Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long discusses Testosterone Replacement Therapy, including research supporting its use, side effects, understanding dosing, and common clinical presentations related to TRT use. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show. It is Fitness Athlete Friday, the best day of the week here on the podcast. I'm excited to be with you as your host, Dr. Zach Long. And today we're going to talk about a topic that's a little out there, like it's not something we talk about a whole lot in the profession, and that is testosterone replacement therapy. And we're going to discuss four or five things that I really believe that those of us in outpatient orthopedics need to understand about testosterone replacement therapy because you are for sure seeing these patients in your clinic with certain conditions and being aware of a few things will help you out clinically. Before we jump into that topic, upcoming courses that we have inside the fitness athlete division. Our live course is, we have one more for the end of the year. That's Colorado Springs, Colorado this weekend. Mitch will be teaching that. If you can't make it to that in quarter one, we will be in Portland, Oregon, Richmond, Virginia, Charlotte, North Carolina, and Boise, Idaho. So check out those courses, pglnice.com. We also have our advanced concepts course. We'll be going live at the beginning of the year. That course always sells out. If you've already taken level one, you can jump into the online level two, but that sells out. So you want to look at jumping in and booking your spot as quickly as possible. TESTOSTERONE REPLACEMENT THERAPY Let's jump into testosterone replacement therapy and what physical therapists need to know about that. Testosterone replacement therapy is injecting testosterone into your body, which is the male sex hormone, prescribed by doctors at times to treat hypogonadism. We've seen a giant increase in the number of people and the acceptance of people being on TRT in the past few years and I think that's why it's so important for us to understand that because so many individuals are now when they you know get into that 35 40 50 year old age range where their libido goes down a little bit. They stop improving quite as much in the gym as they used to. They start to have a little bit more general fatigue, anxiety, et cetera. We're seeing more and more men jump on TRT. I found a research study from 2017 looking at the rates in the US population of people being on TRT. And in 2017, they estimated that between 1% to 3% of men were on testosterone replacement therapy. which that number was a threefold increase in the number of prescriptions of TRT from 2007 to 2017. So threefold increase in those 10 years. And I would even say since then, in my opinion, it has become more popular or at the very least more accepted. Back in 2017, you wouldn't hear a whole lot of people talk about being on TRT. And now I feel like I see it all the time. I see big time influencers talking about being on TRT. all the time on social media, when I'm talking to people at the gym, they're regularly talking about their doctor just put them on TRT, whatever. So there's a lot less stigma around it and there's a lot more people getting on it. And I think that's really important for us to understand because there are gonna be a few things that we see in the clinic in people that are on TRT. And so asking this question more frequently to your male patients, especially that are between the ages of say 30 and 50 years old, is going to change a few things that you might be thinking of clinically. So three-fold increase in those 10 years and probably a little bit more than that. Another really interesting study that I found with testosterone replacement therapy was this study called Testosterone Dose Response Relationships in Healthy Young Men. So this was a really cool study where they took individuals that had previous resistance training experience and they told them that they weren't allowed to exercise during this six-month study. So If they've done previous resistance training, we kind of know that they're going to be through their beginner gains, their newbie gains in the gym where they would have really easily put on several pounds of muscle. So these aren't people that you're going to expect to see drastic increases in muscle mass in a short period of time. especially when they're not working out. But what they did in this study was for six months, they put these men on testosterone replacement therapy at different dosages. So the dosages were 25, 50, 125, 300, and 600 milligrams of testosterone for 20 weeks. So a wide range of doses from 25 milligrams a week to 600 milligrams a week. And they looked at a number of different things, such as their fat-free mass and their leg press strength, and then a number of other different physiological factors. But I'm gonna focus on those two, mostly muscle mass here. So again, we wouldn't expect these individuals when they're not resistance training, but having had previous resistance training experience to gain a lot of muscle mass in this time period. But what they found was that the group on 125 milligrams a week during those six months gained six pounds of muscle on average. The group at 300 a week gained 12 pounds of muscle mass on average and the group at 600 milligrams a week gained on average 19.5 pounds. So a lot of increase in muscle mass during that time period, especially when people aren't doing any resistance training. UNDERSTANDING TRT DOSAGE And so I bring those dosages up because I think that's one really important thing when you have a patient on testosterone replacement therapy, I want to know what that dosage is. So when you're treating hypogonadism, less of this like people getting on TRT to try to improve their sports performance, their aesthetics, their strength, et cetera. What you tend to see is much lower doses in terms of testosterone replacement therapy. Like getting on those low doses under typically 200 milligrams a week is what you'll see a lot of doctors prescribe here. And that's going to do a lot to help improve libido and anxiety and other symptoms like that of hypogonadism. But when you get to that 125 milligrams a week, that's when we start to see a large increase in muscle mass. And what you'll often hear referenced by doctors prescribing TRT is sports TRT dosages versus hypogonadism dosages. And the cutoff there that you'll hear most people discuss will be 200 milligrams a week. So when you're taking 200 milligrams or more, that's when you're getting into a bit more of the sports performance arena than just purely addressing hypogonadism. And I think that's important because of the next studies that we'll talk about in a second here. But 200 milligrams a week, when people are on that, I'm thinking, all right, we're on a pretty good dosage. And if we go back to that study where the milligrams per week range from 25 to 600. It's important to note that testosterone is obviously a performance-enhancing drug. It can be used for medical reasons. It can be used for recreational and sports performance reasons. And when people typically do like a steroid cycle, not TRT, like trying to put on as much strength, muscle mass, sports performance as possible, the dosages that people will typically be at will be at 300 or more. Typical dosage that you'll hear a lot of people talk about doing a starter steroid cycle is like 500 milligrams a week So this study was really aggressive in the dosages that they did there like especially the group that was doing 600 milligrams a week for six months like they were doing a full-blown steroid cycle, but remember 200 milligrams a week is kind of your cutoff there in terms of sports TRT versus just standard TRT. THE RELATIONSHIP BETWEEN TRT DOSAGE AND TENDINOPATHY Why that's important and why I want to know the dosage that my patients are on if they're on TRT is because One thing that I clinically see quite a bit is that those individuals on TRT, I'm frequently finding them showing up to the clinic with tendinopathies more than any other injury out there. In fact, when I see a male between the ages of 30 and 50 years old that's coming to me with a tendinopathy and I know that they're exercising and they look relatively fit, this is a question that I will just straight up ask them. because I think it's valuable information to know. And the reason why it's valuable is that there are actually two research studies out there that have found, one of them found an increased risk of rotator cuff tears in men on testosterone replacement therapy, and another one found an increased risk of distal bicep tendon tears and increased risk of needing surgical intervention to repair that distal bicep tendon tear. And so if we know from these two research studies that these men on TRT are at increased risk of a tendon tear, that would suggest that there's likely some degeneration already happening to some tendons in men that are on TRT. Now, why that is? Can't for sure say though. One theory could be here when we go back to that dose-response relationship study where men taking 125 milligrams or more per week are putting on significant amounts of muscle mass in a six-month period. It could be. those muscles are responding really fast, and those tendons are responding a little bit lower. It could be that maybe these men had low energy, anxiety, depression, they get on TRT, now they're feeling better, and they go from a low amount of activity to getting more aggressive in the gym, so they see training load spikes that challenges those tendons more than they're able to recover from. Whatever reason that is, it happens. We're probably seeing degenerative changes in tendons of men on TRT. TENDON HEALTH ON TRT And we need to be aware of that because that might lead us to want to have more discussions with individuals. on taking care of their tendons if they're on TRT. Like maybe they need to spend a period of time every few months doing heavy, slow tempo work on their spots. Like if you're in CrossFit, maybe not always bouncing out of the bottom of the hole as aggressively as possible. Maybe they have to spend a period of one month every six months where that tempo's going really slow. Maybe we need to be prescribing some extra rotator cuff loading, tendon work, or maybe even different supplements that might have a positive effect on their tendons, such as taking Collagen and vitamin C. There's some research by Keith Barr on that potentially having some positive effects on our tendon health. But that's definitely something worth discussing and having in the back of your mind when you see men taking testosterone replacement therapy is what can you do to help improve their tendon health? INJECTION SITE MATTERS WITH TRT And then the final thing that I think is important for us to understand with TRT, I would have never thought of this unless Jordan Berry, my business partner at Onward Charlotte, also a faculty member for ice in our spine division, hadn't treated somebody that was on TRT and came into the clinic with incredibly debilitating neural tension. So this guy had previously been a bodybuilder that had abused performance enhancing drugs and now was on TRT, but the guy could barely walk, couldn't pick anything up off the ground, had a 10 degree straight leg raise. As Jordan evaluated the guy's lumbar spine, the lumbar spine was completely clear. And Jordan kind of recognizing in this guy's body type that he looked like somebody that may have previously or currently was on performance-enhancing drugs, Jordan went ahead and kind of broke out that with the individual, started talking to him about his previous performance-enhancing drug history. It turns out the guy was still injecting testosterone regularly. He was on TRT after years of being on more performance-enhancing drug dosages of that. And Jordan asked him where he was injecting. And the guy was injecting his TRT dead center in the middle of his… to inject TRT or the place that's safest to inject it is actually going to be glute med. So if I'm looking at your butt from behind, if I drew a line straight down the middle of your glute, both horizontally and vertically, we want to be in that upper outer quadrant or in the vastus lateralis. Those tend to be the safest areas to needle. When he was going dead center in the glute, he was constantly hitting his sciatic with his injections. And so hitting his sciatic nerve as he was giving himself TRT injections resulted in some scarring on that nerve. And that was what was leading to his intense sciatic and neural tension. So I hope that gives you some ideas and things to think of clinically when you see guys on TRT, or at least makes you more aware of the prevalence of this, and that when you see people with it, you might want to be thinking of some different strategies and different questions if they're coming in with things like tendinopathy or weird neural tension. Hope that helps. Hope we see you on the road at a future Fitness Athlete Live course. Have a great day, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #TechniqueThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE COO & Fitness Athlete Division Leader Alan Fredendall discusses utilizing the rack pull as a way to begin to load the spine isometrically. Alan demonstrates the rack pull, how to set it up, how to modify & scale it, and how to prescribe & dose loading of the rack pull. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. ALAN FREDENDALL PT on ICE Daily Show, happy Thursday morning, hope your day is off to a great start. My name's Alan, happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer and a faculty member in our Fitness Active Division. We're here on Technique Thursday, that means it's also Gut Check Thursday. This week's workout, we have a 15 minute AMRAP, so a little bit more chill than previous weeks. We have an ascending rep scheme of American or overhead kettlebell swings, 5, 10, 15, 20, so on and so forth. Recommended weight, 53 pounds for guys, 35 for ladies. And then you're going to pair that every round with 10 back squats. We're going to do that at 135, 95, and then 30 double unders after every round. So a good goal there is to get maybe four or five rounds deep into that AMRAP. accumulate a good volume of everything. You're going to end up at about 50 to 75 reps of the kettlebell swings, of the back squats, and of the double unders. So that's Gut Check Thursday. Courses coming your way. We are basically done with live courses for the year. We have live courses this weekend, but they're all sold out. And then our very last live course of the year is next weekend in Salt Lake City with Paul for dry needling. So if you're trying to make a course before the end of the year, that's the last one you can sign up for. All of our other courses starting up in 2024 are on our website, ptenice.com. Remember, price change going into effect January 1st. Our rates are going to go from $6.50 per course to $6.95. So if you already have an eye on a course, make sure you sign up before January 1st and save yourself 50 bucks. MASTER THE RACK PULL Today, Technique Thursday, what are we talking about? We're talking about the rack pull. So I want you to go back to last Tuesday's episode with Jordan Berry, episode 1608, Spine Isometrics, to talk about all the research and the clinical reasoning supporting something like a rack pull. I want to take a deep dive into this, because on the topic of spine isometrics, I think this is a very effective exercise to use in the clinic with patients with low back pain, folks who are having trouble deadlifting, to really build a strong, robust low back, so that bending over and picking up stuff from the floor is no longer bothersome. Today I want to talk about why we're doing this, I want to talk about keys to success, and most importantly I want to talk about how to load and dose this and prescribe this to patients. WHY THE ISOMETRIC RACK PULL? So, why do we do this? First of all, it's simple and effective. It's essentially a very small partial range of motion deadlift. It is very scalable based on your patient's presentation. Somebody who's very irritable has very severe low back pain, we can move the safeties and the J-hooks to maybe above the knee, maybe right below level of hip, so we have a very small range of motion that we're contracting through. And we can scale that back down though as somebody starts to feel better. We can take that all the way down to a rack pull from mid-shin as if somebody was lifting from the floor. We can meet our patients where they're at with the scalability of that. The nice thing, like Jordan said last week as well, the key to a lot of isometrics is that most people can do these at home. A lot of folks have a squat rack. or a barbell in plates in their garage or the gym. So they can set something up close to this at home and be able to do that for home exercise. Those individuals already active in the gym already have access to this equipment at the gym they go to, so they can also do this as part of their home exercise program at the gym. Now that's why we do it. KEYS TO SUCCESS What are some keys to success? The keys are The setup here is everything. So you'll see I have a pair of safety bars here and a pair of J-hooks. My preferred way to do this whenever possible is to set it up like this. Whether I have two pairs of J-hooks or cups in the rig, I have a pair of safety bars and a pair of J-hooks. I have basically two start and stop points that's gonna let me control that range of motion. So setting it up is really, really, really important. So set up your environment correctly. The J hooks should be upside down. So what we'd like to see is that they're actually upside down so we have more surface area to lift the barbell against. So I'm going to show you a rack pull right now. and show you what it should look like. So, in this example, I'm starting right at the top of the knee. The goal with the rack pull is not to finish the deadlift. If I'm standing at the top of my deadlift, there is no tension here, there is no work needed out of the low back. I need to somehow stop myself short of full range of motion, so my back has to work to keep myself in the position. So, from mid-shin, a nice hinged position, and now I'm gonna lift and pull up against the J hooks and now I can't reach full extension and here my low back is just working to keep this barbell in place and then when I'm done I don't have much room to go to set it back down. So again the issue with the J-hooks put into the rig like normal is that that barbell can actually roll off in a way and lifting a bunch of weight off like that, surprisingly, can upset some people's low back. So if you're going to use just J-hooks, again, take them, turn them, and then flip them upside down. Now we have more surface area. We also have kind of a framing here of the J-hook so that the barbell can no longer slip down, out, and around the J hook. So that's setting up the rack pull. Again, meet your patient where they're at. Adjust the range of motion as needed. If you don't have two pairs of J hooks, by a second pair or what you can use in place of two sets of J-hooks, you can place the barbell on some plates as the lower edge of your range of motion and use the J-hooks to stop the top motion. Again, the key here is that this is an isometric exercise, so we wanna be pulling up against something for 45 seconds. All the benefits that Jordan talked about last week, the stress relaxation response, strengthening, blood flow, pain relief, and then being able to reproduce this in the gym or at home. Now finally, why do we do this? How do we set it up? DOSING THE RACK PULL How do we actually dose this? Again, that's gonna depend, what is it gonna depend on? Your patient's current level of irritability. Somebody that is very flared up, maybe you're thinking about starting with something like a reverse Tabata, so you're gonna do eight rounds, 10 seconds on, 20 seconds off. progress them maybe to a full Tabata, where they're now doing eight rounds, 20 seconds of work, 10 seconds of rest. And then for me, my ultimate goal, following some of the tendinopathy literature, is to get to that 220 seconds time under tension. I like to see patients be able to progress to five sets of 45 seconds of work, and then really however much rest they need. 15 seconds is probably too short, so an EMOM timer is probably not appropriate. I like five seconds of 45 on, 45 off. 5 sets maybe of 45 on, a minute, a minute 15 off, so maybe you can set every 2 minutes for 5 sets on your timer. Something like that though, building to that 220 seconds time under tension, ideally showing the capacity to be able to hold that rack pull for at least 45 seconds. So meet your patient where they're at, progress them, progress them, progress them, time under tension. Now what about loading? This is a partial range of motion that you don't need to lift from the floor. What does that mean? That means this should be quite heavy. This should be near, at, or maybe even above that patient's deadlift max, if we know it. Again, we don't have to lift it from the floor. The hardest part of the deadlift is done for us. It's already sitting above our knee. All we need to do is just a little lift and then hold. So, that means that this should be quite heavy. How heavy? whatever weight they can feasibly hold for maybe that reverse Tabata, and then that full Tabata, and then that full 45 seconds on with the rest coming. The key human beings who come into your clinic are not gonna be challenged by an empty barbell rack pull, even if their low back pain is really irritable, so keep that in mind. SUMMARY So the rack pull, why? We like that it's scalable. We like that it is easy to set up. It basically requires no thought or mechanical skill to be able to get into that position, We'd like that we can transfer this to home. A lot of folks have access to a barbell and the setup needed to do this rack pull. We'd like that we are really easily able to make people successful with this by just modifying the environment, setting up with plates as blocks and J-hooks as the top limit, two pairs of J-hooks, squat safety bars or J-hooks, whatever. This is very easy to set up and be successful with it. And then we like that it is easy to dose. We can see patients make progress from maybe 10 seconds on, 10 seconds off for a couple sets, to a full reverse Tabata, through a Tabata, and then maybe into somebody who is probably now ready to start deadlifting from at least the knee through a partial range of motion, if not from the floor, is somebody that can come up here, lift and hold for sets of 45 seconds. Five sets of 45 seconds really seems to be the sweet spot for the back to start feeling good, for the back to start feeling strong, and to now reintroduce full range of motion deadlifting, things like kettlebell swings, back into a person's exercise routine if they're already doing, or now, maybe for the first time, instruct that patient in the deadlift. So, the rack pull, easy to set up, easy to mess up too if you don't have a lot of attention to detail, but relatively easy to set up, load, dose, and prescribe as homework for our patients. So try that out. Thanks everybody, have a great Thursday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses the scary stats of sarcopenia: increased risk of falls, fractures, loss of independence and the list goes on and on. Dustin emphasizes that rehab providers have HUGE opportunity in this department but often leave so much on the table.

Listen in as Dustin shares some new research about Sarcopenia and it’s implications for our work. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. DUSTIN JONES Alright Instagram, good morning, good morning YouTube. This is the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division and today we are going to be talking about leaving nothing on the table when it comes to sarcopenia. Leaving nothing on the table when it comes to sarcopenia. We're going to be covering some new literature that looked at the variations of intensity of different exercises with and its impact on sarcopenia and what that means for us as clinicians or fitness providers. Before we get into the goods, I do want to mention CERT-MMOA is rocking. CERT-MMOA is for those that complete our three MMOA courses, our online level one and level two. then our live courses. We have shut things down for the rest of this year but I want to let you know as soon as 2024 kicks off in January we are hitting the road hard. Both of our online courses are gonna be starting that second week of January and then we've got a few courses I want to mention that are gonna be absolutely awesome in that month of January. We got Santa Rosa, California January 13th, 14th. On the 20th, 21st we're gonna be in Greenville, South Carolina the 27th and the 28th we are going to be in Missouri. So we'd love to see y'all on the road. SARCOPENIA So let's talk about this, sarcopenia. So sarcopenia, for those that are not familiar, is age-related loss of muscle mass and strength. Sometimes now you are going to see the word function or physical function be thrown into that definition, but by and large, most of the time when you see this, it is age-related loss of muscle mass and strength. This is very important for every single person listening to this podcast because the vast majority of y'all are treating older adults in some way shape or form. But what we're seeing is that the term sarcopenia is starting to apply to individuals that may not have that older adult tag on them. Maybe those folks that are south of 65, maybe those folks that are in their 50s, sometimes even their 40s that are gonna qualify based on the criteria of sarcopenia. So this is a big issue and it impacts a large, broad audience. Just some stats, just so you are aware of how this could impact the folks that you're serving. 10 to 40% that's a wide range, but estimates are saying that 10 to 40% of community dwelling older adults have sarcopenia. All right. So 10 to 40% of folks, independent older adults that are walking amongst this, out in the community walking into your outpatient clinic would be categorized as having sarcopenia. And we would argue that that number is largely artificially low, that there may be even more. If you are a clinician that is working in a more acute setting out of the community, right, like acute care, home health, skilled nursing facility, this number goes up exponentially. So for you all, the vast majority of individuals, particularly older adults, would fall into that category of having sarcopenia based on the diagnostic criteria. So all to say, a lot of folks across the whole healthcare spectrum would fall under this category. SARCOPENIA: WHAT'S THE BIG DEAL? Now why is this a big deal? This is a big deal because if you have that label sarcopenia, you are at 60% increased risk of falling, If you fall, you're at an 84% increased risk of having an injurious fall or with a fracture. Those are big statistics, and we know the negative implications of those health outcomes. It is a big deal. It is an absolutely big deal, and it's important for us to understand how big of a deal this is, but then also to know what to do with it, all right? And this is where this new research, this new literature that was just published comes into play. There's a recent systematic review and a network meta-analysis that was published in the European Review of Aging and Physical Activity that looked at randomized controlled trials that use exercise in different intensities of exercise and how that impacted different outcome measures with folks that have sarcopenia. So they found that there were about 50 randomized controlled trials that totaled of about 4,000 participants. And all of these studies looked at the following outcomes. They looked at muscle mass, which we're usually measuring with something like a DEXA scan, right? Muscle strength tested by hand grip strength, chest press, and then a leg press on a machine. And then physical function, functional outcome measures, five times sit to stand, 30 seconds sit to stand, timed up and go, short physical performance battery, which is, you'll commonly hear us refer to it as the SPPB, the six minute walk test, and gait speed. All right, so these studies were measuring a lot of things that have huge implications for a lot of physical therapy and even fitness outcomes. All right, so all these studies were looking at those things. and they performed exercise at different intensities. So they performed exercise potentially at light intensity. This is categorized as at zero to four out of 10 on that modified Borg score where we're looking at relative intensity or RPE, rating of perceived exertion. that could also equate to under 49% of someone's one rep max. So typically what you saw in this meta-analysis is that the randomized control trials that were using that light intensity, they were often using aerobic-based training. So we're going to throw that in, kind of that light intensity category. Then we had moderate intensity. So this was that five to six out of 10 on that RPE. kind of 50 to 69% of a one rep max was considered to be moderate, and then vigorous, six to eight out of 10, and kind of that 60 to 80% of that one rep max. All right, keep in mind the updated ACSM recommended guidelines are calling, particularly for sarcopenia, are calling for 60 to 80% of someone's 1RM. They're calling for vigorous exercise, in particular resistance training for these individuals, all right? So they had those different intensities and they saw, all right, what's going to happen here with these folks that have sarcopenia? And the interesting thing to think about this is there's a lot of individuals, particularly when someone has sarcopenia on board, that the main focus is that, hey, this person may be relatively sedentary. They have low physical activity levels. Let's just get this person moving, right? Let's get them started in some type of physical activity. Let's bump up their overall physical activity. That's going to be a huge win. I would agree with that. Anytime that we move someone from being relatively sedentary or low physical activity levels and we can bump that up, we are going to see some positive benefits. We cannot deny that there's good in getting people to move more. STOP STOPPING AT LIGHT INTENSITY But what we need to acknowledge, especially after these results, is we cannot stop there. That is the first part of the journey to pushing people to more activity, but more intense activity. So what they found with this meta-analysis is the individuals that only received that light intensity, the only improvements that they saw across all those different outcome measures that I mentioned before was they did see some improvements in their hand grip strength. Awesome, that's great. That's a great correlation to lots of health outcomes, right? It's not a bad thing to have an improvement in hand grip strength. Great, that's awesome. There's a point for light intensity exercise. Now, moderate intensity exercise saw improvements in hand grip strength and important outcome measures like a 30 second sit to stand, a timed up and go, and leg press. Awesome. That's a few points for moderate intensity. We should probably be giving more preference to that than light intensity. And then the vigorous intensity crew saw improvements in all of those things previously mentioned that the light and moderate intensity experience, but they also saw improvement in muscle mass. They saw improvement in gait speed along with 30 seconds at the stand, five times at the stand, timed up and go, hand grip strength, leg press, chest press as well. They saw significant improvements across that broad spectrum of outcome measures that I talked about before. They get 10 points for those types of benefits, right? So if we're to rank them, the vigorous benefited tremendously much more than the moderate and the moderate benefited more than the light. So what this is basically telling us is that these folks that had that sarcopenia tag, which is based on, you know, a DEXA scan, but then also, you know, SPPB under 8 out of 12 or hand grip strength under 26 kilograms for males and under 16 for females. That's what we would typically look at, right? SARCOPENIA NEEDS VIGOROUS INTENSITY Folks that have that diagnosis that we need to be giving them vigorous intensity activities, particularly resistance training. If we do not give them vigorous exercise, we are leaving a lot on the table. Yeah, they're going to get better. They're going to improve on some of these outcome measures, but we leave so much potential benefit on the table that we're ultimately doing a person a disservice. So based on this research, I wanna focus on three main takeaways that we should walk away with after coming across some literature like this, all right? The first one, particularly for the ICE crew, you have such a unique opportunity that you spend so much time with these individuals, comparatively more time than any other healthcare provider, that you need to be well-equipped to screen and identify when sarcopenia is on board. We cover this extensively in MMOA level one and in our MMOA live course, but you need to be able to run an SPPB. You need to be able to run a hand grip strength. You need to be able to interpret those results and let that influence your course of care, particularly for the outpatient clinicians, because why do people come to you, right? What is a primary driver for your services? People are typically coming to you for pain, which you need to focus on, but that may not be the biggest issue. All right. So one we're screening, we're identifying number two, we are leveraging intentional under dosage. You've heard us talk about this podcast before. We've done whole episodes on this. So I'd encourage you to search that if you had, if this is a new term for you, but we need to leverage intentional under dosage because that is typically we're lowering the barrier of entry for individuals. So they're going to partake in particularly a new activity, right? For so many of these folks, they have not exercised before, they've not performed any intensity of resistance training. This is completely new territory for these individuals that we need to make it approachable. And so we may typically underdose initially. SHORTEN YOUR UNDERDOSAGE But in light of this evidence, that intentional underdosage period needs to be as short as possible. We don't have a lot of time here with these individuals and we need to make the most of our time. The quicker we can get to that vigorous intensity level so we get all those benefits that this meta-analysis discusses, the better, right? So that intentional under-dosage period needs to be as short as possible. That's a very vague thing, right? For some individuals, you may have their first visit where it may be intentionally under-dosed for their capacity. and then the next visit based on their response, their trust in you, their willingness to perform maybe a more challenging activity, that intentional under dosage period may be the span of one visit, right? But I know for me, particularly in home health, I've had intentional under dosage periods that have been well into the months. based on the person that I'm working with. Whatever it is, make it as short as possible. So we screen and identify, we leverage that intention on your dosage. And then number three, and I think this is something that we really need to grasp, is the clinical urgency in this situation. that if you continue with your light, with your moderate intensity exercise with these individuals, you're leaving a lot on the table. And ultimately, you are harming that person. You are robbing them from the potential benefits that we've seen in this meta-analysis, that they see the big improvements in the functional outcome measures, in their strength, in their muscle mass. These people have the capability to get those kinds of results. And if we waste our time and spend too much time in that intentional underdosage period where we're doing that sedentary, doing light to even moderate intensity activities, you are doing that person a disservice. You are doing that person a disservice. It is a dangerous situation that you're playing with. We need to have a sense of urgency when we're talking about sarcopenia. All right. I'm going to drop the link to this meta-analysis at Open Access. Really good read. It gives you a good idea of kind of the big body of literature around sarcopenia, but what they found in terms of these outcome measures. I'll drop that in the comments. If you have a tough time getting that link, just shoot me, DustinJones.dpt or the ICE account a direct message and we'll get that over to you. But this is a big conversation for many of you. You all are seeing tons of folks that would have that sarcopenia label put on them if they were properly screened and identified and you have a huge opportunity to give them that vigorous intensity, that amazing dose that is going to give them huge benefits across such a broad spectrum of outcome measures that have a huge implication for their quality of life. Alright, y'all have a lovely rest of your Wednesday. Go crush it. I'll talk to y'all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses recent research supporting the effectiveness of conservative care compared to invasive care, but in particular, the efficacy of chiropractic care compared to physical therapy care. Zac postulates that being hung up on the concept of spinal manipulation is often to blame for reduced PT outcomes when it comes to spine pain. He challenges listeners that the majority of patients are going to seek out & receive spinal manipulation for their pain, so the best course of action is to learn spinal manipulation, practice daily, and understand how to explain treatment to patients in a manner that does not facilitate dependence. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course, our Cervical 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 INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZAC MORGANAll right, good morning PT on Ice Daily Show. I'm Zach Morgan. I'm lead faculty here with the cervical and lumbar spine management courses and lead that spine division as well. Wanted to bring forward some content this morning. So the title of this episode is the deck chair on the Titanic or deck chairs on the Titanic. But before we jump into the actual content and kind of unpack what we're, what I'm talking about with that metaphor, I wanted to start out by kind of pointing you all in the direction of the next courses that you can jump into from the spine management side. So we're wrapped up for the year, but if you're looking for next year, two options in the middle of the country for cervical spine on the weekend of February 3rd and 4th, we've got Wichita, Kansas, as well as Hazlet, Texas. So if you're in the middle of the country looking for cervical spine, those will be good options. At the end of that month, we'll be in Simi Valley, California on February 24th and 25th. If Lumbar is the one that you're looking for, there's one in January. So Rome, Georgia, 27th and 28th of January. And then March 9th and 10th, Cincinnati, Ohio. And then March 23rd and 24th over in Brookfield, Wisconsin or right outside of Milwaukee. So several offerings there to start the new year for cervical and lumbar. If you haven't looked into the ice ortho cert, do so. So we've, we've revamped our website and you can go on there and kind of look at what all is included. Um, but that cert is kicking off. We're testing people out on the weekends already and it's been a really good kind of, uh, initial rollout here. So if you're looking for an orthopedic cert, um, check out the new ice cert and let us know if you have any questions. FIRST PROVIDER SEEN FOR ACUTE LOW BACK PAIN I just wanted to kick off today by actually unpacking an article. This article was published in the PT Journal back in September. It came out of the University of Pittsburgh, so that's probably the crew that does the most looking into back pain, at least in our profession. University of Pittsburgh is pretty famous for a lot of their back pain research. Essentially, this article was titled, First Provider Seen for an Episode of Acute Low Back Pain Influences Subsequent Healthcare Utilization. So definitely a bit of a wordy title, but essentially looking at who do people present to first and how does that influence downstream medical costs. And this was from Christopher Baez and his colleagues over there. Anthony Delito was on this paper as well. So if you're familiar with Anthony Delito, he's definitely done a ton in the low back space as well. So really good university, really well done study here, published in our journal here just very recently. So very recent data that we're looking at here. And let me just kind of talk briefly through what they did with this article with the method standpoint, and then we'll talk about the outcomes. And then we'll unpack the metaphor and end with some action items this morning. So really what was done for this article was a retrospective analysis. So they looked back at cases of acute low back pain, meaning that the person had not been to any sort of a medical provider within the last three months for back pain. So they looked at acute cases of low back pain and they looked at where they presented and then those downstream medical costs and how those things were affected based off of where they presented first. So they were looking at chiropractic care, physical therapy, primary care physician, emergency department, and so on, and basically comparing the outcomes downstream depending on where the person went from one of those professions. As far as outcomes, what were they looking into? They were looking into things like episode length, future CT MRI use, how often did those patients wind up getting that advanced medical imaging, how often did they opt for things like injections or opioid prescriptions, specialist referral downstream, getting to a spine surgeon, those types of referrals. Actual surgery was one of the outcomes they looked at, and then just unplanned care. So they looked at all these variables, retrospectively after these people had presented to the health care system one way or the other to see if there was any difference in the variables over the following year after they had that first episode of acute low back pain. And two things really jumped out to me as I was reading this article. So there's two very obvious things to me. CONSERVATIVE CARE OUTPERFORMS INVASIVE CARE First, conservative care definitely outperforms more invasive care when it comes to the reduction of those expenditures. So physical therapy and chiropractic would be the ones we would lump into conservative and physical therapy and chiropractic significantly outperformed basically the emergency department primary care physician any of the other places that patients would have presented, which makes a lot of sense to us as the conservative care crowd. We know that a lot of times getting that patho-anatomic diagnosis is not helpful at all and often drives a lot more care. So if a person ends up getting that type of a diagnosis early on, often they're going to end up in the health care system for longer. as physical therapists and then even often as chiropractic work, we're more targeting symptom behavior versus anatomical diagnosis, so it makes a bit of sense that conservative care outperformed non-conservative care. CHIROPRACTIC CARE OUTPERFORMS PHYSICAL THERAPY CARE But the second thing that jumped out to me as I was reading through this paper is that chiropractic care significantly outperformed physical therapy. Basically, at pretty much everything other than use of radiographs, which is not overly surprising. Chiropractors have the ability to prescribe radiographs. But if you look at things like episode length, they got us by a couple days. If you look at CT, MRI use, injections, opioids, surgical referrals, actual surgery and unplanned care, The chiropractic profession outperformed the physical therapy profession within that conservative care chump pretty significantly. I'm not really trying to pin our professions against one another. What I'm more trying to point out is they pulled their weight. Whenever we look at this data set and we see essentially how this course of care went through for the patients, it's clear the chiropractors pulled their weight. Yes, we helped from the physical therapy side as well, especially compared to non-conservative care, but within conservative care, I would say we left them stranded a bit and didn't do as good of a job as they did. And so I couldn't help but start to think about why wow, we've really got to step it up as our profession. Like if we want to be in this conservative care battle, it's not enough for us to not contribute to that side of the fight. We have to step it up. We have to pull our weight in this fight. So let's talk a little bit about maybe some of the ideas as to why PT didn't do quite as well as chiropractic care in this study. Because they didn't postulate too much on that in the actual article, but I have some thoughts surrounding it. And so I just want to talk through those things a little bit. WHY ARE WE SO AGAINST SPINAL MANIPULATION? Let me just start by saying, team, every year since I've been a PT, even from school till now, things like spinal manipulation have always been super challenged within our profession. So it's very clear when you look at medical practice guidelines, when you look at our clinical practice guidelines, when you look at most of the clinical practice guidelines, especially for the management of acute low back pain, they have suggestions for spinal manipulation. But within our profession, what I've always witnessed is anytime we, as I put out posts about spinal manipulation, we get a decent amount of kickback from our own profession. we get all sorts of commentary on those posts suggesting potentially that it's not as safe as it should be or maybe it's going to create dependence or things of this nature and I think in our profession we argue about that a lot and it winds up plaguing us when it comes to the execution of those techniques or even feeling okay about using those techniques on patients and team This is something we have to get rid of if we're going to contribute our share to the fight with conservative care for the management of acute low back pain. ARGUING AGAINST MANIPULATION IS LIKE ARGUING OVER DECK CHAIRS ON THE TITANIC I don't remember when I first heard the metaphor about arguing over the deck chairs on the Titanic, but it really fits in my mind to this current conversation. It doesn't make any sense to argue over the deck chairs on the Titanic, right? But imagine that. Imagine the ship is sinking, it's dropping underwater, it's hit the iceberg, And you're up at the nose of that ship that's going to sink last, arguing about where the deck chairs go, which table they go out, how you want to orient those. That makes no sense, right? The ship is sinking. So I think in our profession, we tend to do this. We tend to argue over the deck chairs on the Titanic. Let me unpack that a little bit. What's the Titanic in this metaphor? The Titanic is that people are going to have their spines manipulated when they have acute pain. You can like that or not like that, but the fact is true that patients or just our communities seek that intervention out in relatively high volume when they have acute pain. That's happening. What are the deck chairs that we're arguing about as a profession? That's where these things like Will it create dependence? Does it work? Is it safe? These types of questions are arguing over the deck chairs. We know it's safe, right? Like that has become very clear. If you look through the literature, when spinal manipulation is done well, it's a very safe and effective technique, especially relative to other techniques that people might would choose or even other medications that people might would choose for the management of their acute pain. So we know it's safe. We know it works well for acute pain. We've got enough data to show that it works well. Also, I mean, I would say even empirically, just looking at how many people are driven towards that intervention, I think empirically we know it works. And then, does it create dependence? I think that comes a lot more from the narrative for how it is presented to the patient than it does from the actual technique. So I don't think it has to create dependence. And we sit here and argue over these types of variables. Meanwhile, people are going to have their back manipulated regardless of whether we come to some sort of a conclusion or not. And that conclusion doesn't really influence the end result of those people seeking out that intervention because they think it'll be helpful to absolve some of their pain scenario. So it's very clear to me that we need to start pulling our weight here. We're too busy arguing over meaningless variables. START LENDING A HAND What we actually need to do is lend a hand in this fight to our chiropractic colleagues who are doing a very good job managing things conservatively. It's time that we take some action here. So team, I wanted to end this podcast by talking about what that action might would look like as a profession and hope that over the coming years we can start to shift to the profession in this direction. I do feel the wave of that currently and it's really exciting to see that more and more therapists are starting to utilize interventions that their patients want to meet that patient expectation and help create a narrative surrounding it. But I wanted to leave you with just a few action points. So first things first, I think you have to learn how to thrust manipulate. I understand there's a lot of argument in this space, but if you aren't able to do the intervention, the patients will never hear these arguments. So if we leave them stranded, or even leave them to just seek out all sorts of other health care, when what they want is spinal manipulation and if you could provide that to them, you could then help them understand the mechanisms, those underlying mechanisms that might make them feel more robust about their body versus feeling weaker or feeling fragile. We want to learn to do it so that that way when patients need it, we can provide it and we can also provide a supportive narrative that creates independence, not dependence. And this is possible. And so I think we have to learn to manipulate, otherwise we have no fight. Nobody's going to listen to the data. They're going to need to see it empirically. And so I think for us, we've got to get them in and actually do these interventions with them. To get good at that, I think you have to practice daily. So first, learn to manipulate, then practice daily. So whether that's on your spouse, on a family friend, or practicing on patients that are in front of you with no contraindications and perhaps even some indications for doing those techniques, I think we should practice these techniques daily so that you can get good at the psychomotor skills. Once you've mastered them, of course, focus on other things. But if it's still a skill set that you're refining, I would do those speed drills that you pick up in classes. I would practice on your colleagues and friends and patients. And then lastly, I think we have to, while doing these techniques, support a better narrative surrounding why they work. We want our patients to feel more empowered by feeling better following thrust manipulation, not to feel dependent by feeling better. So I think changing that narrative requires the learning of techniques and ability to execute the techniques well. That way the patient is actually interested in what you have to say. If you can't do the technique and you tell the patient that the technique doesn't work, a lot of patients are going to leave feeling like, well of course they think that, they're not able to do it. So I really don't think we can win any sort of battle of decreasing the dependence on things like spinal thrust manipulation without being experts ourselves in doing it. SUMMARY So team, that is just kind of the overarching thoughts on that article. It just jumped out to me that It was really nice to see the conservative care on the whole did really, really well. But I was just disappointed because I feel like I would love to carry more of the load alongside of our chiropractic colleagues and not leave them out there to fight this battle on their own. And I think a decent amount of professional infighting creates challenges surrounding actually learning these techniques and then utilizing them on patients. And I think we have to stop the professional infighting. We have to stop arguing over the deck chairs on the Titanic and just accept the fact that the ship is sinking. And it doesn't matter the orientation of those chairs. We have got to quit arguing over these factors and we've got to get to where we can actually do these techniques to people that are in pain so that we can help the chiropractic profession start to reduce a lot of those long-term costs that get associated with also not just costs but worse outcomes for the humans in front of us. You can criticize it all you want, but at the end of the day, what we're trying to avoid are things like opioids, things like injections, things like advanced medical imaging. These things, not just within 12 months, create a lot of expenditure and a lot of disability, but within the rest of that person's life, they do the same thing. So that's all I've got for you this morning, team. Let's tackle this problem together. Let's get out of the way. As far as the profession is concerned, stop arguing over little things and start to add these valuable interventions to our patients with acute pain. Hit me up if you have any questions, comments, or concerns in the thread here. I'll be checking it all day. Happy to further the conversation. But that's all I've got for you this morning. Take it easy and have a good Tuesday, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. April Dominick // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick as she wraps up her series on postpartum depression. In this episode, she will focus on first line of defense treatment for PPD including including medication, psychotherapy and exercise. As well as how to support someone with PPD as a friend or healthcare provider. She concludes with some important resources for emotional and mental health support that are free and extremely helpful to share with someone who is postpartum. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.APRIL DOMINICK Hello and welcome PT on ICE. My name is April Dominick. I am part of the faculty for the ICE pelvic division. And today's topic is all things treatment support strategies and helpful resources for postpartum depression. This is the final episode in my three part series on postpartum depression. So I am excited to dive in. But first I wanted to remind everyone of our array of course offerings in our pelvic division. Our first few live courses of 2024 are in Raleigh, North Carolina. That's going to be January 13th and 14th. And then Hendersonville, Tennessee, January 27th and 28th. And let's not forget about our not one, but two online eight-week course offerings. The level one cohort is going to start January 9th, while our brand new level two advanced concepts course will take place April 30th. If you've got someone asking you for some gift ideas or asking you to let them get you a birthday present, if you have a winner birthday, then have them help you out with some courses for ICE. That would be such a great gift of learning. And you can head over to ptonice.com to secure your seat in one or all three of those offerings, which is what is needed for our brand new ice pelvic certification. TREATING POSTPARTUM DEPRESSION All right, let's dive in today to the treatment section of postpartum depression. So one of the most common ways to treat postpartum depression is with antidepressants and psychotherapy. For those who are lactating, the conversation may include discussing the benefits of breastfeeding and known risks of antidepressant use during lactation. A lot of folks have concerns with the side effects that can occur when starting antidepressants. These concerns are totally valid and really excellent questions to bring up with their physician. For some, not being on the medication and leaving symptoms left untreated from a medical management standpoint could be just as risky in terms of their mental health and emotional health as well. For those who are concerned about the interactions that breastfeeding would have with antidepressants, or for those who would not prefer to take antidepressants, Psychotherapy is actually the first line of treatment. When looking for a mental health provider, we want to remind our clients, if possible, you want to find one that lists some sort of training in or special specialization of perinatal health as they will be really well-versed in the unique challenges that a postpartum individual faces.  EXERCISE AS A FIRST LINE TREATMENT Now, Let's talk about a treatment that is within our PT scope of practice, and that's going to be exercise. So exercise is a great alternative or supplement to treating postpartum depression. Now, as a postpartum person, finding time to exercise while caring for a newborn, as well as taking care of the rest of life's demands, including chores or a job, That can be incredibly difficult and is a huge barrier for many to either return to or begin exercise in the postpartum period. When I was searching on the American College of Obstetrician and Gynecologist website, just seeing what all they have in terms of resources and recommendations, they didn't really have exercise as readily mentioned on their main pages when they were discussing how to address postpartum depression symptoms. And rather, they had like the medication and the mental health therapy, which was the greater focus, which is wild given that it Exercise is an excellent treatment offering that's conservative, it's generally accessible, and non-pharmacological. Not to mention, some of the forms of exercise can be cost-effective. And this may be a gap that we as rehab providers can remind our physician colleagues on the latest research that we know about of the effects of exercise and depression. and reminding them that, hey, we're those musculoskeletal experts in your community, and we are willing and able to help guide their clients in starting or continuing exercise, as we know, improving the postpartum individual's physical well-being and directly supports their mental health and well-being. THE EFFECTS OF EXERCISE ON DEPRESSION So what do we know about the effects of exercise in general on depression? Exercise helps to increase levels of endogenous endorphins and opioids, all of which have positive effects on mental health. And the team from Singh et al published a paper in 2023 on an overview of systematic reviews on physical activity for improving depression. they found that physical activity had medium effects on depression compared to usual care. So specifically, they suggested that aerobic resistance and yoga exercise was the most beneficial and exercise with higher intensity was associated with greater improvements. And then there was another study that was published in September of 2023, and this one was by Zhao et al. And they aimed to determine the association between seven lifestyle factors and lots of other body functions to see what their impact was on depression. They studied data from 290,000 individuals across nine years, with about 13% of those individuals developing depression. We love that length of time for data collection. Some of the seven healthy lifestyle factors that they found were associated with a lower risk of depression were healthy sleep, about seven to nine hours, that reduced the risk of depression by 22%. Frequent social connection that reduced the risk of depression by 18%. it was the frequent social connection was the most protective against recurrent depressive disorder. And then the other two of the seven healthy lifestyle factors was regular physical activity that reduced depression risk by 14% and then low to moderate sedentary behavior. When it comes to our postpartum population, we have to recognize that seven to nine hours of sleep is extremely unrealistic for most, but we can offer suggestions for improving the quality of that sleep, curating the best environment with maybe the control of limited noise. Can we make the room colder when we are going down for two to three hours, start to nap, uh, darker, uh, light or like less light and then cooler temperatures. Um, So those were some of the studies that looked at the effects of exercise and lifestyle behaviors on depression overall. What about the role of exercise in prevention and treatment of the postpartum population with depression? A little more niche. When it comes to aerobic exercise, there was a qualitative systematic review from 2023 by Xu et al. And it actually just came out last week. And it was studying the efficacy of aerobic exercise in preventing and treating postpartum depression. They found that compared to standard care, aerobic exercise, particularly 30 to 45 minutes of moderate intensity, three to four sessions a week, had a significant effect in treating postpartum depression with a greater emphasis on prevention. Many of the studies we have on exercise effects on postpartum depression, look at aerobic exercise. But what about resistance training? So in a study by Le Chemin et al. from 2019, the group examined the influence of resistance training in women during postpartum depression. They found that compared to a stretch-based program, those who engaged in resistance training reported a significant decrease in their depressive symptoms four months postpartum. compared to when they measured immediately postpartum. We also have data from our very own ICE faculty, Dr. Christina Prevett, who did a study that looked at the impact of heavy resistance training on pregnancy and postpartum health outcomes. And compared to the national averages, those who lifted heavy showed lower rates of perinatal mood disorders as well. So there's quite a bit of heterogeneity in the method sections of these studies that these systematic reviews are looking at when it comes to exercise and depression. This makes it difficult to specify any sort of intensity or specific type of exercise or timing frequency domain for what is best practice, what is most effective for using exercise to help with reducing depression. The SHU article was one of the first that I had run across giving a specific time and frequency domain for exercise in the postpartum depression period. It would be interesting if researchers could look at the effects of exercise alone, as many of the studies look at the combination of the treatment of psychotherapy, medication, and exercise. I'd also be curious about, hey, does it matter the specific time that someone returns to exercise postpartum. As in, is it most effective if someone returns to movement within two weeks, four weeks, six weeks? What makes the most difference? So while we're waiting for more dialed-in research in the clinic, If you're going to create a program or suggest a rehab EMOM for someone with postpartum depression, make sure that you're including a mix of aerobic exercise, resistance training, and mobility, as well as some sort of reconnecting with their breath and body, just to help tap into that downregulation of the nervous system and hit those preliminary time guidelines from Shu et al. of 30 to 45 minutes, three to four sessions a week. So to sum up treatment, while there are multiple options to address postpartum depression currently, our first treatment approach is usually a combination of the treatments of antidepressants, psychotherapy, and exercise. So that was treatment. SUPPORTING PATIENTS WITH POSTPARTUM DEPRESSION Now I want to talk about how do you support someone who has postpartum depression as a rehab provider or a friend. Overall, validation, education, and reassurance and psychosocial support go a long way in helping someone experiencing postpartum depression. Making the new mom feel taken care of. Everyone has shifted focus to the baby, so how about asking how the mother is doing, checking in with their needs or whoever the postpartum person is. So there are so many ways to support a new parent and these are just going to be a few suggestions for how providers or friends and family can support that person. As a friend and provider, highlighting and celebrating the wins is key. Small, big. How they have made a huge impact on caring for their child and supporting their family. How their baby needs them, the postpartum person, to be consoled and that that person is able to console the baby and how they are learning what their baby needs are and recognizing the needs for comfort, for food, for diaper changes. As a friend, if you're looking for a way to help them that may not have as high a financial ticket as some other ways that folks can help, offering to drive the postpartum person to their appointments or to sit in the stay with a baby so they can get out of the house or get in some exercise without being interrupted by the baby waking up. Or as a friend, offering to help them with some chores. Bonus, you'd get some quality time together. And then another option as a friend is just communication. A simple message can make someone's day offering consistent check-ins, text messages, phone calls, FaceTime, snail mails. You can share something funny about what you just experienced or maybe you just thought of them and wanted to share that with them. As a provider, brainstorming with the postpartum person, how they can ask for help from their support system and help offload their mental and physical demands. Um, maybe they could create a meal train or ask, um, friends to set up a grocery delivery or, uh, ask for some gift cards to a favorite restaurant or self care services like physical therapy, um, a massage, a facial or a haircut or a babysitter. Obviously those come with a little bit higher price tag, but just options to, um, suggest for the, uh, postpartum person to tap into their support network. And then as a provider, reviewing and sharing some resources with the client that are particular to postpartum depression, such as phone support lines, community groups, or even providing them with some postpartum depression related pamphlets so that if it's a hard conversation that they don't want to have, then they could read it on their own time. RESOURCES FOR POSTPARTUM DEPRESSION So I'll go over some resources now and put them in the caption for you to reference. That is my cat. She is joining and also wants to hear the resources. So the first one is the Postpartum Support International website. It is one of the best resources overall that I've encountered. It is good in that it is going to be helpful for connecting folks with local resources in their region, offering emotional support during pregnancy and postpartum. with online support groups and they also have live phone sessions every Wednesday and I think they're capped at about 15 to 20 people. They also have perinatal trained medication providers or therapists or community groups and tons of blogs with others sharing their stories and so Folks can also use the Postpartum Support International's directory of trained perinatal mental health providers on folks who are specialized in postpartum anxiety, postpartum depression, and they have a director specifically for those humans, which I think is awesome. The next resource is the National Maternal Mental Health Hotline. They provide free conventional support confidential support resources and referrals from professional counselors to help pregnant and postpartum individuals facing mental health challenges. And this is also available 24-7. They also have interpreter services that are available in multiple language, which is huge. The third resource is the 988 Suicide and Crisis Lifeline. It provides free and confidential emotional support to help people in suicidal crisis or emotional distress. This is also available 24-7 and individuals can call, they can chat, or look up all the different educational information on their website. The fourth resource is the Postpartum Progress website. It is just chock full of information on the postpartum period in general, with a big section on postpartum depression, They have a provider list, including a black mental health provider list. And, uh, one of their extras was a Spotify playlist, uh, called warrior moms, which I love the strength and energy behind that. And then finally another, um, uh, resource, which is on the ACOG website. Uh, it is an infographic on anxiety and they do a beautiful job of, um, pretty much going through all of my, uh, podcast series, but for anxiety. about the prevalence, what is postpartum anxiety, and what are some treatment methods, what are some resources, just kind of sharing information because it's helpful to know that other folks are going through the same thing and that there's help out there. This pamphlet is a great idea to put up in the clinic, put up in bathroom stalls, maybe even have on your clinic website, but making one for postpartum depression. So we as PTs, we are perfectly positioned to help break the silence of folks with postpartum depression who may also be unaware that they're even dealing with this condition. We can make a difference in these clients' lives. Combined with educating ourselves, we need to be educating the birthing individuals, their support system on what postpartum depression looks like and ways to prevent it. then actually informing the individual on a number of treatment strategies available to them, including the combination of medication that is right for them, psychosocial mental health therapies, or alternative therapies like aerobic or resistance training exercise, whichever of those treatment strategies makes sense to them. And of course, speaking with their medical provider for the medication and psychotherapy piece. Oftentimes finding the right care support and gradually adding in movement, physical movement, aiming for good quality sleep, which is so tricky with this population and addressing nutrition can be huge steps in treatment of postpartum depression. But there's so much more. The essential pieces are asking someone about their current ecosystem in their postpartum world, allowing them space to share the tough things and knowing when to refer out for postpartum depression. as well as encouraging them different ways that they can lean on their support system or offering them the free resources such as the support groups or hotlines I talked about. And those are available in the caption. So treatment for postpartum depression, remember it's not a one size fits all. And individual specific situations, their preferences, they all have to be taken into account. If you miss the other two episodes in this series that go over the prevalence, risk factors, how to screen and what to say to someone who you suspect has postpartum depression, check out episode number 1553 and number 1572 to learn more. And thank you so much for your time and attention today. And I hope you find some brightness in your day. And as a bonus, if you have anyone who is recently postpartum, send them a warm message and let them know that you are thinking about them. Take care, everyone. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses one of the most effective and efficient ways to improve VO2max/fitness/endurance/conditioning both in the gym as well as in the clinic for your fitness athletes (and all clients). Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. GUILLERMO CONTRERAS Okay, live on YouTube and live on Instagram. Good morning, everybody. Welcome to the PTI Daily Show. My name is Guillermo Contreras. Happy to be here with you on the best day of the week, Fitness Athlete Friday, talking all things fitness athlete and improving overall fitness in the individuals that we work with on a daily basis, in our clinics, in our gym settings, et cetera. Before we dive into the topic at hand, Let's go ahead and talk a little bit about the fitness athlete courses coming to your area as well as online. Fitness Athlete Live is going to be on the road over the next three months, quite a bit. Next weekend, we're going to be in Colorado Springs, Colorado, the weekend of December 9th and 10th. The weekend, and that's it for 2023, right? But 2024, we jump in right back onto the road. January 27th and 28th, we're going to be in Portland, Oregon. February 10th and 11th, Richmond, Virginia. And then February 24th and 25th, we will be in Charlotte, North Carolina. So plenty of options, whether you're in the mountains on the West Coast or on the East Coast, we're going to be traveling throughout those areas in the next three months or so. So feel free to check out the website, ptinex.com to find out how you can sign up for those. As a reminder, courses in price at the end of this year. So if any of these courses look like something you can get to, you want to get to, you can travel to, you're going to make a plan to get to. Snatch that course up now because right now courses are $650 and they're going to be bumped up to $695 in 2024. So take advantage of the lower price now. Get yourself signed up for those courses and then find a way to get to these courses but just check those out on the website for where those are going to be. And then fitness athlete level one online. The next cohort is going to start up on January 29th. Currently in the middle of a cohort right now. Started finishing up week four right now. So four more weeks there, a little short break, and then we kick back up on January 29th. And then fitness athlete level two, or what is formerly known as advanced concepts, that kicks off on February 4th. Those courses always sell out. We rarely have anyone that wants to get into it that can't get into it after they sell out. So if it's something you've been looking to do, if you're looking to become certified in clinical management fitness athlete through that certification process, then you need to be able to take a one, take the L2, take the live course. And again, that L2 only comes twice a year. So if it's been on your bucket list, something you want to take, sign up now sooner rather than later, because as I mentioned, those courses, All right. Um, so that is the introduction there. That is what we have on the docket. Um, as I mentioned, again, my name is Guillermo Contreras. I'm a physical therapist, uh, over here in Milwaukee, Wisconsin, and a part of the fitness athlete team here with the Institute of Clinical Excellence. THE ASSAULT BIKE FOR VO2MAX DEVELOPMENT The topic today, uh, the title, uh, is VO2 assault or assault on your VO2. I don't know why I wasn't too creative today, but there's there's a reason we're talking about it is The assault bike or the echo bike or like any air bike right we're talking about like this this beast This beautiful thing we have back here the assault bike I have here in my office Is one of the best tools that we can use to work with individuals in the clinic out of the clinic in the gym trying to improve overall cardiovascular conditioning, fitness, metabolic stress, like all these different factors that we can improve upon using a simple piece of machinery. This piece of machinery costs anywhere between $700 for the Assault bike, the standard or the original, I believe is what it's called, up to $840, $850 for the Echo bike, which you can get through Rogue, the Rogue Echo bike. It can go as low as, if you're really just kind of want to pinch pennies there, a couple hundred dollars, maybe $100, $150, or a Schwinn Airdyne. And those Schwinn Airdyne bikes, right, those are, like we used to have one of those from like the 90s that still worked like it was new. They last forever. they work forever, easy maintenance if you just take care of the chain with the rope echo bike a little more expensive because it's belt driven and again that lasts forever very little maintenance so they're just really really nice pieces of equipment to have. The weight limit then on them is around 300 for the soft bike 330 pounds for the echo bike and probably sure a little bit less for just your standard twin airdyne but they make like the airdyne pro that i'm sure has a 300 pound weight limit as well. last and survive through the apocalypse. That's how good these things are. Not only that, but in the clinic space, they are fantastic for working three limb conditioning. If you have any a knee injury, a hip injury, something that does not allow them to do something like running or standard biking or skiing or rowing, right? They have a limb that they cannot use. You can rest that limb and work the other three in a very effective way that increases conditioning overall. And the reason I'm saying all this, and the reason I'm touting up the Assault Bike, the Echo Bike, right, is because there is no reason that we should not have a piece of equipment like this within our clinics. And if we have something like this, there's no excuse for us not using it with our patients. Especially if you work with an athletic population. When you look at the NFL right now, how many people are getting injured? How many injuries are you seeing on a weekly basis? You've seen an excessive amount of Achilles tears, knee injuries, high ankle sprains, all those things. And one of the biggest things you hear when an athlete comes off of what they call the injured reserve is that, are they in game shape? Like they have the strength back, they have their motion back, they can handle the stress on whatever was injured, but are they truly in game shape? Do they have the ability to withstand rep after rep after rep on the field? And honestly, when it comes to conditioning, there is no better device. in a more efficient way than this behemoth, this beast right here, this monster, this thing we love to hate in the fitness athlete realm, in the CrossFit sphere, and in pretty much anywhere you see this bike. EFFICIENT RESULTS WITH THE ASSAULT BIKE This is proven in a wonderful study where it took 32 individuals and it put them in three different groups. The control group was given moderate intensity cardiovascular training. 30 minutes of 75% heart rate max, cardiovascular cycling, 30 minutes rate of 70, 75% of heart rate max. Group number two was given what we know as a Tabata or a half Tabata. They had to do 10 seconds sprints, five seconds of rest for eight sets. They then rested for two and a half minutes and repeated that whole cycle three total times. Group number three was given a standard Tabata, three sets, of eight repetitions of 20 seconds of work at 10 seconds rest. That is your standard Tabata 20 on 10 off eight rounds. They had to do that three sets with a five minute rest between each uh three set round you call it there or each eight set round I'm sorry eight round set. All in all the modern intensity cardiovascular training group did around three The 10-on-5-off group did around 72 minutes of work per week, so around an hour, a little over an hour. And the standard Tavada group, that three, or the eight rounds of 20-on-10-off, did around 144 minutes of work, or just over two and a half hours, sorry, around two and a half hours of work per week. What they found at the end of the study was that there was no significant difference in improvement across all three of them. All three showed improved time to fatigue, improved VO2 max, improved conditioning, and improved ability to create force, improved MET, M-E-T-S, M-E-T-S. But the big picture here, gang, right? Like what we see there is like, okay, like that means we can pick any of those and get someone more cardiovascularly fit. Yes, that is true. You can kind of pick your poison whichever way you want to do it. What we're talking about here is that the short group, the 10 on, five off, 72 minutes of work per week, one hour of work per week, that group was 250% more efficient in the use of their time to improve their cardiovascular fitness, to improve their conditioning, to improve their power output, to improve their time to fatigue than the other two groups that doubled and six times the amount of work. And how we can apply that is like when we're looking at individuals in the clinic, we probably don't have six hours of week to add to their program, to their plan of care, to get their conditioning up. They might not have six hours additional per week to jump on a bike and do 30 minutes of work three times a week as well. And if we want to get someone more conditioning, better shape, better heart health, improve health markers, blood markers, all those things, while also improving pain, reducing pain, improving function, increase in range of motion, whatever our plan is or whatever our goals are for them in the clinic, this device, the AssaultBike, the EchoBike, a nice quality Schwinn Airdyne bike, that is the way we can do it in a very effective, efficient manner. If you can do the same If you can have the same results in less time, people are going to buy in. If you can show somebody, hey, we're just going to do 8 sets of 10 on, 5 off before we start the session. I'm going to jack your heart rate up. I'm going to get your blood flowing. We're going to not only improve your overall cardiovascular fitness, we're not just going to improve your overall health markers. We're not going to just improve your conditioning, which again, if you're looking at working with athletes, whether it be in professional sports, amateur sports, high school sports, whatever it is, you need to build up their conditioning space or their conditioning ability. SHORTS BOUTS; GREAT RESULTS But across all populations, we can all benefit from this. We can all benefit from having better heart abilities, better cardiovascular fitness, better VO2 mass to be able to stand and do things for longer with less fatigue. So by using this device, using short sprint intervals, things like you see behind me, things like 10 on, five off, or eight rounds, three sets, two and a half minutes rest, or simply one set, one set of eight repetitions of 10 on, five off, right? We can have these small things that can affect individuals. It's also something they can easily do for a home program. if conditioning is an aspect they need to work on. If we're trying to get their VO2 max up, we can give them, hey, I want you to jump on the assault bike, jump on the echo bike. I want you to do 10 rounds. Just go as hard as you can. Rest five seconds. Do that eight times. Do that a few times a week. When you're looking at individuals who have Achilles tears, knee injuries, something where they cannot use that limb or it's uncomfortable to use that limb, they can still get after it with three limbs. They can use left leg and both arms and get after it on a soft bike. Again, effort is what matters here. Intensity is what matters. And when we're talking about working with individuals, trying to give them the most effective, efficient way to get better, get stronger, get healthier, and we're thinking of a fitness-forward approach to everything we do, this device, these tools, these strategies, these techniques, in doing that. and nauseam about getting people fit or getting people strong, using intensity as the way to do that. And if you're curious how it works and if it works for you, simply get on an assault bike, get on an airdyne bike, push yourself hard for 10 seconds, work a five seconds rest, repeat, rinse and repeat for eight rounds and see how you feel after that. See how the improvement comes upon there. Hope to see you on the road, gang. Hope to see you online. Thank you for tuning in. Have a wonderful weekend and we'll see you next time on the PT on ICE Daily Show. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses the origin of the term "fitness-forward" and how developing your "nose" for the essence of your business principles can help clarify your mission while helping your brand. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. JEFF MOORE All right, team, what is up? Welcome back to the PT on Ice Daily Show. Thrilled to have you here. My name is Dr. Jeff Moore, currently serving as the CEO of ICE, and always thrilled to be here on a Leadership Thursday, which is always a Gut Check Thursday. Let's do the workout, let's chat about some courses, and then I can't wait for today's topic. I've been waiting a long time to do this one, so I can't wait to jump into it, but first, the workout. Gut Check Thursday, it is Lynchpin Test 14. It's quick, but it's painful. It is 15 clean and jerks at 135/95, then you're going to go 30/20 on the fan bike, and then right back to 15 clean and jerks. Relatively simple couplet, but one can be certain that second set of clean and jerks is going to feel nothing like that first set of clean and jerks. You're going to be exhausted from the first set. And if you went big on the bike, Lord knows you're going to be feeling every bit of that energy on every rep of that second set of clean and jerks times. Probably five six seven minutes. I mean this should not be a long workout Especially if you really put out on that bike, so please tag us ice physio Hashtag ice train get them up on Instagram Let's all suffer a bit together here on gut check Thursday as far as course is coming up I want to say two things number one The first couple weeks of January are going to be packed with all of our online courses. We have six of them firing up in the first couple weeks and darn near all of them in the first month. But in the first couple weeks, we've got Injured Runner, Persistent Pain, Brick by Brick, we have Pelvic Level 1 and Older Adult Level 1. We also have Older Adult Level 2. Now what I want to say is, if you're going to jump into one of those, remember that prices go up to $6.95 on January 1st. So buy your ticket before January 1st. It's only $45 or $50, but save a little bit of cash and snag that ticket at some point here during December. If you're jumping in early January anyways, you might as well save yourself $50. So hop on the website, PTOnIce.com, and get that done. FITNESS-FORWARD: THE ORIGIN OF A TERM Let's talk about fitness forward, specifically The origin of the term. So I get this question all the time. Where did that term come from? What does it even really mean, fitness forward? So I'm gonna answer that once and for all. I'm gonna give you some clarity on that. But I also wanna share a branding lesson while we do so. So if you're not overly concerned about where the term fitness forward originally came from, stay tuned because I hope that by the end of this, you see a significant branding pearl that you can incorporate into your own business or practice. First things first, to understand the origins of this, you have to know a little bit about kind of our company's evolution. And if you look at it over the past 10, 12 years, there have been kind of what I look at as three really significant changes that fostered our evolution that really helped us solidify the who and the why we exist. STRENGTH & CONDITIONING ACROSS PHYSICAL THERAPY The first one is a huge increase in strength and conditioning principles across the professions of physical therapy, occupational therapy, chiropractic, especially around like the early 2010s, like 2012, 13, 14. I was out there teaching almost constantly. I mean, every weekend, every other weekend. And we were teaching, you know, kind of traditional manual therapy and patient expectation and sales stuff. and things to level up your practice. But the questions that I was getting was so oftentimes not so much around those things, but more around, OK, cool, how do I incorporate strength and conditioning principles? What about after the fire's out? How do I keep people on my schedule and really deliver above and beyond just making them feel a bit better? How do I incorporate strengthening and resistance training into injury prevention? And it was very clear to me during those years that that was where the profession wanted to go. That was where a lot of the more exciting research was coming out. Even things around like longevity and healthspan and life quality and all of these things around lifestyle behaviors, resistance training, strength and conditioning were just flooding the research and everybody rightfully so was so excited about it. What nobody had though was answers for them, myself included. I remember looking around thinking, I really don't know where this stuff lives. It certainly doesn't live in PT schools. It still really doesn't. It wasn't in traditional residency and fellowship programs. Those were a lot more focused around the exciting manual therapy research of the early 2000s. They were built from that space. So it didn't really exist out there. Nobody seemed to have the answer. So watching this interest grow, is what led me to reach out to Mitch Babcock and say, big guy, you got to show the profession this stuff. Like this is in your DNA. You live and breathe this stuff. You got to build a course that shows the profession of physical therapy, occupational therapy, chiropractors out there, how to move a barbell around. how to get fit, how to get other people fit, basics of programming, how to work around injury. There is a clear desire for this information that if we had, it could lead to significantly better lives for our patients, but we don't know what we got to build it. So that's where the fitness athlete curriculum started, right? Started off as that first, what we used to call the essential foundations course. It's now level one. And of course, over the years, it's now built into advanced concepts, the live course, the entire certification. But that's where it started. And as it was building, first of all, the reception from our profession was unbelievable. Like, we totally underestimated the demand for that material. To have a concise course that showed people how to do these lifts, how to program them, how to get people fit while getting themselves fit, we underestimated demand. The enthusiasm was incredible. but it wasn't just the students. We as faculty were learning along the way. We were getting more and more into it. Becoming fit and living that life and being about it became more and more important to all of us. As it did, we were hiring people who were already living and breathing that life. And so the compilation of the ICE faculty was moving in that direction as we were learning and teaching this content. Well, what happened then was really important. As we all began to get more excited about it, live, breathe it, demonstrate it, we really started to understand the power of be about it. As we started swapping stories with each other, we began to realize the impact that us working out and being fired up about the stuff at courses was having on participants. We were getting emails of people who said, hey, great class. Love the content. But I also want to say, hey, thanks for the workout. I've been slipping a bit in that space. And that really called me back to action. It really motivated me. Here's what I've done since that course. I've gotten into the gym. I've gotten my family into the gym. And we started realizing this is where the magic's at. DEMONSTRATING A FITNESS-FORWARD LIFESTYLE: PEOPLE FOLLOW PEOPLE It's actually demonstrating this stuff. It's actually living, it's being an example. Well then, we all carried that kind of from the classroom over into our clinics. And we got louder about it in the clinic. We started sharing workouts for the community. And we really realized this is where it's at. Being about it is the answer. People don't need more education, they need more inspiration. That quote kind of came from this evolution of like people don't need more knowledge, they need an example to follow. If you lead people, they will follow you. It's not about education, it's about inspiration. As all of this came together, our growing enthusiasm ourselves, the enthusiasm in our students, then the enthusiasm in our patients and our communities, we realized, and I can point to one moment when it all kind of crystallized, it was in 2017, the very first ICE sampler. We were sitting on Justin Dunaway and Morgan Denny's patio in Portland, Oregon. And we're sitting there throwing around these stories of people who had come to our courses and had this great experience working out, how fired up they were, how their lives are better off now for it. And I'm sitting there on the patio, and I said, that's it. From this moment on, you never go to an ICE course that doesn't have a workout. It's mandatory. It's who we are. And I remember it felt so right to say that it was now, we were already doing it organically, but it was now baked into the process. This is who we are. If you engage with the ICE community, you get fitter because of it and all the beautiful sequelae that come along with that. So this evolution really helped to solidify our mission. We now knew exactly what we taught and what we did. We managed symptoms to maximize fitness for every age and stage. That's it. We know now exactly who we are, what we're teaching others to do, and the wording of all of that is really important, right? The order of that. We manage symptoms. We don't need to erase symptoms. We don't need to cure symptoms. We need to manage them. We need to improve them when they can, but we need to work around them at times. But we manage symptoms for the higher goal of maximizing fitness. Because when you maximize fitness, you don't just change back pain, you change lives. I mean, you transform that individual's life. That's why it's in that order. You are totally managing symptoms, and your efficiency at doing so is critical. But it's for the goal of maximizing fitness, and it's for every age and stage. If you look at our course catalog, that's who we are. We're breaking down barriers for older adults, right? It's old not weak and it's avoiding one rep max living. We're taking it to the pregnancy and postpartum space and getting rid of those myths, right? And debunking all that stuff that you can't lift heavyweights further on into your pregnancy. That you can't do things at more of an individualized timeline afterwards before the generic six weeks. We're breaking down barriers because everybody gets fitness. And we're going to find a way to make that happen. Quotes like, you don't leave the gym, you use the gym. You work around the injuries. The point is, this evolution through fitness being incorporated into our company is what allowed our mission to be solidified, that we manage symptoms to maximize fitness for every age and stage. FINDING A NOSE FOR YOUR ESSENCE OK, but why the actual term? So you get the importance of fitness now within the ice culture, but why the term fitness forward? It still sounds kind of funny. The answer to that is kind of funny. So before I became a physical therapist, my first professional love was wine. So I managed restaurants. I sold wine. I learned everything I could about wine. I love wine. I have not drank alcohol in years. I still love wine. I love everything about it. I love how it brings people together. I love how it's cultivated. I love literally everything about it. Not to get too technical and go into a big wine lesson, But an important thing about enjoying wine… is understanding how to savor the nose of the wine. Most of you are familiar with this idea, right, of swirling your glass, right, and making some of those aromatics volatile so you can put your nose in the glass and you can take in some of those beautiful senses, right, of the different smells and characteristics and the heat of the wine, right? It's beyond just smell. By the way, not to get really technical, but if the wine is high alcohol, don't put your nose so far into the glass, right? I see this all the time. If you've got a big cabernet that's 13.5% and you swirl the glass, if you bury your nose way in there, it's just going to be hot. Because that alcohol is going to be so like, whoa, so upfront, you're not going to really enjoy the nuances of that experience. Higher alcohol, keep your nose closer to the brim of the glass. You have a lower alcohol, you got a German Riesling, 8.5% or something, by all means, dive in. But higher alcohol, just give yourself a little bit of space to make sure you enjoy all the complexities. Now getting back to the podcast, the point is that nose is kind of what you walk away with when you think about a wine. It's the essence, right? I looked up the term essence before this podcast, the actual definition. The essence is a property or group of properties of something without which it would not exist or be what it is. To me, when you're getting the nose of that wine and you're getting that really subtle tone of leather, right, or some of that French oak, right? And you're like, oh, I can really catch that. That really jumps out at me. Without that, it wouldn't be the same wine. That's what you walk away with. It's the wine's essence. The nose, if you will, of ice is fitness forward. Right, no matter where you engage with us, it comes through. It's the essence, it's the thing that's always there. I hope when you see our logo, things like Be About It, Lead From The Front, Old Not Weak, I hope all of these are almost synonymous with that logo. I hope that's what our essence is and you can feel that. Now the brand lesson I was talking about with you all earlier is that's what you wanna create. SOLIDIFY YOUR BRAND BY CLARIFYING YOUR ESSENCE The goal of solidifying your brand should be clarifying your essence. You should all know exactly what it is that no matter where somebody engages with your product, that comes through. That is a beautiful thing. And when you think about really bonding people around a common purpose, knowing what that is and then clarifying it and solidifying it, that's where the magic happens. To fully answer the question, where did the term come from? Well, that's the details. But when did I first say it? I said it in early 2018. It was after that Portland Sampler. It was the next year we were rebranding our ICE logo. And Ryan from THINK Marketing asked me, dude, in one sentence, What is ICE? Who are you? And I said, dude, we're the and, not, or company. We are fitness-forward, manual therapy skilled, and psychologically informed. And as soon as the words fell out of my mouth, I said, that's it. That's who we are. And now you've seen the logo, right? It's got all three of those things on there, but that's where it came from. And I know that fitness forward came out of my mouth first because that is our true essence. Now, what's our goal for you, right? Let's get away from us for a second. What's our goal for you? Our goal is that your practice becomes fitness forward, right? That when you, if you engage in our content long enough, your practice transforms in that direction because that's where people are going to make the most life-changing gains. So we love when we walk into your clinics, and we see all the things, right? We see the squat racks, we see the mats, we see the barbells, we see the kettlebells. We know that people are challenging themselves in a way that's actually going to transform them as a human, not just ameliorate their back pain. It's part of it, not all of it, right? We hope your practice patterns move in that direction, your equipment moves in that direction. But honestly, to wrap this show up, we hope you move in that direction. We hope that your life becomes fitness forward. Not to get too philosophical on you here, but while I deeply love all the comments and emails about, hey, ICE really transformed my practice, this, that, and the other, I love that stuff. That's the core of what we do. But I'm not telling you the whole truth. If I don't say that, what means the most to me is the note that says, hey, I gotta tell you something. I went to this course with a few of your faculty, and they really made this fitness lifestyle approachable and non-threatening, but also relevant and meaningful and emotional in a way that made me change the way that I live my life. And I wanna tell you a bit about why I'm different now than I was before I went to your course. I wanna tell you the effect it had on my family, on my team. If I zoom all the way out, that, that's what I hope. Us being fitness forward in whatever evolution we took to get here, that's what I hope the outcome becomes at scale for every single one of you and every single one of the people whose lives you touch in turn. FOREVER FITNESS-FORWARD We are forever fitness forward. We know who we are and we know where we're trying to go. And I'm so thrilled you're all going with us. I hope that explains the term ptiice.com is where all the goods live. Thank you so much for joining me this morning. Take care, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses her personal experience with end-of-life care, comparing different scenarios between family members who had hospice/palliative care and those who did not. Christina challenges listeners to step back and recognize if they are being mindful of the patient's choices when nearing the end-of-life, and respecting the dignity of those choices as it relates to physical therapy treatment. Christina also reminds listeners to always advocate for their patients and be a resource, especially with hospice/palliative care as it is often not recommended as an option for patients. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. CHRISTINA PREVETTHello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of the lead faculty within our modern management of the older adult division. We are in full-blown, like end-of-the-year mode. I hope you all had a wonderful Thanksgiving. We are getting ready for a really big 2024. Our next online courses are level one and level two, running January 10th and January 11th. And then we have two courses left for MMOA Live, Chandler, North Carolina, this next weekend, and Portland, Maine, that have maybe one or two seats left in them. And then, oh, hi, Hospice Nursing tuning in. We are really getting going for January so we are in Santa California Santa Clara on January 13th and 14th And we were in Maryville, Ohio that same weekend. Sorry, Santa Rosa and then I am in Greenville, South Carolina the 20th and 21st All right. HOSPICE CARE Let's get talking about hospice. I graduated from PT school about 10 years ago and there always are some moments in your education that really stick out for you. And the one that to this day sticks out for me was we had a panel that came from a hospice that talked about end-of-life care. There was a nurse, there was a social worker, a PT, and a physician who all worked in nursing and they all worked in hospice. And this session about respecting the dignity of end-of-life care was so powerful. I left that session thinking, about what a job, is like to be able to facilitate that person's dignity and respect at the end of their life. I remember thinking about the people that were on that panel and they all loved their job. but you could see that there was some sadness behind their eyes because they've seen a lot of beautiful and tragic transitions into the end of a person's life that can be really difficult to manage. And I have been lucky, three out of the four of my grandparents, this is gonna be kind of a bit more of a personal episode, three out of the four of my grandparents have In my mind died of natural causes my grandmother on my mom's side died at 89 my grandfather on my dad's side died at 93 and my grandmother on my mom my dad's side died at 97 she was almost 98 and I truly believe she was gonna live to 100 but um She ended up with stage 4 cancer, but you know mutated growth at 98. I feel like it's natural causes And they all had different variations of their end-of-life care. And my grandparents, my grandfather and grandmother on my dad's side, both ended up with hospice care and they received different types of hospice care. So I kind of wanted to speak a little bit about what hospice care is, palliative care in general, and just some of the personal experiences about how beautiful that transition in hospice care can really be. WHAT IS PALLIATIVE CARE? When individuals think of hospice or palliative care, they think that an individual is dying imminently. And this was true with my family as well. When I suggested that my grandmother, who was diagnosed with stage four cancer, be given hospice care, my dad thought that I believed that she was gonna die tomorrow. Hospice and palliative care is when the prognosis is not great when there are no thoughts for intervention, or when the person has decided that they are not going to intervene to try and change their diagnosis. And that was kind of what happened with my grandmother. So she was diagnosed at 97 with stage 4 cancer and she said, you know, what am I gonna do? She was of sound mind and she said, I'm not gonna fight this thing. It's gonna make me feel really bad. I'm almost 98 years old. I do not want any intervention. She was very clear in that. And that was really hard for my family because she was the matriarch of the family. She had been so healthy. We literally all had her that she was living past a hundred and she decided that she did not want any interventions. And when she decided that I made the recommendation that we go to a hospice or we put her on the palliative care list here in Canada. And it was a really tough discussion with my family because they believed that, you know, she had a lot that they could still do, and it always came back to this discussion of, in palliative and hospice care, they are going to respect the comfort level of the person that is with them, and they are gonna respect their wishes that they're not gonna do any extraneous interventions to try and change the cancer. COMFORT & DIGNITY AT END-OF-LIFE They're gonna make her comfortable, give her dignity, and allow her to continue with end-of-life care. And I said, you know, as soon as she gets on the list, you know, we may not be accessing, you know, pain management and all those things right now, when that time comes, she's gonna have the capacity to be able to access those services, access those individuals, hospice, support personnel of various forms that are going to be able to help her. Then she was able to access a hospice care home when the time was coming that she couldn't be independent anymore. And so for her, she declined and there was a lot of conversations back and forth about, let's try this ultrasound, let's try that ultrasound. And I was very adamant about coming back saying that this was not what she wanted. She wants to be in palliative hospice care and be comfortable and surrounded by family as she starts to transition to the end of her life. And there was a time when pain was starting to come up because her cancer had transitioned to her bone and she was having a hard time toileting independently. It was around that time that our family had a discussion about putting her into hospice care. Again, my family had a really tough time with it, but when she was in hospice care, she was able to have visitors. There were not tons of lines and tubes and monitoring that was happening. The room was so quiet. She was able to have all the pain management that she wanted. I'm probably gonna tear up at this, but when it was her time, they did this beautiful pass through this archway that had angels and a cross, she was religiously inclined, and it talked about creating this pathway to the end of her life. And it was a beautiful thing. And I remember thinking that there are so many people who don't have that beautiful experience at the end of their life because they are surrounded by so many lines and tubes and sometimes that's just the nature of what happens at the end of a person's life. But I felt so fortunate that my grandmother was able to have this transition to her afterlife in a way that was so respectful. My grandfather was 97, and she passed away just recently. And my grandfather, he was 93, and it was kind of the same thing that was happening. He was starting to decline, he was generally unwell, but he was 93, he didn't really want any interventions, but he did not want to go into the hospital. And so we were able to access palliative care at home. And so by accessing some of those services, we were able to get a hospital bed in the room at that point in Everybody's life we were able to do round-the-clock care. We had hospice Palliative nurses and palliative care physicians coming in and checking in on them. But the same thing we didn't have was he didn't have any lines and tubes He gradually kind of slipped into a coma. We didn't do any extraneous measures except for pain management and he was able to die surrounded by his loved ones at home and again, that was something that I So kind of different versus going from a, you know, into a home of hospice versus transitioning into the afterlife at home, but still two very calm, very peaceful transitions into the end of a person's life. And so I kind of lead with those two, one of, you know, peacefully dying at home, the other around, peacefully passing in hospice care. And I want to kind of contrast that with my other grandmother. So I had a grandmother at 89 who honestly just did not want to live anymore. She had lived a long life. She had been widowed for a long time. And the love of her life, she never really recovered from that. All of her kids were grown. They were all doing well. And she just started to generally decline. She just wasn't doing that great. One of her kids, she had 10 kids, and one of them called an ambulance. She was just kind of not thriving at the hospital. So they brought her to the hospital. Her labs were kind of all over the place. She wasn't really doing that well. And she just didn't, she wasn't really doing great. They couldn't really figure it out. They had decided not to do any invasive therapy. She ended up transitioning to a long-term care home. Now. This is not to say anything negative about long-term care though in Canada There's a lot of conversation about how to create a better environment in long-term care. This is to speak a little bit more to like the medical side, you know So she was kind of getting around-the-clock care and she was on kind of hostilities hospice palliative, it was a very different experience where It just felt like, it felt a lot more lonely because she didn't have that same type of support that my other grandparents had had. And she was, she ended up passing away in long-term care, which was adamantly what she did not want. She wanted to pass away at home. And she didn't know when she was kind of just feeling unwell that it was the last time she was going to see her home ever again. She was very upset by the fact that that decision had been taken away from her because now she was too sick to go home and they wouldn't let her go home. So there were a lot of sad emotions around my grandmother on my mom's side transition into a long-term care facility that wasn't kind of in the same bucket as hospice or palliative care. THE REMOVAL OF DIGNITY AT END-OF-LIFE And so why do I kind of bring all these things up? One of the things that I did not recognize as a person in geriatrics is how I was gonna be confronted with a lot of things around end-of-life care that I would not have expected going in. You know, you kind of go into PT a lot of the time thinking that you're interacting with pain, and you are, but you're gonna have these situations and circumstances where a person that you're interacting with will take a turn. When you go into acute care, you will be having these individuals who were doing fine the day before and then you come to their room for PT and they've passed away overnight or OT overnight and they've passed away. And it makes you think a lot about end-of-life care. And Atul Gawande wrote a book called Being Mortal and he talks about our medical system. It was a book that had a profound impact on me, especially being a person whose loved ones have had different experiences at the end of their life. He talks about how our medical system takes so much work of metrics of safety and length of stay in hospital, things that are very, many times business-driven or a removal of risk, a removal of dignified risk-taking really in a lot of different ways and how there's so much that we can do differently. One of the things that I think we have done right is having these beautiful people in hospice and palliative care who are really changing the way that a person is experiencing end-of-life care. As a geriatric physical therapist, when I'm interacting with individuals whose parents may be having a decline, if I'm talking to family or to individuals themselves, I am just a massive advocate for hospice and palliative care and what that may mean for them. And I think it is a wonderful way for us to be able to have discussions around end-of-life and not be afraid of those discussions. We are always trying to optimize a person's resiliency and keep them living healthier for longer. But there are going to be people that we interact with where that is just not the goal. And that is, we are trying to create comfort. We are trying to move limbs to prevent stiffness and pain in those limbs. we are interacting in a very different way. And by leaning into some of these conversations and being able to have some of these really candid discussions, I think it is a really beautiful thing. As a family member who has had a lot of different experiences with grandparents and thinking even about my own aging experience, and what I would want, I think having those discussions is super powerful. And we have a lot of therapeutic alliances. We have a great role and rapport with many of our patients and we can answer a lot of questions. So I hope that you found this helpful. It was more of a personal kind of anecdote, but I've been reflecting a lot on it. Kind of as we go into the holiday season, you think about loved ones a lot. And so I hope you've had any positive experiences with hospice or negative, I would love to know what your thoughts and feelings are. If you can put them in the chat, I would love that. If you were listening to the podcast, if you want to reach out, please do. Otherwise, I hope you all have a wonderful end of your week and we will talk to you all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jordan Berry // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Jordan Berry discusses the top 5 reasons to begin to utilize more isometric exercises for the spine: they can be scaled based on any level of irritability, they produce a lot of natural pain-killing chemical, allow for the "stress-relaxation" phenomenon, allow for specific targeting of weaknesses, and are easy for patients to replicate outside of the clinic. 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 INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JORDAN BERRYWhat is up PT on ICE Daily Show? Good morning this is Jordan Berry lead faculty for cervical management and lumbar spine management courses. Today is clinical Tuesday and we are talking about isometrics for the spine specifically the lumbar spine but really any area we're talking about isometrics for the spine. Now before we dive into that, I just wanted to mention a couple of the courses that we've got coming up to end the year. We've got, let's see, we've got one more cervical management course that is going to be in Hendersonville, Tennessee, and that's this coming weekend, December 2 through 3. We also have two options for, well, one option left for lumbar management. We've got Charlotte, North Carolina this weekend as well, December 2nd through 3rd is sold out, And then we also have Helena Montana has just a few spots left, also December 2nd and 3rd. So we've got three courses for the spine division coming up this next weekend. And then the first chance to catch cervical management in 2024 is out in Wichita, Kansas. That is February 3rd through 4th. And then lastly, the first chance to catch lumbar management in the new year of 2024 is January 27th through 28th in Rome, Georgia. ISOMETRICS FOR THE SPINE All right. So let's dive into our topic today. We're talking isometrics for the spine and why I believe that this type of exercise for the spine is underutilized across the board for a bunch of different presentations and, a bunch of different levels of irritability. I want to chat just for a few minutes about how we can use this effectively in the clinic. So just to make sure we're all on the same page, when we're talking isometrics, we're talking about a hard, prolonged, sustained muscle contraction. with no movement of the joint. And when we think about using this type of exercise, we're pretty comfortable overall using it in the extremities. You know, we've got tons of research now showing the benefits of isometrics in patellar tendons and Achilles and glute med glute men and rotator cuff. So a lot of those main, you know, tendons and tendinopathies that we're seeing every day in the clinic, we're utilizing quite often some variation of an isometric. But in the spine, however, it's used significantly less. And, you know, there's not as much research geared towards specific tissues in the lumbar spine. with isometric loading, but we can take some of the concepts that we see in the tendinopathy research in the extremities and apply them to the lumbar spine. So I want to chat about our top five reasons why I believe that isometrics for the spine is a go-to exercise in the clinic. ISOMETRICS ARE APPROPRIATE FOR ANY LEVEL OF IRRITABILITY Okay, so number one, they're appropriate for basically any level of irritability. So obviously when someone comes in and they have really severe, really acute back pain and the irritability is really high, you're not gonna have as much freedom for exercise selection, right? You're gonna have to find things that are appropriate for that specific individual. And when someone's super flared up, it can oftentimes be really hard to find an exercise that not only what we're going for is relieving symptoms, but that doesn't flare that person up, And we try to get around this by using really low-level exercises like the cat-cow, like the bird dog, like the bodyweight glute bridge, which is not necessarily bad. I mean, oftentimes for acute low back pain, those can be really good movements to keep that person moving, to decrease fear during the first few days, but it's typically the movement of the spine if anything, that's gonna flare the person up. And so what I see is that we can potentially have not only more aggressive exercises early on, but more of a pain-reducing effect by utilizing isometrics. So again, imagine the person that comes in two or three days of really acute flared low back pain, where the actual movement of the spine, whether that be flexion, extension, side bend, whatever, is the thing that flares that person up. Well, we could use something like a Chinese plank. where the person is laid out in that reverse plank position across two benches, two boxes, two objects, and they're just holding a really hard, sustained contraction. They're contracting the glutes, they're contracting the hamstrings, they're contracting the lumbar spine. Or a back extension machine where you're locked in and you're just holding your back in a set position. Or the reverse hyper. We talked about the benefits of the reverse hyper a few weeks ago, but what about just getting in the position and holding in a straight line in that reverse hyper machine or even something like a GHD holding your body out in a straight position these are all examples of isometrics and what you'll find is that even individuals that have higher irritability they can tolerate a form of an isometric because it is the actual movement of the spine that flares their symptoms. We eliminate that problem entirely here. They get the benefits of the load, they get the benefits of the blood flow, but they don't get any of the potential negative side effects of taking that irritated tissue through the full range of motion. So number one is it's appropriate for any level of irritability. Now obviously if someone's lower irritability, we have a lot more options. We can do it way more aggressively, but usually, it's the higher irritability that can be more challenging to find an appropriate exercise for. PAIN-REDUCING EFFECTS OF ISOMETRIC EXERCISE This leads us to point number two, which is the pain-reducing effect of isometric exercises. And so again, we're going to take some of the research that we've seen in some of the extremity tendon loading research studies like the patellar tendinopathy research around the 5x45 is what so many people either use as a starting point or are basing some of their exercise prescription on. In the older study, they were utilizing five sets of a 45-second hold at somewhere around 70% MVIC. And what they saw in that study for the patellar tendon is that progressive sets decreased the pain significantly. By the end of those five sets, we saw a really significant pain reduction but we did not see that in the other forms of exercise. And so clinically, I'm taking that research and applying it to the spine. And so when someone starts that isometric loading, they might have some pain. You know, let's take the Chinese plank again, that reverse plank as an example. When someone's got significant lower back pain and they lay over those two objects, two benches, two boxes, whatever, that first set might cause a bit of pain. But you'll see that progressive set, set two, set three, set four, set five when they're holding that 30 to 45 to a minute prolonged sustained contraction, that you see this oftentimes this nice pain-reducing effect with each set after. And by the end of it, they have significantly reduced pain by actually challenging and loading their spine. And what a very empowering type of exercise for someone with pretty significant pain to realize that loading the spine and actually challenging it in a way can actually reduce the pain. And so if we see that change in the clinic, I'll just tell the person, this is your new painkiller. Okay, this is your new ibuprofen, this is your new Tylenol. And the cool thing about isometrics is they can often be done not only daily, but multiple times throughout the day. So if you're feeling like the pain is increasing or something is making the spine a bit more irritable that you're doing throughout the day, you can use this as a tool, hit a few sets of these isometrics, those long sustained contractions to be able to reduce the symptoms. So number two is the pain-reducing effect. STRESS-RELAXATION RESPONSE Number three is the stress relaxation response. So again, we see this in some of the extremity tendon research, like the patellar tendon, where we see this, what's called the stress relaxation response. And basically what that is, is the benefit that happens with long-duration isometrics, specifically once you hold a sustained isometric for at least 30 seconds, you see the stress relaxation where the fibers in the tendon have this progressive relaxation until a steady state is reached, essentially the load is being dispersed throughout the entire tissue, throughout the entire tendon. And so the way I apply this clinically to the spine is to take someone that has either excessive or limited motion at a specific level in the spine. Think about your older, middle-aged, stiff golfer who really lacks motion in the thoracolumbar junction, the upper lumbar spine. or take the opposite where you have that young mobile gymnast who has a ton of motion in the thoracolumbar junction, the upper lumbar spine, almost a hinge point right into extension. So those areas in the spine That hinge point, for example, are getting a ton of stress. Oftentimes, a lot of the movements throughout the day, they're using that specific area to move. When you're utilizing these isometrics, you get that stress relaxation response where the load is now being dispersed throughout the entirety of those tissues instead of just moving at these specific hinge points. And so it's cool to now have an exercise to be able to not just isolate the spot that they're oftentimes over-utilizing, but now we can load the entirety of those tissues and disperse some of the force. SPECIFIC TARGETING OF WEAK AREAS Number four targets weak areas. So think about your person that comes in with low back pain and you're screening out the deadlift as one of their aggravating factors. And they oftentimes have this spot in the deadlift that's the weak point. That's the spot of breakdown where when either the technique fails or the pain occurs, it's because they have a weakness at a specific point in the lift. Well, we can utilize isometrics as well to eliminate those specific weak points. So you could have someone, for example, do a rack pull, and you're putting the bar right at the spot that's their sticking spot. You can have them perform isometrics in those specific positions to build strength where the technique starts to break down. And you could hit that at any point in the deadlift, right? It could be six inches off of the ground, right, when they're initiating the pull. We could hold that position. or we could do a rack pull right after the bar crosses the knee and they're struggling to get to that full lockout position. You could use isometrics at any point during someone's movement to build capacity and strength in that specific position to eliminate that weakness. ISOMETRICS ARE EASY TO REPLICATE OUTSIDE OF THE CLINIC Last, they're easy to replicate. So I'm always looking for exercises in the clinic that are easy to do, that you don't have to be at a specific location to do, and take minimal equipment. And isometrics will typically check those boxes. So again, let's take the Chinese plank as an example, the reverse plank that we've been talking about. You can literally do that anywhere. All you have to have is two things you're laying your upper back around your shoulder blades and your heels on. In the gym that could be two boxes, that could be two benches, that could be a bench in a box, it could literally be two tables, it could be a chair in an ottoman, it could be literally anything that you could lay your body across and perform that isometric. Same thing with a reverse hyper. Yes, the actual reverse hypermachine is the gold standard, but you can mimic the isometric anywhere. I mean, you could lay on a table and have your hips hanging off and just raise your legs, keep your legs straight, and hold that position. So I love the isometrics because they don't take any equipment. You can do them anywhere and they're easy to progress because you don't necessarily have to have weight, at least in the start, you can just increase the time. So someone could go from 3 sets of a 15-second hold to 3 sets of a 30-second hold, to 5 sets of a 30-second hold, to 5 sets of a minute hold. You can progress this HEP very easily without having to have equipment or progressively increase the weight. So those are my top five reasons why I am using isometrics very consistently, very frequently throughout the clinic. So just to review, number one, they're appropriate for any level of irritability. So from the lowest of irritability to the most acute and irritable. you can oftentimes find some variation of an isometric that not only is going to load their system and not flare it but oftentimes will reduce their symptoms, which is number two, the pain-reducing effect from isometric. So multiple sets you will oftentimes see a more powerful pain-reducing effect from each set. Number three is the stress relaxation response. So we see that stress disperses throughout the entirety of the tissues when we hit that 30-second mark. So we can load parts of the spine, parts of those tissues that aren't typically getting loaded throughout the day. Okay, number four, it targets weak areas. So if there are sticking points in any movement, we can use that to eliminate the weakness. And lastly, they're easy to replicate. Very little equipment, very easy to progress. That's all I've got, team. I appreciate you hanging out, sticking around, listening to that. I would love to hear from anybody about how you're utilizing isometrics for the spine, either in the clinic, from a rehab standpoint, or more from a performance standpoint, either on yourself or a potential client. Other than that, have an awesome day in the clinic. Thanks for sticking around for Clinical Tuesday, and if you're coming to a lumbar or cervical spine management course, I will see you soon. Thanks, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses subjective & objective measurements to use to track & manage urinary urgency, as well as tools and techniques to utilize in the clinic with patients who are actively symptomatic.  Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. JESS GINGERICH Good morning. I'm sorry about that. I think I was having some difficulty with my internet. Welcome to the PT on ICE daily show. My name is Dr. Jessica Gingrich and I am on faculty here with the pelvic division at ICE. I hope everyone had an awesome Thanksgiving and was able to spend some time with some family and enjoy some downtime. Today, we are going to talk about some clinical pearls of urinary urgency. How can we get objective data to track this progress? And some powerful interventions to help get this under control and really get your patients their lives back. So this can be something that really holds people back from living their life, whether that's at the gym or really doing anything, going out and doing fun things with family and friends, going out shopping. It can really be controlling. So before we get started, we're gonna talk about some housekeeping items. Our next online cohort begins January 9th. So head over to the website to sign up and secure your spot. We have a few more live courses to round out the year. So if you are looking to dial in some of your internal assessments and then treat that higher-level athlete, Head over to ptonice.com to sign up. We also have some certifications rolling out in the new year, so keep a lookout for what you need in order to become ICE-certified for whatever division you're interested in. URINARY URGENCY So, no one talks about bladder habits that we should or really maybe even should not be paying attention to. No one tells us that some of our favorite things like coffee and carbonated beverages, alcohol, can be negatively impacting our brain's ability to tell us when we're full or even if it's irritating to the inner lining of our bladder. We learn to pee just in case or to ignore our first urge and replace it with something other than water. So again, caffeine, carbonated beverages, et cetera. We learn habits that allow our bladder to control us rather than us controlling our bladder. So urinary urgency is a strong and sometimes uncontrollable urge to urinate. This is something where it is smacking someone in the face. They have no heads-up. It is zero to 60. This may or may not be accompanied by urinary frequency. and or urinary urgency so urinary frequency is just going to be peeing a lot in your day we oftentimes get the question of is this what's the magic number really is it's if it's affecting them and if they feel like uh it is controlling them and then urinary incontinence is just um peeing in your pants being unable to control your bladder and there are different forms of that as well So we're going to talk about three objective measures which are interesting because they are subjective objective measures to track progress and then four tools to help give your clients their lives back. So it is important to know if they are experiencing any other symptoms with urinary urgency because as we start to train this we need to be mindful of those symptoms and also how comfortable they are potentially experiencing those symptoms. For example, if they are peeing in their pants and we are now training this, do they have things like a pad? So when they are trying to hold their bladder a little bit longer and they leak a little bit, are they gonna be okay with that? These other symptoms include leakage, feelings of heaviness, constipation, and urinary frequency. Other subjective data includes daily habits like whether are they drinking or how much are they drinking. Are they drinking enough? Are they drinking too much? Timing of what they drink and if they notice any foods or specific beverages that increase their urgency or if they pee just in case. So three objective data points and again like I said these are more subjective but they are so very meaningful so when you go to follow up if these are um changing that is going to be a really big deal. TRACKING STRENGTH OF URGENCY So When their first urge presents, how strong is it? Is it like, Oh my gosh, I cannot control this? It's kind of like, ah, it's more of like a medium or is it more light? Like, yes, it's there. Um, but I'm able, to push it out a bit. Are they able to hold it? So with that urge, are they also leaking or are they just having the urge and no leakage with that? And then do they notice anything that triggers this urge? So for example, some common things that I hear are gonna be seeing a toilet. So they walk into a bathroom, they see the toilet and it is like, whoa. Walking into your home, that kind of like key in the door trigger. Running water or even being in the shower. So a lot of people will pee in the shower and it becomes this thing where you are in the shower and it hits you really, really hard. So when you are confident that they are experiencing urinary urgency, it's time to teach them to remain calm when they have that large urge. Then you're going to teach them how to do a Kegel. Show them what it means to be up in the attic and then also relax on the first floor. When they are able to do a Kibel, we can teach them an urge suppression technique. I'm going to go over that here in a minute. Then once you have the urge suppression technique down, we can start to train them in the presence of triggers. I call this trigger training. So urge suppression looks like this. So there you're going to educate them to when this happens when the urge hits them to stop what they're doing, They can sit, they can stand, whatever it is they're going to stop what they're doing. They're going to take five deep breaths. Do five Kegels, then take five more deep breaths. Then you're going to talk to them about finding a way to distract themselves. This may be, getting back to work. This may be doing a load of laundry, um, playing with their kid, something to distract themselves. After a few times of practicing this, be sure to track when their first urge presents. Is it less or more than what they came in with? Are they able to control it? Are they able to continue what they're doing or does it stop them? And are they able to do it in the presence of those original triggers? So give this a go. Have your patients try this for a week or so. Check-in with them about those objective measures, and subjective objective measures. And we'll see you next Monday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the Concept 2 rower, including each key component & how to perform basic maintenance on it. Alan also coaches rowing technique, including how to use the monitor to establish the ideal "drag factor" so that patients & athletes understand their optimal damper setting as well as strokes-per-minute (spm). Finally, Alan discusses how to improve rowing performance, including testing & retesting established benchmarks on the rower. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. ALAN FREDENDALL Hey, what's up? Good morning. Welcome to the PT on ICE Daily Show. I hope your morning is off to a great start. We're here early on Fitness Athlete Friday out in the garage to talk about rowing. Fitness Athlete Friday, if you're not sure, we talk all things related to CrossFit, Olympic weightlifting, powerlifting, running, biking, swimming, today, rowing, everything related to the recreational athlete, that patient or client who is getting after it on a daily basis. Before we get started today, let's talk about a couple of quick announcements. Courses coming your way from the fitness athlete division, we have no more courses that you can take in 2023 unfortunately. All of our live courses between now and the end of the year are either done or sold out and all of our online courses are finished or have already started towards the end of the year. Your next chance to catch us is going to be in January on the road for our live seminar Your next chance to catch us online is going to be January 29th for Fitness Athlete Essential Foundations, or February 5th. We also call that course Level 1 Online Now. Your next chance for our Level 2 Online course, previously called Advanced Concepts, will be on February 5th. What are those courses? Those three courses compose the Certification and the Clinical Management of the Fitness Athlete, or known as CERT CMFA. Our level one online course is all of the basics. It is a lecture-heavy course. It is a course heavy on clinical application, not only to the fitness athlete but also taking the principles that we teach, how to properly dose and prescribe load, how to increase the intensity of your physical therapy sessions, taking concepts, not only applying them to the fitness athlete but all of your populations, everybody that could potentially come into your physical therapy clinic. Our level two online course, previously called Advanced Concepts, gets a lot deeper into the weeds with a fitness athlete. So if you're looking to learn about advanced Olympic weightlifting, advanced gymnastics, such as those found at CrossFit, muscle ups, handstand walking, pistol squats, all that sort of stuff, and then a super incredible thorough deep dive into programming, then the level two online course is for you. That is for the person who is looking to regularly work with fitness athletes in the community and be the provider of choice in their region. And then our live seminar is focused almost entirely on moving, about understanding what it means to perform a one rep max or a sub max test to predict a one rep max, what that feels like for you to do it so that you better know how to apply that to your patient population, but also how to program based off of that, how to work different therapeutic exercises together to facilitate both intensity as well as recovery during physical therapy. So those three courses compose the CERT CMFA. So p10ice.com, click on our courses to find the next live or online courses coming your way. And I will say this morning ahead of an announcement that you're going to see via email and social media that our prices will be going up per ticket on January 1st. So you heard it here first. Our ticket price will be going from $650 for the majority of our courses live and online to $695 on January 1st. If you were looking to grab one of our courses in 2024, I would do it now. Save yourself the 50 bucks. So that's what's coming your way from the fitness athlete division. ROWING 101 Today we're talking about rowing. We're here with the rower. I love this piece of equipment. I think it's a very versatile piece of equipment. I've had the chance to spend a lot of time on the rower when I first began CrossFit. Was not really able to run. I was so overweight. Spent a lot of time on the assault bike, and a lot of time on the rower. I've done a lot of endurance stuff on the rower, a lot of different programming on the rower. I've rowed two full marathons. So I want to share today the very basics of a rowing machine, what it is, how it works, and how to take care of it. If you're really thorough with your maintenance, even a couple of minutes per month, this is a machine that could last you your entire career without really needing to purchase any repairs or even possibly replace it. And then we're also going to get into the basics of rowing technique and how to get a little bit better at rowing. COMPONENTS OF A ROWING MACHINE So let's start from the top. and describe the rowing machine and all of the different parts, and also some tips and tricks for maintenance. So first things first, the question that most people have about the rower is how does it work? It works with sensors in the damper, which is a flywheel, with a computer monitor here, and then calculations are performed by the computer every pull to give you outputs of a pace of meters or calories, some sort of output of your work. So there are sensors in the chain and sensors in the flywheel. Starting from the front of the rower and working our way out, we have the damper. This houses the flywheel. This is where the resistance from the rower comes from. This handle on the side toggles between 1 and 10. What that does, is the higher the setting, as you approach 10, you're allowing more and more and more air to flow into the damper and create resistance against the flywheel as you row. So you are in charge of a combination of letting more or less air into the damper and pulling the chain you kind of control how the rower feels. A lighter damper is going to feel like a smooth row on really smooth water and a high damper is going to feel like in a really aggressive row maybe through really rough water or something like that. Far and away the majority of people are going to want to row somewhere with a damper setting between four and six. Now you do get more work awarded for a higher damper setting. That being said, it is much more challenging and fatiguing to pull. So the higher the damper goes, you need to be a stronger human being in general, especially with your pulling capacity, and you need to be a more experienced rower. You'll see folks trying to break world records, row at a 10. That's not the majority of human beings who are using a rower. Most folks sitting down on the rower, especially a longer effort, are going to be somewhere between a four and a six. We can calculate the exact damper setting that is best for each individual using a setting on a monitor called the drag factor, and we'll talk about that in a little bit. Taking care of the damper and the flywheel housing is really simple. Take a vacuum, suck the dust out, blow the dust out of there some way to clear the dust so that the flywheel does not get a bunch of gunk accumulated in there. Very easy to maintain the flywheel. Next is the chain. Pretty simple. When you are storing a rower, even if you're storing it horizontally, Always place the monitor down and release the chain. That takes tension off the chain. That's going to let your chain last a lot longer, and it's going to let the screws that hold your monitor upright last a lot longer as well. The chain is pretty simple. It's a handle attached to a metal chain that again pulls on the flywheel. So normally when we're using it in class, we have it out and racked in the handle, but when we're storing it, put it away and take the tension off that chain. Very easy to maintain the chain. Just keep it away as a solvent, not a lubricant. Find an actual lubricant, something like white lithium grease, to grease up that handle, keep it moving nice and smooth, and keep it from rusting as well, especially if your rower is stored somewhere that's not climate-controlled. A CrossFit gym that doesn't have air conditioning, in your garage or something, where it's gonna be subjected to humidity, keep that thing lubricated so it does not rust. Very easy to maintain otherwise. Our footplates, this is where our feet go, pretty simple. We're going to adjust the foot plane based on the length of our foot such that the strap, we want the strap somewhere about mid-foot. We don't want it jammed up in our ankle crease and we don't want it out on our toes either. We want to be able to plantarflex and dorsiflex our ankles and not be restricted by the straps. Taking care of the straps is pretty easy, they're just fabric, use some sort of fabric conditioner. Maybe in the winter, some fabric conditioner so they don't crack and fray. Once a month, again, a few minutes of maintenance and the machine is going to maintain it. And then just clean the footplates. Keep the footplates clean of junk, dog poop, whatever. Otherwise, very easy to maintain the straps and the footplates. The seat, the biggest thing here is that the cleaner you keep the track, the smoother the seat is going to go back and forth on the track. You can coat this with a little bit of grease as well, but the main thing is, especially if you've jumped on here and you've rowed for a longer distance, the pressure of your butt on the seat is going to kind of grind against the track a little bit. It's going to leave little black particles, and a little bit of residue. If you clean that up, it's going to keep the seat moving nice and smooth. And again, maybe once a month, add just a little touch of grease and work it into the metal of the track. Pretty easy to maintain the seat and track. And then the most important component of the rower, the component that is the most expensive when stuff goes wrong, is the monitor. So the monitor is where we keep track of our work. It is battery-powered. It works a lot like a car. It's got C batteries in the back. As you row, you are transferring a little bit of energy from the battery to the rower, kind of like an alternator in a car. And then just like a car, over time, the batteries will decay. These are C batteries. They will decay a lot faster than a car battery. And you may need to replace the batteries every few months. That's far and away going to be your largest expense with a rower. making sure if you're running low on batteries, that you change the batteries out. Now the rower will run without batteries, but it will only run as long as you are actively rowing. So if you stop rowing at any moment, the monitor will shut off. So not something you want to happen in the middle of a workout, especially a longer row. The biggest thing with maintaining the monitor, do not directly spray any sort of cleaning solvent on the monitor. Just like you would not spray it directly onto a laptop computer, You would maybe put it on a little rag and just kind of wipe it. Make sure that you're not putting a lot of chemicals inside of this. Again, it is a computer. So that's taking care of the monitor. So those are the key components of the rower. MECHANICS OF ROWING Now let's talk about the mechanics of rowing. So I'm going to turn sideways here so you can see my side profile. putting our feet in. We want to have tight straps, but we don't want them to be excessively tight on our feet. Again, we want to have the strap somewhere, maybe midway between our ankle crease and our toes. We want to be able to plantarflex and dorsiflex our toes. Tighten it enough so that if you lift your shoe up, you can easily transition on and off the rower. That's how tight the strap should be. Now the mechanics of rowing are very simple, however, they require knowing that rowing is a leg press primarily. Your legs are doing the majority of work on the rower, not your arms. A lot of folks get on here and they do really short strokes and they really do an arm-heavy stroke. and they find that their arms get fatigued, their grip gets fatigued, that should not happen on the rower, even if you jump on here and you commit to rowing three to four hours to get a marathon. You should not feel like your grip strength is a limiting factor on the rower because your legs are doing the majority of the work. So how we like to coach rowing is we like to say legs, lean, and pull. So as I have the handle, I'm thinking about a big leg press, almost like I'm going to deadlift. Legs, then I'm going to carry that momentum forward, lean, and then I pull with my arms. So full speed it looks like this. Legs, lean, pull. Legs, lean, pull. And that should allow a nice smooth rowing pattern. I'm going to let the damper stop for a second so you can hear me. If you hear a lot of slapping, When someone is rowing, that means that their handle is not moving smoothly back and forth. Something is probably wrong with their rowing form. For some reason, their rowing handle is going in an elliptical pattern instead of a straight line. Just like anything else in physics, Straight lines are astronomized. So we need to fix what's going on. We should be using legs, lean and pull. We should be moving as one continuous unit and that handle should be moving smoothly in and out of the rower. So that's the basics of rowing mechanics. A lot of folks can use a lot of simple peeling or more of a lean- back. We're not excessively extending the spine. However, we do want to use the momentum generated by our legs to transfer into a little bit more posterior chain activation to get a little bit more out of the handle. The longer the handle, the more credit you're going to get meters or calories on that rower. DRAG FACTOR Now let's talk about the drag factor. I'm going to turn this rower around again. Drag factor is a calculation of an imitation of what it would feel like if you were actually in a rowing boat on the water. How much drag would you perceive rowing through the water? An ideal drag factor is going to be 115 to 135. How is that calculated? It's going to be different for every person based on how hard they pull the rower and the setting of the damper. How we get to it, it's going to be in the menu on our rower. We're going to go to more options once the rower is turned on. We're going to go to utilities and it's the setting under display drag factor. So it's going to say row to display drag factor. Now what you're going to do, this is again, this is individual to every person. Every person, based on their specific damper setting, based on their rowing mechanics, based on how strong of a rower they are, it's going to be different, but we're shooting for 115 to 135. So if I get on the rower, I'm just going to start rowing, and it's going to tell me my drag factor. So right now, after a couple of pulls, it's telling me 99. I'm at a dip or a 4. I'm going to bump up to 5. I'm going to do a few more pulls. And now I'm at 121. So I'm between 115 and 135. What does that mean? A damper setting of 5 for me is going to get me right where I want. So the most important thing, especially if somebody's going to be using a rower a lot, for our CrossFitters who are probably going to be rowing every week, For maybe a patient who has a rower at home in the basement, working on drag factor can really help them know when they sit down, no more mystery about where to put the damper setting. You're going to be able to say, you know what? For you, damper four, damper five, damper six. Maybe for a very tall, very strong, very experienced rower, maybe they are at damper seven or damper eight. That's going to be rare, but also not impossible. So drag factor is really going to help folks know when I get on the rower, where should I put that damper based on my mechanics, based on my experience and strength with rowing. MAKING PROGRESS ON THE ROWER The final point I want to talk about aside from the components, maintaining it, mechanics, and drag factor is making progress on the rower. A lot of folks want to get better at the rower. The unfortunate truth is to get better at the rower, much like anything else in life, you should do more rowing. So, rowing is a great accessory thing to add in, especially for our CrossFitters. It's unloaded. It's not going to be as tough on the body as maybe adding in an extra session of Olympic weightlifting or running per week. Very easy to add in an extra maybe 30 minutes of rowing a week to try to get better at rowing. A lot like anything else with monostructural work, with cardio, with running, rowing, biking, The answer to the question how do I get better is where are you weak at on the rower? Are you weak under fatigue in the middle of a CrossFit workout? Are you weak at very short sprint efforts about getting on a rower and rowing 500 meters? Are you weak as the fatigue fall-off factor sets in and you row maybe a 2k or a 5k row as you get into longer endurance rowing? Where is your weakness? If folks say, I don't know, that's a great time to establish some benchmarks. A lot like wanting to know somebody's 400-meter run time, Their mile run time, their 5k run time, we can do the same thing on the rower. We have established benchmarks on the rower. A lot of them are pre-programmed in the computer. What is your 500-meter row time? What is your 2k row time? Your 2k row is going to be equivalent to a mile run. What is your 5k row time? that's going to be fairly equivalent to a 5k run. A lot of folks are going to be faster on the rower than running, but that's about equivalent as well. So establishing some benchmarks, looking and seeing how far speed falls off going from 500 to 2k, from 2k to 5k is going to let you help that patient or athlete better program that accessory rowing to get specifically better at the energy system they need to work at. Getting better at rowing too is recognizing where my paces at. Pacing on the rower is per 500 meters. That's the pace that you usually see pop up on the screen, two minutes per 500, two minutes and 20 seconds per 500, and so on and so forth, and understanding each person needs to learn what is a fast, maybe a PR pace for my 500-meter row pace. If there's a workout that has maybe three rounds of deadlifts, pull-ups, and a 750-meter row, what pace should I look to establish if I want to hit that fast? What pace should I establish if I want to hit a sustainable pace that I can hold for maybe a longer effort, like a 750, and then what does a recovery pace look like? If we have a longer workout that maybe has some 1000-meter rows, we had a workout this week that was 50 burpees, 2000 meter row, a one-mile run, and a much longer endurance-focused workout, what should my 500-meter pace look like on the rower for a longer effort, a 2000 meter effort, and understanding when you get on the rower you settle in what pace am I hoping to hold here based on the outcome that I want. Do I want to get on and off this rower as fast as possible, treat it like a sprint effort, Do I want to get on here and sustain a longer effort, or is this maybe a very long effort, a 2,000 meter row in the middle of a workout, and I'm thinking about primarily using this as recovery until I recover a little bit, and then I can begin to pick up the pace again. So understanding where your benchmarks are at, where your paces are at, and what the goal of the goal we're at. where it is in the workout, it's very important to get on here and not go too slow and give up the workout, but also not jump on here and just burn out and be that person on here that looks totally miserable because you started off way too fast and now you've wrecked yourself and you still have a long way to go. So the rower, the damper, the chain, the seat, the foot plates, the monitor, what they do, how to take care of them. Rowing mechanics, it's a leg press, not an arm pull. Legs, lean, and then pull. Drag factor, different for everybody. Very important to understand to get on there and play with drag factors so that you understand for each person, and they understand for themselves, why and how I'm choosing the damper setting that I am, and then how to make progress. Test benchmarks, train rowing, get more comfortable being on the rower, especially for long distances, and then reassess those benchmarks. So I hope this was helpful. Join us in a couple weeks, we're going to go over some more advanced rowing, how to turn the rowing machine into a skier, and then how to use the rower for adaptive purposes for adaptive athletes, or just for folks who come in the clinic, who maybe can't row because they're only able to use one leg or one arm or both, how to use a bunch of different equipment that you probably already have around the house or the clinic to get those people rowing. So hope you have a fantastic Friday. Thanks for joining us. We'll see you next time. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

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

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

Dr. April Dominick // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the anatomy & physiology of phonation, the mechanics of breathing, and the relationship between the pelvic floor & the demands of speaking/singing. In addition, April covers unique considerations for professional singers & speakers and implications for physical therapy treatment. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.APRIL DOMINICK What's up PT on Ice fam? This is Dr. April Dominick from the Ice Pelvic Faculty Division here today to talk about the pelvic floor and its role in breathing and voicing today. I have a feeling it'll take your breath away. But first, some updates from our pelvic division. First, we have our last live course offering of 2023. It is happening December 2nd and 3rd. with Christina Prevett, and that is gonna be in Halifax, Nova Scotia. And let's not forget about not one, but two of our online eight-week course offerings. Level one is going to kick off next year on January 9th, and the brand new level two advanced concepts are going to get rolling on April 30th. So head over to ptonice.com and secure your seat in one or all three of those offerings. So we wanted to hop on today to outline what we know about the pelvic floor and its essential tasks and things that you've probably already done today like breathing and talking. THE PELVIC FLOOR & PHONATION I'll discuss the essential anatomy and then the structures that are involved and then we'll unpack the complex physiology of breathing and voicing with a special focus on what the literature supports right now in terms of what the pelvic floor's role is in phonation. Spoiler alert, there's not a ton. And when I say phonation or voicing, all those terms mean talking. So we need to understand what normal function is in order to identify dysfunction during pelvic floor assessment, especially when it comes to an individual complaining of any bladder issues or bowel dysfunction, leakage, pelvic heaviness, or pain during tasks like breathing and talking, or yelling and singing, This can happen to anyone. Think about the last time you were in a really loud bar or at a concert and you're yelling at someone or trying to talk to people and your voice gets a little fatigued. Maybe there's some fatigue in the pelvic floor as well. This can also happen with other occupations that primarily use their voices. So I'm thinking about teachers, maybe chefs in a busy kitchen or coaches, professional singers even. Another point to bring up is breathing and more recently phonation have been used in the clinic by physical therapists to treat pelvic floor dysfunction. Yet we lack robust evidence to support these clinical practices. So when it comes to breathing and voicing, I want you right now to think of some body parts or structures that are involved. I'll give you three seconds or you can pause. THE ANATOMY OF PHONATION Most of us probably thought of the obvious structures like the nose, the mouth, the lungs, and maybe even the diaphragm. And those are great starts. And we're going to run through the other important players for breathing and voicing. Breathing and voicing work in a closed system, which involves the interplay of three regions. with different diaphragms. So the cervicothoracic diaphragm, the respiratory diaphragm, that's the diaphragm that you think of when we talk about the diaphragm, the dome shape, and then the pelvic diaphragm. So when it comes to the cervicothoracic diaphragm, the major surrounding structures of interest are the oral and nasal cavity, the larynx, which is also known as the voice box, and that houses the vocal folds, the trachea, and then there's supporting musculature. There's paralangeal musculature like the SEM and scalenes, as well as the intercostal muscles. From a nerve standpoint, we cannot talk about the pelvic floor or voicing or breathing even without talking about the vagus nerve, as well as the phrenic nerve that runs along this area. The vagus nerve innervates the vocal folds and the phrenic nerve innervates the diaphragm. So that's the cervicothoracic region and diaphragm. Then we've got the respiratory diaphragm. That's going to separate the thoracic cavity from the abdominal cavity. And the diaphragm at rest, it's that dome-shaped muscle And it's got many origins, the xiphoid process, some of the lower ribs, the lumbar spine. Indirectly, it also attaches to the psoas and QL or quadratus lumborum. And then in that same region, we have the abdominals and they aid in power production for respiration or phonation. We're talking the internal and the external obliques, the rectus, and then the transverse. Then we have the pelvic diaphragm, our third area. The pelvic floor muscles are actually the floor of this entire closed-core canister system. Its three layers involving the levator ani, the coccygeus, piriformis, optorenus, and ternus are all muscles that span from the pubic bone back to the coccyx, and then from the ischial tuberosity to the other ischial tuberosity. Functionally, the pelvic floor is involved in so many things, abdominal and pelvic support, modulation of intra-abdominal pressure, postural and respiratory support, bowel, bladder, sexual function and arousal, and reproductive function. When those pelvic floor muscles contract, they close off the urethral, vaginal and anal openings. When they relax, they open those openings so that if we need to, we can urinate or poop or do any of those things. So that's the anatomy piece. THE PHYSIOLOGY OF PHONATION Now I want to go into the relevant physiology when it comes to pressure generation and management. So breathing is the transmission of air into and out of the lungs. Sounds simple. Right? No, not so much. We're going to go through how each region that we just discussed supports respiration in two forms, inhalation and exhalation. For the cervicothoracic diaphragm, the vocal folds are there and they march their own drums. So during inhalation and exhalation, those vocal folds stay open, and that's to allow airflow in and out. In terms of the intercostals, during inhalation, the external intercostals are going to elevate the ribs and go upwards and outwards, which expands the thoracic cavity, and then they'll relax on exhalation. The SEM and scalenes are going to assist in the inhalation portion as well as provide some postural support for the head and neck. So that was a cervicothoracic diaphragm. THE MECHANICS OF BREATHING Now we're going to go into the respiratory diaphragm physiology and mechanics of breathing. So during inhalation, that dome-shaped muscle contracts and changes from dome-shaped and then flattens as it descends towards the abdominal cavity. This is going to create a vacuum that pulls air in. And then during exhalation, that flat diaphragm passively relaxes and returns back to its dome shape. Then we have the abdominal muscles. They are a little more straightforward. On inhale, they're going to relax and expand outward. On exhalation, they're going to contract and draw inward. Then we have the pelvic diaphragm. So during inhalation, the pelvic floor muscles relax and elongate. Then on exhalation, in the presence of now increased intra-abdominal pressure, the pelvic floor should contract and lift, which closes those openings, preventing any unwanted leakage or prolapse symptoms. And we have a few confirmations of this happening in the literature. In 2011, there was a group Telus et al, and they confirmed that these pelvic floor movements are happening with respiration during real-time dynamic MRI. We love some of that research. We also have other studies that show, hey, via EMG activity, there's actually some pelvic floor activity prior to resisted expiration. And this is cool because it demonstrates that maybe the pelvic floor has some sort of neural pre-planning during the expiration phase. So I know that was a lot of information, so I'm going to put it all together for you in terms of respiration, what's happening from head to floor. During inhalation, the vocal folds are open to allow the air to flow in. The external intercostals are going to elevate the ribs up and out. The SCM lifts the sternum. and clavicles, the diaphragm contracts and descends downward, the abdominals expand outwardly in response to the displaced organs, and then the pelvic floor elongates inferiorly. Whereas exhalation is more of a passive process of the muscles relaxing. But it can be a forced process as well, like during exercise or playing an instrument, or if we're under any stress, So now I'll run through the muscle responses during passive expiration, which is essentially inhalation in reverse. The respiratory diaphragm and inspiratory muscles relax, the pelvic floor and abdominals, synergistically contract, and there's this beautiful parallel lift of the pelvic diaphragm and the respiratory diaphragm upon exhalation. And then finally, those vocal folds, remember they stay open. so that air can exit the body. So that is respiration. It is the foundation and the power source when it comes to phonation or talking. As far as phonation goes, the entire body is a vocal organ. So the next time someone asks you at a party, hey, do you play any instruments? Be sure and tell them, heck yeah, I play this little thing, the voice. So next I'm going to detail the symptoms or systems involved in voice production. And I'll point out the differences in function of the two major muscles between respiration and phonation. As I said, the voice is a highly complex instrument involving many different body parts. THE FOUR SYSTEMS OF PHONATION And so we're gonna think of phonation as comprised of four major systems. And these systems are like a four-legged stool. When they're all working in sync, that stool or the voice is nice and stable. When one leg of the stool is a little off, then your whole stool is wobbly and your voice is a little wobbly. Another key thing to remember is that phonation occurs during the exhalation portion of respiration. So the first of the four systems is the air pressure system. It's going to manage pressure and flow. It sets vibration in motion. We can liken that air pressure system to a musician's breath as they are playing the saxophone. In the human body, the structures that are involved in the air pressure system are the trachea, the chest wall, the lungs, diaphragm. Then we move on to the second of the four systems, the vibratory system. It's made up of material that can vibrate when activated. So if we're thinking about the saxophone, we're thinking about the reed as the vibratory system. This creates pitch. In the human body, the vocal folds, are what create pitch. They open and close, and that lets short puffs of air come through the glottis at high speeds. And the number of vibrations per unit of time is what creates pitch. Low pitch is the result of the vocal folds shortening and vibrating more slowly. Whereas high pitch is created by lengthening the vocal folds and vibrating more quickly. Loudness is determined by the subglottal pressure which is generated by the abdominals and modulated by the pelvic floor. And then we have our third system, the resonators. They are going to amplify the vibrating sound. It's the actual physical saxophone itself. They affect the richness of the vocal tone. In the human body, that's going to be the throat, the oral and nasal cavities. This is what is going to create someone's recognizable voice. Then the final and fourth system is the articulators. They are unique to the human voice. So there is no analogy for an instrument here. Articulars add quality and timbre. They modify sound shapes as they leave the mouth, which creates recognizable words. And these are the tongue and the soft palate, the lips. So in summary, for phonation or voicing, the voice is produced via the interaction of those four systems. Subglottal pressure creates sound pressure and intensity, via rapid oscillations, the vocal folds produce sound pitch. Via the vocal tract, the glottal sound is articulated, adding in someone's unique voice timbre. And then intra-abdominal pressure is controlled and generated with the rest of the core canister. And that's going to be mostly the pelvic floor and abdominals helping out with that piece. So during phonation, the primary muscles and their actions involved in the inhalation portion remain the same. So prior to speaking, we usually inhale and then we talk, talk, talk. The exhalation portion of respiration is like I said, when we phonate. COMPARING EXHALATION TO ACTIVE SPEAKING So I'm going to talk about the two differences between quiet exhalation and actual phonation or speaking. One is that the vocal folds don't stay open like they do in quiet exhalation. During phonation, they are doing the vibration, opening, and closing through the different frequencies to produce pitch. Second, when it comes to the pelvic floor, there's very little research on what it's actually doing when we are phonating. Aliza Rudofsky is paving the way in these uncharted waters when it comes to research on the pelvic floor, phonation, and the voice, A study she published in 2020 looked at the glottis and the pelvic floor via bladder displacement. So they used 2D ultrasound imaging and folks without pelvic floor dysfunction. She had participants in a standing position. We love that because most singers stand or most people when we're talking, going about life, we're either sitting in an upright position or likely standing. And she had participants, she cued them to do a pelvic floor contraction, to do a pelvic floor strain, as if they had to go to the bathroom. And she also gave them some cued phonation tasks, like saying, ah, for three seconds at different pitches. She also had them take a note and go from low to high. And then she had them do some grunting. She found that during the pelvic floor contraction, the bladder moved cranially, or upwards, and during straining, the bladder moved caudally, or downwards. This is what we would expect. Interestingly, for the phonation tasks, she found that the bladder displacement was significantly different than that that she saw with the pelvic floor contraction. And remember, with pelvic floor contraction, we tend to see more of a cranial displacement, but with these glottal tasks, she found there was more of a caudal displacement towards the feet. And again, that's different from what we normally see with expiration. So this was some novel information about what's happening with the pelvic floor during phonation. She also recently did, and Aliza did an interview in August 2023, and she talked about some of the research she's currently conducting, still doing data collection, but she's having folks without pelvic floor dysfunction say on one exhale, one, two, three, four. And what she's finding is there again is a tendency towards pelvic floor lengthening that's happening and there's also this buoyant nature of the pelvic floor with a specific up and down response to each of those numbers. So again, that's early data collection, but really cool to hear about what could be happening that's a little different than what we would likely hypothesize with the pelvic floor and phonation. And to me, that buoyancy kind of likens to running. So in running, we know that with repeated impact, the pelvic floor is responding like a trampoline. It's going up and down. It's automatically doing this. And so this sounds to me very similar to that. Quiet respiration requires much lower subglottal pressure than phonation. So per Aliza's work, in those without pelvic floor dysfunction, as subglottal pressure demand increases, with the task of voicing, the pelvic floor has an overall tendency towards lengthening and then potentially going up and down with each voicing. Clinically, we can use these results to coach and educate patients, maybe those who are pre-abdominal or pelvic surgery or during pregnancy. We can talk to them about what may happen to the pelvic floor if it's unable to support those higher subglottal pressures that occur with certain phonation, like yelling or even singing. The pelvic floor system may give way in the form of urinary or fecal incontinence, pelvic pain, and feelings of heaviness. especially in that immediate phase, postpartum, vaginal delivery, or cesarean section because we just don't quite have those muscles or that muscular support to help with managing the intraabdominal pressure. And now I want to wrap everything up because that was a lot of information. So in terms of respiration and phonation, We can agree that those are both very complex systems of the body that use a number of body structures that start from the glottis and make their way down to the pelvic floor. Respiration is the process of inhalation and exhalation. During inhalation, the vocal folds, stay open, the SEM and external intercostals lift, the diaphragm contracts, and descends down, the abdominal slightly expands, pelvic floor elongates. Exhalation is either passive or forced, and generally the reverse process. When it comes to phonation, there are four main pressure systems in place. The air pressure system, the vibratory system, the resonators, and the articulators. They all work together to create unique vocalization. During the exhalation portion of phonation, everything stays the same with the exception of those vocal folds, moving back and forth, opening and closing, and then the pelvic floor showing a tendency towards lengthening with a potential buoyant response to each individual vocalization. The inability to support the intrabdominal pressure generated by these tasks with higher sub throttle pressure, such as phonation, may result in pelvic floor dysfunction. Clinicians can use this data as a preliminary sounding board for blending the intricacies of the vocal respiratory and pelvic floor systems, especially when they're treating someone who's coming in for pelvic floor and or vocal dysfunction, as we eagerly await even more research for these systems. Thank you so much for listening. And if you all celebrate Thanksgiving, have a wonderful week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. 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Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel introduces the concept of an off-season for runners in order to focus on physical recovery, mental recovery, strengthening, and rehab. Rachel lays out a structured off-season approach for clinicians to use when working with runners. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. RACHEL SELINA Good morning, everyone, and welcome to the PT on Ice Daily Show. Okay, I'm happy to be here as your host today. My name is Rachel Selina, and I'm a TA within our Endurance Athlete Division. So I TA for our Rehabilitation of the Injured Runner, both our live and our online courses. Our online course starts again on January 2nd, so if you're hoping to get into the next cohort of that, registration is open now, you can jump in online. It'd be a great way to kick off your new year Um, so we'd love to have you there again, January 2nd is when we start that next cohort. Um, so today, today we are going to dive into some running related topics. THE RUNNING OFF-SEASON I want to talk about the running off season and kind of what it is, how it could be structured and really at the end of everything, like why we should take one or why we should encourage our runners to be doing an actual off season and what that could look like. Why do we need this? It's a big missed opportunity. I don't think many of our runners are taking an actual off-season, even though in almost any other sport, we see an off-season that has a particular structure that looks different than our typical in-season, pre-season kind of training. But we don't often see that in running. And here I'm mainly talking about our recreational runners. So not our elite, elite, highly competitive, like they're getting paid to run. Um, but our everyday person that has goals has things they're trying to achieve with their running. Um, but again, not quite that high end elite athlete. Um, and it's really not what I see people doing. Okay. So what I often see. And I live in Michigan, so this is a bit skewed for kind of our timeline, but the same kind of like concept applies. I live in Michigan, so most people end up having like a fall goal race. And that might be a like a marathon or a half marathon. But they train a lot over the summer, building up to that race. It happened in the fall. And maybe they're using that race as a like a they're going for a goal. They're going for a PR or they're using a lot of people are trying to qualify for Boston. OK, so either way, that that fall event is something that someone is really training for, has a specific time goal, and is pushing, usually pushing their limits to get there. After that, right, event happens, and then people usually take one to two weeks off totally, like no running. And then usually I see it as people kind of taking that totally off of like anything. And then after that two week period, I kind of jump back into running, back into training, maybe slightly less volume, right? Long runs aren't going to be quite as long, but I typically see people kind of jumping back into the same type of schedule, like training five to six days a week. I'm still usually working in some like sprints or hill work, track work, something like that. Um, so really not a, apart from those two weeks immediately after not a clear, like differentiation from what their training was prior to that race. On the flip side, I see some people where they do the race and then they're just done running. Like I don't want to run in the winter. Um, so I'm, I'm not going to run it all after my goal race until spring. Can I argue both of those probably are not our ideal situation. So I think, like I said, it's a missed opportunity and I think it's missed because there's a lot of benefit in doing an off season. Primarily four reasons we're going to cover. So I'm going to take this down a little bit. PHYSICAL RECOVERY I think the first one is physical recovery, right? Someone typically, if they're building up to a goal race, has just spent the last three or f