Women's Basketball Summit

I'm participating in the Women's Basketball Summit!  This event is like attending a conference from the comfort of your couch.  You can wear sweats, make some popcorn, put your feet up, and watch interviews over a four day span from people of all different backgrounds talking about basketball!  The target audience is for young female athletes, their parents, and their coaches - to gain new perspectives about ways to improve performance both on and off the court.  The panel includes college basketball coaches and administrators, strength and conditioning coaches, physical therapists, injury prevention specialists, personal trainers, communication experts, and more!

Today I was able to record my discussion with host Jen Brickey. Jen is a strength and conditioning coach in Massachusetts who played Division I College basketball at Hofstra University in NY.  I've been fortunate enough to meet several of the other presenters throughout my career working in women's basketball - and I can tell you they're really bright people with unique and interesting backgrounds.  Right now, if you want to register to watch, you can have access to all the videos for only $5 when they go live in September!  Prices will go up in about a week!

We had the opportunity to talk about my responsibilities with the Seattle Storm, work I do in the clinic at Seattle Children's Hospital as a Sports Physical Therapist, common injuries in women's basketball, and recommendations for youth athletes.

Check out the website.  Sign up here! Mark your calendars. And then let me know what you think!

Random Things I've Learned at Work

This past week, the new North Clinic of Seattle Children's opened for patient care! The facility is beautiful, a lot more space than the previous location, a whole crew of new staff that I've been having a great time getting to know along with all of my previous favorite coworkers making the transition.  It certainly doesn't hurt that there is a basketball court fully stocked with Seattle Storm basketballs and a fellow physical therapist who keeps beating me at knock out... eventually my shot will begin to fall!  (We're keeping score - he's up 9 to 3 in knock out wins... there is hope!) So after a few days of orientation, learning important things like where the AED is kept and how to badge into the parking garage, we're back to our usual routine of patient care and I'm up to my typical shenanigans - making silly jokes and setting up my desk with photos and toys like my Breanna Stewart bobblehead.  

Having just completed a pretty lengthy continuing education course about the knee which I wrote about here, I'm taking a short hiatus from my continuing education to read "The Princess Bride" (SO GOOD!) and catch up with friends while watching the WNBA playoffs get into full swing... so no PT talk this week! For the pasta few months, I've kept track of some of the random things I’ve learned at work, and now I’m going to share them with you. Watch out trivia- if we ever group together and compete, we’ve got all the major categories covered. It really helps that I spend every day surrounded by unique, intelligent people who have varied interests and experiences. This might be a simple way of saying my coworkers are awesome.

Random fact number one - learning about the NBA.  Today is Kobe Bryant's 40th birthday! I mistakenly thought he had made it to playing in the NBA until he was in his 40's because I also wrongly thought he had made it more than 20 years in the league.  While I knew he had gone into the NBA right after high school, I hadn't realized that he was only 17 years old coming in... too young to sign his own contract, which his parents had to co-sign.  While Kobe is not my all time favorite NBA player, what I love about him is that he played his whole career with the Los Angeles Lakers.  As a Boston Red Sox Fan, the only positive thing I've ever said about Derek Jeter is that he played all of his career with the New York Yankees.  Diana Taurasi and Sue Bird, both still playing in the WNBA but having spent more than a decade with their teams, are well on their way to doing the same thing.  Something about that loyalty and your relationship with fans in your community is really special... it makes me wonder what it would be like if I had the same job for 10 years.  I'm about to hit two years at Seattle Children's and hope they'll keep me for eight more!

Now, sometimes it isn't up to an athlete to stay put on the same team - other times it is their choice.  Someone who didn't stay with the same team for their whole career is LeBron James.  Interesting fact about LeBron is that he is 33 years old, (born December 30th, 1984, two days after I was born).  His older son is about to start 8th grade, which means that based on the current NBA rules, his son could be eligible to play in the NBA in 6 years.. making him 39 years old, about 2 years older than Kobe was when he retired.  I would argue, based on personal observation of health science used in the NBA, that LeBron has managed to stay healthier and keep his body in better physical condition to make it that far... and how insane would it be if LeBron could be playing in the NBA while his son was?  I searched - and could only find this article that describes fathers/sons playing/coaching in the major sports.  In the NBA it only has fathers that coached their sons or against them, but never were they both playing at the same time.  I'm rooting for this to occur, now. 

Second random fact: Do you or someone you know chew on ice? This could be a sign of a psychological (eating) disorder called pica characterized by craving or consuming non-nutritional items such as ice, paint, clay, glass, or paper.  This often corresponds to people with a nutritional deficiency such as anemia or celiac disease.  I learned about this with a patient who chews ice who also happens to be anemic.  So it might warrant some medical evaluation if you're experiencing this, because there may be a nutritional deficit occurring.  This is not to be confused with oral fixations like chewing on pens or gum or smoking that relate to Freud's psychosexual theories, which, according to this non-scientific article, occurs due to issues in infancy such as with breastfeeding and may not include consumption, but rather stimulation of the mouth. 

Third, I don't remember the context of the conversation in which I recently learned about stinging nettles, but, there is a plant that grows all over the world including in the United States, particularly in areas that rain a lot (yes, it rains a lot in Seattle), which has leaves with tiny hairs that when touched, basically turn into needles stabbing you all over your body!  (Too dramatic?)  It reminds me a bit of poison ivy, because that's what I encountered as a kid, but apparently it was shocking that I was unaware of this type of plant and have now read all about it.  Fortunately, I have not encountered this beast.

Are you having as much fun reading this as I am writing this?  Let's talk about wasps.  One of my coworkers is in a constant battle with his yard.  Several conversations about weed whackers, soil, lawn mowers, tilling... every time I'm grateful that I don't own a house yet.  Anyways, he was working on his yard and came upon a mud wasp nest.  Say what??? I did not realize how many types of wasps there were, but basically you can break it down into social wasps that make the typical paper nests I was picturing, more like a bee hive (though they're not the same) hanging from a tree or generally above the ground - or solitary wasps that make mud nests, more typically on the ground.  I'm never walking barefoot outside again.  I'm not sure how I haven't come across wasps while reading The Origin of Species... better get back to reading that so I can learn more!

Lastly - a little Physical Therapy related fun fact for my favorite type of patient: post operative Anterior Cruciate Ligament (ACL) Reconstruction.  If someone tears their ACL and has it reconstructed, the piece that is used to replace the torn one is called a graft.  Grafts can either come from the person who was injured - in which case they can use a portion of the hamstring, a portion of the patella tendon, a portion of the iliotibial band, or a portion of the quad tendon.  Sometimes, however, the graft is taken from a cadaver, and in this case, they may use the patella tendon, Achilles tendon, or the tibialis anterior.  I found this interesting because they have more choices coming from the ankle than from the knee when taken from a cadaver - and I also did not know that they used different sources for the graft, before now!

Anybody have some random thoughts to share?  Now's your chance!

Online Knee Seminar and Three Key Components to Patient Care

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I’m starting to look like a groupie of Champion Physical Therapy and Performance in Boston, MA- but that’s for good reason! I’ve previously written about this crew, particularly Mike Reinold and Lenny Macrina here and I just completed their Online Knee Seminar.  This class was awesome- and I’ll tell you about it - but I also want to share some of the underlying themes about patient care that were introduced that relate to how they (and I) practice physical therapy. This could be particularly helpful for the new grad PTs entering the work force after passing the NPTE exams in July but as a PT who is almost four years into my career, I still learned a ton from taking this class.

On my first orthopedic clinical rotation during PT School, I worked with Craig Katko - then the PT for the Connecticut Sun WNBA team and now the PT for the New England Black Wolves National Lacrosse League team. As far as clinical rotations go, Craig was the best instructor for my first time working in orthopedics.  I was very lucky to have that opportunity. As I prepare to take my first student, I'm reflecting on what my rotations were like and what helped me most.  What I remember from my time with Craig was mirrored in the introductory portion of the knee seminar, and I was grateful for the refresher:

First - Patient history and evaluation components are essential to guiding your treatment, but learning how to do an evaluation, and getting to be good at it, is challenging.  Craig recommended that I find an evaluation system that I trusted to use consistently until I was confident in recognizing patterns, and then to later on use as a fall-back plan.  He lent me his copy of Grey Cook's "Movement" book to read - and I learned the SFMA - which I used for my rotation with him. Lenny Macrina has mentioned the SFMA in a few of his courses, and every time he mentions it, I think to myself - he's not checking cervical range of motion in a patient with knee pain.  (Are you, Lenny?)  New grads - you may want to check out the SFMA principles if you haven't yet learned them - especially if you're not confident in your evaluation skills, yet. Now, four years out of school, I don't use the full SFMA for every patient... but I use many of the principles from it constantly. Specifically - I examine neighboring joints proximal and distal to the pain region and check mobility and stability in those regions - both key concepts in the SFMA.  These apply to the knee in numerous ways.  You must clear the spine with patients who have pain in their extremities, and for a patient with knee pain, you need to consider both the hips and feet.  When a patient doesn't fit a pattern that you've come to recognize, the SFMA is always there as an option to re-assess them.

Second - Don’t get too bogged down with diagnostics.  As the PT profession moved into Direct Access and patients started coming into the clinic without seeing a doctor first, I was excited to try to identify patient pathologies. What I came to realize was a specific diagnosis usually doesn't really matter! There are a lot of structures involved in the knee (or elsewhere) that need to be checked, but special tests don't have great reliability and use of palpation to diagnose an isolated structure being injured is about as good as guessing.  As I've learned more about the biopsychosocial model, and treated more patients, it has become apparent that sometimes specific tissue diagnoses do more harm than good, and they often don't help guide treatment. For example, as described in the Knee Seminar, a patient can have patellofemoral syndrome from numerous causes: foot mobility or control issues, strength deficits or imbalances of the hips, overuse, improper jump-landing mechanics, body alignment considerations... the list goes on.  If you tell a patient that their leg is lined up improperly - something that genetically they're unlikely to change - you can create a fearful situation that is unnecessary.  I've actually come to prefer referrals that list a diagnosis as "right knee pain" because I'm not treating a diagnosis... I'm treating the specific person sitting right in front of me with their unique presentation. While clinicians do need to be able to explain what's going on to patients, you can do it in a way that will empower the patient/client to embrace their personalized recovery strategy.  I work with kids.  It's really easy to tell them that I can see some reasons why their knee might be hurting... tell them they're strong... and then give them a home exercise program with some things they can do to make themselves move in new ways that should change the way their body is loaded.

Third - Use functional impairments to guide treatment. I use the slogan "find a problem, fix a problem" as my guide.  This might infuriate some of my PT colleagues because it isn't how their belief system works... but there are lots of patterns that can be applied to all body parts for rehab and progressing through these in a sensible manner to achieve optimal function leads to patients achieving goals.   For example... if I'm working with someone experiencing knee pain and they can't tolerate going down stairs (function), I can break that down to see why (impairments).  Following the progression of working to improve inflammatory processes, then to restoring range of motion, then increasing strength, and finally focusing on proprioception/motor control/higher level activities applies to all knee pathologies, though the timeline of progression varies by person.

So these three concepts were identified in the introductory portion of the Knee Seminar and reminded me of when I first started learning about patient care.  I found these concepts valuable to get my career started and have built on them and developed my habits with additional continuing education courses... which leads me back to the Knee Seminar.  If you're looking for a continuing education course specific to the knee - this is the most comprehensive one I've seen. 

The seminar is broken down into seven key components: 1) examination of the knee, 2) treatment of the knee, 3) ACL, 4) Patellofemoral Syndrome, 5) Meniscus, 6) Articular Cartilage, and 7) Osteoarthritis.  There are videos for each section along with some key selected articles.  Just like I experienced with their Shoulder Seminar - the articles they picked were really useful and I'm glad to have added them to my library for future reference.  The top three considerations that I'm looking forward to implementing in my own patient care were 1) The biomechanics of the knee, particularly with regard to the forces at the patella at different points in the knee range of motion, 2) better understanding of the meniscus anatomy, how it moves, when it is stressed, and considerations with rehabilitation for repair versus removal, and 3) treatment options with regard to articular cartilage pathologies.  There are new surgeries (at least new to me) being used to treat these conditions - such as the OATS (Osteochondral Allograft Transplantation Surgery) and the ACI (Autologous Chondrocyte Implantation) procedures.  If you're a new grad and you haven't seen these yet, this course helped me understand the procedure and the rehabilitation protocols, but better yet - when you would use these treatments and why the rehab is progressed so slowly.  This was a great continuing education course!

Good luck, new grad PTs!  I hope this is helpful.  And just remember, ask for help.  And teach us more seasoned PTs the things you're learning in school so we can all make the profession better!

Sleep Deprivation and Risk of Injuries

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A few days ago, I wrote this post describing some recent air travel stories.  Included was the plight of the Las Vegas Aces WNBA team whose travel delays heading toward Washington D.C. to play the Mystics ended up with the Aces cancelling their game - and a twitter storm of discussion over whether or not that should have been allowed.   At the time of this writing, the WNBA has not yet presented its decision on what will be the outcome of the Aces canceling the game - since they did ultimately make it to D.C. in time to physically be present.  The delay in the outcome of this saga is a bit surprising... twitter has been buzzing waiting to see what will happen... and it has huge playoff implications for both teams. 
The Aces released this (abridged) statement:  "To all of our WNBA fans around the world: We are so sorry that the Aces were not able to take the court tonight against the Washington Mystics. We trust that you know this decision was not made lightly...Given the travel issues we faced over the past two days—25+ hours spent in airports and airplanes, in cramped quarters and having not slept in a bed since Wednesday night—and after consulting with Players Association leadership and medical professionals, we concluded that playing tonight’s game would put us at too great a risk for injury. Naturally, the issue of player safety is of paramount concern for all involved in the WNBA..."

As a WNBA fan - I was sad that the game didn't occur.  If I had tickets, I'm sure I would have been disappointed, especially since people travel to get to games, and they canceled only an hour and a half before tip off.  But as a physical therapist who works with a WNBA team (and would never play any role in making the decision of if we would be playing), I think this was the right decision.  I didn't have enough research to back it up before - so now I've gone searching.  Full disclosure - I'm biased.  I searched for research relating sleep deprivation and fatigue to injuries.  I'm sure I could potentially find papers that would state the opposite outcome... but this is one of the problems with practicing evidence-based medicine.  For every paper that has an outcome, there could be differently designed papers that have the opposite outcome.  So here's what I found, and we can take it with a grain of salt...

1) Durmer et al wrote in a a 2005 about the "Neurocognitive Consequences of Sleep Deprivation."  They wrote about increased risk of car crashes in sleep-deprived males with injury severity and frequency of accidents similar to those of alcohol-related incidents.  This paper focused more on the chronically sleep deprived - people who sleep less than 7 hours per night consistently - though it does mention other types of sleep deprivation such as short term sleep deprivation for less than 45 hours or long term for greater than 45 hours.  Changes in mood, confusion, anxiety, and depression are noted issues across types of sleep deprivation.  Of key importance is that there was a correlation with decreased response time and increased rate of errors with multitasking... which is essential for sports participation.

2) Milewski et al in 2014 also examined more chronic sleep deprivation and found increased risk of injury in adolescent athletes who slept less than 8 hours compared to those who slept more than 8 hours.  Higher grade level in school (older kids) also had increased risk of injury in this study. 

3) Of course I did a search for the relationship between ACL injuries and fatigue...because in the women's basketball world, a torn ACL is considered one of the worst things that could happen. Last month, this brief article was published summarizing increased risk of ACL injury when jump-landing mechanics were assessed following aerobic exercise (acute bout of fatigue) which corresponded with 20% of local muscular fatigue.  It's hard to compare this to 25 hours of travel like the Las Vegas Aces underwent - but in that case we're talking about more of a full-body fatigue with increased risk because of the above-mentioned cognitive factors - in addition to this localized muscle fatigue which would potentially also be present from sleep deficits.  In 2008, Borotikar et al published this paper looking at central and peripheral fatigue influence on ACL injury in females. Again, the fatigue factor was not induced by air travel... it was caused by repeated squatting or jumping tasks, so the correlation is difficult to make.  This study was interesting because it looked at muscular (peripheral) fatigue as well as decision making (cognition/central fatigue) in tandem where previous studies had only looked at the impact of either type of fatigue on ACL injury.  Based on the length of the Aces travel, it is likely that they were mentally fatigued and muscularly fatigued... so it is absolutely reasonable to extrapolate from this particular study that their risk of ACL injury would have been increased by playing under their conditions.

I know there are plenty of people who say they should have played.  I understand those reasons... it's better for the league not to miss games, it's essential for fans to see their favorite players - especially since the teams only would meet in DC twice this season and it's close to South Carolina where Aces superstar A'ja Wilson played in college... South Carolina fans would really have to go to either DC or Atlanta to get to see her, and I saw a few posts online with some devastated fans that they couldn't see her play.  But the statement released by the Aces was clear that there was concern for injury - and thruthfully, if someone tore their ACL in this game - win or lose - that's a huge loss for someone's career and for the team finishing out the season.  Taking a single loss might just have been the best protection for the health of their team.

I can't believe we don't know what the league will do about this yet... but I'll go ahead and guess that the Aces will take the forfeit, the Mystics will get a win, the game won't be made up, there will likely be some financial penalty the Aces will have to pay to the Mystics for imposed costs... and the league will continue to move forward.  Even better - the WNBA players union will open up conversations in a few weeks for their collective bargaining agreement, and travel expectations are bound to be part of their negotiations moving forward.

The end of the WNBA regular season is rapidly approaching - last day is August 19th and then straight into the playoffs.  The blog may be a little heavy on WNBA basketball right now... and then I'll go through my end-of-season mourning period and return to more writing about physical therapy topics... at least until college basketball starts.  Can't wait to see what the league decides for the Aces... it could set a major precedent moving forward.

Airplanes

"Can we pretend that airplanes in the night sky are like shooting stars, I could really use a wish right now..." - B.O.B.

I love to travel.  I enjoy seeing new places, eating new foods or the comfort foods of home, reconnecting with old friends and making new ones... and my family lives on the East Coast while I'm on the West Coast, so often my travels lead me to them.  Last weekend I went to the East Coast, flying through Chicago O'Hare each way... and my personal travels started the thought process for this week's blog.  And then the WNBA had a massive flight disaster...

Today, the Las Vegas Aces WNBA team are scheduled to play the Washington Mystics in Washington, D.C.  Initially scheduled for 7PM EST, tonight, the game was moved back an hour as the Aces were not likely to arrive in town with enough time to get to the arena before playing.  (Update: ultimately the game was canceled!) They started their travels on Thursday mid-day with repeated delays shifting back their departure and arrival.  What a nightmare! They spent several hours stranded in the Dallas airport... and with a good sense of humor... posted an injury report listing every player with a sleepy emoji.

Many of these details are outlined in this article... though I was following the action on twitter, primarily through Carolyn Swords, A'ja Wilson, and the Las Vegas Aces accounts. I'm really not sure what's been going on to cause these problems... doesn't look like there are weather issues in the mid-west... but shortly after the Aces got off the ground, the Indiana Fever had their flight cancelled heading to New York to play the Liberty - that game is scheduled for 3PM EST tomorrow... who knows when they'll arrive.

Anyways... a few days ago, I was flying from Hartford to Chicago with the entire US Women's National Soccer Team.  I waved hello to superstar Megan Rapinoe who I've had the pleasure of crossing paths with a few times in Seattle, and I was seated next to Christen Press, across from goalkeeper Alyssa Naeher and two rows behind Tobin Heath... they were all very pleasant, were able to avoid middle seats from what I could tell... and were happily taking photos with fans who recognized them.  Their matching travel outfits with the USWNT logo on them didn't help them stay incognito.  I wonder if the men's national team flies commercial... we all know the NBA doesn't.  I don't have the time to make this a gender issue, today.

Years ago I worked as the Travel Coordinator for the Connecticut Sun WNBA Team and had been looking into chartered flight costs thanks to the help of the UConn Women's Basketball office... the cost for a charter then was about $40,000... flying commercially, even if it's an expensive flight over $500 per person on the whole team and staff made a travel party around 25 people... total cost per flight is about $12,500.  It just isn't feasible right now for the WNBA teams to travel at this type of cost - especially since teams aren't permitted to travel together (unless league rules have changed).  Maybe the cities that have National Women's Soccer League teams and WNBA Teams could arrange travel together so the Storm and Reign could travel to places like Chicago together and split costs of charter... but you definitely need to have more people to fill a charter to make this cost effective in the WNBA.  The coaching staffs and medical staffs in the NBA make a much larger travel party than the WNBA is limited to at this point, as well.  I'd certainly love to get back on the road with the Seattle Storm along with the rest of the medical crew... but the budget can't fit all that!

Lastly... when I flew out to the East Coast last week... Seattle to Chicago... I experienced my first time when they paged over the speakers for a doctor on board.  Now... I know that I'm a physical therapist... but years ago I was an EMT and I am working towards urgent response training... so I figure if there wasn't a doctor on the plane, I'd potentially be more useful than someone without any medical training.  I walked to the back of the plane and made myself known to the flight attendant.  A nurse was sitting next to a gentleman who had experienced a seizure.  The nurse said things were under control and asked me to share my seat number in case another episode occurred and more hands were needed.  I went back to my seat.  But this got me thinking... you see this in movies and I don't actually know what the rules say about whether I'm supposed to help.  So I looked into it... and would you believe I could not find resources for physical therapists under emergency circumstances other than PTs working in an emergency department?  We're supposed to be CPR and First Aid trained - but that's all I found!

I also found this article which stated that airlines hope a physician won't be on board when this occurs because an on-board physician could require urgent landing where if there isn't a doctor available, the crew reaches out to medical crews on the ground who try to help remotely triage or treat the situation.  I noticed that the flight attendant had an oxygen tank and mask, first aid kit, and that there were some medications available to them.  Another article shared that 70% of in-flight medical emergencies are handled by the flight crew.  That paper outlines the most common medical emergencies that occur in-air, with chest pain being the number one listed outcome.  I did learn that there is a federal law that protects physicians and health care providers who assist during in-air emergencies, though you should always practice medicine with the intent to "Do No Harm" and within your training restrictions.  Doing absolutely nothing was not an option, in my opinion... but I'm certainly glad I didn't have to help with CPR on an airplane.

Overall - there's a lot going on up in the skies.  Back to B.O.B. ... "I could use a dream or a genie or a wish to go back to a place much simpler than this..." I'm sure the Las Vegas Aces are really looking forward to flying to Connecticut tomorrow after the disaster they faced today.  Let's hope they stay healthy through their game and get some good rest... and that no doctors are needed on their flight requiring them to land mid-route.