2019 in Review

Reflecting...

This is my third "Year in Review" blog post since starting "Abby's World" in 2017.  (If you wish to read my previous versions, 2018 is here and 2017 is here.)  When reflecting on this blog, I feel gratitude to those who have read posts - one or many, I cherish the experiences that I've been able to document here, I acknowledge that I still don't know my target audience and I've embraced that.  I like that I chose a name that allows me write about random topics, though I wish I had come up with something more creative.  My mind wanders a lot... my blog topics only tend to wander occasionally. For the most part, I've stuck to Physical Therapy/Health and WNBA Basketball/Women's Sports, but I've thrown in some odd topics along the way, too, like this post which had weird photos of my eyelids.

In summary, since starting the blog, I've written 110 posts with a collective total of over 25,000 readers. I've had two posts eclipse 1,000 hits (this one about Physical Therapist Board Certification and this one about sport specialization), and I'm sure they're not my mom reading the same post 1,000 times. I posted less in 2019 than in 2108, but I also traveled and read a lot more. I like this pace and expect it will be similar in 2020.  Here are a few of the highlights from 2019, both personal and professional, and a look forward to what's coming in 2020. 

The beginning of 2019 was insanely busy.  From January through early April I supervised my first PT student who I wrote about here. In March, I presented advanced anatomy and biomechanics of the shoulder at a Youth Upper Extremity Injuries conference, which I wrote about here, and which showed me that I really enjoy teaching, though I would miss clinical work way too much to dive into that full time. At least for now. And then a week later was the Sports Certified Specialist PT Exam which I wrote about here.  Taking a student really opens up your time to focus on other things, at least when they're as good as mine was. I took full advantage of that opportunity. 

In 2019, I "came out" about my eating disorder with this blog post and shared some mental health struggles.  It's amazing how much better things can get when you 1) learn there is, in fact, a problem and 2) do something about it.  I faced these issues with a much bigger support system than I had anticipated, along with an army of healthcare providers, which made things so much better.  I spent many hours and even more dollars between my Therapist's office and my Dietician's office along with visits to my Naturopath and Gastroenterologist because adding foods back into my diet that I had been previously binging or restricting ultimately made me pretty sick. Like bent over in pain, leaving work early, and carrying extra clothing around in case something horrific happened sick. Unbelievable how much damage you can do to yourself but also how resilient the body is!  It could be that some of those foods made me start restricting in the first place, but we'll probably never know that. I'm certain that we need to continue working to de-stigmatize mental healthcare in the US. Too many people need help but are ashamed to get it, and it can make a huge difference in your quality of life.  

Justin Timberlake!

Despite having a persisting gut ache, I also traveled more in 2019 than ever before.  It started with a day trip to Vancouver, BC, on Valentine's Day to see Justin Timberlake in concert. Amazing.  So Amazing.  In March, an East Coast visit with the family and Climb to the Top of Rockefeller Center for Multiple Sclerosis for the fifth time (which I've previously written about here). I won't be climbing in 2020 but if you'd like to donate and support the cause, please let me know and I'll connect you to fundraisers! In May a trip to the Olympic Peninsula to check out Dungeness Spit and learn about that type of land formation. In June I headed East twice more for weddings, once with family in Ohio and then in New Hampshire two weekends later.  

World Travels

In August I enjoyed a life-changing opportunity to volunteer in Tanzania, Africa, for two weeks which I wrote about here, and which was has captivated my thoughts and prayers since. In September the AASPT Traveling Fellowship brought me to Ohio and Minnesota, which I wrote about here, and which impacted my learning and career goals in several ways. In October there was a quick snowy vacation weekend to Denver followed by a Thanksgiving trip to Connecticut to see the family, which I wrote a bit about here.  The year will wrap up with my birthday celebration in Portland, OR for some Trailblazers vs Lakers basketball.  Basically, I was all over the map and spent a lot of time reading and writing in airports.  Shockingly I have zero travel plans for 2020 right now, but I'm sure that will change. 

I read a lot of books in 2019, both fiction and non-fiction, thanks to audio books for the commute and OverDrive on my phone for while I was on the road.  Four books were listed in the syllabus for The Level Up Initiative, which I wrote about here, all of which were really awesome. My favorite reads of 2019 were "The Moment of Lift How Empowering Women Changes the World" by Melinda Gates, "Yale Needs Women" by Anne Gardiner Perkins, "Educated" by Tara Westover, and "Hunger: A Memoir of (My) Body" by Roxanne Gay.  I also listened to some podcasts and binge watched "The Handmaid's Tale" on Hulu... can't wait until the next season comes out!

There was continuing education, kayaking, basketball, and time with family and friends.  I didn't spend nearly enough time with my family, but hopefully that will change next year.  My biggest goal for 2020 is to purchase a house, so perhaps I'll write about that experience.  My student loans are finally under $80,000, so it only seems appropriate to acquire more debt, right?

As the sun sets on 2019, I'm wishing everyone a safe holiday season and look forward to writing more in the new year.  

How I Spent My Day

Remember when social media first started to become popular and people started posting on Facebook every little thing they did?  Like folded laundry, took a shower, went to the gym... nothing really out of the ordinary, usual everyday kinds of things?  Like today, my brother just re-posted his first Facebook post of each month of 2019.  How four people liked that is beyond me.  Or remember when AOL Instant Messenger had "Away Messages" that would automatically get sent back to anyone who wrote you because you were away from your computer?

One time in college, I had an "Away Message" up that was a quote from the band "3 Doors Down."  Here's a YouTube link to one of their hits, "Here Without You," in case you need a refresher. I don't remember the quote I used, but it was probably from this song.  Anyways, I had their quote as my away message and I probably didn't have proper punctuation to identify it as a song because my sister called me at 2AM and when I sleepily answered from my own bed in my dorm room, she asked "Who lives 3 doors down from you that you're spending all this time with?"  Ha!

Anyways, now that you are reflecting on all the simple things you used to post on your own social media or the things that annoy you when you read them from others, I'm going to tell you how I spent my day today. An Abby Play-By-Play for your reading enjoyment.  I'm sure you all want to know.

Today is Monday, December 16th.  I woke up around 7:30AM, before my alarm.  I usually don't need my alarm to wake up, so today was no exception.  I have Mondays off and was excited that I had signed up to watch the Breakthrough Summit, a digital leadership conference for women in sports.  If you missed it, you can still watch the replay by signing up here.

LaChina Robinson and Jill Ellis

The Summit kicked off with introduction from ESPN Basketball Analyst LaChina Robinson (Twitter @LaChina Robinson) interviewing Jill Ellis Head Soccer Coach for the 2019 World Cup Champions US Women's Soccer  National Team.  I didn't plan to live tweet quotes from today... but then the inspiring quotes just wouldn't stop coming.  Coach Ellis talked about her career path, things coaches should consider as they work towards the top, her experience working with outspoken professional athletes in the current environment where women are voicing their opinions, loudly, about the inequalities in opportunity, pay, the workforce, and so many other areas.  My favorite quote from this interview was Coach Ellis saying "If I'm the same leader today that I was two years ago, I'm failing."  The value of personal growth is enormous, and I heard her loud and clear.

At this point, I got out of bed and made a bowl of Frosted Flakes with Almond Milk and some grapes which I enjoyed while watching the next portion of the Summit. LaChina had an interesting discussion with a panel coming from three different sports backgrounds.  Dr. Jen Welter (Twitter @jwelter47) is considered to be the first woman who worked in the NFL when she joined the Arizona Cardinals Coaching Staff in 2015 after a successful career as a Pro Footballer herself.  She said she called herself a 'Pro" because they didn't earn enough money for the "fessional" and that when her team won a championship following a 12-0 season, she got her first paycheck along with her championship ring. The check was for $12.  But she was paid to play her sport, football, and that was a big deal.

LaChina and Panel: Jen, Ginny, and Charmelle

Also on the panel was Seattle Storm co-owner Ginny Gilder (Twitter @ginnygilder) who I've previously written about here and who is an Olympian Rower.  What stuck out to me from Ginny's talk was how the Storm ownership group, Force 10 Hoops, initially came together to determine why they wanted to collectively purchase the Seattle Storm.  They wanted to support a team that the community loved, but they also wanted a platform to use to support the changes they saw necessary in the world.  After five years working with the team, I had never heard that story, and now I can't wait to hear more about it.

Third on the panel was Penn State Senior Associate Athletic Director Charmelle Green (Twitter  @charmelle44) who played college softball at Utah and was the only black female athlete on campus at that time.  She talked about her career path and about learning from your mistakes and using them for growth.  Carmelle is also the President-Elect of WeCoach who sponsored this event.  The Vision Statement of WeCoach is "recruitment, advancement, and retention of women coaches of all sports and levels."  Throughout today's event, data was presented showing that female coaches don't stick around as long as their male counterparts.  The data improves if the female coach was, herself, coached by a female coach.  The data also improves if females were asked as student athletes if they would consider coaching as a career after college - compared to those who were never asked to consider that path.  The data was presented in an online live Q+A chat during their lunch session by two of the later presenters.

It was at this point that I unfortunately had to head out for my appointment with my therapist because #mentalhealth.  In the car I listened to the presentation of Felecia Mulkey (Twitter @BaylorAcroCoach), Acrobatics and Tumbling Coach at Baylor University who discussed the process of developing a team culture using Dr. Bruce Tuckman's "Developmental Sequence of Team Development" model.  She uses boundaries, clearly defined expectations, and consequences paired alongside coaching staff congruency to make sure her team functions as a program.  I liked her discussion of how a coach can't really choose the culture of their team, the culture is what the team thinks it is and the coach can impact that culture with how they lead.  Then I had to miss some of the Summit, but it's going to be available in recorded form and I guarantee I'll catch up and watch WNBA All Star playing for the Connecticut Sun, Layshia Clarendon (Twitter @LayshiaC) because she's an awesome human being and I was bummed that I missed it today.

Betsy Butterick

Following mental health came physical health.  I made it to the gym in time to catch my old pal Betsy Butterick, The Coaches' Coach and Communication Specialist. (Twitter @BetsyButterick) with her presentation. What could be more motivating on the treadmill than watching Betsy demonstrating how easy it is to tangle up communications as she was instructed to make a PB&J sandwich.  Something so simple went horribly wrong in a memorable visual presentation.  I first met Betsy in 2007 when I worked for the Connecticut Sun and she worked for the Seattle Storm.  We were both doing laundry for our teams and there was a small group of us around the WNBA at that time who were around the same age, all hoping to find our paths in women's sports. She's paving the road for many behind her and elevating so many coaches with her work, doing amazing things.  We both participated in the Women's Basketball Summit which I wrote about here, and you can check out her latest work here!

I missed the next presentation and a half because I needed amped up music to deadlift, but then saw the second half of the data on women in coaching presented by Dr. Nicole Lavoi (Twitter @DrSportPsych).  Dr. Lavoi is the Director of the Tucker Center for Research on Girls & Women in Sport at the University of Minnesota, but what I did hear was a combination of optimistic room for growth and disbelief at the current status of the NCAA.  It made me sad to hear how few women hold higher up roles in NCAA Intercollegiate Athletics as well as coaching women's teams around the country.  Women in higher ranks will ultimately help women get the jobs in sports they aspire to have, so the future will hopefully have room for more female athletic directors. There are report cards grading athletic departments based on their gender hiring practices.  UConn doesn't look good with their D, but the shining light was seeing my college professor, Dr. Laura Burton, on the Tucker Center staff.  She was always pushing for improved gender opportunities 15 years ago.  I didn't know the Tucker Center existed, but I can't wait to read through some of their research in the upcoming weeks and finish watching her presentation.

LaChina and Holly Warlick

By now I had made it home for a late lunch... I'm sure you're wondering... chicken salad in corn tortillas, taco style. I was able to finish watching the last interview with former Tennessee Lady Vols Women's Basketball Head Coach Holly Warlick, who spoke highly of legendary Women's Basketball Coach Pat Summitt.  Holly's top quote was "You meet the same people on the way up that you do on the way back down, so treat people with respect."  She also gave the advice to young coaches that they really need to love what they're doing.  Coaching is a huge time commitment that requires you to sacrifice time away from your family, so loving it and having family support are essential.

Then I went to Target.

Overall, a pretty awesome day.  I really enjoyed the parts of the Summit I was able to watch and can't wait to fill in the gaps soon.  Hopefully they'll do a repeat next year.  What did you do ttoday?

In the Spirit of Thanksgiving

The Family

I just returned from a great week on the East Coast celebrating Thanksgiving with my family. It's always great to see them, as well as my friends, but this year was more emotional than usual. My parents are moving to Florida after spending their entire lives in Connecticut and the future of family get-togethers now falls to the unknown. Though they may not realize it, they're the pillars of the family, the matriarch and patriarch. They're the glue that keeps everyone together. Without them in New England, it's hard to know when my whole immediate family will all be in one place. I think that's sad. It's also great for them to escape the snow... I did that five years ago and I've grown soft because of it. I hate to see snow, now, and can't really tolerate the cold the way I used to. I'm really happy for them to get away from the winter, enjoy more sunshine, and spend time with their friends who escaped the winters in the past.

Justin Timberlake 2/14/19

Fortunately my parents didn't move out of my childhood home this week... that occurred over a decade ago and I rarely spent the night at their most recent CT place. It had a lot of the same things in it that my childhood home did - similar artwork, family photos, the same board games they always beat me at, same dining room table and china closet, plus my parents. But it wasn't my old bedroom. There were no Justin Timberlake photos taped under the bottom of the top bunk where I had created a collage of all my favorites. My stuffed animals and high school yearbook never lived there. My sister's family was close by so if I wanted to stay in my hometown, I sometimes stayed with her.  Usually, though, I stay about 40 minutes away with my roommates from graduate school, one of which has been my friend for fifteen years, who keep a room available with a set of my pajamas in the closet (plus I never returned my key when I moved out), and they're more centrally located to all the places I tend to visit and closer to UConn and Boston-Logan airport.  Plus they have a really cute almost 3-year-old who wakes me up at the crack of dawn saying that the sun is up and I should be too... can't argue with that.

So with a lot of emotions of an unknown future and big changes staring me in the face, it seemed difficult to focus on gratitudes this Thanksgiving. I think I'm generally a grateful person. I pray with gratitudes. I try to see the positive in any situation. But at a time when gratitude should have been pouring out of me, I felt myself struggling to find what I'm most grateful for. And then I remembered the "Things I Take For Granted" list which I wrote on the super long flights back from Africa this summer. (I wrote about Africa on the blog here).

Things I take for granted (not listed in any particular order):

1) Fresh water, in the tap, that I can drink to my heart's content without immediately causing me diarrhea. 

2) Ice. In unlimited quantities. For making my water cold, or for use to deal with acute pain, or countless other ways I can use ice at home. 

3) Fresh fruit and vegetables that won’t make me sick because my fresh water does not contain parasites. 

4) Clean clothes, cleaned in a washing machine and with a dryer. 

5) My parents - who happen to be American, who happen to be white, who happen to live in the United States. Who love me unconditionally.  No child gets to choose their parents. No child gets to choose the color of their skin or where they are born. 

The Siblings

6) My siblings, and the fact that there are only 2 of them. Who support the ways I chose to spread my wings and leave the nest, even if it means thousands of miles between us and far too infrequent sibling selfies. Who manage the time change between the East Coast and West Coast with early morning or late night texts and regularly scheduled Happy Thursday phone calls.  Who came to visit me in Seattle, met my Seattle friends, and saw first-hand the beauty of this side of the country.

7) My friends. Near and far. Who helped make Seattle feel like home. Who meet up for sushi on a moment's notice. Who keep in touch despite the distance and time change. Who let me share in the joys of their children's milestones while I simultaneously laugh at them for having moved onto the diapers and minivan lifestyle. Whose husbands and parents are kind and willingly take the kids so we can have friend time. Who have seen me at my worst but love me anyways. Who tell me the truth, to my face, even when I don't want to hear it.

8) Hot showers. As hot as I want. All the time. And not wondering if the water might be hotter if I wait a little bit longer.  Or needing someone to heat the water to have it poured over my head. Or that one time when I got so excited to have a hot shower after a few too many cold ones that I left it running and woke up my travel buddy, Kristen, and told her she had to jump in immediately so she could have a hot shower, too!

9) Brushing my teeth using the sink rather than a bottle of water. 

10) My education. The fact that it was available to me, at the highest level, provided by excellent schools and professors from my littlest years all the way through graduate school. That, even though I’m still paying for it for the next several years, is ultimately affordable and a choice that I made, and was able to make. I chose to attend the University of Connecticut. I could have chosen elsewhere or not to pursue higher education - and I still could have had a successful career in this country. Being a female in the United States allows for access to feminine hygiene products, which are often a limiting factor around the world for why young women must stop attending school. 11) So I guess I also take tampons and maxi-pads for granted.  And similarly birth control pills and contraceptive methods which considerably restrict accidental pregnancy, where many women around the world do not have access to these items or are mistreated if they are caught using them.

12) My home, which is cozy, well-heated in the cold season with ample blankets and a fireplace, cool enough in the summertime, with running water and apparently endless electricity, with a secure roof over my head and a roommate who consistently cleans the bathroom. 

13) My job. Which gives me a generous salary to do work that I love, that gives me the opportunity to have enough money to buy things I want. Which I can have despite being a woman, (which I believe pays me equitably to the men who work alongside me with similar amounts of experience), which won’t kick me out if I ever choose to have children and will make it possible for me to breast feed if I ever choose to do so. And which empowers me to grow and supports my individual career goals.

14) Paved roads that don’t have livestock freely roaming alongside them and which allows me to drive my vehicle, which I own, rather than walk carrying my goods on my head. 

15) My health.  My access to healthcare when something is not right, including access to well-educated doctors who can prescribe medications that are readily available if that's what's needed. My ability to communicate with a variety of specialists who will explain their findings to me and answer all my questions to help me advocate for my own well-being.  My ability to openly use mental health providers - who are readily available- something that does not exist in other parts of the world. 

16)  The ability to choose my own spouse- man or woman- because I do not belong to a tribe where my father could choose my husband in exchange for 10 cows, as a teenager, where my husband could have multiple wives, where I could be living in a country whose laws would imprison me if I chose to marry a woman.  This is the case in at least one of the tribes in Tanzania, who have ancient beliefs, that I can respect but which I do not agree with, and for which I'm now realizing how much gratitude I have for being born in the United States to Jewish parents who passed on religious beliefs that help me to appreciate other peoples' beliefs, but which are vastly different from what I learned about on this trip.

17) My bed, which does not require a mosquito net over it, which I own, which I do not have to share, which is not on the floor, and which is clean. 

18) Women's basketball. Or just basketball in general. Or women's sports. Because some places in the world can't afford to allow their children to grow up playing games. Some places in the world have children sent away from home at young ages, into the fields and working manual labor jobs. For sure those places won't be having their girls playing a sport, for fun or for a career. Probably not the boys either.

19) Did I already mention Justin Timberlake? And the Goo Goo Dolls?  Access to concerts of my favorite musicians? There was some really interesting music in Africa, but they didn't have my favorites.  

20) This blog. Where I can say whatever I want.  Which I use to collect new bits of knowledge and then share those with the world. Which I write on my personal laptop and include photos taken on my personal cell phone. And that I then go ahead to share on unrestricted social media with all my friends and family.  I'm sure my mom will read this, and at least three other people, all of whom I'm surely taking for granted.

Reality check. There's so much I'm grateful for and I'm certain I've missed more.  But these are the things I realized I missed while I traveled to a place considered to be less fortunate than the USA. It was helpful to have a reminder of all these things when I needed it most. As we head through this holiday season, I hope everyone is able to spend time with their families and the people who mean the most to them. Most of my favorite people are far away and I don't know when I'll get to see them next, but whenever that is, I'll be grateful. 

The Level Up Initiative

with permission from the Level Up Initiative

The healthcare industry, including the field of physical therapy, is experiencing a revolution.  A paradigm shift. A wave of new thought. A reform. A change in perspective. An upgrade, in my opinion. Despite Dr. George Engel defining the biopsychosocial model in 1977, it has only recently become more common for clinicians to consider this form of practice. Chronic pain as a health condition is costing a ton of money in the US, and I think that this is one of the drivers for change. Healthcare providers and researchers are looking for ways to improve our treatment approach for people who are suffering.  The Level Up Initiative is trailblazing the path for young clinicians to better learn this model and tools for patient-client relations that the model inherently requires, which is not the typical model taught in healthcare education programs. If you're a physical therapist - new grad, student, or even a veteran - and you haven't heard of the Level Up Initiative, click that link and check it out.

Zak Gabor with me in 2017

I met Zak Gabor, founder of the Level Up Initiative, in November 2017 at his "Hip Hinge 101" course which I blogged about here. He included a patient case (who happened to be my friend from high school). She was experiencing low back pain and Zak showed her MRI along with cartoon images of a stick figure bending forward and an explosion coming out of its back. The MRI showed disc herniations and the patient had been told her back was "destroyed" and that she shouldn't bend over to pick up her kids. Imagine being a young mom with two active little boys and being told you can't pick them up because you could risk damaging your back! What would you do? When this type of message comes from a medical provider, a patient will often take the advice to heart and follow it with blind faith. This is why healthcare providers have a HUGE responsibility to consider the impact of the words we use with our patients. (Click here for JOSPT "Sticks and Stones" article on this topic.)

The Level Up Initiative strives to educate physical therapists (and other healthcare providers) on a biopsychosocial approach to patient care focusing on soft skills and therapeutic alliance in addition to the anatomical tissue healing factors and movement patterns we learn in school. The goal is to teach clinicians ways to interact with their patients with critical thinking, to connect, to prioritize using positive language and a growth mindset, and to focus less on a medical diagnosis and more on the whole person. Increased consideration for mental health and psychology, far more than what I learned in PT School is a factor of the paradigm shift.  My school taught the biomedical model with primary consideration of anatomy and biomechanics without much attention to the psyche or nutrition or sleep or a whole host of other stressors that impact our patients.  Most schools are just like this, though as the shift continues, more programs are giving attention to these considerations.

Ellie leading our Mentorship Group

As a company, The Level Up Initiative puts out content on various social media outlets including Facebook and Instagram posts, as well as having a podcast, a recently initiated blog, and a free mentorship program. I participated in the third cohort of their mentorship program where my mentor was Ellie Somers, owner of Sisu Sports Performance. ***Sign up for the next cohort NOW!  Enrollment ends November 24, 2019*** I enjoyed my experience working through this program and wanted to explain what it was like for those who are unfamiliar with it. Again, I can't recommend checking out their website strongly enough. It has impacted my patient care in only positive ways and I hope I'll have the chance to serve as a mentor in their program in the future.

The mentorship program lasts four months and, as already mentioned, is free. Free! These skills will immediately impact your patient care, but you have to put in the effort to go through their materials. They send you the full course syllabus in advance which outlines the recommended books, podcast episodes, TED talks, and publications to go through over the program and you can really dive in at your own pace. The course is organized with themes that help to focus the group discussions, but going out-of-order with the reading didn't impact my experience.  I chose to complete all the tasks on the syllabus, but I could see that if your schedule didn't allow for that, you could take it as a reading list to work through in the future while still getting a lot out of the discussions and watching the modules.

I won't tell too many details about the specific resources because you should participate in it to get the full experience, but I do want to share some of my favorite parts and describe the structure hoping that it will encourage you to sign up for their next cohort (HERE). The three key topics explored in the mentorship program are Growth Mindset, Critical Thinking, and Communication. Even as a PT for the past five years, I learned new things with each topic, and regularly wished I could have had this knowledge as a new grad. Each topic had discussions amongst our assigned mentorship group as well as reflection questions to consider for personal growth.

Photo from Module 1 with permission from Level Up

Module 1 examined "Growth Mindset."  If you're not familiar with this concept, start reading about it! Once I learned it, I could easily identify when this was an issue with a patient and there are some simple strategies on how to approach this problem to optimize patient care. Our group had an awesome discussion about failure during this module. I personally have experienced some professional failures this year... I submitted a manuscript for publication that was rejected, worked on a project for the WNBA that seemed to crash and burn.  With a growth mindset, I can look at those failures as opportunities rather than disasters. One of my personal favorite strategies is to encourage the use of the word "yet."  Working in pediatrics, it is a frequent experience that my patients may not have done an activity before - so when I ask them to try, sometimes they default to "I can't."  And I tell them, they need to try.  Maybe they can't complete that task, yet - but they need to try, and maybe they'll surprise themselves!

Module 2 dove into Critical Thinking. If we want to see change across PT and across healthcare, we have to start changing how we practice so that the field can catch up to our individual change.  We need to challenge the things we learn in school and we need to challenge our own thought processes in order to grow.  Critical Thinking is an umbrella term that really encompasses many concepts - including an open mindset (like module 1) and communication (the next two modules), but for me, the biggest part of critical thinking is to recognize our own biases and look for ways to disprove our own opinions and beliefs.  When I took Greg Lehman's "Reconciling Pain Science with Biomechanics" Class which I wrote about last week here, I asked him how he organized his learning because he reads SO MANY articles.  He told me that he will pick a topic and then collect several resources on that same topic looking for ways that his beliefs can be changed while reading the collection.  That is intentional critical thinking.

with Permission from the Level Up Initiative

Module 3 and 4: Communication
One of the recommended books for this topic was the toughest book I've read since "Explain Pain Supercharged," but once I got past the big words I needed to learn, I was really impressed by the brilliance of the book and by the importance of the concepts outlined in it.  Where does vulnerability fit into our careers as heathcare providers?  How much can we tolerate uncertainty?  We need to reflect on the care we provide so that we can identify our personal areas with room for growth.  We also need to recognize that our interactions with our patients are directly impacted by our own beliefs and the patient's beliefs.  The motivation of a patient will impact their participation in your home exercise program.  If it looks relevant to an activity they strongly want to return to, that's different than if your recommendations seem arbitrary and unable to help them achieve their goals.  If I believe that jumping up and down is going to help my patients and I can convince them to do it with intelligent rationale of how it will help them return to running, they're going to do it.  If my coworker uses a different approach, they're going to use an alternative treatment technique. Potentially neither of us wrong, but if the patient thinks my way is better, it will impact their care. Because of this, earning a patient's trust can really outweigh other things in care.  Remember, we're not treating robots.  To focus entirely on the objective and ignore what the patient thinks is going on with their own body, aka the subjective, leaves holes in their story and makes it harder for you to effectively treat patients.

So after four months and lots of new learning, I'm excited to share about the experience with you, and hope that if you're a new graduate PT, you'll consider participating in this mentorship program in the future.  Sign up this week, or wait until the next round.  Follow the Level Up Initiative on their social media sites, all linked above.  And then let me know what you think.  Tell them I sent you.

Reconciling Pain Science and Biomechanics

Greg Lehman

It's finally happened. I finally attended a course presented by a Canadian! I also work with a
Canadian Occupational Therapist and from my sample size of n=2, I think it's possible that Canadians are smarter than Americans. Why is it that Canadians seem to know more about American politics than we do? I can only inadequately describe how our government operates and I know absolutely nothing about theirs.  It's like they care about what happens in the world, or something. We should do better, America.

Anyways, since I'm sure you also want to take a course instructed by a Canadian, I'm sure you want to know what course it was? "Reconciling Pain Science and Biomechanics" by Greg Lehman. Greg is a physiotherapist, chiropractor, strength and conditioning specialist, and biomechanist who also teaches a course called Running Resiliency, which is probably excellent if you run or treat runners, which I try to avoid.  (I avoid running.  I don't mind rehabbing runners).  "Reconciling Pain Science and Biomechanics" is a two day course that bridges the gap between the clinicians who focus heavily on pain neuroscience education and the psychological side of the biopsychosocial model versus practitioners who tend to focus primarily on perfection of movement patterns and anatomical tissue structural damage as potential drivers of pain.  If you're working in orthopedics or with pain management you should definitely check this one out.  The course was overall broad with big concepts that ideally could apply in multiple situations.  It also came with an extensive set of resources including his presentation and a huge number of literature papers for consideration.  So much evidence to support the discussions. 

I've previously written about pain here (and several other posts).  Greg defines pain for this course as "When all your loads/stressors exceed your ability to adapt/cope."  Pain is the balance between all the things that are harmful to you and all the things that are good to you. I often like to use the concept of inputs versus outputs with my patients, especially because people often don't recognize that pain is an output. I can't put pain into you. Pain is an output message from your brain in response to stresses that have been applied.  I can apply stresses to you so that a painful output occurs, but instead I try to find the minimum effective dose of stress to input so that your output is positive adaptation, not pain. 

Some examples of inputs: mechanical stress to tissue such as an incision or deep touch or the feeling of your rear end on the chair you're sitting on, chemical stress such as dehydration or improper nutrition, emotional stress such as those from your family or your job, light, sound, and temperature changes.  Inputs are not good or bad, they are just stresses that we have to process in our body.

Some examples of outputs: pain, emotions, sweat (loss of heat), neuromuscular adaptations such as increased strength, seeing your mental health counselor and talking it out, breathing, coping/calming strategies.

So when a person is experiencing pain, anywhere, the options for treatment could include:
1) Can you decrease some of the inputs?  Examples: Turn off the lights, focus on some breathing strategies, go for a walk, change your body position, change the temperature, increase or decrease the amount of touch on the area that hurts. 
2) Can you increase some of the outputs?  These could actually be the same as above because of things like hot versus cold where changing temperature in one way actually accommodates both, but also doing some yoga, exercise, see your therapist, take your regularly prescribed medication if you have diagnosed anxiety or depression that is being medically managed, or spend time with friends.
3) Or can you make it so that you're able to accommodate for more inputs without changing the input or output?  Again, there is overlap here.  But for many people, building up tolerance through strength training or meditation practices or learning ways to desensitize your skin can all have this sort of impact. 

It's important to also consider what is getting in the way of making some of these changes. Is the patient fearful of going for a walk because they have pain in their foot?  Are they catastrophizing or perseverating on horrible possible outcomes by participating in a certain activity so they're unwilling to try?  What are the current beliefs and expectations about their condition?  Knowledge about how the mind and body connect and work together can help decrease these roadblocks to facilitate recovery.

Greg provided some important questions to ask patients to help them return to their favorite things.  For example, "In what ways do you think you could be healthier?"  This open-ended question allows a person with headaches to consider that maybe they could better hydrate, have more nutritious meals, sleep at more optimal times, go for a walk at lunch time, maybe acknowledge some of the recent spikes in stress at their job or school... but it allows them to identify potential sources of their pain, allows them to outline what they believe is happening, and also gives you a chance to better learn about the patient. 

Greg Lehman and Me

He also discussed the importance of asking "What activities are meaningful to you?"  So, for me, I really like to play softball.  When I hurt my knee a few months ago, I was disappointed that I couldn't play for a week or two, but then I was able to return in a modified way.  If I hit well enough, I could hobble my way to first base and get myself a substitute runner for the rest of the bases.  I didn't think I would damage my knee worse by doing this, and I actually didn't have much pain when I tried that.  I spent a little more time in the dugout instead of alternating innings so I could avoid spending so much time in my catcher's squat position.  So, I was able to dose my activity so that I could do some rather than none at all, and this actually built my confidence to return back to my usual level of participation after healing and recovering. 

Which leads perfectly into "Encourage the patient to ask themselves 'Will the activity harm me? and/or 'Will I pay for this later?'"  Like with my softball example, I didn't hurt myself worse by participating and I didn't hurt more after playing. Certainly there are times when doing activities can be harmful. As a physical therapist, it is our job to recognize when that is the case and appropriately guide our patients, but modifications are often possible.  In particular, I really think it's important for our post-surgical patients who can't be playing their sport to spend time around their teammates. Be the team manager!  Learn more about your sport.  Spend that time with your friends.  It's better for mood, learning of the game, growth with teammates (and they'll get better support if they're around and showing their progress over time." 

Best Thanksgiving Food

In another example, this past weekend I attended a delicious Friendsgiving dinner at my friend's home. I've been managing some gut issues lately and had been eliminating several foods to try to identify where the problem was coming from. After a month with no wheat and two weeks without any onions or garlic, I wasn't exactly sure what would happen if I had some stuffing... but I really wanted it!  I actually did use this line of reasoning while I ate.  Will I do any permanent damage to my body by eating this? Not likely, no. Will I pay for it later? When I made the decision, I wasn't entirely sure, but I thought it was possible, which impacted my decision for quantity of stuffing that I took (dose). And yes, I felt like crap from it.  But was it worth it? That's very individual, and up for me to decide, and now I have data. Next week when I'm home for family Thanksgiving, I get to decide if I want to repeat this same thing knowing what the likely outcome will be, or not.  But I'm empowered to determine what I do to my own body, and that's something I think we can teach our patients, too. 

What else can we do as physical therapists to help our patients who are experiencing pain?  We need to help make sense of their pain using their own understanding of what's going on. A person who thinks their "back is out" can't just be told "that isn't really a thing, backs don't ''go out.'"  They'll never buy into your message if they have a belief of what's wrong and you just strong-arm them into an opposing idea.  So instead, we acknowledge their beliefs, educate them on how adaptive the human body is, and we facilitate cognitive restructuring.  An example that was suggested in the class was "I bet someone has told you that your spine is twisted," and by acknowledging their perspective, you can try to bend that belief just a little bit, "but actually your pain could be from something else, so why don't we work on getting you moving in ways you can tolerate."  You create a small hint of doubt into their beliefs and see if the patient gives you an opening and slowly you can chip away at the beliefs over time.  We can facilitate adaptability by using intentional application of specific stressors that induce adaptation for increased resiliency, and this includes with beliefs. We must meet our patients where they are at with the psychological and physical approaches, progressive loading ooth their thoughts and their tissues, which might be a really little bit of loading at the start, but sometimes that's all they can manage. We work hard to encourage their autonomy and self efficacy.  One of Greg's quotes which I really enjoyed: "Requirements for adaptability: 1) Human. 2) Not Dead."  He also made sure to include a statement about how physical therapists don't fix people.  We facilitate them.

Bob Ross

And so physical therapists need to understand barriers to recovery, which could be at the tissue healing level, or could be in the psychosocial realm, or a whole host of areas in between.  And we need to appreciate that what we do is, in fact, an art, while also being a science.  That makes Greg Lehman just like Bob Ross, I think.  He painted this one beautifully. So many happy trees.

And with that, I'll finish with another quote from the course "Limping is a helpful adaptive pattern. It is successful in keeping people moving. It decreases pain. But should we advocate for everyone to start limping?"

Thanks so much, Greg.  I hope you'll come back to the USA soon!

Mindfulness in the Sensory Deprivation Float Tank

Today I did a thing.

No big deal, really.  You can stop reading, now.  Seriously... I'm not even sure why I'm writing this post. Today I did an activity that initially seemed far outside my comfort zone. You see, I've been working on my vulnerability and my mindfulness. For some, that may be easy. Ever climb a huge mountain?  Facing vulnerability and mindfulness seem that difficult to me. I can't explain why, but they're a struggle.

According to dictionary.com, Mindfulness is "1) The quality or state of being conscious or aware of something 2) A mental state achieved by focusing one's awareness on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations, used as a therapeutic technique." I won't bore you with the issues I have acknowledging and understanding my own feelings or my dissociation from my own body, but mindfulness is one of the strategies I've been working on for those issues.

My first attempt to work on mindfulness was when it was recommended that I read the book "Eating Mindfully" somewhere around February 2015. I really tried to absorb what was being recommended and even attempted some of the activities in that book. But when they walked me through putting a pistachio nut, in its shell, inside my mouth to taste the salt and then break it with my teeth to experience the cracking sound so close to my ear and then focus on the textures of the soft, green nut... I couldn't handle it.  Too many adjectives.  Too much thinking about food. Too much self awareness.  No thank you. I think the book even recommended trying to feel the ridges of a raisin with the tip of your tongue, but maybe I made that ridiculousness up... it's been a while. Either way, I didn't think mindfulness was the route for me to go to approach the eating issues I was facing, so I gave up. For a while.

Now, years later, I've learned that I don't actually practice mindfulness in a whole boatload of areas of my life. I am still not a mindful eater. I eat breakfast in my car twice a week paying attention to traffic and not to whatever I'm consuming. I eat a snack in my car on the way home from work daily so that I make myself a sensible dinner rather than hitting the drive through. There is a snack bin on my back seat now.  I usually also drive while listening to an audio book... so, yeah. I eat lunch while I'm talking to my coworkers or, on the rare occasion when I would be eating alone, I also read a book or scrolling around aimlessly on my phone.  The last thing I do while eating is pay attention to my food. But I am also not mindful of the space I take up when I'm moving around.  I bump into things.  I've been called a "bull in a china shop" more times than I care to admit. In sessions with my therapist, sometimes she'll ask me to sit with my feelings on a topic of conversation and I burst into laughter or start fidgeting and can't even look her in the eye.  It's horrible.  This could continue, but the purpose of this whole mindfulness conversation is more about things I'm doing to try to be more mindful, not really the reasons why I need to.

The most mindful activity I've come upon has been yoga, which I wrote about here, during which I'm very present in that moment. I definitely feel my emotions and they change in various positions. I also am more aware of my body in yoga than in most other ways.  So far, yoga has been my favorite mindfulness strategy... but I haven't gone in progbably six weeks, so I should maybe get that in soon.  I sometimes find swimming to be pretty mindful... I did that a few days ago.  It makes you focus on your breathing and your body or else you drown.  A little bit of life-or-death mindfulness, anyone?  And lifting weights does this a little bit, but is usually a lot more distracted than those other activities.

The problem is that I've been searching for mindfulness strategies that don't make me move.  I've tried those progressive relaxation strategies where you relax your big toe, then your foot, then your calf, up the whole trunk and to the top of your head and back down the other side. Eh. I can't seem to tolerate meditation the way most people seem to. All of these things seem harder than I think they should.  Why can't I just sit in a quiet space and focus on my breathing for ten minutes?  That doesn't seem hard.  I have never made it ten minutes. So when it was recommended that I try a Sensory Deprivation Float Tank, and would be forced into a quiet, dark space for a whole hour, I was very intrigued. I made a reservation a few days ago at Float Seattle in Greenwood (neighborhood in Seattle) and talked to several coworkers and friends about it over the past few days.  Only one person I spoke to had ever tried it and had some really interesting perspectives on it. Most people felt exactly how I felt... like it was insane to try and that I would probably freak out.  Despite those expectations, it was actually pretty awesome.

I arrived at the Float facility where Dean, the owner, gave me a little tour of how things worked, made some recommendations about positioning in the tank and best way to get the ear plugs into your ears and making sure your face is really dry before getting into the pod to avoid touching your face with a super salty hand while in there. He showed me how the tank worked, where the lights and sound are adjusted, and then left me in the quiet.  I took a neutrally temperatured shower to be clean, but not too hot because then the tank would feel cold, before entering the pod filled with 10 inches of water and 1000g of Epsom salts.  Because the water is set to basically match your body temperature, you almost don't even feel it.  There were a few periods while floating that I felt a little cold and then moved around a little bit and it quickly resolved. I was shocked that it didn't really smell like anything - which was one of the concerns I had because I tend to be smell sensitive, particularly with florals and some soaps that make me miserable and headachy - but later learned that reduction of smell is one of the many sensory inputs they're trying to reduce. The room had towels with just enough fluff to them, which brought me Marie Kondo level of joy.  I hate rough towels and would have been super annoyed to remove a ton of sensations for an hour only to come out to sandpaper towels.  And so I did the thing.

Me, in the Dead Sea, on January 14, 2004

I got into the pod, closed myself in, and transitioned from what felt like sitting in a bathtub into supine floating on the Dead Sea.  I've done that before... but I was covered in mud, it was nearly fifteen years ago, and I was not alone. That salt burned my skin.  This salt did not.  That trip was so long ago, I didn't have a Facebook account yet and I was still using a camera with film.  Guess I can't share images from that day. Just kidding, I dug into the scrapbook and took a picture of this picture to share with you. It took zero effort to get to floating and all the fears I had about potential claustrophobia were gone.  I turned off the blue light, and tried to relax while looking at the little twinkle lights in the ceiling of the pod.

Carmen, in case you don't know.

It felt a little like I was inside a planetarium and I had a flash of "Where in the World is Carmen Sandiego" because she was exploring outer space when I went to the planetarium as a kid.  And maybe because one of my friends was her for Halloween, so it was on my mind.  And then I started to let it all go.  I had the option of listening to music - I went without.  I had the option of keeping more light than the twinkle lights or going all the way into the darkness.  I did a little twinkling, but mostly in complete darkness.  I had the option of using a little foam pillow for my head if I wanted it - I tried both ways.  And let me tell you, I really enjoyed it. The only thing that seemed odd to me was that I had completely lost sense of time.  I don't think I fell asleep, but maybe I did.  I don't think I moved around a whole lot, but I did a little bit.  They told me that I would know the float was over because the music would start playing and then the light would come back on.  Maybe 30 seconds before that happened, I put the twinkle lights back on feeling like I was starting to get a little antsy.  OK actually I was starting to think I had to go to the bathroom.  But I made it!  The whole hour!  And I didn't lose my mind!  I also didn't cry, which I had thought was a serious possibility.  I hadn't really thought about anything that much... mostly I just let my mind go blank, which is something I really struggle to do.

According to the Float Seattle website, "There are many benefits of floating regularly. Most commonly our guests and members float for stress relief, pain relief, athletic recovery, and meditation/introspection."

It makes sense that you might have some stress relief from removing many of the inputs our body receives constantly throughout the day.  I spend a lot of time working with kids in pain, trying to find ways for them to output various stresses - through exercise, emotions, breathing, desensitization sensory input overload strategies... but it's so hard to remove input!  Removal of the input of light or computer screens, changing temperatures, sensations from sitting or from clothing allows the brain some freedom that is normally occupied by these things.  It makes sense that you might have pain relief soaking in saltwater that could potentially reduce inflammation and allowing muscles to relax in new ways.  But just having it make sense is not good enough for my science-minded brain.  I needed to see research!

So the Float Seattle site does include a list of publications here and when I searched, this other floatation company had an even longer list here. It summarizes that "The float environment systematically minimizes external sensory input to the nervous system including signals from visual, auditory, olfactory, gustatory, thermal, tactile, vestibular, gravitational, and proprioceptive channels."  A 2005 meta analysis is cited suggesting that this type of treatment does reduce stress and there are papers studying different hormone levels of change following sensory deprivation treatments.  I couldn't read all the articles between my float and getting this post put together, but I did read numerous headlines and how they used it with challenging patients with severe autism to reduce sensory input with some successes, and how several health markers improved by using floating.

Then I watched this YouTube video from comedian Joe Rogan about his experience floating, and all in all, I decided to share my experience with all my blog followers. If you're in the nearby Seattle Area, the cost at Float Seattle was $39 for the first session (and for all Happy Hour time sessions right now, which is basically the normal work day for most people, but I work a healthcare provider schedule and have days off during the week which means I can go on my day off for that rate). Yes they tried to sell me a package. No I didn't buy one... I think I would prefer to achieve the mental state I get from doing yoga, instead, but yes, I do think I would go again, particularly if I'm having a stressful week... or if the clocks have just changed and the world seems like it's going bonkers around me!  Have you tried floating?  Let me know what you think!

Rainy Days = Continuing Education

Steve Allen assesses the Lumbar Spine

The rains are upon us here in Seattle. Gross!  If you've never been here during the doom and gloom season, what you've heard is true.  It's grey, dark, cold, wet, and everyone is a bit more cranky.  (Or maybe that's just me?) But the leaves are beautiful to look at and the candles are lit and ALL the blankets are ready to get cozy and it's hot chocolate season... so that's all exciting.  And what better way to hide from the weather than to take some continuing education courses?

This past weekend, I completed my fourth NAIOMT (North American Institute of  Orthopedic Manual Therapy) course.  I've previously written about my experience with these courses on the blog here following the last one I took way back in 2017.  Since I started working at Seattle Children's Hospital in 2017 I've used considerably less manual therapy so these classes have fallen lower on my learning priority list.  The kids don't tend to need it so much and I've learned so much about the impact manual therapy sometimes has on patients psychologically that even when I'm in the adult clinic, I'd prefer to use it less.  As I continue to grow in my career, I keep learning what I like and what I don't which changes how I interact with patients. In general, I try to avoid "doing things to patients" and prefer to help them learn how to do things for themselves.  That's not to say I don't use manual therapy at all... it just isn't my first step most of the time. I do occasionally work with adults and they typically have expectations of receiving this sort of treatment, particularly because of the way the clinics I work at organize their schedules.  Sometimes they really do need it - but for sure not always.  And in the State of Washington, physical therapists who manipulate the spine need a special certification with specific continuing education, so to maintain my certificate, I took this class.

Amanda Scharen teaching lumbar instability tests

To be fair, these NAIOMT courses aren't just about manual therapy, either.  Sure, the photos I've included are of a manual technique performed by Steve Allen, NAIOMT faculty member and a Physical Therapy Historian who exudes love for the profession along with my friend and Director of Therapeutic Associates - Queen Anne - Amanda Scharen. I'll even quote Steve from this weekend, "Manual therapy is a small ut vital part of our practice.  Combine it with exercise for the best outcomes." But these classes also include advanced review of anatomy and biomechanics, which is important when you haven't studied it specifically since PT School.  There are many cases presented during the weekend which challenge clinical reasoning.  The partiipants of NAIOMT courses are all physical therapists so there are really interesting discussions about evidence supporting different topics, sometimes even debates, and some of the scientific literature is included for participants to read ahead of time.

SI Joint - from Wikipedia

For example, this course included this paper "Evidence-Based Diagnosis and Treatment of the Sacroiliac Joint" from 2008.  I had not previously read it, but did learn this in PT School.  It describes the different tests you can use to try to identify if the joint between the sacrum at the base of the spine and the ilium (pelvic bones) is contributing to a person's pain presentation. During class this weekend, we had a discussion on whether or not this joint moves at all - as many believe that it is fused and therefore immobile. I personally believe that the SIJ does move for three reasons: 1) I have seen too many patients with pain that improves with changes in their pelvic positioning or with exercises training stability for this region 2) When I have a specific pain pattern, treatment to my own SIJ resolves my symptoms almost immediately, and 3) I don't think women would be able to give birth if this was an immobile structure.  Doesn't really explain why it would be as mobile in males - but I don't usually see this as a problem region in men as much. If you're a PT who hasn't been exposed to the tests that may help identify the SIJ as a contributor to pain, the article outlines each one and presents pretty good psychometric properties when using them as a cluster.  Interestingly, the author describes the tests and then admits that he no longer uses SIJ manipulation as a treatment because it tends to be unsuccessful.  He recommends stabilization exercises and, if that is unsucessful, injection into the joint.

What I've come to understand more and more is that the healthcare you receive from any provider is biased to the beliefs of that provider.  For example - if you came to see me and I determined that you had tight hamstrings, I tend to guide you to strengthen the hamstrings in an effort to relieve some of that tension.  Some of my coworkers, however, would teach you how to stretch your hamstrings. There are articles supporting both methods. There are groups of people who support both sides. As a patient, if you don't have any prior knowledge on the topic, you're probably just going to take your therapist's word for it that they know what they're talking about.  As another example - I've been experiencing some really annoying abdominal pain for the past several months.  My GI doctor sent me for tests like an endoscopy and colonoscopy and is treating me for acid reflux.  Yes, the medication made me feel better, but I didn't think that was the underlying problem, so I sought out another opinion.  She's treating me for something entirely different.  Her beliefs about my symptoms match more with my own beliefs of my symptoms and I'm far more optimistic that I'll have a good outcome with this method.  As long as the patient gets better, does the method used to get there even matter? Regardless - the evidence is strong that for low back pain, physical therapy should be your number one choice for care.  Not medications.  Not injections.  Not surgery.  Not imaging.  PHYSICAL THERAPY.  Get PT First.

These are the things I think about during these dark Seattle fall-winters.

I have another continuing education class coming in two weekends.  I'd imagine it will still be raining then... so a blog post about it is likely.  It's very different from this one, so that will be a fun juxtaposition.