"Every athlete dies twice."

"Every athlete dies twice.  Once when they take their last breath and the other when they hang it up." - (Original version, since this quote has been modified numerous times, is credited to Roger Kahn, The Boys of Summer.)

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Last night was the death of the 2017-2018 UConn Women's Basketball team.  With two graduating seniors, that group won't play as the same unit ever again.  A similar - but different - team will be born in the fall for the 2018-2019 campaign.  It will look about 90% like this one, but with the departure of Gabby Williams and Kia Nurse, it just won't be the same.  This outgoing team lost a hard-fought battle in overtime to long-time rival Notre Dame, 91-89, in a spectacular Final Four game.  Almost all sports teams change season after season, so win or lose, the last game of the season is the death of any team.  But after last year's stunning end and this one looking so similar, my heart is broken for the Huskies.

I feel like I'm in mourning... a little numb from the replays of the last minute bucket that gave Notre Dame the W.  I also sit back and appreciate how much better the Women's Basketball NCAA Tournament has gotten.  Beyond that - how much better women's basketball has gotten.  Period.  I grew up without a WNBA and now these college athletes have had years to watch professional women's basketball and strive to achieve a life in professional sports.  Both final four games went into overtime for the first time, ever.  The rise of the Mississippi State Women's Basketball team, new to the top echelon in the past three years, is only one symptom of  improving parity to the game. Sixth seeded Oregon State's team has also had increased success the past three seasons with a respectable upset of #2 seeded Baylor.  There were 11 seeds upsetting the 6 and 3 seeds all over the bracket.  There were some really, really good basketball games all season long.  And we don't even need to talk about how much better the Women's Final Four games were to watch than the Kansas vs Villanova men's game tonight.

And what about off the court?  ESPN-W published this piece on 11 of the 12 assistant coaches in the final four, who happen to all be women.  There is only 1 female head coach, Muffet McGraw from Notre Dame, in the Final Four (and now she's 1 of 2 in the Championship Game).  But there are so many more female commentators and reporters providing game coverage - including Hall of Famer Rebecca Lobo, Kara Lawson, and Holly Rowe who have each elevated the game with their contributions in such a significant way.

The loss hurts, but the underlying truth is so much more valuable.  I can't wait to watch the National Championship game, and then it'll be time for the WNBA Draft with the WNBA season starting just a few weeks later.  In the women's basketball world, we get to watch our sport year-round, and I couldn't be happier.  The Huskies will be back soon enough.

#BleedBlue

Who needs drugs when there's hot yoga?!

Photo Credit: Geralt

I once wanted to be a runner. Not an elite runner, just someone who liked going for a long, casual, weekly run as part of a healthy routine.  This seemed like a good plan for my future, so I read several books about becoming a runner - all of which said consistency was key.  So I ran.

In 2011, I trained for (and completed!) a half marathon.  Starting at three miles, I followed a charted training program with progressively longer runs every week for at least 12 consecutive weeks. Once I got lost while running an 8-mile route, ultimately going 13, and at some point I ran out of water and cried to a gas station attendant who gave me a cup and showed me a map to get home.  My sense of direction is THE WORST.  It was a few weeks before the race and the only positive of that experience was learning I could crawl 13 miles to complete the race if I had to, but I would cross that finish line.

And then race day came. Several of my best friends were also running that weekend in Providence, RI.  Four of us had booked a hotel room near the finish line.  The race started without issue, mostly flat with a little bit of a hill at the 3rd mile.  Mid-way through the race, a lady thanked me because I had been belting "Party in the USA" by Miley Cirus at the top of my lungs and she had forgotten her headphones. Poor lady.  I remember hitting the 10 mile marker and thinking: only 5K left to go! I've run several 5K's.  No big deal! And then my body started to say "Nope!  No More."  It was horrible and I wanted to die right there on the side of the road. I decided then that running wasn't for me.

I think I recall the day so clearly because upon waking the next morning, incapable of moving my legs despite the ice bath I had endured the night before, I remember watching the news to see President Obama announcing that Osama Bin Laden was dead. Last night, I finally learned why running is the worst.  In all the training runs, the 5K races, the half marathon race itself, and in every road race or stair climb I've done since then, I’ve never experienced what is commonly called “The Runner's High”. Sure, I feel good after a workout, but something was missing. 

"The Runner's High," according to this 2008 publication from the journal Cerebral Cortex, is defined as "a euphoric state resulting from long-distance running." The paper goes into detail about how they were studying opioid receptors in the frontal and limbic regions of the brain (the brain parts responsible for personality, behavior, mood, fear, and pleasure).  The measurements were done when the runners completed about a half marathon distance, so likely I just don't run long enough distances to get there.  But I don't want to run those kinds of distances to feel so good.

Last night I achieved the fabled runners high in the most unlikely of places.  I went to a power vinyasa class at Fusion Hot Yoga.  Sixty minutes of constant motion with a room full of strangers (and one friend) sweating profusely. They were celebrating the company’s birthday with a day of free classes and the participants were packed in - sardine can style.

The instructor, Brian Pittman, started class off with some supine bicycles. I have patients do 20 of them in the clinic all the time - nice! I know what I'm doing.  When we hit 50 I started to lower my legs, and then he said half way! Ha! I was sure I was done for and basically ended up in a static dead bug pose thinking “what have I gotten myself into?!” I’m not sure how hot the room was but if I had to guess it was about 85F with 1,000,000% humidity. It felt like I was swimming in a bowl of soup. I LOVE the heat.

I was thrilled to remember the names of many of the common poses and a frequent sequence of a low plank into an up-dog followed by a downward-facing-dog. I only felt like I might pass out twice and gave myself a few extra breaths in child's pose and some water to recover.  Afterwards, the adrenaline started.  I turned off the audio book in the car for the ride home so I could sing along to the radio.  I stopped for gas and was jumping up and down full of energy, and still sweating.  I slept the greatest sleep ever.  And then I woke up today and felt the high energy continue for most of the day.  Maybe it's all in my head... but I'm happier believing that I had a whole day of runner's high from an hour of yoga.  All day long I've wondered - how is there an opioid epidemic in the world - yoga has to be cheaper than heroin and this high has to feel infinitely better.  It was hard work to get there, but it didn't require me running 13 miles.

So this is my new solution to the opioid epidemic: for treatment of back pain or for detoxing off a heroin addition - see a physical therapist and go to hot yoga.  I already bought my Groupon for more classes, so you can come join me to sweat it out!

Professional Women's Soccer - The Seattle Reign

Hello March Madness!   My brackets for the men's NCAA basketball tournament are hanging on by a thread and UConn Women's Basketball is on a roll!  There have been so many awesome basketball games and there's still a week left to go! I openly admit that I love basketball, but soccer has started to steal a tiny place in my heart.  I think it has something to do with the fact that it's played outside and the weather is starting to get nicer. And soccer players are insanely athletic!

Last night I attended the Seattle Reign season opener versus the Washington Spirit.  For those of you who don't know, the Seattle Reign is a member of the National Women's Soccer League.  This is professional women's soccer.  The Reign play at Memorial Stadium which sits in the shadow of the Space Needle, just a stone's throw away from Key Arena where the Seattle Storm plays.  Last month it was announced that the ownership group for the Seattle Storm - Force 10 Sports Management - would be adding management responsibilities for the Seattle Reign to their ever growing portfolio.  Having been around the WNBA for the past decade, I've learned a lot about how the league operates and I know a little bit about the teams and some of their ownership groups.  Over the past few years, I have attended a handful of Reign matches, but, prior to now, hadn't given much thought to how little I knew about the team, their players, the ownership, or the league.   So I did some digging.

The league: The National Women's Soccer League (NWSL) was launched in 2012 - so 2018 is their 6th season with competition between their nine teams.  It is the longest running professional women's soccer league as the (several) leagues that came before it only lasted up to three seasons.  In 2017, the league averaged about 5,000 tickets sold per game with the Portland Thorns leading the way averaging 17,000.  Interestingly, on the men's side, Major League Soccer games averaged about 21,000 tickets sold per game in 2016 with the Seattle Sounders averaging over 40,000 per game.  Seattle is just a huge sports city!  In the WNBA, ticket sales for the league and the Seattle Storm averaged 7,700 tickets per game.  When looking at salaries, this 2016 article listed limits to NWSL salaries as $37,800 per season.  That's the limit!  WNBA minimum salaries are $35,000 and NWSL minimum salaries, according to this article, were $15,000!  In comparison, the average (men's) MLS salary of $300,000 (median $100,000) is a liveable wage.  The gender discrepancy is appalling.  The best way I can try to help combat this is to attend games and buy an occasional ticket to show my support.

The team: The Seattle Reign is owned by Bill and Teresa Predmore.  Bill Predmore founded the company POP in 1996 - they're a digital marketing solutions company whose website looks like they're doing some really cool stuff.  Fun fact about Mr. Predmore, though, is that from 1993 - 1996, he was Assistant Director/Assistant Editor for the Bill Nye Show.  His wife, Teresa Predmore, played college soccer at Oregon State and a quick google search brought up her twitter account which looks like she does some work with Water 1st which is a super cool organization that helps provide clean water and sanitation to communities who would otherwise not have access to it. (They also look to empower women and help communities own their water works once the system is implemented.)

The players: You can find the Seattle Reign roster here, but a few quick notes worthy of mention.  In last nights season opener, which the Reign won 2-1,  Megan Rapinoe scored in the 7th minute and Jodie Taylor in the 35th.  Megan is a US Women's National Team player and Olympic Gold Medalist and Jodie, born in England, plays for their national team which won a Bronze at the 2015 World Cup.  The team underwent a major overhaul with 12 new players since last season and a coaching change.  In addition to the ones I've already mentioned, the team is full of athletes who have played for numerous national teams including: Allie Long - USA including the 2016 Olympic Games, Nahomi Kawasumi Olympic Bronze medalist for Japan, Rumi Utsugi former Japanese national team member, Theresa Nielson for the Denmark national team, Jess Fishlock plays for the Welsh National Team and Elizabeth Addo plays for Ghana.  I haven't even mentioned how many of their players are on US teams that are U-23!  So much talent.

Who wants to join me for a game?!

I Failed The 28 Day Challenge - and Built Up my Anti-Library

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In early February, I wrote this blog post stating that I was planning to participate in the "28 Day Challenge" of reading a journal article every day for the month.  I failed.  Big time.

Here's what happened:  I started the challenge two days late and managed to catch up on day three.  I managed to stay on track through day 7.   (4 days... not so strong). And then the weekend came, and I had plans with friends and a job to go to with patients to treat and.... all of a sudden I had six more articles in my "to read" folder on my computer and I just couldn't get myself out of that hole. I think I got through 12 of the articles in total in the month. 

I find that I have been collecting papers to read later on because there's so much to read and so little time.  I have a file of them on my work email all about concussion research, a growing collection of journal articles about shoulders/throwing injuries and anything at all related to ACL injuries at home.  I follow several PTs online and when they recommend an article to read, I add it to the stack.  And so, my list of papers to read keeps growing.  It's the same with books.  My "to-read" shelf on Goodreads is now more than 600 books.  I don't have the space (or funds) to accumulate all those books - but if I did, my house would be overflowing with books.  My continuing education plan for the year is written out and developed and I work my way through it but other things I'm interested in keep coming in my path and leading me off course.

This week I was listening to "The Movement Fix" Podcast Episode #60 with guest Brett Bartholomew, author of Conscious Coaching (which happens to be on order and should be one of the next books I'll be reading). Ryan DeBell (founder of The Movement Fix, headquartered nearby in Lynwood, WA) asks Brett about how much he reads, and Brett presents the point that it's not about how much you read, but about taking the time to digest new learning so you can apply it.  Some days I feel like I'm bombarding my brain with loads of new knowledge, taking in whatever tidbits I can grasp.  Other days I can't shove anything into it no matter how hard I try.  And some days, I can read and take in so much information it's like I'm in the desert and was just given a tall glass of water.

That's right - in addition to journal articles and books, I also have a list of podcasts to work my way through and a list of blogs to read.  The approach I've been taking has been listening/reading from the oldest posts to the newest from the same authors until I've gotten through all of them and can just read or listen to the newest ones as they come out.  A few examples: I'm currently reading through all of Eric Cressey's old blog posts starting in 2002 when he wrote for "T-Nation." He posts several times per month so I need to get through more than he's currently posting to catch up.  I'm doing a better job now of skimming the topic and seeing if it is at all relevant to my practice - but most of the time, I read the whole article and keep track of my progress.  Hopefully in a few months, I'll catch up and then any time he posts something new, I'll have the background knowledge of his prior posts.  Similarly, I listened to all of "The Ask Mike Reinold Show" so now any time a new one is posted, I'm caught up and it's just the new one to listen to.

Sometimes, as I'm working my way through my plan, something with a deadline comes along and pushes me off my track.  I requested the book "Explain Pain Supercharged" from the work library and only have until April 7th to get through it or the Seattle Children's Library Overlords will come take it away from me.  So this is delaying my progress in reading everything Eric Cressey has ever written.

We're in an era of information overload and my colleagues and friends keep getting smarter and smarter and can cite literature easily - which is a struggle for me.  It's hard to keep up when you have so many interests and aren't a fast reader (or even worse, a fast comprehender).  I shouldn't compare myself to them or care - but of course I do. 

Then I came across  this article and the embedded six minute YouTube video that describes the concepts of the "Anti-Library" and the "Black Swan."  An Anti-library is a collection of resources to help you find an answer to a question on a topic you are aware of but that you are not fully educated on.  Because of the internet, we have a virtual anti-library at our fingertips constantly.  The anti-library is where you go to look into "known unknowns." For example, I treat patients who have experienced concussions, but I'm not skilled with vestibular rehabilitation.  I know that my list of saved concussion papers includes some research regarding this area, so if I face a patient who needs this knowledge, I can quickly access it and get better informed.  But right now, this isn't in my case load and to spend time focusing on that learning when I can't apply it doesn't make much sense for me.  In contrast, the Black Swan is the "unknown unknowns."  These are the topics that I know nothing about, where I would need to start from scratch to even start educating myself.  A possible example of this could be a patient coming in with a brand new surgical procedure that I've never heard of or a rare disease with unique complications where I have no knowledge and would need to hit the books and don't even have a list of resources to go through on my mind.

Surrounding myself with knowledge so that I can access it if I need it shows that I am aware that I have so much to learn and that I want to surround myself with ways to gain new knowledge.  The article made me feel better about having a growing anti-library.  Now I just need to figure out a more efficient organizational system to keep track of everything.  Any suggestions?

Physical Therapist Continuing Education Requirements

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This past week I was on an airplane reading some journal articles included in Mike Reinold’s “Shoulder Seminar” when the gentleman sitting next to me asked if I was still in school. (Yay for still looking young enough to be a student!) We discussed our careers and he explained that he is a home health nurse in Indiana where he is not required to do any continuing education.  Seriously?

I immediately shot off an email to a good friend who is a home health nurse in NY, soon to be in WA, and asked if she had the same requirements.  She told me that in NY State she also has no requirement, which she thinks is because of the administrative burden so many providers doing continuing education would cause on the state health department. As she’s preparing to relocate, however, she knows her requirements will change. Despite not having a requirement, she noted that she has participated in continuing education- some independently and some offered through her job. I didn't ask the gentleman on the plane if he did education even though it wasn't required - because I didn't think I'd like his answer.

This got me wondering about the requirements for continuing education as a Physical Therapist.  I have had a license in Connecticut and currently practice in Washington so I knew they both had requirements (that happen to be fairly similar).  My PT School classmates from UCONN are practicing in New Hampshire, Massachusetts, Rhode Island, New York, Colorado, and Texas (plus me in Washington).  For a class of sixteen people, we've spread out far and wide to be in seven different states! We're about to hit the four year mark out of school and I remember my friend who works in acute care in NYC telling me that she had no requirements for the first three years, but now does.  Thinking back to the past three years, I've probably averaged more than 75 hours per year of continuing education, far more than what was required of me, and can't imagine what it would be like to have not done all that work. 

I wanted to look at each state's requirements and was surprised to find that the APTA website links you to each state's practice act from which you could search for your specific requirements.  It makes sense that this would be the most up-to-date way to get the desired information, but I expected the APTA to have an easier way to look at the information.  Fortunately, WebPT has published a state by state list found here and published in December 2017.   I found several alternative lists of continuing education requirements for physical therapists such as this one from 2005 which only listed 29 states as having  requirements. That was a study examining practitioner opinion and healthcare outcomes along with continuing education and may have had an impact on states developing requirements.

 That paper outlined the following results:

1) "Of respondents from states without mandatory CE, 5.9% reported that they had not attended any CE over the preceding 5 years and 10.8% reported that they had attended, on average, 2 or fewer hours per year over the preceding 5 years"

2) Table 4 interestingly outlined that Washington State (where I live) Physical Therapists participate in 97% more continuing education than the required 40 hours every two years. 

3) "For the overall sample, respondents reporting membership in APTA participated in more CE than those who did not report membership in APTA."

4) "The overwhelming majority of all respondents, 96.2% (95.6% of therapists from states with a mandate and 97.2% of therapists from states without a mandate), believed that they improved as physical therapists from their participation in CE."

I went through WebPT's list and found that only Maine, Massachusetts, and South Dakota do not currently require continuing education for Physical Therapists. While each state varies, the average per year seemed to be between 10-20 hours of continuing education. Some states were very specific and others more vague regarding certain content and means of participation such as online versus in person course work. For example, in Washington, physical therapists must complete a three hour course for suicide prevention.  Many of the states also listed PTA requirements for continuing education which had a few more states that did not require hours.  

I wondered if any research has been done on the impact of continuing education requirements on patient outcomes. That search was a bit of a bust.  There were almost no articles that specifically examined physical therapists' education with patient outcomes. I did come across this paper which assessed patient outcomes following physical therapists completing a 2-day course for neck pain with minimal impact on their patients.  According to this 2010 paper from the Journal of the American Medical Association which looked at continuing education for physicians, the evidence for improving patient outcomes was not strong.  There isn't a strong body of evidence to support participation in continuing education, and what I could find showed minimal improvement in patient outcomes at best.  Both papers suggest that new ways of participating in continuing education may need to be developed and bigger sample sizes may also be beneficial.  More research on the topic is needed.

Regardless of these two papers, I'm not planning to stop my continuing education efforts any time soon.  I'll continue to pursue a variety of course topics and presentation methods including video presentations, in-person learning workshops and conferences, and self study, so that I can try to achieve optimal outcomes.  Also, in the future, when I'm the patient, I'm going to ask my providers what type of continuing education they've recently done because it shows a dedication to growth, and I want to be treated by practitioners who also value learning. Watch out Dr. Knudson - I'm asking you at my teeth cleaning next week!

Climb to the Top for Multiple Sclerosis

Today I climbed to the top of Rockefeller Center for the fourth consecutive year. Why would I do such a thing? Because it’s a fundraiser for Multiple Sclerosis and that cause is important to me- and because I can!

View of NYC from the Top of the Rock

The Climb is 66 flights of stairs- 1215 steps- that today took me 23 minutes and 45 seconds. Those 24 minutes were grueling.  My legs started to feel like lead around the 10th flight and my lungs were gone around the 20th- not to recover for several hours because it’s pretty cold at the top and they burn as I tried to catch my breath. This year’s preparation included a lot more weight lifting along with regular stair training steady pace and intervals including at least 11,500 steps in the past 8 weeks.  I endured one ridiculous training session in an apocalyptic hail storm in Seattle just a few days ago.  There was some foam rolling - because #RecoveryDays.  There was biking and running and circuits.   Last year it took 26:05.  The year before that 28:13.  And the year before that, my first effort in 2015, it took me 30:59.  So, totaling up all the minutes of training, and all the minutes of climbing for these events - I've collectively suffered maybe one week’s worth of discomfort.  Perspective: my friend who has MS (who also makes this climb every year and rocks it!) deals with so much more and on such a larger scale. Every ache I've experienced for this is such a small reminder of a much greater cause- and motivates me to fundraise and train harder. 

Let me be clear - this event is not sad.  It's raising money for a serious health condition, Multiple Sclerosis, which a friend lives with every day.  Having sick family members and friends may be sad- but this event is not. It’s empowering! And it’s challenging It's a bit of a party with an MC and DJ and free t-shirts and Pom Poms. An indoor vertical 5-K road race with lots of bananas and granola bars and weird drinks to sample and pamphlets and tracking bibs and both a start and finish line. I love it.  I love flying to the East Coast to visit with my family and friends for the weekend.  I love that it is an annual event that I regularly train for and fundraise for.  I love that my friend has a huge group of people rallying with her and collectively climbing up those 1215 steps.   I love that it is something that benefits a serious health condition.  And I love that the event raises tons of money!  As my friend said when she greeted the team at brunch following the climb, “Let’s keep raising these funds every year until we no longer have to!” 

Here are a few facts about Multiple Sclerosis (MS) from the National MS Society Website:
1) The cause of MS is unknown - but it is thought to be impacted by environmental factors.  It is more difficult to find a cure when a thorough understanding of a cause is unknown.
2) MS is an immune condition in which your body fights off it's own central nervous system.  The central nervous system includes your brain and spinal cord, so when this occurs, a variety of symptoms can occur depending on where the degeneration occurs.
3) MS is most often diagnosed in people between the ages of 20-50 and is two to three times more common in females. It is most common in caucasians with northern European descent.
4) According to this website, the Pacific Northwest has the highest rate of MS in the world.  There are studies looking at geography, vitamin D and environmental factors such as bacterial infections in an effort to determine the cause.
5) There are numerous types of MS.  Commonly, the condition is broken down into four types, but in actuality, because each person presents differently, there are many more than are generally outlined.
6) What can you do to help?  You can donate here to support further research, or you can join me to climb next year and raise money with me!

Overall- a successful training season with improved climb time compared to last year, much better fundraising, and a fun time had by all!