Sunday, September 23, 2018

Book Alert: The Origin of Species

I’m so honored by the number of people who read my last post and who reached out to comment on it. (First post to pass 500 hits!) I can’t imagine any of my currently planned posts will have as much interest- so today we’ll go a completely different direction and I’ll tell you all about the book I just finished reading: Charles Darwin’s “On the Origin of Species” originally published in 1859.

Overwhelmingly, whenever someone saw me reading it (since it took so long), they'd ask "Why would you do that?"  This book is not for the faint of heart and, sorry to whoever gets the royalties for purchases of it, I would not recommend you go out and pick up a copy.  I was out with two friends at a used book store in Edmonds, WA when I came across a reprint of the first edition which, for some reason, had to come home with me.  When you work in medicine, you study A LOT of science and Darwin's theories are at the core of so much of that learning, it seemed like fate.  I had to check it out, and while I'm glad I did, I think I could have better used my time reading an article or two on Wikipedia and then moving on.

I started reading it in January 2018 and was fascinated by many of the ideas and with the scientific approaches Darwin considered while writing it.  In my opinion, there were far too many pages on the structure of bee hives or on the hybrid forms of dogs or on the reproduction mechanisms of plants, but Darwin was trying to show numerous examples of the same concepts to prove his points and I came to respect his methods.  Other readers might be fascinated by these parts and less amused by the similarities between the animal and plant kingdoms that I was so enthralled by.  I stopped reading for a few months mid-way through to do some continuing education courses, picking it up again recently to finish it.  I'll spare you the time of reading it by providing you with this summary!  If you’re a true fan of science- feel free to check it out, but you've been warned.  It wasn't as bad as Moby Dick - which I tried to read for six months before finally giving up and watching the movie.  At least I learned things from this book...  I found some of it to be fascinating between segments of repetitive boredom.

First, a bit about the author.  The introduction of the book notes that Darwin was destined to be a physician, but that he couldn't stomach observing surgery, so he changed career paths and studied botany and geology. Plants and rocks are definitely less nauseating than incisions and innards. He spent five years (1831-1836) on The Beagle, a ship that traveled around the world with inland expeditions to collect his data.  He wrote a different book about his observations on the ship, called "The Voyage of the Beagle," after which he wrote many other publications on his research.  "On the Origin of Species." was published in 1859, 23 years after his voyage. At that time, religion overwhelmingly superseded science, so a book about evolution went against many societal beliefs and accepted thoughts.  This book was groundbreaking and Darwin is considered to be the Father of Evolution because of this work.   Fun fact: Charles Darwin shares the same birth date as Abraham Lincoln: February 12, 1809.

There are two overarching themes throughout "The Origin of Species" that are founding theories of evolution. These main themes are supported by additional observations that Darwin described in detail.  The first theme is natural selection - the concept that creatures evolve into more and more advantageous versions of themselves and will reproduce to pass on these more ideal traits.  This aligns with "survival of the fittest" in which the strongest beings survive and multiply while the weakest will not procreate and will ultimately become extinct.  The second concept is “common descent with branching evolution.”  This is the idea that all living creatures on Earth come from the same origin, and are genetically related. It is the basis of the belief that humans are closely related to apes.  Darwin never mentions the relationship between humans and primates, but it was nonetheless extrapolated from scientists who reviewed the book, and that is how it has remained understood to this day.

Darwin comes across as both humble- referring often to those whose work came before his- as well as open-minded.  He recognized that though he had scientific evidence supporting his theories, he could suggest ways that they could be disputed - and he sought evidence to disprove his own ideas.  He ultimately did not find contrary evidence to his proposed theories of evolution.  In fact- most of his ideas have remained undisputed. He even recognized that his suggestions were controversial and did not align with the beliefs of the church, but that they were backed by scientific data. While I’m sure this isn’t the oldest piece of evidence-based literature, by any means, it’s certainly the oldest research I think I’ve ever read.

Some of the concepts he described that support his overarching themes include variation between creatures, adaptations to stresses, instincts, heredity, extinction, geological time, and environmental influences on development.  He presents numerous ideas with all sorts of animal and plant examples to demonstrate his principles.  Here are some of the examples he presented that I found most interesting.  

On adaptations to stresses: 
A duck in the wild was compared to a duck in captivity.  The bone density of the wings and legs to compared to the bone density of the rest of the body differed.  The wild duck had larger wing bones whereas a captive duck had larger leg bones. This makes sense because the duck in the wild will fly to escape from predators more often than a duck in captivity which would have a greater tendency to walk, as it is protected.

But what would happen if you took one and put it into the other’s circumstances- would it ultimately adapt to the opposite presentation?  Over time, would it evolve back into the adaptations that were previously present?  The duck adapted in response to the stresses of its environment.  I liked this because it corresponds well to principles in physical therapy and body healing - such as adaptation to stresses in bone after a fracture or the response of muscle tissue to progressive loading.  

On interacting with the environment: 
Similar to the above example, wild dogs generally have their ears erect more than captive dogs, who would adapt more floppy ears - because they are not in danger and use those ear muscles less. 

On variation:
Darwin spends more than 80 pages in this edition discussing variation and how this contributes to natural selection and heredity. At length he compared pigeons of all different types ultimately concluding they must have come from a common ancestor. He describes differences in their characteristics with regard to color, size, and bone structure and discusses how different types of pigeons may not resemble one another very much, but through long periods of time with small changes, tracing steps backwards, they would likely have a common ancestor.

In consideration of my work as a physical therapist, I can appreciate that all my patients are human but that they don't have exactly the same anatomical features, and that they certainly look different from person to person. This is not a good example of variance, however.  More of a variance would be a child born with Down Syndrome, who has a genetic difference - Trisomy 21.  The likelihood of a person with Down Syndrome reproducing is decreased compared to the typical population. Darwin also goes into detail about ways that variation can influence fertility and how it fits into the "survival of the fittest" mentality with varieties that are most efficient becoming more and more prevalent.

On extinction:
The negative response to variation is when changes occur which do not optimize function for the species.  When a creature no longer exists on earth, it is extinct.  Based on Darwin's theories, people with Down Syndrome will not reproduce sufficiently to continue passing on the Trisomy 21 trait and ultimately (over a very, very long time) the whole group would be extinct.  But the mutation doesn't come entirely from heredity... the cause is unknown.  I wonder how Darwin would have dealt with some of the unique circumstances of 2018 if he was here to see the world today, and had access to the equipment now available.

I had previously never considered that this is the ultimate effect of natural selection, but it becomes apparent that if a species is repeatedly at a disadvantage, it should ultimately cease to exist. These changes take extremely long periods of time to occur, and as such, the descendants of an original species may have created other variations that persist- the long lost cousins may not even resemble one another and their ancestors being extinct are not likely to be identifiable.

There are many other ideas to consider throughout the Origin of Species, but overwhelmingly, a more thorough understanding of "The Survival of the Fittest" was what appealed to me most.  With an appreciation for the slight variations that occur within a species, it is easy to understand that any variation that occurs which is profitable will be passed through generations.  Darwin chose the name Natural Selection because the way nature selects differs from how humans select the characteristics of their animals when they breed them - but the purpose for doing so is ultimately the same: to make the best version of an animal or plant possible.

Ultimately, Darwin should get the credit for the science behind “is it true that if you don’t use it, you lose it?” Because yes! According to Darwin it is!!!  His presence on my bookshelf makes me seem a lot smarter... but now I'm ready to go do some light reading, like a Harry Potter book.

Friday, September 14, 2018

My Life On The Sidelines

(This is my longest blog post yet.  You've probably heard the saying "When you make it big, make sure you remember the little people."  The Seattle Storm winning the WNBA Championship this past week was a big moment for me... so I'm taking the time to remember some of the people who were there along the way.)

On Wednesday, September 12, the Seattle Storm won the 2018 WNBA Championship.  They battled the Washington Mystics in the Finals to conclude, in my opinion, the best year of WNBA basketball yet... and I've been watching for at least fifteen of their 21 seasons. I've previously written about how I feel at the end of a basketball season here... but as a recap, for me, the end of a season is always sad... a period of mourning... even with a championship! Standing on the court after the win as WNBA President Lisa Borders presented the Storm with their trophy, there were tears in my eyes.  Tears of pride and joy and relief and sadness... so many emotions!

The 2019 season can of course be amazing, too, but it will never be the same. This year, the Storm led the WNBA standings pretty much all season, league-wide there was incredible basketball, more media promotion, increased awareness and fan support, and continued exposure for players to promote their causes to make the world a better place. My role as the team physical therapist was similar to past years, though I was able to attend more practices and also spend more time in the front office than in previous years working on some different projects.  The WNBA is so important... at the end of the day, the league is about much more than just basketball.  Changes from previous years were palpable. Beyond great competition, the league also had new partnerships with their “Take a Seat. Take a Stand" initiative - I just love this video:


Everyone in my circle knows how much I love basketball and how grateful I am for the opportunities I've had from working in sports.  I was excited the Storm ended up playing against the Washington Mystics because it gave me a chance to visit my brother who recently moved to D.C., but also because Coach Thibault was my first WNBA Head Coach from 2007 until 2010 with the Connecticut Sun, and I have immense respect for him and his family - so it's always great to see them having success, even though it ended in our favor.  After Game One of the WNBA Finals, I saw the whole Thibault clan leaving the arena, had the chance to catch up, congratulate them on their recent successes, give hugs... and reflection mode started to kick in.

It's a little weird, right? I work in the athletic training room and the weight room and I stand on the sidelines watching, rarely touching a basketball, but I'm still reflecting. What went well this year? Did I make an impact? Does the time I spend with the Storm have any value for them?  What should I change next season? How can I do more? Is the balance of my job at Seattle Children's and my time volunteering with the Seattle Storm working out for everyone?  Will the team keep me on their medical staff next season? How mad will my family be when they hear me tell them (again) that I'm not moving back home to Connecticut because this is where I want to be? But mostly, I think, how did I get here and is this the path I’m meant to go down?

Each year I've been with the Storm, (this was my fourth) I've had a few people reach out - usually high school or college students - asking me if I would share my story because they aspire to have a role like mine.  They're seeking career advice.  Young women want to know that they can work in professional sports, even if doesn't mean they're going to be a professional athlete. I'm always happy to share how I got here, and I like to give people hope.  I wanted to play in the WNBA as a little girl, long before I realized I was never going to be a basketball player... but look how close I came to my childhood dream?!  I'm in a rare position... more than half of the WNBA teams don't even have a physical therapist listed on their staff - and most of the teams that do have a PT, the same person is their athletic trainer.  There just aren't that many opportunities to work in professional women's sports. So, knowing I'm in a unique role as a female physical therapist working for a professional women's sports team, I'm going to share my journey and tell you all that I'm working hard to create more opportunities for women in sports medicine... so keep working, and keep hoping.

My Life On The Sidelines:
(This spans 19 years... so maybe grab yourself a cold drink and get cozy before you start reading?)

I grew up in Connecticut. In 1995, I was nine years old when the University of Connecticut Women's Basketball Team won their first NCAA Championship.  People's Bank gave away free posters that had Gampel Pavilion in the background with Rebecca Lobo, Jennifer Rizzotti, and Coach Auriemma and it hung on the wall of my bedroom.  I played rec basketball and watched UConn on TV, because that was starting to be possible.

Four years later, in 1999, I was a freshman at Cheshire High School, still in Connecticut. I went to the girls basketball team tryouts which started with a meeting where the head coach outlined his expectations for the season.  Following the meeting, instead of getting changed to try out, I asked him if he could use a team manager.  I don't think I’ve ever said this to anyone before, but the truth is I really wanted to play basketball. I had zero self confidence, I weighed almost 250 pounds at age 14, I didn't exercise, I didn't eat well, I had only played a little rec basketball before then, and I didn’t think I could make the freshmen team... so I took myself out of consideration without ever trying. It was cowardly. I’m still ashamed. But I loved the game, and this was how I was going to be part of it.

On my first days at practice as a high school team manager, I yelled at some of the varsity girls to run faster during practice. The senior captain at that time, Michelle (Libby) Vieira, now the current Head Coach of Cheshire Girls’ Basketball and also a great friend told me that she immediately thought “Who does this kid think she is?”  I just wanted to win... while sitting on the sidelines.

When basketball ended, I met with the softball coach. Again I wanted to play... but I was committed to Hebrew High School on Wednesday evenings that conflicted with many of their games (and with Dawson's Creek - which aired on Wednesday nights and starred Cheshire native James Van Der Beek. Hebrew High School really got in the way of my life!). So I planned to be the softball team manager.  A few days later, I was sitting in Rich Pulisciano’s (2018 Nominee for National Boys’ Lacrosse Coach of the Year and all around awesome guy) freshmen health class when he said I was his new team manager.  He was pals with Girls' Basketball Coach Sarah Mik and somehow had decided to steal me from the softball team. I didn’t actually know what lacrosse was, but I never made it to a day of softball.

Fast forward a little bit. I sat on the sidelines (or scorer's table) for every Cheshire Girls’ Basketball freshmen, junior varsity, and varsity game for four years. In 2001 and 2002, my sophomore and junior years, we lost in the Connecticut State Tournament Quarterfinals. I don’t really remember games, though.  Or practices.  I remember the people.  I remember bus trips, pizza parties, playing Cranium, crazy hat days, hanging out in Coach Mik's office, and decorating lockers.  I remember gel pen notes and movie nights... doesn't every teenager hang out at the movie theater? I remember having friends because I was part of a team, which is why I encourage so many patient families to get their kids involved in ANY sport.  And I remember my pal Brittney Arisco tearing her ACL, not knowing until many years later that it had impacted me so much. (Wrote about that a little bit in the past, too, here). That was the first time I saw someone tear their ACL in front of me... unfortunately it wasn't the last.

I only worked with the varsity lacrosse team.  I'm not sure why I loved it so much... but those guys were the best.  They always gave me the front seat on the bus as the only girl surrounded by a group of guys with the worst smelling equipment ever. It's the gloves. Gross. They taught me to never drink the yellow Gatorade.  They drove me home in their beat up cars, proud that they had just gotten their driver's licenses. They were polite and respectful to me, they made their moms proud.  And talk about talent! In June 2002, the Cheshire Boys Lacrosse team won the Connecticut State LL Lacrosse Championship. I still have the coin from the toss for that game.  That was the first championship team I ever worked with.  #RamPride
2002 Connecticut State Champions - Cheshire High School Boys Lacrosse
And then senior year came around.  One of the basketball coaches asked me if I wanted to dress and play in the game on senior night, but we had five seniors, and... ARE YOU KIDDING ME? Of course I did not do that. I sat in a special beach chair at the end of the bench with a non-alcoholic frozen beverage with an umbrella in it, under a beach umbrella with a blow up palm tree, holding my stat clipboard, wearing a pleather skirt, and, you guessed it, held back the tears in my eyes.  Or not... they flowed freely.  I wear my heart on my sleeve.  Emotion can also be redefined as passion.  I'm full of that.

After high school was UConn. I was one of the team managers for the greatest women's basketball team and the best college coach and associate head coach of all time, Geno Auriemma and Chris Dailey. #GOAT Four amazing years of sitting on the sidelines.  My freshman year was Diana Taurasi’s senior year- the team was coming off back-to-back national championships and would go on to win a third consecutive trophy that year.  (Ironically, the Seattle Storm have three UConn players on their roster, but none of them were in college with me... though I did meet all of them in Storrs long before ever working with them in Seattle.. and all three participated in my graduate school thesis.)  Again, I mostly don't remember the games... I remember the friends I made, the other managers being some of my closest friends, still, hotel nights, team meals, chartered airplanes, selection show parties, and falling down the stairs at Coach Auriemma's house on New Year's Eve.  One game, the managers And I were trying to get into the locker room, and a security officer said we couldn’t go there because it was only for the team. I yelled “We are the team” because we had work to do... the sideline crews always become a team in their own way, a part of it but also quite separate. I remember them winning the National Championship freshman year... I was sitting in a packed Gampel Pavilion watching it on a huge TV screen.  That week, the UConn Women and UConn Men's basketball teams both won their Final Four and National Championship Games so basically we spent a whole week watching amazing basketball in Storrs, CT.  When the team won, I again cried... and I wasn't even with the team. And there were three graduating seniors who I had grown to love.  #BleedBlue So now I had gotten to work for a team that won the High School State Championship and another who won the NCAA title.  Unbelievable.

2004 NCAA Women's Basketball Champions - University of Connecticut
Fast forward to senior year- April 7, 2007- I was in my hotel room in Fresno, California getting ready to go to the Elite Eight game where Sylvia Fowles and her LSU team ultimately whooped UConn to go to the Final Four when my cell phone rang... it was the Head Athletic Trainer for the Connecticut Sun, Jeremy Norman, offering me a job as their Equipment Manager and Travel Coordinator. I was already discussing a similar opportunity with the Seattle Storm when he called, but moving to Seattle before graduation seemed impossible and the Sun just made so much more sense!  I took the job. When UConn lost that night, my college basketball chapter ending, me - again - in tears, a fellow team manager gave me a hug and said “Cheer up, Abby, you’re going pro tomorrow.”  Ha! We took a red eye charter flight home from Fresno and I was at my first team staff meeting at Mohegan Sun the next night, sitting a few seats away from Coach Mike Thibault.

I LOVED working for the Connecticut Sun. It was my first real job out of college. They were pretty good, but not great. I remember we lost a few games in a row and had a record of 5-10 and Coach Thibault called me into his office and asked me what was wrong. The four previous years, the team I worked for had never lost back-to-back games.  In fact, UConn Women's Basketball only lost nine games total while I was in college!  We had just lost 10 games in 2 months.  I was struggling.  Did I mention that I was the Equipment Manager... and I was getting depressed over the team losing? The Sun ultimately made the playoffs, losing in Indiana in the first round including a first game triple OT win, the only triple overtime game in WNBA playoff history. It was the beginning of another four seasons on the sideline. I spent my first off-season in Spain with one of their players, who was traded when we came back to the USA.  That was the when I learned about basketball as a business. #GetSun

I left the Sun when I realized that I would be doing laundry for basketball players forever if I didn't figure out what to do with my future.  Ultimately I landed back at UConn for graduate school to study Physical Therapy.  Fortunately, they had an incredible faculty member, Dr. Lindsay DiStefano, who was working on ACL Injury Prevention research and was willing to advise me on writing my own thesis project studying leg injuries in Women's Basketball Players at the college and WNBA level.  This project really interested me - as I was sure that basketball players were tearing their ACLs because they weren't stretching. I was wrong.  But the project kept me in contact with all my colleagues in the WNBA over the years I was in grad school, which was vital for my future.

I had been fearful upon leaving the Connecticut Sun that I wouldn't be able to get back into the WNBA because many of the teams didn't have a PT.  As graduation approached, I reached out to everyone I knew in the league.  Seattle Storm Head Athletic Trainer, Tom Spencer, who also owns a PT Clinic, had an opening in his office, but the Storm had never had a PT before.  I arrived at his clinic wearing a boot on my left leg from having had an ankle reconstruction surgery eight weeks earlier.  Tom treated my ankle - which got super swollen from the cross-country flight - while he interviewed me.  Talk about an interesting interview!  I had not yet taken the PT Licensing exam.  I had not yet treated a patient independently.  All I wanted was basketball, and I was willing to move 3,000 miles to get that.

After the interview, Tom took me to Key Arena for the Seattle Storm versus Chicago Sky game which he needed to work that night.  I'm good friends with the Sky Strength and Conditioning Coach, who hugged me as we bumped into each other walking into the arena. The timing of that was helpful.  Tom didn't say anything about what I was supposed to do while he worked.  I quietly sat in the corner (no really, I was quiet!) watching how things operated in his training room.  The chiropractor introduced himself - Dana McCracken - best chiropractor name and all around nice guy.  And then Sue Bird walked in.  I don't think Tom realized I had met her ten years earlier and that our paths had crossed countless times.  We're not friends, but she knew me well enough to give me a hug and ask me what I was doing there.  I told her I was interviewing with Tom for a job in his clinic. She looked at him and said - to be with the team, too, right?  He told me after the game that her reaction was enough for him to hire me on the spot. Four seasons later, I watched her win her third championship. #WeRepSeattle

2018 WNBA Champions - Seattle Storm
So that's the journey.  I hope you'll notice that it's really all about the people.  Career advancement occurs because of the people you surround yourself with.  I have awesome supervisors at Seattle Children's who support me working towards my dreams on the basketball court.  I give my time away in an effort to elevate women's sports and, hopefully in the future, to provide more opportunities for women who want to work in sports medicine.  I've worked with some of the greatest athletes in the world.  I've posted three championship photos above, and I worked on the sidelines for all three of those groups... but you may notice I'm not in a single one of those photos. I know my role and I cherish that. The advice I give to young people aspiring to work in professional sports is to meet new people and keep on working hard.  Give of your time doing things you love and the rewards will come.

Coach Auriemma used to send me to get him a hot tea almost every day for practice. Soon after the team won the National Championship and the season was over, I picked up a tea and went into his office.  I asked him how he measures success.  He told me it wasn't about the Championships, trophies, rings, awards.  It was about the fact that his players come back to visit.  I've heard him say this since then, too. His former players choose to look back and cheer for the young teams still playing in the same jersey they once wore.  Players who don't want to look back and connect with the places they came from or the coaches they played for - that says something about their past.  I still swing by the Cheshire High School Gym and Gampel Pavilion and Mohegan Sun Arena when I get a chance to, because there are connections there that will forever be part of my heart.  The first text message I received sitting in the stands on Wednesday night, just after tip off, was Sarah Mik.  My High School Coach sent me a text saying "Where are you sitting?"  I didn't tell her I was going to be there.  I hadn't talked to her in about two weeks. She just somehow knew it.  And my heart skipped a beat knowing it started with her almost 20 years prior.  I turned to my brother and told him it was about to be the biggest night of my basketball career.  And it was.  The basketball world is a family, and though my role in it is small, it has been an awesome ride.  I've received far more than I can ever give... and I couldn't be more grateful.

Thursday, September 6, 2018

One More About Pain

Homonculus
Sorry readers!  I know I promised a three-part series on pain... but I've been side-tracked by the excitement going on in the WNBA. In case you haven't been watching, the WNBA Finals begin tomorrow with the Seattle Storm hosting the Washington Mystics!  You should watch. Or come to the game and say hello!

Anyways, here's long-anticipated part three!  (I'm pretty sure the future will bring more pain posts because I'm working hard to learn more about it.)  I still don't feel like this is necessary for every patient, but with patients experiencing chronic pain - pain that has lasted more than three months - it has been essential.  The biggest takeaway from reading several resources and watching a Medbridge course about pain science while implementing it with my patient care is that this topic is super complicated but sometimes can be mind-blowing in its impact!  You can find part one of my series, which describes the book Explain Pain, here and part two discussing the "Seven Things About Pain That could Change Your Life" from Lorimer Moseley's visit to the University of Washington here.

How is this one different from the previous two?  There may be a little bit of review, but I'm also going to explore a few concepts from the Explain Pain Supercharged book as well as a few from watching "Teaching People About Pain" a Medbridge course presented by Adriaan Louw.  Along with those concepts, I'll go into a bit of a case study regarding how I observed the impact of some of these concepts and also used this information with a patient with positive outcomes.  Again - do I think that using this approach is necessary for all patients?  No.  Do I think clinicians (and I mean more than just physical therapists) can be more mindful of their word choice so that we aren't creating issues for patients in the future? Yes. 100%.  Do I think that Physical Therapists can, in general, do a better job of helping the general population understand pain and how the body works?  Yes.

The Explain Pain Supercharged book was like climbing a mountain... you start off walking at a fast pace, moving along quickly through the switchbacks, the air is good and you can breathe... then you hit a huge incline (chapter 3 - Pain Biology) where you slow down, have to be more careful of your steps, and consider each move with caution, before you reach the summit to enjoy the view.  In the case of this book, the journey is learning the science behind pain and the destination is learning how to treat it.  It was, without question, the most challenging book I've ever read - and I think, at some point, I'll have to read it again.

The Adriaan Louw presentation was quite the opposite, maybe because I had already read the book, but he describes the mechanisms of pain in his South African accent using excellent images that really helped me improve my understanding of pain.

Key things I learned:
1) When teaching a patient about pain, the use of metaphors and/or images is critical.  To try to describe how the body works is functional for some people, but creating a mental image really increases the understanding and helps increase communication about pain.

For example, a common metaphor used is that pain is like the body's alarm system.  Picture your house having an alarm.  You want the alarm to go off when a burglar breaks your window.  You don't want your alarm to go off when a bird sits on the roof.  Pain operates similarly - you want your body to experience a pain response if your hand is touching a burning flame, so that you can respond and pull the hand away.  You don't want your hand to hurt when you're petting your dog.  The house alarm - and the pain response - can both malfunction.  Chronic pain is that malfunction - when petting the dog starts to be painful.  Unfortunately, where the house alarm can be rebooted with a flip of a switch, the human brain doesn't work so easily.

I've used this description with patients, as well as others.  In the example of our case, a young girl tripped and fell on the playground and hurt her foot.  A few days later, her foot was still hurting and she started to limp.  Negative XRays, negative MRI.  There certainly may have been some inflammatory processes occurring... but no major tissue damage.  By the time she came in for physical therapy, she was on crutches and had not put her foot on the floor for several weeks.  I used the metaphor of a thermometer for her.  She drew me a thermometer and colored in the red tip where it would be very hot, the blue tip where it would be very cold, and in between, could be comfortable, but it would be a range of temperatures.  I asked her, because she liked giraffes, to picture that a giraffe started the day in the normal temperature zone, but then it got a little bit warm.  Could the giraffe go for a swim to try to cool down?  Sure! And it wouldn't be in danger, but it would be warmer.  Now, if the giraffe can't cool down, and keeps getting hotter and hotter, couldn't it reach a place where the temperature was dangerous?

She experienced pain when her foot was on the floor - and so she stopped putting it down entirely.  But, while picturing a giraffe in a bathing suit, she could recognize that just by putting her foot on the floor a tiny bit, her foot wasn't actually in danger.  And thus, recovery began.  Pain is meant to be an output in response to danger messages, so once she learned about the danger signals and could start to recognize that she could tolerate small amounts of the pain and work to increase that tolerance over time (progressive overload), we started to set small, realistic, achievable goals for her to achieve.

2) When a person experiences pain, they move differently.  They oftentimes start to associate movement with pain.  I hurt my back - it hurts when I move - if I stop moving, it won't hurt - so now I can't move.  You're still actually able to move - but it may be uncomfortable.  This concept may seem obvious, but it's actually a bigger problem than it seems.

You've seen someone stub their toe and limp.  Limping in general is meant to protect the foot from further injury because it had a momentary threat of danger - but as long as the limping does not persist long-term, it's really not an issue.  After a longer period of time, however, if they won't put their foot on the floor for several months, they're also not using their calf muscles, their thigh muscles, their glutes, etc in their normal fashion.  The control of their hip and ankle in space will adapt to the new stresses (or lack of stresses) applied to them.  Fortunately, in the case of the little girl, she didn't have any issue with lifting her leg - and so she could do hip strengthening exercises right from the start without any issues from her feet.  Getting her to move in ways that didn't affect her pain levels was essential in her willingness to participate in activities.  She started to trust that some activities we did would not hurt at all and that all of the activities chosen for her PT sessions were intended to keep her out of danger.

For an older, bigger, stronger, more athletic patient, such as a teenage football player I'm currently working with who also has not walked on one of his legs for several months, this battle is going to be a little more difficult because of the amount of muscle atrophy and disuse his leg has gone through.  But still, it surprises these patients, sometimes, when they can do several activities that don't hurt at all.  He could do sit ups no problem.  He could do a bench press without issue.  Muscle strengthening activities don't just target that specific muscle- they increase circulating hormones that can benefit the entire body.  Move the parts of the body that are able to be moved without issue - so that you can start increasing tolerance to activity in general.  Then focus on the specific body part that needs loading.  And you can build trust with the patient.

3) According to Adriaan Louw's presentation, certain types of people are more or less likely to experience chronic pain.  I actually didn't like learning this - but it was thought provoking.  People who participate in contact sports or who work in manual labor type jobs tend to experience less chronic pain. People with lower incomes or lower education levels tend to experience more pain.  Educating people about pain can decrease this.  People who have experienced pain and then recovered from it in the past tend to have overall less chronic pain.  This last thought, I think, is perhaps why I see more chronic pain now that I work in the pediatric population.  Most of the kids who I've worked with who experience chronic pain have never had an injury before the one that started this path.  They don't always fit the above criteria, such as working with a football player experiencing chronic pain, but these are considerations that cannot be ignored.  Generalizations can be dangerous because, as a clinician, I should not assume that every child I work with who comes from a low income house and has had pain for a little longer than normal is following a chronic pain pathway, but it needs to be considered, because often some of the stressors associated with family life may be contributing to the pain pattern.

4) Your brain makes a pain map that is specific to you, and the more you experience pain, the more distinct that map becomes.  Close your eyes and picture your pet.  What does it look like?  Feel like? Fluffy? Hairy? Spiky?  My friend has a chinchilla as a pet... so... what would that be like?  How about smell? Does your dog stink?  Does your cat meow?  Ok... you've just put an image in your head of your pet- and it will collectively activate multiple centers in your brain.  If I simplify it, the smell center and the vision center and the touch center of your brain all activate in a specific way when you think of your pet.  My pet is different than yours - but a smell center, and a vision center, and a touch center will all be activated in my brain, too.  The centers in the brain are similar, they activate as a group when processing a certain idea, but these differ between people.  Similarly, when you experience pain, centers in your brain are activated, and though the areas in my brain will also be activated, they're not describing the same pain.  Your pain is yours - mine is mine.  And the brain maps are similar... if we're both picturing dogs, they're likely to have similar characteristics, but they're still not the same.

As you can see from having written three posts on pain, I could keep on going.  For now, I'll just say that I think we're going to see changes in the future when it comes to chronic pain.  I already see it at Seattle Children's Hospital where we have specific groups of clinicians who work with kids experiencing chronic pain.  We're going to find that people having had pain for extended periods of time are going to seek out clinicians who have worked with this patient population.  This is challenging and I'm really enjoying learning about it so that I can better serve children who are struggling to get back to their lives.  The best advice I can give, though, is to prevent your pain from reaching this stage.  If you've had pain for a few weeks and think that leaving it alone will just make it better - or that pain medication is going to be the answer - I urge you to find someone who works with chronic pain and can help you get moving.  Movement, after all, is the ultimate answer.






Sunday, September 2, 2018

"Like A Girl"


Physical therapists observe how people move and try to guide them in ways to move more efficiently. In case you missed my previous post "What do Physical Therapists Do: Installment #1 - We Look at Mechanics" - you can review that one here for more specifics and then come back...  Go ahead, I'll wait.

Welcome back.  Today we're getting a tiny bit political.  Not White House political...good heavens no.  This is a social issue.  You may feel like I'm rambling... I felt that way, too.

I'm currently playing in an adult co-ed softball league... see photo to the left where I'm rocking  my tall socks, batting gloves, and BoSox hat.  Have to look the part... and keep my hands soft... they're my money makers!  I digress.  I was warming up with a teammate, progressing our throws into longer distances, chatting about our days, and I observed that he was throwing almost exclusively from his elbow, no rotational motion of his trunk, no follow through, not really using his legs at all.  I've only played with him a few times before, but I was concerned that he might hurt himself.  I asked him, "Who taught you how to throw?" And he said, "Why, do I throw like a girl?"

Poor guy - he never heard the end of it from me. The whole night. I'm still proud of myself for the timing and word selection of my immediate response - that he should wish he threw like any of the girls on our team. My female teammate was warming up next to him, snapping her tosses with beautiful efficiency and consistently reaching her target.  He did apologize.  I'm sure he didn't intend to use those words.  I'm sure he didn't mean to put down the entire female gender in a flippant manner.

I'm definitely not an expert on throwing mechanics, but I know a few things that could have helped him get better.  More importantly, I could have given him a few tips that might prevent him from having an injury.  None of those pointers were provided because I was too stuck on his words.  I don’t walk around making suggestions to random strangers- though sometimes I want to.  I don't go to a gym and interrupt others who are working out to change their mechanics, even if it makes me cringe.  But this is my fun time... and I really hate having to play physical therapist at the field. From a Physical Therapist's perspective, I was concerned that he could hurt himself (and his throw is inefficient if he cares about being any good at rec softball).  He's not just looking like he's going to hurt his elbow and shoulder, his back is taking a toll every time he tries to make a long throw from the outfield.  

The next morning in the clinic (I couldn't believe it!) - one of my patients, a ten year old girl, was wearing a "Like a Girl" tee shirt.  I high-fived her!  #GirlPride I asked her about her shirt.  She said girls can be superheroes.  I love working with children.  They're hilarious.  Anyways... I had just started getting over the little softball episode, when more situations like it occurred.  Maybe I was already on the lookout for them because of it - but with repeated episodes, this blog post was born.

A few days later, Breanna Stewart was named MVP of the WNBA! I was able to attend her press conference where she made an amazing speech about using her platform to promote the issues she finds important to improving the world.  The posts from the league and various media sources had the worst comments!  Terrible.  She's trying to bring awareness to important issues - like registering to vote - and someone posts a comment with a photo of an empty kitchen - like that's where she should have been instead. I'm so disgusted.

And then another episode.  I was working with a young male who told me that he wouldn't do some of the exercises I recommended for his home exercise program because they were "mom exercises."  I had asked him to deadlift a barbell that was not loaded so I could see what his form looked like and had recommended some accessory exercises to supplement the workout.  He said he may as well go to a Pilates class because that's what moms do.  And, though I tried, I failed to make any change in this perspective.  These are learned behaviors! 

During the 2018 NCAA Basketball Tournament, 16th-seeded UMBC Men's Basketball upset first-seeded Virginia.  Several people in my life - and boatloads of people on social media - said it was the first time this feat was ever accomplished. WRONG.  It was the first time in men's college basketball, but Harvard Women's Basketball had upset Stanford Women's Basketball in a 16-seed upsetting a one-seed twenty years earlier.  Women did it first in 1998.  I spent days correcting everyone, responding to posts online.  I'm not really sure why all of these things keep bothering me.  I can't explain it.  Maybe educating others is the best I can do to start bringing awareness to what people are saying, but for the sake of my niece, my cousins, my friend's daughters, my young female patients - and all the young people - boys and girls, we MUST do better.

Words Matter.  Don't let these occurrences continue.  Speak up.