the next cohort of Essential Foundations, that'll be starting in August, August 9th. If you're looking to get your advanced concepts, if you've already taken Essential Foundations looking for that next step, that'll be October 12th. Next opportunity to see us live, you've got three opportunities in July. We're going to be in Connecticut, Georgia, and Idaho this month. If you have been itching to see us on the road, get to do some of these fun labs and things that you've probably seen on social media, book your seat, come see us. We're going to be all over the place as we do 2023. Many of our older adults are worried about their cognition. They may already be experiencing cognitive changes. Maybe they've got just mild cognitive impairment. They don't have an official diagnosis. Maybe they've got early stages of cognitive change all the way to advanced dementia. It's not uncommon for us to be treating community dwelling older adults or older adults in an institutional setting that have experienced some cognitive changes. When we're thinking about our exercise interventions and how to prioritize, making physical change while keeping in mind we know there's a cognitive component. Sometimes a cognitive component ends up being more critical than the physical component for some of our older adults. We're talking about safety. We're talking about independence and their ability to manage their home environment, for example. This can be huge. The reality is a lot of us don't know where to start when we're thinking about how do I do both get the physical training piece and keep in mind they've got some big cognitive impairments on board that I'm concerned about. There was a 2019 article titled, Preferred Type of Exercise for Cognition Enhancement in Older Adults. It did just this. It broke down what types of exercise we should be focused on. Once you get through this article, and I'll share it in the caption as well if you want to look it up yourself, but there were two types of exercise that we're going to cover. The third thing we're going to do is just talk about the practicality of how to get those cognitive changes for our older adults in our sessions. The first type of training that was most beneficial for driving cognitive enhancement was a category called physical training. If you're familiar with CrossFit or not, I'm going to describe a workout to you that would be very squarely in this component of physical training. So MERF, very common Memorial Day workout done to honor a fallen soldier. The workout is one mile run. We've got 100 pushups. I'm sorry, 100 pullups, 200 pushups, 300 air squats. So that would very much squarely fit into the grunt workout. You're grinding. It's a long workout with high metabolic demand. So the first category was physical training that was intense. High intensity physical training was the number one thing that they found was beneficial for enhancing cognition for older adults. So many of our patients are not going to be doing MERF. So the question is, what's this look like clinically? So any workout that's using compound functional movements and you're moving at high intensity where you've controlled the work rest ratio, you've controlled the number of repetitions or the volume, and you've controlled the pace, you can modulate to get up to high intensity. But high intensity training is superior for cognitive enhancement. So for a patient that may be doing a remom, every minute we're doing different activities. We've controlled the amount of work and rest time. The patient is going to pace that themselves. So say minute one, we're doing 10 sit to stands. Then the next minute we're going to do carries over and back across the room with the weight that's challenging. So there's maybe 10, 15 seconds of rest. And on the third minute, maybe we're going to be doing some supported jumping. So grunt work type movements. There's not a whole lot of thought involved. Hold this walk, stand up, sit down, put your hands here, jump. Very simple, basic activities, but their nature of them being compound functional movements where we've controlled rest, we're going to drive intensity and we're going to drive metabolic adaptation, which was key for enhancing cognitive benefits in training. So that's what we want to be thinking about. Category one, physical training. They found that the change happened because of changes in the metabolic system and hitting intensity was key. So high intensity grunt work style training improves cognition. That's good news. That follows right in line often with what we're trying to do with our older adults because we know most of them are sedentary and need physical training. They need to be stronger. They need higher cardiovascular capacities to really keep themselves on a healthy trajectory as they age. So the second type of training that was beneficial for enhancing cognition was a category they just called motor training. So a good example of this would be a Turkish getup. So maybe you've never done a Turkish getup, but if you can imagine yourself laying on your back, you've got one arm pointed at the sky with the weight in your hand. You're going to move from lying on your back all the way up to standing with the weight overhead. You're going to be balancing the weight the entire time and then going all the way back down to lying on your back. That would be an example of motor training. It's a complex task. There's actually 14 steps in a Turkish getup for just one side. A lot to think about, lots of positions to hit, complex movement, a novel task for a lot of people in general, but especially older adults getting up and down off the floor without using an arm, but also adding load and having to balance that weight makes it complex from a motor training standpoint. So maybe our older adults are not doing Turkish getups. Some definitely can. There are research articles that have shown that older adults can do Turkish getups and it's beneficial for them, but maybe a more practical example for a lot of us would be working on floor transfers. Many of our patients need to work on getting up and down off the floor, doing that where we're working around a cranky joint, a knee, a shoulder, maybe a hip that is super stiff or doing this at a novel environment. Maybe we take them outside on the grass where maybe they don't have furniture or they've got limited furniture where we've just created a complex, novel task. It's motor training that's complex and that's what's going to drive cognitive adaptation. This motor control category, the driving factor was complexity and it was direct neuroplasticity. So directly impacting neuroplasticity when we do complex motor tasks. So getting up and down from the ground in a different environment would be a great way to drive neuroplasticity directly. So we've got these two categories. We've got high intensity physical training and then we've got high complexity motor training. Those are the two different avenues we can use with exercise to improve cognition for older adults. So the question is, well, what do we do? Which one is most important? And if you've been around the ICE community very long, you've probably heard this before. Or if you're new to following along with the journey here on what we're doing with our clinical approach, you're going to know the answer to this. And that is and not or. We want to do both. So we want to be greedy when it comes to our patients. We want to give them the maximal benefit, the maximal value out of every single session. And we can do that by driving intensity while driving complexity of task. And the easiest way to do that is a strategy we call layering. So a good example of this would be, say we want to drive intensity with gait training. Lots of great ways to do this. We can put a gait belt on our patient and hang on to it and add some resistance that way. We can do the same thing with a resistance band. We can throw a weighted vest. We can have them hold weights. Gait training just got much more intense at whatever resistance is appropriate to challenge our patient by just adding resistance to that walking. So we've already achieved intensity there. So how do we add this motor training piece? How do we add complexity to also enhance cognition at the same time? Lots of different ways to do this. You could do a weighted vest and maybe we've got someone with two cups in their hand and they're transitioning water from one to the other while they're walking. Man, we've just layered on a dual motor task while we're hitting intensity with a vest. Another great example, we can ask simple preference questions. That's usually an easy way to ease in on the cognitive load. Just ask them some random questions that sound like conversation. You may already be doing this, adding a cognitive layer and not realize it, but asking them questions while they're concentrating adds a cognitive component. We can scale that up. We can ask for mental math while someone is doing intense gait training. That can be super beneficial. We can ask, what's your favorite color? We can ask them to subtract three from 74 out loud while they're walking under intensity. We can move them to novel environment. There are lots of different ways we can add that in. You want to control the two things you've got to do to put these things together. For physical training, you've got to control intensity. You can increase load, you can decrease rest, you can increase work time or volume. All those things will help you reach intensity, which is crucial for cognitive changes. The second piece is adding a dual motor task like we talked about the water back and forth. You can add the cognitive layer by asking questions, preference questions, mental math, those type of things. Moving them into a busy environment. Maybe you have your sessions in a quiet one-on-one room. Maybe you move out into busy clinic space or into busy hospital hallway, or maybe you're in home health and you can take someone outside or into busier environment where there's unpredictable things and there's some cognitive load on just skating and keeping yourself safe. That's another great way to add cognition. That's what I've got for you, team. You want to hit intensity through physical training. You want to add complexity with motor training. The third thing is you want to add layers. You want to layer up your intensity and cognitive difficulty as much as possible to get the most bang for your buck, especially when there are cognitive deficits on board. If anyone's got any cool strategies, layering tips, tricks, things they've done that they found fun and beneficial, or you've just got questions or comments, drop them. I'd love to see those and interact with you. I hope that was helpful for someone out there. Have a great rest of your Wednesday, team. See you later.

14:52 OUTROHey, 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. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey discusses how to empower patients with osteoarthritis by shifting their mindset and behaviors. She emphasizes the importance of treating patients with MEDS (mindfulness, exercise, diet, and sleep) to combat systemic inflammation. Take a listen or check out the episode transcription below.

If you're looking to learn more about our Extremity Management 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 DR. LINDSEY HUGHEY, PT, DPT Good morning, PT on Ice Daily Show. How's it going? Welcome to the PT on Ice clinical podcast. Today is clinical Tuesday. I am so pumped to be with you all. I'm Dr. Lindsay Huey. I guess that would help if I actually introduced myself. Today, I am going to chat with you about how we let freedom reign in our patients with osteoarthritis. Last clinical Tuesday, I hopped on here and I wrapped on the underlying battle of systemic inflammation that we are fighting with these folks with hip and knee away and the importance of treating them with MEDS, which stands for mindfulness, exercise, diet and sleep. Check in for more information there from last week on what MEDS and how we can unpack that and prescribe it for our patients. This week, this clinical Tuesday, we're going to dive a little deeper into the trenches of battle by really discussing how we can impact our folks with osteoarthritis. Whether it's the shoulder, hip, knee, hip and knee are more common things we'll treat from an extremity management perspective. But this battle involves a lot more than manual therapy and exercise. It actually involves less. Today, I will discuss how shifting our patient's mindset and behaviors really helps fight that underlying systemic inflammation battle that our patients have. But before I tell you and dive in a little bit about that, I'd love to share with you some courses extremity management has coming up. So our next upcoming course is July 15th, 16th. So in a couple of weeks, we'll be in Holmes Beach, Florida. I've hopped on a couple Tuesdays and just let you all know what beautiful beach that is. It still ranks the top beach I've been to so far. Crystal blue water, I'll be with Melissa Reed out there. There's lots of spots left. So join us if you want to do some summer extremity management learning. And then July 26, 23, I'll be in Simi Valley, that course is now to 15. There's probably only three to five spots left. So if you're on the fence, definitely sign up for that course. And then onward Madison is July 29th and 30th. So lots of opportunities to hop in in July. And then in August, we are going to be in Rochester Hills, Michigan, and then the 12th and 13th. And then August 19th, 20th, we will be in Fremont, Nebraska. So be on the lookout if you're on the fence for signing in just because these courses are starting to fill up. And then other courses in the beginning of fall in September and October. We hope to see you out there. All right, let's dive into the topic at hand. So last week, we really last Tuesday established that hip and knee osteoarthritis is becoming one of the leading causes of global disability. So worldwide, this is affecting our society. And there are so many challenging aspects of treating these folks. The battle is not just in modulating their pain. It's not just an increasing range of motion and addressing strength deficits, you know, in their hip and in their knee. And it's not just about prescribing meds. And I really made a solid case for that last week. That mindfulness, exercise, diet and sleep. It's really about confronting the uncomfortable conversations. It's about challenging and changing thoughts and beliefs with these folks and some of their daily living behaviors. I think this is our hardest job as physical therapists, whether you're in outpatient or home care, even acute care. But it's our hardest job and our greatest opportunity with these folks to really address how they think about their body and then just daily behaviors. These conversations that I'm going to bring up, they are really uncomfortable. Addressing harmful thoughts and beliefs, behaviors, we know humans, we are kind of entrenched in our beliefs and our behaviors and it is really hard if we can reflect on our own challenges. It can be so uncomfortable. And so I acknowledge that this is very uncomfortable, not only as the provider, but for the patient. So some thoughts that we really need to start addressing. And I alluded to this last week a little bit, but the patient that thinks and says to you that first visit, I have bad knees, my dad had bad knees, my great grandfather had bad knees or I have bad hips, right? My great grandmother had bad hips. So it's just inevitable, right? That I'm going to have bad hips. You are not your ailment or your pain is one of the first things that we have to establish and break down with our patients. The thoughts of this is just inevitable, this is my path, right? To be in pain, which leads to disability and dysfunction. These thoughts take a human's mindset captive. It takes captive their whole way of living and being. If you think about some of these patients and they don't just often just have osteoarthritis, diabetes, hyperlipidemia, they might even have heart disease or history of MI, stroke, these are unhealthy systems. Every thought and decision and behavior starts to be planned around their pain experience. Going out with family or friends is planned around pain. How long does it take me to get to the front door if we're thinking about going out to eat or going to the movies? Can I actually make that distance? Or will I be in too much pain to even enjoy the dinner or the movie? Or I cannot do this because it hurts. Or I can't go to that family gathering because it hurts. Or because my knees or my hips are bad. Pain, OA, osteoarthritis starts to become the patient's identity. How they do everything in life is surrounded by this. This is all super uncomfortable and enslaving for your patient. If we're honest and we even think deeper about this, it starts to become the normal. So this discomfort, right? This pain starts to actually become the patient's comfort. It's how they do life. It starts to become their identity. I need you to start as clinicians and this charges to myself as well to start thinking about how we can help our patients do less harmful mindset. Do less thoughts about how much they're in pain and how much their knees are bad. How can we help shift their mindset to be healthier? To be more productive? Can we shift and say my knees have an opportunity to be stronger? Or yes, my knees hurt but I'm on the path to recovery. Yes, my hip hurts and it's limiting how I can walk right now. But I know with doing my program from Alex Drumano, our MMOA faculty, I know I'm going to be able to walk a little bit longer every day. Helping patients shift how they think right away is a must. If we cannot shift how they frame their pain experience, how they frame their range of motion deficits, how it impacts their life and amount of walking, we will never make an impact here, right? We can have the best manual therapy, the best exercise dosage prescription and it won't make an impact if they don't believe it can help. If they are telling themselves every morning they wake up, my knees suck, I don't want to get out of bed, my hip hurts, I don't want to do this today, they're not going to be successful. And so we have to give them little phrases to help them keep going, right? Yeah, it hurts right now but here's what I can do to help that, right? And it seems small but if we're not addressing this at all, we're really doing harm. We're not doing enough and so we need to implore less harmful thought patterns in our patients to help make an impact, to help really make our exercise and manual therapy be worthwhile. So I just want you to pause and think about what are some things or reframes I can start giving my patient in their mindset. Doesn't just stop though with our mindset shifts, right? It's not just thinking that influences our beliefs about our body. We also have to shift some of our daily behaviors and here's where it gets really tough. Folks with OA have a lot of comfortable behaviors that are quite destructive. And addressing these conversations by the way are nuanced and we have to do it in a loving way and of course we first have to build rapport with our patients before we start diving in to behavior shifts. And so it won't be our first conversation with our patient but it has to be a conversation that happens in our bout of care and it has to be ongoing. And it's behaviors regarding eating and exercise habits. They have to be addressed. It becomes really comfortable that person that's in pain, right? That's coming to see you maybe three days a week, right? They worked out with you for an hour. It's a lot more comfortable to sit around and watch shows. It's all day. It's a lot more comfortable after a big meal, after dinner, to turn on Netflix and binge watch Netflix, right? Two or three episodes. If you're a big Ted Lasso fan it's really hard not to just watch the whole season in one bout. It's really hard if it's in your process and family process to have dessert after every meal that you have, especially dinner, right? And then compound that with Netflix and sitting. Extra calorie consumption kind of goes under the radar with these folks. The eating piece and our behaviors around eating have to be addressed. And you know, the Netflix, the eating, this might not be your patient specific thing that they need to worry about doing less of, but I'll tell you in a lot of our folks with me and HIPAA, there is some very familiar trends surrounding our eating and our extra calorie consumption. Things that bring us comfort like Netflix, like that extra helping of food or dessert. We have to acknowledge that this is so complex and hard. These things are often tied to family, right? They're tied to connection and community and identity, especially if that's the time where you all kind of get together, right? You share a meal, you share dessert, and then you go watch your shows. Let's all come together and rewrite some of the ways we gather and do our meal time together or handle stress, right? Some of us are stress eaters. Sub that extra helping or that extra Netflix episode with taking a walk after dinner with your family. Or maybe instead of that dessert, right? You're already feeling full, but somehow you think there's a little bit more room for that dessert. Go for a walk with your family, right? Or go for a bike ride, right? These kind of behaviors help get that food moving and processed better, and then it subs those extra calories or it subs that extra sedentary time where you're just sitting. How about some of our folks with HIPAA and NEOA that are retired, right? Where they're watching their shows throughout the day, right? They love watching Price is Right. Yes, Bob Barker is better, but Drew Carey is doing his best, right? But these kind of behaviors, maybe it's a midday walk, right? Or suggesting they walk their dog midday. I know these HIPAA close to home, folks, and I'm going to tell you a lot of the behaviors I'm listing hit close to my direct family. I am sprinting away from metabolic disease. It runs on books, both my mom and my dad's side. Diabetes, heart disease, cancer, hyperlipidemia, myocardial infarction, stroke. Whatever list that you've probably seen on your patient list, my family has it. And so I totally, I am listing out behaviors that I know my family and myself has taken part in. I've witnessed them firsthand, but I also know they can be changed gradually, and I also know the change is uncomfortable. I want to fight this battle of OA because it hits so close. It hits for me, it hits for my children and my surrounding aunts, uncles, grandmothers, right, that have passed because of this. So I don't take the battle lightly bringing up this shift in beliefs and behavior. Think about this. And I know I touched on some hard ones, right? Everyone loves a little extra Netflix episode, dessert sometimes, that extra helping of food. It is comfortable. But no one says, I wish I hadn't taken that walk last night after dinner. I wish I had had that second helping, second and third helping. I wish I had had that extra slice of apple pie. I wish I had stayed up till 1 a.m. watching Netflix. I wish I had binged, watched all my shows all day and sat in a chair for three hours. I wish I had had that another beer. No, people don't really reflect and say that, right? They're usually the next morning, oh, I wish I would have had that earlier. I wish I wouldn't have had that extra helping. I didn't really sleep well. I wish maybe I would have gone on a walk or that bike ride when my kid or grandkid asked me to do it. Instead, I just sat here and I watched these shows. No one says they wish they didn't do that uncomfortable behavior. Uncomfortable shifts in mindset and behavior, they are always uncomfortable, especially when you're making the decision, especially when you're actually doing the thing, right? When you don't really feel like taking a walk after a meal or going for a bike ride. But there is nothing more ironic, more peaceful than doing the thing that's uncomfortable. While it may not feel great during you, if you can think about some uncomfortable decisions you've made and your patients, they will feel better after. They will be thankful after when they made these shifts in their mindset or in their behavior. There is so much reward in the discomfort. Of course, it's delayed and that's what's hard about human nature, right? Our psychology wants comfort, especially when we're in pain. But just think each day, the compound reward of making one to two uncomfortable decisions surrounding our mindset and surrounding our behavior around food and our eating behaviors. One less thought of my knees suck, I don't want to get out of bed. One less helping of dessert or Netflix binge. Imagine that compounds day after day, 365 days and that becomes a year and then you do it again, right? 365 times two, right? And it patients start to see the healthy reward of these shifts in mindset and behavior. Let's stop the acceleration of OA as one of the leading causes of disability worldwide. Let's help our patients handle and battle this low grade systemic inflammation by leaning into the hard belief and behavior shifting conversation. We have to fight for our patients, our loved ones and ourselves to have these conversations because we're not doing enough. It's still going up the levels of disability, right? Lifespan is increasing, right? But our health span, the quality of life is not. These are hard and uncomfortable conversations, right? But discomfort tends to birth opportunity and change and really only always for the better. If you can think about most of the uncomfortable decisions that you've done in your life, if you can think about the yield, the reward, we can and we must start to battle beliefs and behaviors if we want to impact this space. One little mind shift and behavior shift at a time. Freedom comes in the form of less for our folks with hip and knee OA. Yes, our primary drug of choice is exercise for our folks with hip, knee, shoulder OA. But if we want to have the greatest impact, we need to deal environmental modulators to manage symptoms, to maximize fitness. We need to deal mindset and behavior shifts that change lives. It will be hard, it will be uncomfortable for both parties, clinician and patient. But along the way, we also deal encouragement. We deal hope. We deal laughter, right? We laugh in PT and we are a partnership and alliance as the patient negotiates these new mindsets and behaviors We're there every step of the way when it's hard. Free your patience. There is freedom in choosing less harmful mindsets and less harmful behaviors. New beliefs and behaviors are for sure uncomfortable. But help your patients think about their hip or their knees more positively or help them walk instead of that extra episode of Netflix. Show your patience there is freedom in discomfort. Show your patience there is freedom in the reframe in their mindset. Let freedom and independence reign for your patients through introducing them to healthier mindsets and behaviors. Help them indulge less in destructive thinking and behaviors. There is so much untapped potential in this space. I'm hitting the 20 minute mark I need to shut up. But I want to say a final thank you to our military and our vets who have fought and continue to fight for our nation's independence. Happy Fourth of July. I'll thank you for letting me rap on something I'm super passionate about. Happy Clinical Tuesday.

19:30 OUTROHey, 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.