The Importance of Breathing

Breathing Exercises Are Challenging!

This past week, the Seattle Children's Hospital Sports Physical Therapists held their quarterly in-service meeting which included a presentation by three of our PTs who recently attended a PRI - Postural Restoration Institute Seminar.  The presentation was led by Natalie Johnson, DPT, Paul Moraski, DPT, CMP, and Jeremy Kirschner, DPT, ATC, CSCS and was a great introduction to the basics of breathing.  I was really excited about the topic because I have had the PRI courses on my "to-do" continuing education list for a really long time and it was a great introduction to how breathing can impact movement.  The PRI courses are definitely going to move up on my priority list from this experience.

I have previously encountered breathing as a continuing education component when I went through my FMS (Functional Movement Screen) and SFMA (Selective Functional Movement Assessment) certifications through FMS - Functional Movement Systems.  I read Gray Cook's book "Movement" on my first orthopedic clinical affiliation during school and used the system to evaluate patients frequently back then.  While I don't use the SFMA or FMS in my evaluations very often now, I do like having them available to me as a fall back or as I'm progressing patients back to return to sports activities.  I really like using rolling techniques which comes from these systems and, when those aren't successful, breathing is the primary regression that remains.  Oh how I wish I had paid better attention during my motor control and developmental stages during PT School - but at that time, I just couldn't understand how these things were relevant.

Key concepts I took from the in-service:
1) Breathing is at the foundation of all activities.  If you're not breathing - you're not moving.  And if you're not breathing "properly" this can contribute to dysfunctions.  To work with patients that have a breathing dysfunction by training at a much higher level, you may be able to guide them to fully restored function.  However, focused training for proper breathing is sometimes necessary.
2)

photo (and additional information below) from: http://novusfitnesstraining.com/zone-of-apposition/

The Zone of Apposition (ZOA) describes the positioning of the rib cage and how it influences the function of the diaphragm which directly impacts breathing.  This also directly relates to posture, as the skeleton on the right side has a loss of ZOA due to the bottom of the rib cage flaring and influencing the available excursion of the diaphragm.  While I have joined the bandwagon of "there is no bad posture, only positions that are sustained for too long or that you can't get out of," I still feel that there are optimal postures for various activities.  For example, a basketball player who attempts to dunk but has increased thoracic kyphosis limiting shoulder elevation and anterior weight shift while squatting that limits the stretch-shortening cycle of the posterior chain while jumping will have difficulty getting the ball over the rim unless they're 8 feet tall.  The current trend of saying there is no perfect posture relates more to static positioning throughout the day than postures for activity.
3) There are commonly seen breathing fault patterns.  Three that were described at the in-service were:
- an anterior internal chain dysfunction which presents with quad dominance and decreased extension through the hip that is more often a unilateral pattern.
- a brachial chain dysfunction more related to the upper body presenting with accessory musculature facilitating breathing and rib flare with shoulder flexion.
- a posterior external chain dysfunction which often presents as a forward head with increased thoracic kyphosis and lumbar lordosis and anterior pelvic tilt and more often a bilateral pattern.
4) Basic breathing techniques to improve apical expansion generally require focused training of the left internal obliques and improved ability to breathe into the right upper lungs region.  In the picture at the top of this post, I'm siting in a position that allows for the right side of my rib cage to open up and increase my ability to breathe into the right side of my lunges while I'm using my left arm to reach forward and increase activation of my left interior obliques while simultaneously using left hip adduction that integrates the pelvis and the lower portion of the internal obliques.

Overall, an awesome learning opportunity and good reminder of the importance of breathing.  I know that I have far more to learn on this topic and hope to get to a PRI Course at some point.  Feel free to check out the link with the Zone of Apposition photo because that blog had really interesting information about breathing - among several other topics!

Five Reasons You Should Attend PT Pub Night

logo from: http://ptpubnight.com/

What could be better than a Friday night spent with friends?  A Friday night spent with fellow physical therapists having drinks chatting about patient cases, the health care system, recent conferences, and suggesting new articles to read.  #AllTheCoolKidsAreDoingIt.

When a former coworker first invited me to PT Pub Night about 3.5 years ago, I was a little hesitant to attend because it sounded just as cheesy as my above statement.  I was new to Seattle, and new to being a PT, though, and a networking event sounded like something I should do.  Actually, I didn't know any PEOPLE in the area - PTs or otherwise.  I had been harassing her to have dinner with me so I wouldn't have to eat alone sitting on my living room floor since I was a poor new grad without furniture.  It wasn't a hard sell.  We headed over to Hales Ales in Fremont, WA and since that time I have been to several PT Pub Nights.  Here's why you should check one out if you get the chance.

1) You meet new PTs in your city.  Obviously.  This is helpful for learning, future employment opportunities, finding new continuing education courses, securing a mentor, finding local specialists for things like bike fits or pelvic health or running mechanics, learning about referral sources and surgeon preferences with their rehab protocols, discussing the changes in legislation that directly impact patient care in your region... this list could go on forever.  Having colleagues that are in a similar line of work but don't work in your office is incredibly valuable.  Alternatively, bringing along your coworkers can help build up your work relationships because these events are really about physical therapy and health care - not your personal life.

2) You meet PT students either studying nearby or on clinical affiliations in your city.  The last two PT Pub Nights I have attended, the same student was present.  He's graduating soon and it's interesting to hear what he's learning in school, how his rotation is going.  It could help me if I'm ever a CI (scheduled in 2019!) to get the opinion of a student who I have no professional responsibility towards, but also it helps me grow as a professional.  I remember attending PT Pub Night-type events when I was a UConn PT student attending the Combined Sections Meetings (Chicago and Las Vegas) and loving the opportunity to talk to my faculty in a more casual setting.  Later, when I was a practicing PT and attended CSM in Anaheim, it was even more comfortable to have dinner and drinks with my former instructors because we're colleagues now!  In the three years since I graduated, there have been a handful of times where I've directly reached out to them for advice regarding patients, careers, and the status of the UConn PT program.  It makes sense that your instructors shouldn't be sitting next to you at the on-campus bar (shout out to the sticky floor at Ted's with delicious chicken cutlet sandwiches), but after your grades are finalized, your faculty immediately becomes your first network of colleagues.  That relationship can start sooner with this type of function.

3) For me, like I said, I had no friends when I moved to Seattle. This isn't an exaggeration.  As a physical therapist, I spent all day long talking to patients - so I didn't feel like I was missing out on the human connection entirely. But meal times alone at home were super lonely.  I would be lying if I didn't acknowledge that my closest PT colleagues are also some of my closest friends in Seattle and that this was a direct result of PT Pub Nights.  I even joined a softball team because of a friendship made at PT Pub Night - but that ended with me having a broken nose and a concussion - we can talk about those another day.

4) The group is always different.  At least here in Seattle, where the location changes each month, the attendees are often more local to the host location.  This weekend's Pub Night was a small group, but sometimes it's a large crew.  Most of the time the attendees are from orthopedics and sports PT, but sometimes there have been therapists from other settings which is a refreshing reminder of the things we are trained to do.  I do not miss my time in the skilled nursing facility, but several PTs I have met love working in that environment.  To see them passionate about their setting is refreshing and the end-game for all of us is to improve human function. Additionally, we previousyl had a mayoral candidate join us, we have had Washington Physical Therapist Association board members attend to increase awareness of upcoming legislation, and sometimes a physician from the neighborhood will even stop in.  It's a true networking event.  

5) You can respectfully debate the issues going on in health care - because at the end of the day, we all want our patients to get better. If our approaches or our political opinions differ, the end-game is the same.  This past Pub Night, for example, some of the participants had just returned from a Pain Summitt in California.  They had a lot of insight to share and they treat their patients with strong consideration for the biopsychosocial model.  While I, too, consider this model in my treatments, it's a new concept for me and so I still find myself more in the biomedical model camp.  I like some of the language that the biopsychosocial model uses and I like to hear how they talk and think about the patients in front of them.  I treat mostly children so I see a lot of fear avoidance behaviors and have observed the way the wording we use with patients directly affects some of them. Any time you get a group of people together who have differences of opinion, the conversation can get intense.  This Pub Night's talks were deep - but they made me think - and I respect that.  The conversation is notably different when March Madness comes around - because we're all rooting for our alma maters. 

PT Pub Nights have spread throughout the country, particularly in the cities.  I encourage you to check one out - or come hang out with us in Seattle.  You might learn something, but you'll definitely meet some interesting people. 

Photo credit: Sarah Cruser 
Location: Magnuson Athletic Club, hosted by Ellie Somers and Sisu Performance

Seattle Ignited Women Project #SIWP

 📷: http://seattleignitedwomenproject.com

Last night I attended an event that was devoted to women empowering women. The Seattle Ignited Project, started in 2017 by Allison Tenney to "redefine what strength and success means as a woman." The speakers, catering, sponsorship, and facility space were all consistent with the idea of inspiring women in all their roles - as female business owners or entrepreneurs or fitness pros or athletes or innovators or moms.

The Riveter is a space devoted to empowering women moving their businesses forward.  They host events that support female initiatives and serve as a work space for thinking, networking, and productivity to start or further develop your company.   I typically write my blog from my living room or from Walnut Street Coffee - but I loved this concept.  And the food! Catered by That Brown Girl Cooks were roasted veggies and chicken sliders with garlic aioli and Chef Kristi Brown's famous hummus.

The sponsors were a series of tables by mostly local companies - all women owned - with a variety of purposes and goods.  I'd love to tell you about them all - but instead I'll pick my two favorites.  I was super excited to see my good friend and fellow Seattle Storm sideline pal Emily Blurton to learn more about her personal training and athletic development business - Emblem Fitness.  She's bright and talented and I'm so fortunate to have her in my circle - Check out her site! I also really liked meeting the crew from Intentionalist - an online directory of businesses owned by women and/or LGBTQ individuals so that consumers can choose to spend their money intentionally in support of these organizations.

The speakers were inspiring.  I had never heard of Erin Brown before this event - TRAVESTY! She presented a list of "Ten Things She's Reasonably Sure Of" which included many valuable lessons.  One of those was "Take Time to Digest" from which she discussed that people are consuming information at a rapid-fire pace and we can't process or fully comprehend it all at the rate in which we receive it.  Her recommendation was to be mindful of how we choose to access these inputs - such as potentially spending less time with the social media and respecting other peoples' stories.  It made me think about how I just finished reading Pride and Prejudice about 2 weeks ago, and how in those days (early 1800's), you would receive a letter by horseback riding mail carrier, and you would take the time to sit at a desk with a quill and ink, carefully process the information,  and write a deliberate and thoughtful response. If you send me at text, I almost instantaneously respond - sometimes without actually even comprehending the full incoming message and too often with an impulsive reaction.  The emotion of our communications is lost with our new means of interactions and it's not moving us in a positive direction.  I like to think this blog post is a small way for me to digest the information from last night, process it and see what I really took away from it.  (CT Pals - she's coming your way soon!)

Gina LaRoche was the second speaker and she very eloquently spoke about three of the seven laws that are in her soon-to-be published book "The Seven Laws of Enough."  I understood her message to be more about introspection.  Spoiler Alert: Law Seven is "Love is the Answer" but the question surprised me:  "How well have I loved myself today?"  I'll be honest - I generally think meditation and mindfulness are garbage... but this view is an ignorant one because I have never given it a try.  In the past several months, I've been working on a focused program for a healthier me, and only last week did I even consider that there should be some amount of mindfulness practice included in that.  But I don't like doing it! (Maybe because I'm so terrible at it!)  Gina led a meditation practice and I could see the reaction others in the room had to this moment, and I decided I had to give this a fair shot for the next few months. I practice skills for my career and for getting better at this blog writing stuff and for my physical fitness - why couldn't I practice something to improve my mind?

The evening wrapped up with a panel discussion including: Crossfit Competitive Champion and Olympic Weight Lifter Elisabeth Akinwale,USA Soccer Olympian turned speaker/activist and performance trainer Lori Lindsey,  and ESPN Journalist Dianna Russini, moderated by The Riveter CEO Amy Nelson.  They talked about their journeys, obstacles, accomplishments, and what drives them to support women personally, in the world, in the workplace and in athletic endeavors.

I can't ignore the people in the crowd because the room was full of about 100 women and they were awesome too!  For example, I met Sally Roberts, two-time world bronze medalist in wrestling and founder of Wrestle Like a Girl which supports young girls through college-aged women who want to participate in wrestling.

Ultimately - it was a fun night that provided me with some new perspective and numerous ideas to ponder.  I'm excited to see where Allison Tenney takes the event in the future, and I'd definitely attend in the future.  I hope you'll click a few of the links and look into some of the people who participated to learn more about some really strong women working to improve the world for the next generation of girls to have better opportunities in the future.

February Challenge: Read 28 papers in 28 days!

I decided to participate in a challenge to read 28 journal articles during the 28 days of February.  This challenge was organized by: Jacob Manley and Michael Fitzpatrick (a PT and PT Student, among several other areas of expertise - the Movement Doc), Samuel Spinelli (a PT - The Strength Therapist), and Jason LePage (Prime Physio Fitness - a PT Student at Quinnipiac University in CT so he automatically gets my support!). 

(P.S. Please don't tell Dave Ramsey I'm going off track of my current plan to get through a boat load of research articles - this was time sensitive and felt like a great opportunity!)

The idea that these guys have - to read more of the literature to improve their practice and knowledge - is commendable.  Way to go fellas!  Their goal is "to improve our ability to read research, improve our evidence appraisal skills, and read research studies that we may not have read before." They post the articles open access and they also write up a summary on the article to start conversation and get feedback.

I won't be posting about all the articles they've selected to discuss this month - but I wanted to share about the challenge in case others might want to participate - it's definitely not too late to jump on board.  Also, the first article they included deserves some attention as it fits into the chronic pain theme that I've already started posting and learning about.  I may do others moving forward - but since I haven't seen those topics at the time I'm writing this - it's too soon to tell.  Also- I should note that I'm writing this post as I read the article with all my thoughts on it and will read their posted review of the article afterwards so it won't bias my process. 

This particular article (and the entire challenge), can be found by going to the Movement Doc site and joining their members only section, is entitled, "Indviduals' Explanations for their persistent or recurrent low back pain: a cross sectional survey." It is from 2017 by Jenny Setchell et al.

Introduction: The study begins with a description of the biomedical model versus the biopsychosocial model.  I've previously mentioned pain with consideration for the biopsychosocial model and the need to consider non-anatomical contributors to pain here, here, and here.  If you're new here - it's the idea that psychological components such as stress, anxiety, depression, and even the word choice used to describe pathology can impact our patients and their pain.  In consideration of this model, the article states, "how people think about their pain is an important predictor of severity and chronicity." 

Purpose: This paper examines patients with low back pain to determine what caused their pain and where their understanding of their condition came from.

Methods: The study used a survey marketed via social media and postings in local health centers to recruit participants with low back pain.  The majority lived in Australia - locale of the primary investigator - and about 75% were female.  My thoughts: Whenever I see that a study was marketed in this manner, I immediately consider the fact that this means that participants had to have the time and the means to participate as well as a way to come across the study in the first place.  It automatically rules out those who don't have a computer or health club membership from participation which might mean an influence of socioeconomic status of participants.  I consider this important because, based on the biopsychosocial model, a person with less financial means has been excluded, but this financial status could be a significant impactor to their pain experience. 

Analysis: The authors used "discourse analysis"  - a statistics term I had never heard before.  "Discourse analysis is based on the premise that the language we use has a role in creating or constituting reality, rather than simply reflecting it thus discourses are seen as having a real world effect."  It is a way to assess how people think.  This is the basis of the fear-avoidance behavior model- where, for example, if someone was told they herniated a disc in their back, they may avoid certain motions that they think are associated with that pathology.  The study responses were analyzed to determine four discourses which all the participants were then categorized into. My thoughts: statistics is super hard and I'm so thankful that there are people who specialize in studying this.  This concept, discourse analysis, is really interesting because in my mind, no two people will respond the same way to the same input information so to categorize responses into groups for better understanding seems sensible.

Study results: The four categories (discourses) to the question "What is your understanding of why your low back pain is persisting or recurring" were: 1) the body is a machine that has a defective part - this is the biomedical model and was most common, 2) Low back pain is permanent, 3) LBP is complex.  Those who were unsure of the cause of their pain were ultimately included in this grouping. This is the biopsychosocial model.  4) LBP is negative, should be avoided, and has a poor impact on life.  The second question was "Where does this understanding come from?" and 89% of the responses identified a health care provider as the supplier of these discourses as well as about 25% from the internet!!! My thoughts: WE'RE HARMING OUR PATIENTS!  We need to do a better job communicating with patients as healthcare providers.  Hippocratic Oath People!

Discussion: The authors summarize that most of the surveyed participants responded with biomedical responses as to the cause of their low back pain and that they learned this information from their healthcare providers and/or the internet.  There was an expression of hope as some responses to where the pain came from included both an anatomical/biomedical response as well as a biopsychosocial model type response

My assessment: I thought this article was very interesting and that it aligned with the recent articles I've read on chronic back pain and the biopsychosocial model.  It is clinically applicable and relevant as it is a strong reminder of the importance of the language that clinicians use with patients.  Following my write up of the above information, I read the review document from the challengers and was able to recognize a few differences in how I interpreted the information versus how they did.  First, in the introductory portion, I had picked up on the interests of the authors looking at the biopsychosocial model as contributing to the patient's outcomes, but I had not picked up on the idea that the authors include here that how the patients perceive their pain and what they think their outcomes will be, are also contributors here.  For example, if a person thinks their back pain will never get better, this can impact their outcome.  Overall, the study limitations the group found were all similar to my understanding, which was pleasing to me, and this experience of literature appraisal with someone else to compare to was overwhelmingly beneficial.  I'm looking forward to the rest of the articles this month - and you should feel free to join in or check out the articles - or even the reviews being posted - because it's a fast way for you to get a lot of information!

Article referenced:
Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskeletal Disorders. 2017;18(1). doi:10.1186/s12891-017-1831-7..

What do Physical Therapists Do? Installment #2: We Listen.

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© Anatoly Tiplyashin

ID 595706 | Dreamstime Stock Photos

We listen to you describe your physical ailments.  This is usually what brought you in for treatment.
We listen to your stories about mechanisms of injury.  Many of these stories are fairly straight forward and simple.  Occasionally they're a hoot.  It's only funny if you're laughing, too.
We listen to how your pain or pathology affects your daily life.  Can you sleep?  Can you bathe?  Can you get dressed?  Can you drive? Can you work?
We listen to how your current issues are affecting your favorite activities. Can you run?  Can you jump?  Can you play a sport?  Can you read a book?  Can you do a hand stand?
We listen to you describing your family - in positive and negative ways: Upcoming weddings.  A new baby on the way. Divorce concerns.  Challenges with children and siblings.  Helping your parents with aging. Loss of a pet.
We listen to you telling us about your day or your week.  You just went on a trip? You just bought a new house?  Your favorite co-worker just quit?  You got a promotion?
We listen to what you've been eating, cooking, and the diet you're interested in pursuing.  Paleo, Whole 30, Keto, Weight watchers, Dairy Free, Nut Free, Gluten Free, South Beach, Atkins, 30/10, Low FODMAP, calorie counting, intermittent fasting, Kosher, Vegetarian, Vegan, The Purple Diet, Jenny Craig, Egg free, Mediterranean... so many choices!
We listen to your political views, and may have even cried together when our candidate didn't win the election.
We listen to you describe the books you're reading and maybe have read them...  like Dave Ramsey's financial stuff or some of the Classics - or 50 Shades of Grey. (and we might pretend we haven't read some of those, too!)
We listen to your dreams: getting into college, making the varsity team, writing your first novel, making first chair of your band, running a mile in a certain time, losing a certain amount of weight, owning your own company, traveling the world.
We listen to your troubles in relationships, financially, legally, negotiating obstacles, managing time.
We listen.

Why do we listen? We listen because all of these things can impact YOUR outcomes.  According to the biopsychosocial model of pain, if we didn't listen and find some of these issues to be relevant to your healing, we'd be neglecting an important part of who YOU are.  We listen because we care.  And because even though we're physical therapists, sometimes the name therapist is all you hear  - or care about - or need - and that's ok.  We're happy to help you.

Just know that at some point after I'm done listening to you, you're going to get moving, lift heavy stuff, and get to healing.