#PTonICE Podcast

In this podcast, Dr. Dustin Jones discusses the alarming impact of sarcopenia, including increased risks of falls, fractures, and loss of independence. He emphasizes the significant opportunity for rehab providers in this area. The podcast explores new research on sarcopenia and its implications for work with patients and athletes. It also emphasizes the importance of resistance training and gradually increasing exercise intensity for individuals with sarcopenia.

Spine Division leader Zac Morgan discusses research supporting conservative care vs invasive care, specifically chiropractic care vs physical therapy. Learning spinal manipulation can improve PT outcomes and reduce patient dependence. The podcast also covers the effectiveness of conservative care for acute low back pain, the need for PTs to contribute more, and the role of spinal manipulation in reducing reliance on opioids and injections.

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.

The podcast discusses the benefits of using the assault bike or echo bike for cardiovascular conditioning, importance of conditioning for athletes after injury, efficient workouts for cardiovascular fitness improvement, and improving cardiovascular fitness and conditioning for athletes and all populations.

They discuss a challenging workout of the day and the benefits of heel lift shoe inserts. Learn about the origin of the term 'fitness forward' and its impact on their company. Discover the importance of incorporating strengthening and resistance training for injury prevention. Delve into the concept of 'fitness forward' and its connection to their brand. Explore embracing a fitness-forward lifestyle and its transformative impact.

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.

This podcast discusses the benefits of isometric exercises for the spine, including pain reduction, tendon health, and targeted strengthening. It also explores the advantages of incorporating isometric exercises in rehabilitation and highlights the flexibility in choosing surfaces for these exercises.

Learn how to track and manage urinary urgency with objective measurements. Discover tools and techniques to use in the clinic. Find out how to effectively manage urinary urgency and regain control with techniques like urge suppression and distraction.

Alan Fredendall discusses the Concept 2 rower, including key components and basic maintenance. He coaches rowing technique and explains how to establish the ideal 'drag factor' and strokes-per-minute. He also explores improving rowing performance through testing and retesting established benchmarks. The podcast covers VersaLifts heel lift shoe inserts and upcoming courses for fitness athletes. It delves into understanding the rowing machine, maintaining the seat and monitor, and establishing rowing benchmarks for better pacing.

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. 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