Words My Mom Doesn't Want Me To Use

Many Words of Mental Health

This post is long overdue.  So are many, many others that are similar that I've half-written but are not completed and haven't published because I hate dealing with my own vulnerabilities and weaknesses. That's right.  Hate.  A word my mother banned me from using as a kid because it is so intense.  I remember her telling me that if you use the word hate regarding another person, you mean that you want them dead.  I'm sure I probably had used it towards my twin brother for hitting me... and ultimately I got in trouble for using a bad word rather than him getting in trouble for physical violence.  Of course I didn't want him dead... just to quit it with the wet willies. So hate is an intense word and I don't take that lightly. But it's appropriate right now.  The alternative would be saying that I can't do it... I'm unable... but that portrays weakness... and I'm perfect so I won't use that word.

Perhaps you've heard of the author Brene Brown.  I may have mentioned her in a past post, but honestly I can't remember.  She has written several books on various topics including, according to her website, "courage, vulnerability, shame, and empathy."  She has this quote on her home page: "I believe that you have to walk through vulnerability to get to courage, therefore...embrace the suck."  Ha! Suck is another word my mom wouldn't let us use as kids... funny how both of those words came up and a blog post was born.  I hate facing my own vulnerability so much that I was incapable of reading Brene Brown's book, Daring Greatly.  I tried. Multiple times.  I checked it out of the library, read the first chapter over and over again because I couldn't process it, and when I got the notice that it was due, I returned it.  My roommate really liked it and others by this author, and usually I agree with her taste in books, so I watched her Ted Talk on YouTube - which was OK... or tolerable - and checked the book out again.  Couldn't read it.  Physically incapable.  So I returned it and tried the audio book, but I never made it past her discussions of vulnerability.  It's dangerous to black out while you're driving but I felt like I tuned out the book and the whole world.  Specifically regarding Daring Greatly... and a few blog posts.... I can't walk through my vulnerability to get to the courage.  I'm a coward. Maybe I'll try to Dare Greatly again in 2019.

I've been writing this blog for many reasons... all of them selfish.  I'm not writing for you... I'm writing for me.  While I'm glad others are reading it, I don't actually care when a post only has 20 readers versus the more popular ones that have hundreds of views.  Oh!  There's another phrase I drove my mom crazy with as a kid... "I don't care."  She'd ask what I wanted for dinner... this was probably around 7th grade... and I'd say I didn't care.  But that's when I was trying to stop eating red meat so when meatballs or lamb chops showed up on my plate... I absolutely did care!  So many life lessons... thanks, mom!

Mom

Selfish or not - I'm hopeful that something I say helps other people.  I'm hoping some young physical therapists check out some of the continuing education courses I'm doing or some PT students learn from the mistakes I made earlier in my career. It would be awesome if suggestions I make help decrease some injuries in youth athletes or help people cope with their chronic pain.  When those more vulnerable posts do finally sneak onto the published side of the blog, I absolutely hope someone benefits from them... but I'm getting out what I'm putting in.  I won't pretend I'm doing this to be generous.  This blog has a much bigger purpose that has not yet reached full transparency.  Yet.

So why today's blog post?  A friend is in pain. Maybe not the physical pain that I treat in the clinic or chronic pain that I've written about so many times on this blog.  I'm not sure.   But there is suffering.  Sadness.  Emotion.  I got a phone call today and was told that they had decided to self-admit for inpatient mental health services a few days ago.  Only a very small number of people know and for some reason, I'm on the short list.  They wanted to know what I thought.  Talk about vulnerability.  Courage.  Strength. 

I think that others may be struggling who might need to hear this too. To be honest... when I'm having a down day... I need to hear these things myself.  Despite all my jokes, laughter, and smiles... I do have down days.  So here's what I think, and also some of what I told my friend.  And I'm sharing with whoever reads this... because it's the start of facing my own vulnerabilities.

1) Mental Health, per dictionary.com, is a) psychological well-being and satisfactory adjustment to society and to the ordinary demands of life; b) the field of medicine concerned with the maintenance or achievement of such well-being and adjustment.  Wikipedia says it's the absence of mental illness.  EVERYONE has a mental health status. And it isn't some concrete place that you're always going to be in. It's a fluid construct. There are times in life that are more stressful or more sad or overwhelmingly happy...  and your psychological well-being changes during those times. That doesn't make it pathological - or mental health illness.  But just by looking at someone - you really can't tell if a person has a pathological mental health or not.  Just like you can't tell I'm Jewish by looking at me... there's no sign on my forehead telling you these things you can't see.

Remember Robbin Williams?  He was a comedian and all around funny dude... and all you ever saw publicly as a fan of his movies was happy, jovial, doing voices Mrs. Doubtfire or Genie from Aladdin.  But underneath the skin was a dark place that most people couldn't have known about.  I refuse to believe he was sad all the time on the inside while happy all the time on the outside.  But I have no way of knowing.  And so - everyone has a mental health status - but more importantly - you never know what's going on with other people under the surface unless you ASK.

2) They are not alone.  I don't know what specific mental health circumstances my friend is going through. It's none of my business if they don't want to tell me.  I can be a supportive friend without details. Maybe other people react differently? What I do know from recent reading about mental health illnesses is that there are a long list of them - potentially including: anxiety, mood disorders, depression, body dysmorphia, PTSD, eating disorders, personality traits, social anxiety, diagnoses like schizophrenia or bipolar disorder, gender and sexuality issues... and TONS of people experience these problems. Unfortunately, this friend isn't the only person I know having some struggles right now.  The people I love are hurting... which hurts me, too. And so I told my friend about my own recent mental health journey and we couldn't understand why neither of us had discussed these things before now. Well... actually I don't talk about it because of that V word I talked about above... you know the one. Maybe that happens for a lot of people?

3) There's a lot of darkness going on in the world right now.  The news is sad. You can't go on social media without seeing really big issues - global warming, separation of children at the border, economic policy, gun control, starving countries, natural disasters.  All those big issues can make an individual feel pretty small and less important. But less important is NOT unimportant.  The holidays are coming up.  I'm personally looking forward to seeing more photos of children looking at Christmas Trees and Menorahs, families having meals together, and drowning out some of the bigger stuff.  Let's bring it all a little smaller, find ourselves a little bit, take a deep breath, and focus on the positives and things we can control.  Even if it's just for the month of December.

I can promise there will be more where this came from.  If you feel there is a negative tone to this post, you should know that in my head there is only optimism.  hope.  healing.  and love.

Book Alert: The Omnivore's Dilemma (and The Jungle)

I recently read The Omnivore's Dilemma: A History of Four Meals, by Michael Pollan.  I had been meaning to get to it for several years, probably since I read Upton Sinclair's The Jungle which fascinated me.  Both books I would recommend to people who are interested in learning about food in the United States.  They're very different.  The Jungle was written in 1906 and goes into great detail about the living and working conditions for workers in the meat-packing industry.  It was appalling and an interesting way to learn a piece of American history.  I'm certain that if I was a meat-eater when I had read it, I wouldn't have been afterwards, despite how much the industry has changed (I hope!) since that time.  Most days I wish I was a vegetarian but I just can't get myself to do it.  You've been warned!

In The Omnivore's Dilemma, Michael Pollan examines four different pathways to a meal.  He considers the sources of ingredients and what the go through to make it to your fork.  It starts as a story about corn and it’s impact on our food supply as well as contributing to the obesity epidemic, economics, and politics. Fun fact: There are about 45,000 items in a typical grocery store and 25% contain corn.  Looking at a chicken nugget: the chicken while it was alive was fed on a corn-based diet. Once the chicken is used for meat, the nugget is held together with corn starch, then breaded in corn and fried in corn oil.  My favorite quote from the book: "If you are what you eat, we are mostly processed corn." 

Corn evolved to be able to grow under a very wide variety of weather and soil conditions. Because it is used for so much, farmer's were almost forced into growing it and ultimately had difficulty feeding their families because they devoted all their land to corn instead of a variety of animals for meats, vegetables, and fruits.  When the cost of corn decreases, the government helps subsidize farmers so they can stay afloat.  I won't lie - I didn't understand all the political implications that were described, but I did comprehend that the government and politics are intermingled into farming and into our food and that makes things complicated for everyone.  

A huge portion of the corn that is grown becomes high fructose corn syrup (HFCS), a sweet form of refined sugar.   A lot of it goes into soda. A farmer gets the tiniest fraction of pay for the corn and the beverage companies get a much larger percentage for what they make from it.  In 1980 Coke changed from sugar to HFCS because corn is cheaper than sugar. Pepsi followed in 1984, and people couldn’t tell the difference in taste.  After a better understanding of how corn is the basic substance of so much of our food, meals from four different food chains were examined. 

First: The industrial corn chain followed to McDonald’s: With the advent of fast food, a family can eat separate meals while still eating together. Separate meals generally means larger portions. The nugget is the reason chicken is more popular than beef in America.  A meal for 3 people from McDonald’s was analyzed for how much corn was used to make it. The six Chicken McNuggets that Pollan’s son consumed used enough corn to feed a handful of people. And the 4,510 calories of the whole family's meal required processing that could have supplied tens of thousands of calories of corn to feed starving communities.  The cost of production of the products we eat is higher than the energy we're getting out of our meals.

The second meal is of mass-produced farming to stock our grocery stores.  This portion was interesting because it looks at some of the imbalances with fuel requirements to produce the food where that fuel could be used in an alternative means.  Similar to the energy cost of making the Chicken McNuggets only looking at the feeding of the animals that are then sold at the grocery store.  Pollan goes to a cattle farm and observes the conditions there, but he meets quite a bit of resistance from facility owners trying to protect their secrets. 

The third meal was based on organic farming. Pollan spends time on a smaller farm learning about the animals and their grass feed and even how to kill a chicken and prepare it. He cooks a meal from the chicken, corn, and eggs of the farm. It was interesting to learn that there are farmers who won't send their produce far from where it is raised, because they're not using anything to preserve the meat so the quality would be poor if it was shipped cross-country.  Pollan's experience participating in the chicken butchery was fascinating... like a new version of The Jungle - but so much safer for the workers and so much less gruesome for the animals.

The fourth meal was a hunter-gatherer-home grown meal. He learns how to forage for mushrooms - which doesn’t sound too hard until you’re holding a mushroom, unsure if eating it will kill you or not since they can be poisonous.  Then growing a garden and getting a hunters license and learning to shoot so he could hunt for the meat.  He kills and prepares a pig and makes the whole meal from ingredients he had grown or scavenged or hunted on his own. 

Overall I really liked learning about the different ways food can end up on the table.  If time constraints and money were no issue - it would be amazing to have a meal every night that was grown in my backyard.  I definitely couldn't hunt an animal and then eat the meat... I can't even fathom the idea of going fishing and on the few occasions when I've made lobsters and cooked them, I've felt terrible about my meal.  But I could see myself milking a cow to make my own cheese... because I love cheese and that doesn't hurt the cow.  If only there was enough time.

I'd recommend both of these books, just like I previously recommended Deep Nutrition here.  There are some other nutrition/food books on my list coming up, too, but any recommendations for what I should read next? 

Seattle Children's Inaugural Sports Medicine Symposium: Mental Health

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© Abidal

 

| Dreamstime.com

On November 14th, Seattle Children's Hospital held their Inaugural Sports Medicine Symposium with the topic of Mental Health Care for Athletes.  As I briefly mentioned in my Blogiversary post, here, Mental Health is something that interests me and that I have been learning more about because of its relationship with chronic pain (which I have previously written about several times.)  It is also something I've been learning more about regarding my own mental health practices, lately, which I hope to explore in the blog in the future.

The Symposium was a multi-disciplinary event including the orthopedic physicians and surgeons and their PAs, the sports physical therapists, and the athletic trainers from Seattle Children's Hospital.  In my almost 2 years working at Seattle Children's, it has historically been a rare occurrence for all of these providers to be in one place at the same time - but we're treating the same conditions and working together on so many patients, that it was neat to have this opportunity. 

There were two speakers at the event discussing various topics from mental health.  First, Dr. Cora Breuner, a physician at Seattle Children's and a professor at the University of Washington with expertise in pediatrics, adolescent medicine, orthopedics, and sports medicine discussed some of the critical components of evaluating patients with consideration for finding mental health or substance abuse red flags.  She was listed as one of Seattle's best doctors in 2018 (and several previous years!) by Seattle Magazine, and her presentation was engaging, informative, and entertaining. 

From her presentation, I learned two new acronyms to include in my evaluations which I previously had only included small parts of, but now have better understanding for the importance of going into more detail.  These are mental health screening tools meant for the adolescent population and which fit into the biopsychosocial model of care nicely. The acronyms: HEEADSSS and CRAFFT examine the adolescent's personal life while CRAFFT is a screening tool for substance-related risks such as drugs or alcohol that fits into the HEEAADSSS assessment. 

HEEADSSS breaks down into: Home, Education, Eating, Activities, Drugs, Suicidality, Sex, and Safety.  There are a few different versions when I searched for better understanding of this acronym - where some of the dual letters are combined into groups.  Let's look at these in a little bit of detail.  Every time I sit down with a patient, and usually they have a parent with them, my first job is to make them comfortable and try to connect with them.  If I'm going to treat you and help you manage your pain, there's a chance I'll need to touch you or have you move your body in ways that are new to you - so I need to earn the kid's trust.

Ever try to make friends in Seattle as an adult?  It's hard!  Want to make friends with a teenager in less than 5 minutes?  Find out what they like and make sure they know you're talking to them - rather than their parent - and you might have hope!  Fortunately I have a wide array of interests and background- so I can talk a little bit of sports, a little bit about music, a little bit about Harry Potter, a little bit of Disney Movies, and a little bit of "I also went to high school once so I can relate to your hatred for Spanish Class" to try to connect with these teenagers!  I always ask components of the HEEADSSS assessment because it's an easy way to break the ice with a kid.  Here's some of what I already would typically ask: Home: Who brought you to the appointment? Who do you live with? Do you have any pets? Are you nice to their little brother or sister?  Education:   What grade are you in and what school do you attend? Do you have friends? What are your favorite classes?   Activities: What do you do for fun? Any sports, musical instruments, clubs or after school activities/hobbies.  How about a job?

You might notice that I've left out some of the essential topics with my usual line of questioning.  I rarely ask about Eating, and I don't think I've ever asked about Drugs, Suicidality, Sex, or Safety.  That doesn't mean these things have never come up... I've had more than one patient in my career (adult and under-aged) tell me they're using some sort of marijuana product for their pain control.  I've worked with a few patients who have had issues with suicide in their history and who bring it up as something to be aware of in their past.  Discussing eating habits is a great way to assess the basic health understanding of the child and family or to gauge an understanding of the basic needs of the patient.  I'm glad I can give out snacks to kids who may not have enough to eat. 

Questions about drugs should include the use of alcohol, marijuana, or any other substance to get high in the past year.   Those drug questions are followed by the CRAFFT acronym which stands for: Car, Relax, Alone, Family/Friends, Forget, Trouble.  These are specific questions:  Have you ridden in a Car where the driver (which could be you) was high?  Have you taken drugs to Relax?  Do you ever use drugs or alcohol Alone?  Do any of your Family or friends tell you to cut back on your use of drugs or alcohol? Do you ever Forget things because you were using drugs or alcohol?  Have you ever gotten into Trouble while using drugs or alcohol? This assessment can be scored to determine high risk of substance abuse.  It was also discussed that kids are much less likely to have these conversations in front of their parents - and they're also more likely to talk about their friends than themselves - so asking your patient if any of their friends use these substances might get you more information than starting out asking them about personal use. 

With kids who may have some mental health issues that need to be considered as a component of their care, adding these areas will be vital and incredibly challenging at first.  But as healthcare providers, we have a responsibility to look out for these teenagers who may not have any other way to get help if they're in need. There were some interesting and startling statistics presented regarding some of the high risk behaviors.  Particularly memorable to me were: 1) In a survey of high school-aged kids, 94% of the ones who used drugs or alcohol started between ages 11-15.  2) In a survey of high school-aged kids, less than half had engaged in sexual intercourse, but only 60% of those had used a condom. 3) Condoms only prevent pregnancy about 82% of the time.  That's a B- grade. So too many kids are having unprotected sex and even those who are trying to be protected don't have the best stats on their side. 

Dr. Breuner also discussed the importance of recognizing the rights of a teenager.  In the state of Washington (this could vary where you live), a teenager can have their mental health records kept confidential starting at age 13 and their reproductive health records kept confidential at age 14.  This means that a healthcare provider can discuss this information with the child and does not have to inform the parents - or anyone else - unless the child is being hurt or is hurting themself or another person.  The information should be documented in their medical record but is not to be released to the parents.  We need to be educated so we can serve as resources to teenagers who need help.

The second speaker was Sport Psychologist Dr. Elizabeth Boyer, owner of Northwest Performance Psychology.  Dr. Boyer gave numerous examples of ways that injury can influence mental health.  We see this in the clinic often - where an athlete is working to get back to their sport and is sad or depressed or fearful... for a wide variety of reasons.  Athletes who are injured often feel like they have let their team down.  They may lose confidence and could become more isolated from being separated from their teammates and friends.  They should go to practice!  Maybe not every single day, particularly if they need to be doing regular rehab appointments, but we can easily encourage injured athletes to attend a practice every week and be part of their team.

A key takeaway from this presentation was that developing some mental health skills for recovery can also help improve athletic performance.  Skills like imagery - where you visualize drills in your head - or goal setting - in the short and long term - can both help with recovery and with performance.  While we always set goals for our patients in the clinic, the patients should have more say in their own goals rather than having a therapist select things that may seem arbitrary.  And reminding patients of their goals throughout the treatment so they can see their progress is also a useful tool. 

Lastly, Dr. Boyer mentioned the importance of self-care as a healthcare provider.  I love my job.  Every day.  I can't believe how blessed I am.  But sometimes I forget how much of myself I'm giving to others and how little I'm giving to myself.  Sounds like I need to find some different options for that for the new year... more focus on my own mental health will only help me better serve the patients I'm working with, and keep myself going. 

And with that, a Happy Thanksgiving to all my readers.  I hope you'll take the chance to care for yourself this holiday season.  And to care for those around you. 

Warm Up Like You Mean It

Photo Credit: Seattle Pediatric Sports Medicine
I'm front-right, and I need to work on my landing.

High school and college basketball season is here!!!!!! (YAY!) I'm so fortunate to have many friends who coach or work in high school and intercollegiate athletics.  This post is for all of you.  It's tinted towards basketball, but it could apply to any sport. 

Working in pediatric sports medicine, I notice clusters of injuries which coincide with the change in sports seasons.  This is, of course, a generalization, but it seems that there are patterns. Some examples: shoulder overuse injuries in swim and baseball season, concussions as football gets underway, "shin splints" in cross country runners who may have ramped up too quickly, and ankle sprains with soccer and basketball.

So now that the sports seasons are changing and I'm expecting to start seeing basketball players in the clinic, I thought it was time to hop on my soap box suggesting the use of a dynamic warm-up as an injury prevention tool. It has recently come to my attention that some of the local high schools are so overbooked on their gym time that the athletes are expected to warm-up on their own before they're allowed access to the court.  The team does not warm up together unless the captain organizes the group beforehand.  To me, that means it isn't mandatory.  It isn't a priority.  If teams only get 2 hours of on-court time per day, they'll use the time to focus on sport-specific activities, no time wasted on preparing their bodies.  I get it, but I don't approve.  I think you might end up with a team that knows a few extra plays, but you also might have a few more injured players on the bench.  Is it worth it?  There's quite a lot of research on the benefit of ACL injury prevention programs, including the 2018 National Athletic Trainer's Association Position Statement written by an awesome group including my mentor, Dr. Lindsay DiStefano, which can be found here.  (That paper includes the components you should include in your injury prevention program... no worries ... they're going to be briefly summarized below.)

I've previously mentioned that an injury prevention program is the same thing as a performance enhancement program here.  Most of these programs are targeting prevention of ACL injuries, but there is no reason to believe they couldn't help prevent other injuries, as well.  The Seattle Pediatric Sports Medicine Group's ACL Injury Prevention Program and the FIFA 11+ programs were both designed to be used as a dynamic warm-up.  Note that I'm using three different names for the same thing: Dynamic warm-up, if used properly, is the same thing as an injury prevention program, which is the same thing as performance enhancement.  (There are many other programs out there, but these are the two I'm most familiar with and have seen teams use most frequently. Ignore that they're set on a soccer field... it doesn't matter!). 

Let's back up for a moment.  What is a dynamic warm-up?  A dynamic warm-up is a progressive increase in the intensity of exercise placed at the beginning of a training session to prepare the body for the work it will do.  It targets increasing the cardiovascular system and getting the blood flowing as well as progressively increasing the use of the musculo-skeletal system and the nervous system to optimize the body for movement.  There are numerous publications that recommend doing this for a variety of reasons.  Like this article for injury prevention, and this one to optimize power. You've probably learned that you shouldn't skip meals leading up to Thanksgiving Dinner (though many people wrongly think this means more room for extra desserts, you're better off having some breakfast earlier in the day and regular eating the day before.  You're welcome.)  Why would you go from sitting in school all day long to sprinting up and down the basketball court without preparing your body?

Great, so now that we've determined that you're going to include a warm-up in your teams' practices and before games, why not decide how to design the warm-up for optimal performance?  This really can't be just about going through the motions.  It needs to be intentional.  It needs to be focused.  This is a great opportunity to develop a plan that team captains can lead early in the season so you can help teach individuals who might need more help with some of the movement patterns.

No more sitting in a circle stretching and chatting about last night's episode of Grey's Anatomy. Focused, purposeful movement.  There are SO MANY activities you can include if you're not able or willing to use one of the programs already designed for you due to the amount of time they may take.  I urge you to consider one of those programs, but alternatively, take the components from those programs and use them interchangeably.  If you structure your practices so you know what things you're going to work on, you can also structure your warm-ups so you know what you're going to work on in that time. What good is running a play for your shooter if they're not yet getting off the floor with their jumps?  What good is spending an hour teaching your team how to get a pass into the post if your center doesn't understand the benefit of getting low (in their squat pattern) to back down their defender and take it to the hole.  I'll say it one more time for the people in the back, injury prevention IS performance enhancement and a dynamic warm-up is an easy way to fit this into your daily routine.  If you help develop your athletes into just that - better athletes - they'll have more skills available to them to apply to whatever sport they're playing.

Components you should consider using in your warm-up.
1) mobility/flexibility (walking stretches)
2) strength (of the hips and core as well as the upper body) which can be done using:
3) movement patterns (squat, lunge)
4) jumping (plyometrics)
5) balance
6) agility (cutting/change of direction)
According to the NATA position statement, you should be using at least 3 of the above categories.  The prepared programs use all of them.

I don't have data to support this claim, but in general, I would say that most of the injured teenage girl athletes I see in the clinic do not jump or land in an "optimal fashion".  They're generally strong, but need to be stronger for the demands of the sport they're playing.  They often can't squat without falling over and I don't think I've seen any who can control a single leg squat.  As a coach, if you don't know how to teach these things to your players or why they're important, you could ask a local physical therapist to come in and screen your athletes and give you some pointers.  Or call me and we can chat about them!  Seriously... any time.  If this post prevents one high school basketball player from injury, I'll be happy.  Or if this post changes the way a coach organizes their practice to include more of the above components, I'll be elated.

As a reminder -
Every jump shot is, in fact, a jump and a landing.
Most rebounds are, in fact, a jump and a landing.
Jump-landings are, in fact, related to the squat.  If you do it on one leg, it's more related to a single-leg squat.
Defensive stance and the "triple threat" position are, in fact, related to the squat.
If you are standing on one leg for any reason - landing from a rebound, trying to save a ball from going out of bounds - you need to be able to balance.  Most teenagers can easily stand on one foot on a firm surface and balance steadily without a problem.  But if they have had an ankle sprain, it gets much more difficult.  If they're turning their head - like they would for an outlet pass or to avoid a defender - it gets much more difficult.

I'll go back to the discussion of getting the high school girls into the weight room another day, but for now, strength training could be as simple as a few sets of squats and a few lengths of the court with walking lunges and a few side planks - all with body weight - to focus on movement patterns and strengthening.  That could easily be a huge part of their warm-up before playing basketball.  (If you're preparing for a strength training workout, the dynamic warm-up should more closely mimic the motions of the exercises to be completed, but for a sports practice, there's a ton of variety available that will be relevant and beneficial). 

Last thought on these warm-ups.  Something that makes my mind go nutty is watching a team practice where they spend a good 15 minutes warming up, and then the coach has them circle up and stand still to discuss the upcoming practice, ultimately cooling them back down.  Prepare your team's mindset before the warm-up so you can transition right from the warm-up into business.  You can't avoid it during games when you substitute a player from the bench and they've been sitting for the whole first half.  That player is cold and has to use the game to warm up. Hopefully the energy of the game has kept the blood pumping a bit.  Hopefully they do some jumping up and down on the sidelines when your team makes a great play, to keep them warmer.  But on a daily practice routine, you can keep them warm and ready to go.

Any questions?  Let me know if I can help.
Here's to a great basketball season with zero injuries for your team.  And lots of offensive rebounds.  Those are my favorite.

(Go Cheshire Rams! Go UConn Huskies!)

Happy Blogiversary!

I can't believe I've been writing this blog for a whole year!  It's a Blogiversary! I really love any occasion to celebrate... so a year of personal growth and writing seems like as good an excuse as any other!  My first post, published on November 5, 2017, can be found here.  It was an introduction to "Abby's World" and what my three initial topics of interest were: 1) Physical Therapy-related education, 2) the Female Athlete, and 3) Injury Prevention. Looking back on the past year of blogging, I'd say I mostly stuck to my PT education, writing about courses I was taking, patients/athletes I was seeing, conditions I was learning about.  I threw in some posts about female athletes or women in sports and a little bit about injury prevention, too.

What better way to celebrate an anniversary than to use a photo of my parents on their 50th wedding anniversary?!  Aren't they just the cutest?!

This past year I've experienced considerable growth - both personally and professionally.  The blog has basically served as a tracking device for my professional growth. I've really enjoyed writing these and it has helped me stay organized and a bit more accountable to learning something or reflecting.  I anticipate more of the same in the upcoming year, maybe expressing more of my personal growth as well.  Vulnerability is a personal area of struggle, so going more into the personal realm is a bit terrifying to me.  I've written outlines of several posts that I haven't been able to share yet... but hope to find that courage in the future.  I'd love to hear more from those of you who have been reading to better understand what you've found useful.  Sometimes I just think I'm sharing my thoughts to a giant black hole.  Who are you, readers?

And so, I present The Top Seven Things I've Learned from One Year of Blogging.

1) Time management.  I wanted to make sure the I never went more than 10 days between posts.  I didn't go back through all the dates, but I'm pretty sure I was successful.  Somewhere early along the way, I read that if you want to build a blog with a big following, you need to be consistent with posting on the same day of the week.  But - my goals weren't to build a big following - and consistency wasn't always possible.  I did find myself prioritizing time to learn more each week so that I could keep my blog posts regularly coming, and I published 63 posts in the past year... just a little bit more than once per week!

2) I really like lists.  Again, I didn't go back through my previous posts to write this one, but I noticed a while back that about half of my posts are in list form... just like this post.  I've always liked
"To Do" lists... but didn't expect this.  What does it mean?!  Is this how my brain operates?  Funny enough - it just might be! In PT School, we took a learning styles assessment early in the program.  It suggested that people learn in one of three ways: visual learner, auditory learner, or kinesthetic learner.  I scored 33% on each one which was SUPER UNHELPFUL and ultimately made me feel like I needed to learn everything in two ways to really grasp the concept (that's still only 66%).

I was recently advised to take another assessment of my learning type, but this one had a fourth option: the reading/writing learner.  I came out as 91% of this "other" type... I wish I had known during PT School, though I think that's how I ultimately was studying anyways. Yeesh!  The characteristics listed for a reading/writing learner are someone who keeps boatloads of notebooks and who writes and re-writes study guides.  That's me!  Of course I don't really look back at them, but I can't get rid of a huge chunk of my college notes... I just can't!  I certainly wasn't someone who drew pictures or charts very much (visual), or who tape-recorded my lectures to re-listen (auditory) and I don't actually think I learn much at all from acting things out (kinesthetic).  One of my PT School classmates would be contorting himself in the desk at school trying to figure out biomechanics by moving his own body... I was trying to recreate my study guide or flash cards in my brain. I think that discovering techniques that helped me learn have increased my understanding of why I write lists - and was a big self discovery find over this past year of blogging.

3) You never know who might be reading!  I went to a course on the elbow presented by one of my favorite mentors, Lenny Macrina, that I wrote about here.  That post was all about the impact that social media has had on my practice as a PT.  What I didn't mention on that post, though, was that while I was at the class, I ran into a PT I had met around Seattle a few times, who told me he had been reading my blog! I've had coworkers comment to me at work about it.  Family members have reached out and asked questions or shown support.  A former co-worker at UConn told me she sent my blog posts about pain to her mom and they really resonated with her and helped her feel better.  WHAT?  So, thank you to everyone who has read some of my posts and mentioned them back to me... there have been so few comments posted, but I can see the numbers of people who are checking it out... and I am grateful for all of you, and hopeful that I'm helping you in some way.

4) I have a lot of interests and I learned a lot this past year!  I don't think I was really motivated to learn before working at Seattle Children's.  Maybe that's the typical pattern for a new grad... still suffering from school burnout and needing to learn the ropes of how to structure a day in the clinic, interact with patients, write notes, stay on time... basic things.  And then you start to feel like you're not really a new grad anymore and can focus on ways to grow beyond getting better at basic skills.

I started writing this blog about eight months into my time working at Seattle Children's Hospital when I was starting to feel more confident in my skills as a physical therapist and ready to start learning about conditions I didn't know enough about.  Prior to then, I had only treated one patient with a concussion, I had never used iontophoresis (now that I have - I can tell you I don't really like it as a treatment... but at least I know how to do it and can explain why I don't like it or why I would use it), I had never worked with a transgender person (at least who was openly discussing it with me), I knew NOTHING about pain science, and my total number of post-op ACL patients treated was in the single digits.  These are BIG topics that I felt inadequately prepared to deal with and dove into reading and learning as much as possible to better help my patients.  It also shows me how much more there is to learn, how impossible it is to know everything, how important it is to be a lifelong learner, and how critical it is to have a network of colleagues who specialize so that you know who to ask for help.  I know that I can treat a baseball player - and probably help them get better - but that one of my coworkers would be better at breaking down their throwing form than I am.  So I keep learning about how to do it better by sharing patients and learning from coworkers and reading... a lot.  And it makes me proud that my coworkers know that a teenage basketball player who comes into the clinic might connect well with me because of my background, and would recommend sharing that patient with me.

5) I can't believe I started my blog the year the Seattle Storm won the WNBA Championship.  Since I moved to Seattle specifically to volunteer with the team, it was amazing to watch them work and have the chance to blog about some of that experience.  I'm so grateful that I've been able to work with the Storm, the Connecticut Sun, and the UConn Women's Basketball teams because women's sports are on the rise, the WNBA is up and coming, there is more and more coverage for women's sports, and because it has been so awesome learning about women working in sports and trying to promote them.  I wrote a little about that here.  But writing my own posts about the Storm and women's sports showed me how little there even is about injury writing in sports from a healthcare provider perspective, and there's even less when it comes to women's sports.  It's challenging because of athlete privacy - but I thought I had a unique perspective on some of the injuries or risk factors that were being discussed around the WNBA and was glad to write about them.  I can do more.  I will do more.

6) The opportunities for women in sports are still severely limited.  Writing a blog requires a considerable amount of reading and research.  I found a few more women to look up to and learn from during this process... but they were few and far between.  Many of these women are clinicians treating athletes and patients - they're not writing about their experiences or regularly presenting at conferences, so it's hard to learn from them.  They're doing all the right things - but they're not on the social media boards the way so many males are in our profession.  Something I never publicized were my efforts to try to change opportunities for women working in sports medicine.  I wish I could say I'd had more success on my efforts in the past several months, but I've hit several road blocks.  I will not stop this battle... and I hope the upcoming year will result in continued growth and more opportunities.

7)  The world is changing.  Politics are affecting healthcare and women and I didn't really express my opinions of this on the blog very much, but all my increased reading made it very apparent.  I'm sure some of my opinions came across in the blog, but overall I've tried to remain apolitical in this space.  I can't promise it will remain that way because I care about so many of the things that are happening in the world.  I'm interested in global warming - but have not read anything about the topic.  I'm interested in healthcare reform... I spent several days reading the Obamacare (Affordable Care Act) legislation during PT School so I could present it to a clinical rotation as well as to my classmates.  I care about special needs children, people with mental health issues, those who are experiencing chronic illness or chronic pain, and anyone with a pre-existing condition who may be impacted by healthcare change.  I have considerable interest in mental health and know that there will definitely be posts about it in the future.  By and large - I've kept the political opinions out of here, with the exception of gender equality issues - and I expect it will probably stay that way.  Maybe.

So that's a year of blogging!  Thanks for joining me on the ride... it's been fun!  Please comment, even if to just say hi.  I'd really appreciate it.  Here's to another year of learning and helping people get back to their favorite activities.

One Major Thing I Did NOT Learn in PT School

I learned a boatload of information during PT School at the University of Connecticut.  I had incredible faculty and staff, some of which I now call my friends, and many of which will be lifelong mentors.  The curriculum was packed.

I learned about anatomy from a prosected cadaver.  (Prosection is skilled dissection of a human body... meaning someone else did it.  I'm eternally grateful that I have never had to cut human flesh!).  I learned about physiology - how the body works - including how the urine color chart came to be from the developer himself, Dr. Lawrence Armstrong. (He basically dehydrated himself for days and charted the color of his own urine until it was a near-death experience and then later tested it out in other subjects).  I've always thought he was telling the truth about that one.

I learned about healing and disease processes and was astounded by the number of ways that things can go wrong in the body - either from internal causes or external ones. I learned the basics of pharmacology - of which I remember exactly one drug which I have never seen on a medication list: Loperamide - which I learned because it made me think if Jennifer Lopez's booty... it's a bulk-forming laxative.  AKA Immodium.  (UPDATE: Loperamide is an anti-diarrheal... guess I didn't even remember that one correctly!  So thankful for having pharmacist friends!) Seriously - we must have learned about ibuprofen or medications that patients actually do take- but somehow those are not in my brain.

I learned about how people move or how people adapt when they have mobility limitations.  We were either wheelchair bound for a few days or on crutches or in a sling or simulated being blind...   I spent time with patients with numerous diagnoses, interviewing them about their experiences.  I spent time in hospitals, nursing homes, clinics, schools, gyms, and the classroom with all different types of people across the age spectrum.  I learned about different modalities and how they interact with the body - heat, cold, electric stimulation.  And I learned about various types of exercise and their benefits on the body.

This could go on all day! I have binders and binders of things that I learned and wrote notes about during PT School. The funny thing is, even now, several years out, despite all that learning, I still feel like I have so much more to learn.  (Working at Seattle Children's Hospital, I regularly ask kids what they learned at school that day when they come into the clinic.  It's amazing how as a young child you say you didn't learn anything at school each day - but then in your late teens you graduate from high school and know a whole bunch of stuff!)  But I can tell you one thing I learned absolutely nothing about in PT School: how to pay off the student loans necessary to get my education.

I don't know the exact numbers.  I'm pretty sure the first time I added it all up, right before my first bill came in the mail, the total was $124,000.  The paperwork said I could take 30 years to pay it off, and if I did it at that rate, it would cost me a total of $305,000.  I may - or may not - have cried.  And then paid the first bill.

The total is astronomical.  I used $5000 in PT School to go to the 2012 Summer Olympics in London.  Ten days across the pond with two friends enjoying the mashed peas of London and watching so many sporting events cheering for random countries when USA wasn't competing... it was one of the coolest experiences of my life.  Every time my autopay goes through, I remind myself of how amazing that trip was, and how cool my career path has been, choosing to be grateful for what my loans paid for in the past rather than being annoyed that I'm still paying for it.  I've paid off that trip 10 times over now, and it makes me feel better to think that my monthly payments are going to my trip to watch the USA Women's National Basketball Team win the Olympic Gold Medal!

Recently, my student loan total balance finally went below $100,000!  I jumped up and down, posted it on Facebook (otherwise it didn't really happen, right?), and called my parents to share the big news.  It has taken me a total of over $50,000 in payments to get rid of that first $24,000, but at my current rate, I should be able to finish in less than 15 years.  As long as I never buy a house, continue living with an extremely generous roommate, and continue wearing scrubs that cost $22.99 to work every day and last five years before needing replacement, I don't have to eat Ramen Noodles every night and I can pay this mountain down.

So, since I learned absolutely nothing about paying off my student loans in PT School, I'm going to share how I got rid of this first 20%.  I hope it helps someone else, even just a little bit.  I'll highlight the important parts in bold for ya.

There is a grace period between graduation and when you have to start paying.  During this time, interest accrues, but you don't have to make payments.  My loan companies all gave me the opportunity to make payments towards that interest (as well as the interest that was gained while I was in PT school) so that it wouldn't get added into my principal balance.  I couldn't pay off all of the interest, but I did make a few smaller payments before I had to start paying which was projected to save me several thousand dollars in the long run.  Stupid interest.  Unless you're talking about my savings account, and then yay interest!  1) If you're able to pay before you're required to pay, you can avoid compounded interest becoming part of your principal, which saves you more in the long run.  

Immediately following the first payment, I set everything on auto pay.  My student loan companies ALL decreased their interest rates by a fraction of a percent simply by doing this.  I think I did the math and that at a decrease of .25% I would save about $300 dollars.  WORTH IT.  I don't have to do anything except keep working so there's money in the bank account and the minimum payment is taken care of.  Easy way to save. 2) Set your payments to autopay so you can reduce your interest rate!

I personally stuck with some Dave Ramsey principles recommended by a friend in planning my repayment.  In case you're not familiar, Dave Ramsey is an American Businessman and finance adviser who has written several books and done TV shows all about how to best spend and save your money.  He learned it all from buying real estate and then losing a ton of money, only to climb back out of the trenches and become successful. I definitely made a plan, stick to it as much as possible, updated the plan when something big came up in my life that took some of the funds I had planned for the loans, and got back on track.  3) Make a plan.

What I'm doing is working for me.  I can't promise it will work for you.  If I'm ever able to purchase a house, I'll know this really worked.  Some people say he does things backwards and you should pay off the biggest stuff first... but I like immediate gratification and every time I pay off a smaller loan, my minimum payment gets smaller so I have more available to put away - either to the loan I'm focused on - or towards something else.  I asked people if they paid the big ones off first or the small  ones, and if you fluctuate your extra payments and aren't going to be keeping everything the same month after month, it's really difficult to tell which method will save you the most money in the long run, so you just have to pick a method and stick to it.  Don't bounce around. 4) Consistency is how you win.

Some Dave Ramsey principles. 5) Save up an emergency fund.  Before I was willing to make any extra payments on my student loans, I saved some money in a special savings account.  I had moved to Seattle from Connecticut right after PT School and had to borrow all the money to move - which left me super uncomfortable and with no money in the bank. I spent my first several months living in Seattle buying only groceries and bare essentials because I was afraid that I would get a flat tire and didn't have anything saved up to repair it.

Fortunately, I didn't know anybody, so I wasn't eating out.  Rotisserie chickens are inexpensive, delicious and nutritious, and feed you for several meals.  I would buy one on Sunday with a bagged salad kit and again on Thursday. I calculated that I was eating lunch and dinner for about $2.00 a meal for the first month I lived in Seattle. As a special treat, I would grab Pagliacci's Pizza by the slice on Wednesday nights for $5 when I was usually out of chicken and a Diet Snapple every Friday.  When my savings account had $200 in it after the first month, I added PB&J sandwiches to the mix!  My how far things have come! 6) Make financially reasonable choices and recognize that eating at home can save a lot of money compared to eating out. 

So I saved up my emergency fund, which Dave Ramsey suggests should include about three months worth of rent, and simultaneously paid back my parents.  It took me almost an entire year to pay back my move, paying only the minimum on my student loans - which was an entire year of almost only interest payments. (If I ever make a cross country move again, I'm burning everything I own instead of moving it.  Only the car gets to stay and whatever fits inside of it).  When my tax return came back saying I owed the government money - despite paying over $10,000 in student loan interest - I was furious.  But I had a savings account and could pay what I owed out of my emergency fund - and I had enough extra money to make a trip home to see my family after being gone for more than six months.

So my plan at the beginning was pretty vague... pay off family and save up a little money, then get to the loans.  Once I felt like I had enough money for an emergency room visit in the bank (just in case I cut my hand open while cooking - which has happened at least three times but never did I cave in and go to the hospital), I reviewed all the money that I owed to the world.  Yep... the world.  My family was reimbursed, but I had a car loan and two different student loan companies to deal with.  One student loan company only held 3 loans - it was the remainder of my undergraduate fees - and the other had 12 loans compiled into it.  (I actually had a Federal Perkins Loan from another company, but a classmate told me that we could apply for it to go away after five years working in healthcare, so as long as I keep slaving away as a physical therapist - the whole thing gets canceled next year and I don't have to pay it!) So you should look to see if you have loans that you don't really need to be paying because that's $10,000 that I'm never going to pay as long as my boss doesn't fire me before next September.

I wrote a list of all those loans and put them in order from smallest loan to biggest.  And following Dave Ramsey's snowball method, I paid off the ones with the smallest balances first and just paid the minimum on the others.  First I paid off the smaller loan cluster from undergrad - which meant getting rid of an entire payment every month that I could then apply to the next targeted loan. Then I paid off my car - and that beautiful Honda Fit better make it another 100,000 miles.  She recently got a new set of tires... and because I had an emergency fund, I wasn't horrified or even thrown off of my payment plan when the flat tire meant I had to make that bigger purchase.  7) Start making targeted payments to 1 specific loan while making the minimum payment to the others, targeting either smallest to largest, as Dave Ramsey recommends, or largest to smallest - as others recommend, but with consistency.  

This method helped me pay off my car and smaller loan company completely.  So where I started out having a minimum monthly payment of $1200/month ($100 to my undergrad loans, $125 to my car, and $975 to the largest loan company) I now could use the money that went to the completed loans to start targeting the giant mountain that I'm currently climbing.  What I didn't realize was that every time I paid off one of the loans in that giant cluster, my minimum payment would also decrease and I would have even more money available to target to the smallest loan.  (I thought the payment would have been the same the whole time and would just distribute differently across all the loans... that's what happens if you just pay the minimum the whole time!)

Once I got to just this one company, I started making extra payments into my retirement fund.  This doesn't follow Dave Ramsey's principles.  He outlines that you should pay off all debts first, and then prepare for retirement later but at a higher percentage rate.  It made me uncomfortable to delay putting anything away for later - and sometimes the contributions to retirement have helped offset some of the money I've owed on my taxes.  The whole thing feels a bit like a game of Monopoly, doesn't it?  Ultimately, the majority goes towards the student loans, a tiny bit goes to retirement with the hopes that the stock market will make me rich quickly, and I'm mostly sticking to the Dave Ramsey Principles.

Over four years, I've read quite a bit of online discussions between PTs making recommendations about how to do this.  But in almost all cases, I read that the key is to redistribute the money you're making, finding ways to save and budget based on your income.  Sure, this makes sense and applies to most professions.  But as a physical therapist, there are constantly per diem positions available.  So instead of only redistributing the money I was making - I also got another job and increased the money I was making.  While this wouldn't be possible in every career - I do think that there are several other ways you can try to make money that might be outside your career.  Every time I pick up a per diem shift, I take a little bit of the money from it and set it aside for something fun, and the rest goes right to my student loans.  Over the summer I worked ten per diem shifts in two months and it was enough to cover two trips home to Connecticut and an extra $1500 on my student loans.  I'm already prepared with some extra work in November to prepare for upcoming holiday expenses.  8) Don't ignore opportunities to make extra money that can help pay loans down faster. 

So, like I said, this plan has so far worked for me.  It won't work for everyone.  I wonder how differently this plan would look had we actually learned about this from someone who knows what they're doing. Maybe PT Schools should start bringing in a financial adviser as part of their curriculum to help their students out a little more! Good luck current PT students.  You can do it!  Just know that you're probably coming out of school owing more than six figures, unless you live at home with your family and don't need loans to pay your housing and meals... and that you're going to work hard to get it paid off.  You should probably be sure you want to be a physical therapist before diving in!