Chronic Pain Presentation

I'm so fortunate to work for Seattle Children's Hospital in their Sports Physical Therapy Department. There are lots of reasons why- awesome coworkers, creative scheduling that allows for optimal time with patients and their parents, getting to play with kids all day... you get the picture.

But one of the best benefits has been their dedication to practitioner learning. As a group we go through MedBridge courses annualy, but we also participate in group projects including research and speakers are brought in for in-services at regular intervals. Today was our quarterly in-service with a chronic pain focus delivered by three impressive presenters. 

First, Dr. Emily Law, PhD provided the cognitive-behavioral perspective for working with chronic pain patients.  Read her bio... this lady is the bees knees when it comes to childhood headaches and chronic pain.  Continuing the powerful lady presenter trend were physical therapists Janet Morton of Seattle Children's Hospital and Ellie Somers of Sisu Sports Performance.  This duo described the pain science model a la Butler and Moseley with tools for physical therapists and clinicians to utilize. 

Key take away messages in the presentation:

1) Pain needs to be considered from the biopsychosocial perspective. This correlates with the learning from the hip hinge blog post I recently wrote where Clint Dempsey hypothetically injured his ankle... the multiple facets involved in the pain experience. 

2) Pain is one of many outputs from your body in response to various sensory inputs. It is a normal response that is useful for the body to identify potential danger. Sometimes this system functions improperly and results in the need for reprogramming- thus the need to learn Pain science. 

3) Chronic pain is optimally treated by a multidisciplinary approach including numerous practitioners utilizing consistent messages to educate the patient and improve their independence in managing their symptoms.

4) The language that practitioners utilize when interacting with patients and their families can significantly impact their pain experience and their outcomes. Consider your words wisely to make the patient feel safe and hopeful rather than endangered and doomed.  For example- when finding weakness in a patient evaluation, instead of saying they are weak, we can say we will work to make them stronger. Empower the patients!

5) Exercise is vital to recovery in this patient populism. Graded progression of activity is needed to return these patients back to activities though they may continue experiencing pain. 

6) New books for my to-read list: "Explain Pain, Supercharged" by Butler and Moseley and "Managing your Child's Chronic Pain" - by Dr Emily Law. 

I'm midway through a publication by Moseley and will likely write another Blog post on that piece when I get through it.  Chronic pain looks to be a hot topic right now and since I have a few patients with chronic pain on my caseload, it's likely going to be a recurring topic on the blog for the foreseeable future.  

Anybody else read "Explain Pain Supercharged?"

About Me - Professional Abby

I guess I just jumped into trying to be a blogger without actually introducing myself sufficiently.  My apologies.

Hey there.  I'm Abby Gordon - a Physical Therapist living in the Seattle area for the past 3 years.  Job-wise, I'm currently working at Seattle Children's Hospital in their outpatient sports medicine Mill Creek (soon to be Everett, WA/North) clinic.  On the side, I consult with the Seattle Storm and recently have added on consultation for the Spectrum Dance Theater.

How did I get here? The personal basics: My undergraduate education was a BS in Exercise Science from the University of Connecticut in 2007.  While in college, I was also a manager for the University of Connecticut Women's Basketball Team for four seasons along with a season each of Women's Soccer and Softball.  After graduating, I worked for the Connecticut Sun Women's National Basketball Association team as their Travel Coordinator and Equipment Manager for four seasons before returning to UConn for my DPT in Physical Therapy which I completed in 2014.

While in graduate school I wrote a research project focusing on women's basketball lower extremity injuries.  My paper, if you're so inclined, was published in 2014, and you can feel free to be the only person, maybe ever, to read it: here.  The research process was incredibly beneficial in helping me grow as a physical therapist.  I have much more appreciation when I read scholarly writing now, because I know that it took several years for those papers to get to publication - along with blood, sweat, and tears of a group of investigators.  I have, on several occasions, considered further participation in research - but then feel like there's so much information to read - I should start there and get to the research at a later point in time.  This blog is a way for me to keep some of the research I'm reading organized and share key ideas that may help others.

So there's the basics of how I came to be AIG DPT... You'll see the basketball theme permeating the physical therapy career.  Basketball, somehow, is my favorite thing of all things.

Happy Thanksgiving everyone!

Abby

Hip Hinge 101 Course

On November 12th, I had the opportunity to attend a Hip Hinge 101 Course presented by Matthew Ibrahim (@MatthewIbrahim_) from TD Athletes Edge (@TDAthletesEdge) and Zak Gabor (@SimpleStrengthPhysio from Boston PT and Wellness (@BostonPTWellness).  These fellas were kind enough to bring the East Coast to the West Coast!

How did they fill the day?  They started with a focus on pain science - vitally important in the physical therapy/rehabilitation world as well as to be considered for strength and conditioning coaches.  They followed up with discussions around the word selection we use with patients.  The conclusion was lifting some heavy stuff in various ways.

Pain Science:
Zak presented a thorough discussion of the basics of pain science a la Adriaan Louw and several others.  It was a great summary and he used some excellent analogies to help drive his points across.  My personal favorite was a slide with two photos of USA Soccer Player Clint Dempsey - in one he's got his arms up and he's screaming with joy from a big goal to win a game and in the other he's looking down at the ground following the ball bouncing off the post and losing the game... No World Cup for USA Soccer.  But let's say that Clint had broken his ankle taking both of those shots.  Would his pain be the same if he was in a moment of elation as if he was in a moment of sadness and disappointment?  Based on pain science - the likely outcome would differ based on the emotional overlay.

The definition of pain has been evolving.  Zak presented the 1994 definition of Pain by Merskey and Bogduk: "Pain is an unpleasant sensory and emotional experience which follows actual or potential tissue damage, or is described in such terms." which has been updated in 2016 by Williams and Craig to "Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components."  Both of these definitions highlight that pain is an experience but the new definition opens the gates for the psychosocial components that impact pain.

Recently in the clinic I've been seeing more chronic pain patients.  My focus on learning with regard to chronic pain and pain science has been a new topic of focus for me - but without understanding pain, these patients cannot be properly educated sufficiently to get them back to full function.  I'm looking forward to reading more resources about chronic pain to include that information here, and I'm grateful that this course took the opportunity to begin their presentation with this lens.

As for the hip hinging and deadlifting - it was really great to see various ways to break down the hip hinge in differing positions and using different equipment.  I had never tried using TRX bands for the upper body as a component of a hip hinge.  I'd previously never seen the "Squat-Hinge Continuum" the spectrum of exercises that range from hip dominance to quad dominance.  There's certainly benefit to training the front and the back sides of the legs - and to properly learning the patterns.  But for me, the biggest take away of the program was the importance of the pain science.

Anybody else taking  any classes I should check out?

More soon...

ACL Injuries

Of course ACL Injury would be an early topic of conversation on the Blog.  After watching several friends tear their ACL and rehab for months on end to get back to the basketball court, I applied to PT School with the intent of learning how to contribute to ACL injury prevention.  There's tons of research saying how common ACL injury is, particularly in women's sports, and there are also numerous programs available working to prevent it.

But there are also countless sports teams and sporting organizations that don't implement any of these practices.  It's a little bit shocking to me since an injury prevention program could equally be called a performance enhancement program.  Some of these programs have published research showing they decrease risk in injury - but they could easily be assessed differently.  For example - complete the program for 6 weeks and compare maximal strength in a squat and it would be expected that these athletes would improve.  They'll have increased motor control and core stability from the program translating into functional testing.  I guess there's a study to be had there. The way to teach your body to move to avoid injury is the same way to move to be an all around better athlete.

As a component of my graduate school research, I surveyed 35 athletic trainers and strength/conditioning coaches working with women's basketball teams at the Division I and WNBA levels.  In my unpublished data, I asked these individuals if they implemented any injury prevention techniques with their athletes: Twenty three out of the thirty five said yes. That's 66%. Two thirds.  So... what exactly are they doing if not focused on improving performance.. and at this elite level?!  No look at a younger population, such as middle school, where overall the coaches don't have specific training on how to improve human body movement.  How can this group possibly implement programs when they aren't trained in how to use them properly?

Even more startling than the providers who answered that they were not incorporating these routines into their athlete's programs the results of the next question.  When asked what sort of measures were implemented to specifically prevent ACL injury, every single answer was different and not one of them utilized an organized injury prevention program.  So everyone is trying to do it their own way, based on whatever they've learned in the past.

Last night the Seattle Pediatric Sports Medicine ACL Injury Prevention Task Force met to plan implementation stages of their new program.  It was inspiring to see physicians, physical therapists, and athletic trainers brainstorming ways to prevent injury in the kids of our region.  Their intentions are great.  The program is comprehensive.  I'm concerned for the potential obstacles the group will face as far as resources to implement the program and coaching buy-in.  I'm also optimistic that they can sell the program as a combination of injury prevention AND performance enhancer.

The program, once it has been well learned, is 4 components that takes about 15 minutes to complete.  It is intended to be the daily warm-up for practices and games - but could be split into parts if needed.  Videos of each component are available on the website, and each activity has proper mechanics that need to be adhered to and properly trained.  Untrained coaches simply printing the program and trying to teach it to teams won't provide the proper mechanics.  Basically - we need to teach sports team coaches how their players should be moving, so they can help guide them through this process.

Preliminary implementation of the program has had athlete feedback that they feel stronger and move better.  The detractor from coaches is that it takes 15 minutes of their valuable practice time - but in comparison - is a warm-up of arbitrary jogging and sprints without proper body control really making these players better at their sport?

As I see it, there are two primary goals here: 1) Get these athletes moving in a purposeful manner on a routine basis because kids need to learn how to move properly and 2) Educate coaches and parents so that they can help improve the way their athletes are moving to prevent injury.

Here's the outline of the program. Ultimately it gets the blood flowing so the team is ready to participate in practice when they're done.  Interestingly, it similarly mirrors several components of a post-op ACL Injury Rehabilitation Program in many ways.

1) Dynamic Mobility: 
Open/Close Gate, Forward Jog, Side Lunges, Backwards Jog, Cradle Walk, High Skips, Quad Stretch with Reach, Carioca, Butt Kickers, Lateral Shuffle with High Knees, Lunge with Rotation, Inch Worms

2) Strength:
Rotating Side Planks to Prone Planks, T's, Double Leg Squat, Single Leg Kick Stand Squat, Double Leg Squat Jumps

3)Motor Control:
Single Leg Deceleration, L Hops, Diagonal Hops

4) Agility
Partner Jump Bump, Diagonal Backwards Shuffle, Cone Weaving, Bounding

Check out the program if you're interested and reach out if you have a group that would benefit from being trained to participate and I'll help get it set up.

Abby

Introduction

A blog needs to start somewhere, right?

I've been pondering a blog for a while - but was struggling to get organized.  Who would be reading? What topics should I focus on?  My focus has been narrowed down to three components.

1) Education
As a physical therapist, I'm constantly looking for new learning and resources and never able to read quite enough.  This includes discussions of rehab, nutrition, recovery, training, supplementation, psychology, pain science... the list goes on. This blog will be a place where I can share some of the knowledge I'm gaining from the experts. A place to be able to go back and find articles that are clinically relevant and making changes to the way I practice physical therapy.

The experts I've most admired in my first 3 years as a clinician - (not an exhaustive list) - but whose thoughts will inevitably shape some of my posts:
- Mike Reinold - and his whole crew at Champion Physical Therapy and Performance
- Eric Cressey - and his crew at Cressey Sports Performance (and a fellow UCONN HUSKY!)
- Bret Contreras - The Glute Guy
- Tim DiFrancesco - TD Athletes Edge
- John Rusin
- Grey Cook
- Sue Falsone - the lone lady in the crew.  Last, but certainly not least.

2) The Female Athlete and 3) Injury Prevention.
I have a tiny role in the women's basketball world, and I've been there, in varying capacities, for more than 15 years.  I've been at the high school, college, and professional level with opportunities to experience international competition on the world stage.  To me, when the women play basketball, it's an art form. When I see these incredible athletes suffer injuries, especially when they could have been prevented, I am saddened.

My grad school research was devoted to women's basketball injuries, thanks to the greatest mentor, Dr. Lindsay DiStefano.  Now, three years later, there still aren't enough publications in this patient population - or in other women's and girls' sports and I've let them down by not working harder to do something about that.  Hand-in-hand with the body of knowledge in women's sports is a focus on injury prevention.  I've had the opportunity to work with female athletes from so many sports, and when the injuries are from repetitive use and poor mechanics, there are things that can be done to prevent this.

Lastly, when looking to the list of mentors above and in searching for the experts in the physical therapy world, the field is dominated by men.  How is this possible when, according to the APTA website from 2010 - females were 68.3% of the profession?  So here's to trying to get the female perspective a little more publicized.  I am light years away from being an expert - I just want to see more females in the spotlight.  For this, I hope to have female colleague contributors as we move forward on this adventure.  Don't worry guys - you'll benefit from our contributions.


Abby