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!