#PTonICE Daily Show – Tuesday, May 14th, 2024 – The paradox of the fitness-forward clinician

In today’s episode of the PT on ICE Daily Show, Extremity Division division leader Mark Gallant discusses the paradox of the fitness-forward clinician: less healthy patients need to be provided global interventions that focus on increasing overall tissue capacity & resilience while patients already regularly active may need more specific, local tissue interventions.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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We’re live on YouTube, we’re live on Instagram. This is the PT on ICE Daily Show. I am Dr. Mark Gallant coming at you here on Clinical Tuesday. What I wanna talk about today is the paradox of being a fitness-forward clinician. So when the Institute of Clinical Excellence first started back in 2012, so 12 years ago now, the physical therapy landscape was quite different at that time. As a profession, in orthopedics or outpatient orthopedics, what we really tended to focus on was very local tissue intervention. So we would have specific tests to indicate a local tissue or a region, and then we would apply either an exercise or a manual therapy stimulus to that very specific local tissue. And that was pretty prevalent in general throughout the profession. The other thing that was true in the physical therapy profession at that time was most of our referrals, or most of how we got patients, was through physician referrals. So either through a hospital system, an orthopedic surgeon. We were not getting nearly as many direct access folks. There were performance physical therapists, but there were far fewer folks doing that. And so because all of our folks were, most all of our folks were coming from the medical community, what we tended to see was people who were not as fit overall. So people who had a lot of medical comorbidities, they were metabolically unwell, just not as robust of a population. And that makes for a very interesting combination where you have people who are generally not very fit overall and you’re going after very specific local tissues. Those things don’t tend to work well together because If the overall human, the overall organism is unhealthy, it becomes very challenging to treat local and specific things. If cortisol’s high, if inflammatory chemicals are high, if the nervous system is having to allocate resources to keeping basic organ function alive, to keep this person going, it is not going to be allocating resources to fix specific tissues. And on top of that, what we see, What we now know from pain science and general fitness is a lot of the reason these local tissues were getting sensations of pain or not feeling well was because the overall organism wasn’t doing well. So when the company started in 2012, Jeff Moore, our CEO, who a lot of you have heard on this podcast, he started to notice this and some of the other early faculty and we’ve got to get better as a profession. in helping the overall human, getting general exercise better, nutrition, sleep hygiene, stress management, all these things to make the overall human a bit more fit and robust so that we can then potentially go after more of these local tissues. And then in 2016 when the fitness athlete division came on board, when modern management of the older adult came on board, Then we really started getting a lot better at making these folks fitter, getting their metabolic health in check. And what we learned from those two divisions is The CrossFit model of intensity is really the shortcut to metabolic wellness. So the more intense that person can exercise at, we’re gonna see more of a direct correlation to their general overall fitness. And what we learned from the CrossFit model and fitness athlete and modern management of the older adult is the definition of intensity is work divided by time. the more work you can do in a given time domain, we’re gonna see a lot of correlation to general fitness overall. And that could look like a wide variety of things. So if someone’s really into CrossFit and they improve their FRAN time, so 21, 15, nine of pull-ups and thrusters, we’re gonna see oftentimes a direct correlation to their blood markers, their overall metabolic fitness. on the same side of someone’s more deconditioned, if you get them on the new step and you say, I want you to do as many steps as you can in five minutes, and then we see a 20% improvement in that over the course of a month or two, we’re also gonna see a correlation to metabolic wellness. And that’s really what this company was about, is showing folks and getting the profession on board where we’ve got to get these folks more metabolically well and get that intensity up. Now as someone gets metabolically well, if we go the next spot on the pyramid above intensity, you’re going to find work. So just if we take the time domain out of it, how much load can that person move? How many reps can they do? What distance can they go without time as a domain? So we’re taking that intensity out of it. That could become the constraint. someone who gets really into CrossFit and they’re like, hey, I’m getting a lot fitter, I’m metabolically more well, I’m unable to do FRAN because I don’t have the pull-up capacity. Okay, well let’s take the time domain out of it and let’s build your pull-up strength, let’s build your pull-up endurance. Now what that person might find at the tip of that pyramid is, ooh, the reason I’m not able to do these pull-ups is because I have some legitimate constraints at my shoulder. The range of motion in my shoulder is not good. The rotational capacity of that shoulder is not good. And now we can work on some more of those local tissue things. Always keeping in mind that the base of that pyramid is that intensity and that metabolic wellness. And everything is a means to an ends to get back to that general overall fitness. And so that’s what ice has been about for a long time now. Intensity, metabolic wellness at the bottom of that pyramid, get these folks feeling better, and then if they need to focus on some local work capacity, they need to get their deadlift better, their press better, their pull-up better, we’ll work on that. And then if there is a local tissue constraint, then we’ll take care of that. And what we often found is once these people get metabolically a little bit better, all of a sudden their joints are moving better, they’re feeling better, and you don’t have to look as far up the pyramid, that intensity and that metabolic wellness resolves a lot of things.

Now the paradox of the fitness forward clinician is now that you folks, all of you who are listening are out in your communities and you’re known as the fitness forward clinician in your community, what you’re starting to see is way fitter people are coming into your clinic because they know you know how to coach. They know that you know how to program fitness. They know that you believe in fitness yourself and so they identify themselves with you. They’re like, oh man, April is like me. She is really fit. She likes to do this stuff. I’m going to go see her because she’s not going to tell me to stop doing CrossFit or to stop rock climbing or that it’s ridiculous that I want to start running again at 76 years old. She’s going to help me build up and make a plan from there. So when you start seeing these fitter folks, the interesting thing is they don’t need you to train that intensity. They already know how to do a lot of work over a given time domain. They are already very metabolically fit. When Kelly Benfie, who’s in our fitness athlete division, comes to see me in clinic, Kelly is one of the fittest humans on the planet, like literally one of the top 200 to 300 fittest humans on planet Earth. Kelly does not need me to coach her how to get faster at her FRAN or how to do any given of the classic CrossFit workouts faster. What Kelly likely needs to see me for is that because of the high volume of gymnastics and Olympic lifting she’s doing, her shoulder gets a bit irritable. She needs me to do some dry needling, some myofascial decompression to calm that shoulder down and build up some of the rotational capacity and capacity of the lats for her to tolerate those overhead positions. She now needs me to do the 2012 thing. She needs me to focus deeply on those local tissues because the overall organism is so fit and doing well. And now we can deeply turn our attention to making those specific joints, those specific regions as optimal as possible, which will then allow Kelly to keep doing her fitness at a very high intensity level. So either one of these folks can come into your clinic and anywhere on the spectrum between the two of them, What it’s up to us is to be really good at both things.

We need to do the modern fitness forward physical therapy thing where we can coach gymnastics movements, we can coach the deadlift, we can program fitness to build intensity, we can track fitness to help people build intensity and metabolic wellness over a given period of time. What we also need to be really good at is the old school physical therapy thing, so that when really fit people do come into your clinic, you know how to treat the local shoulder. You know where you want to put your needles and what settings you want on your E-stem. You know where you want to put your myofascial decompression. You know how to specifically load that shoulder at various positions, at various amplitudes of motion, under different loads and at different speeds. It is up to us to treat all of these people and to recognize which one of them is coming into your clinic and give them the best optimal program for that N equals one patient overall. Hope this helped overall. Again, paradox of being the fitness forward clinician, that bottom of the pyramid, intensity with work next and then local tissue. Now, because you’re the fitness forward clinician in your area, oftentimes that pyramid will be flipped where your focus is gonna be on working on the local tissues for that folks, so that they can keep their intensity. Comment in the comments, we’d love to chat more about this. If you wanna catch extremity management on the road, Lindsey is gonna be out in Bellingham, Washington this weekend, so definitely go hang out at Onward Bellingham and catch her out there. I’ll be in Dallas, Texas, or Hazlet, Texas, right outside of Dallas, June 1st and 2nd. I would love to see you all out there. Hope you have a great Tuesday. See you on the road soon.

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