Resilience

Resilience.  Major Buzzword.  Everyone seems to be talking about it.  "The capacity to recover quickly from difficulties; toughness."  Particularly in the wake of the recent helicopter crash that ended the life of Kobe and Gianna Bryant and reflecting on Kobe's basketball career.  Resilience is a psychological principle.  Can you cope?  Can you face the struggles in your daily life?  Can you manage conflict and overcome tragedy or trauma?  

You can see it when you look around you, to some degree.  A friend just summitted Mount Kilimanjaro.  Just got on a plane in the US, headed to Tanzania, Africa, and then climbed to the 19,308 foot high summit.  I'd say that takes resilience.   I work with patients every day who are overcoming injuries, surgeries, physical pain, chronic conditions, family struggles... and more.  I see resilience in front of me all the time.

This year, Seattle Children's hosted a leadership conference where Dr. Bertice Berry was the keynote speaker who spoke about Resilience.  She later presented to a remote Seattle Children's staff about Resiliency Connections.  So in the past month I've listened to Dr. Berry speak about resilience twice, and it seemed like a fitting topic this week.

When asked what Dr. Berry would choose as her dream job, she said she wanted the title of "Chief Inspirational Officer."  That sounds like a giant undertaking. The responsibility to inspire staff to improve their life on a day to day basis is not something Dr. Berry takes lightly.  I have the challenge of motivating and/or inspiring (definitely not the same, though sometimes both are needed) patients every day and this is hard!

Here are some things I took from Dr. Berry's presentation.  

First, identify your own purpose and identify your daily intentions.  This could be in your personal ife or in your professional world.  Consider "Why me, here, now?" Why am I here, helping this particular person with their physical therapy today?  How can I make this the best experience for both the patient and for myself so that they have the optimal outcome.  Why is it important to me that I do this?  How can I make a difference in my coworkers' lives, in my patients' lives, and in my own life? 

Second, have I given enough of myself today?  There were many memorable quotes from Dr. Berry's presentations, but one in particular was "you feel poor when you're not able to give."  And I agree.  I struggle the most when I'm facing a patient I can't help. I get frustrated with patients who have conditions that don't have a positive outcome.  I know that I can't help everyone.  I am constantly grateful that I am able to help anyone.  My usual intention is to help my patients learn to help themselves.  I don't like the idea of fixing people or that they need fixing.  Patients, even those with injuries, diseases, or conditions, are still humans and they are not broken.  They are filled with life, experience, and resilience.  Sometimes they may need a little guidance in harnessing their inner drives and motivations.  

Dr. Bertice Berry on remote feed at Seattle Children's

And third, the need for human connection. Dr. Berry said, “You can’t be well without connecting.  You can’t help others be well if you’re not well yourself.”  As a healthcare provider, the amount of time you spend giving of yourself is a lot.  You need to find ways to take a little bit too, to refill your cup or recharge your batteries - whichever metaphor you prefer.  There is a reason why people gather into communities, why the family unit has so much value for many cultures, why prayer is regularly participated in collectively.  A meal can be eaten alone, but is it ever as good as it is with good company? Prayer can be done individually, but doing so in a community elevate the spirit differently. Is singing alone in the shower the same as singing in your car with your best friends?  I find, particularly when I'm working with patients experiencing chronic pain, that they have started to isolate themselves.  They've stopped hanging out with friends, sometimes have stopped going to school, they withdraw from their family members, and they sometimes even say out loud that they don't like people.  It's far easier to suffer alone than to hear others living their lives despite your suffering.  But re-integrating into a community, finding people with shared interests and beliefs, and increasing interaction helps drag people out of that loneliness and into the light. 

As a physical therapist who values therapeutic alliance first and foremost, before my patient care really gets underway, I prioritize connection.  If my patient is not interacting with very many people, my role as their PT may be even bigger than guiding them in exercise.  Showing interest in their life, who they are as a person beyond their pain circumstances, and simply listening may have a much bigger impact on them.  Dr. Berry emphatically encouraged healthcare providers to connect with their patients.  Find the common ground.  Don't confuse your own vulnerability with authenticity.  "Nothing sucks the energy out of you more than being someone other than who you truly are."  Share your experiences to help them find their paths. 

Whether you're mourning the loss of Kobe and Gianna Bryant or someone in your personal life, or you're facing an obstacle or tragedy that has got you down, know that you have resilience inside of you. Know that you're not alone, you just might need to look around to see who else is on your team.  But look and you will find support in the most interesting places.  Maybe it's your dog or your stuffed animal or your online blog that is primarily just read by your mom, like mine.  Know that I'm rooting for you. Hopefully you can look around and find that you have enough inspirational and motivational people around you to move in the right direction.  

Thank you, Dr. Berry.  

“When you walk with purpose, you collide with destiny.”

What Do Physical Therapists Do? Installment #6: We Critically Appraise Research

Link

I'm long overdue for another installment of my "What Do Physical Therapists Do?" series.  I've previously written about the PT role in emergency response, return to sport participation, strength training, therapeutic alliance and listening, and assess biomechanics.

Have you ever seen a toothpaste commercial saying "100% of Dentists Recommend that particular brand?"  Do you think to yourself, 1) "Ooohh, I should go buy that right now!?"  Do you wonder, 2) "Would I like that flavor?"  Do you consider,  3) "I wonder if they surveyed one dentist or 1,000 dentists to get that outcome?"  Or do you 4) just let the commercial come and go and ignore it entirely?

I'm very particular when it comes to all things related to teeth... I hate when people walk around brushing their teeth, I can't stand the sound of the electric tooth brush, I gag in response to watching others floss in my presence. I can't understand why they made cinnamon or grape or bubble gum flavored toothpaste when it's clearly meant to be mint-flavored. Only. And chocolate with mint has been ruined.  Tragedy.  Today I'm giving these commercials more thought than they deserve.

I think that many people probably just follow option 4, completely ignoring the commercial and moving on with their show.  But that path ignores that behind that advertisement, there was some amount of research done, data was compiled, and the information was put out into the world for you to interpret.  So the purpose of this blog post is really about choice number 3) "I wonder if they surveyed one dentist or 1,000 dentists to get that outcome."  This isn't where my mind automatically goes, but it's the way that scientific research needs to be considered.  And it makes me nervous to think that there are physical therapists who don't read any research at all - or who read a paper but then ignore the findings entirely.  Just like option 4. 

Let's say you're a physical therapist and you're working with a patient who recently sprained their ankle.  What does the research say is the best thing to do for this patient?  Did one physical therapist present a case study that you read and you're taking their word for the best approach?  Have you, yourself, done a treatment with a similar patient before and found that it worked so you now think it's the best option for everyone with this condition?  Is there a journal article that says to do certain things, but other papers that show the opposite information?  Were the research tests done on a teenage male, like the patient you're working with, or were they conducted on a group of women in their 40's... and does that matter?  These are just the beginning of the thoughts involved in using Evidence-Based Practice in medical care and show why this is so complicated.  What does the research say?  What does it actually mean?  Is it clinically relevant to your patient? 

I've previously written about the changes that healthcare is experiencing here, but in that post, I didn't give enough credit to the transition in healthcare to more use of evidence-based practice.  I think use of research to support the decisions made with patients is very important, but I also find it to be incredibly difficult.  The example above with the patient with the ankle sprain is just one possible scenario out of tons of different ones to see in the clinic.  There isn't research to support all of our decisions, and even if there was research covering all aspects, there's no way I could ever read it all.

For myself, I work in pediatric orthopedics.  In a typical day, I will see eleven patients.  No two are the same, even if three of them are recovering from ankle sprains.  My job limits me to seeing patients between ages 5-21, which is far more restrictive than most people who work in an orthopedics setting.  But research on kids is often lacking, so to try to make decisions for kids based on research in adults tends to happen a lot.  I know that it may not be accurate - but I also know that I don't have anything else to base my decisions on.  While there is an increase in research available for teenagers with ACL tears, there are many conditions and treatment approaches that have not been well studied with matching characteristics to my patients.  And, again, even if I had all the time in the world and devoted it to reading, I could never read all the papers and really know what all the researchers recommend to make the most educated decisions possible.  So we work to make our best decision and review the literature as much as possible, and this requires the ability to critically appraise the literature.  Reading the papers is only the first step.  Understanding their meaning is even more complicated.

I mentioned in my last blog post (here) that I recently launched the Seattle Children's Hospital Sports Physical Therapy Journal Club.  So far, this project is in its infancy.  To get it started, I was advised by several physical therapists working elsewhere who already participate in a journal club to start by focusing on papers that help you critically appraise literature.  I followed their advice, but had to start with learning more about what that even meant. 

Journal of Sports Physical Therapy

According to the Center for Evidence Based Management, "Critical appraisal is the process of carefully and systematically assessing the outcome of scientific research (evidence) to judge its trustworthiness, value and relevance in a particular context. Critical appraisal looks at the way a study is conducted and examines factors such as internal validity, generalizability and relevance."  The Journal of Sports Physical Therapy (JOSPT) has been publishing a series of articles to help Critically Appraise Scientific papers here and as I've been reading through them and collecting information for the journal club, I've been finding that 1) the topic of critical appraisal of the literature is not very interesting, and as such, I have never previously given it much consideration to learn as a skill and better question the research I'm reading. Lack of interest is a poor excuse for something this important.  I'm also not interested in gymnastics, but I work with gymnasts so I need to take an interest in it to sufficiently work with that patient population. 2) There are a whole lot of ways for a scientific study to go wrong - without the researchers having that intent or despite their efforts to avoid it.  Things like bias, blinding study participants, misunderstanding confounding variables or inclusion and exclusion criteria for subjects, insufficient sample size, improper use of certain types of statistics, lack of awareness to the true definition of terms and what they mean in a scientific setting, and I'm sure more ways that I don't even know yet. 3) Research is super complicated and cannot be taken solely at face value.  Simply reading an abstract and the conclusions of a paper can be incredibly misleading if authors have put a spin on their findings or if the methods of the paper are ignored.  Critical Appraisal requires thought, analysis, interpretation, and questioning.  

As clinicians, I think learning about how to appraise the literature is something many of us need to do better.  As physical therapists, many of us did not have to go through the full research process to get to our clinical status.  This may be a shortcoming of our learning because too many of us are not considering whether or not the findings of a study really mean what is presented and whether or not a lab study actually applies to the clinical setting.   It seems like a lot of research principles come from the pharmaceutical world.  If a medication is provided to 100 people and nobody dies and an abstract for the paper says it saves lives, that is a misrepresentation of data.  What if the methods show that the criteria to select the participants in the study excluded people who would really need that medicine?  What if they only tested the medicine on people over age 75 and you work with children - would it also save them?  What if, when the study is expanded further to maybe 1,000 people, there are deaths in the bigger group?  This is a call for us all to be better about consideration of the research with a healthy skepticism towards methodology and interpretation.  

So the next time you want to do a treatment technique on a patient, have you considered the literature supporting or refuting the efficacy of that approach? This could be anything.  Dry needling.  Massage.  Cupping.  Specific types of exercise - maybe yoga or pilates.  Stretching.  Strength training.  Breathing.  Biofeedback. Foam rolling. Desensitization.  We have a lot of tools available to us - many with different levels of support in the literature. And have you looked to see if there is a paper that suggests outcomes to the contrary?  What do you think is the best option for this specific patient?  I'm struggling so much to read papers that, for example, suggest that manual therapy is no better than exercise.  Some patients really do seem to need manual therapy.  There are lots of papers that suggest it isn't useful, and there are also whole institutes, like the North American Institute of Orthopedic Manual Therapy (NAIOMT), who have evidence to support the exact opposite. A paper cannot study every circumstance, so the setting and the patient demographics and pathological condition have to be considered. 

I'm hoping this post just encourages you to question how you use research and evidence-based practice, which you should definitely be doing, and perhaps you can teach me ways to more critically appraise what I'm reading.  We can all get better at doing this.  And we can all hold each other accountable to be better clinicians. 

I'm a Book Nerd

I really love to read.  I don't think anyone who knows me would be surprised to hear this, and I've written a bit about this in the past.  I've written a few book reviews (you can search the blog for those easily if it interests you), and I wrote about my anti-library here.  I constantly have a book in my bag, an audio book in the car, a creased journal that I'm mid-way through reading usually on the back seat of the car, on the side table in the living room, and in my laptop bag.  There are things to read everywhere!  I even occasionally have an audio book on my phone to listen to, now that I figured out how easy it is to connect an app on my phone to my library account.  The ways to access knowledge continue to skyrocket and I feel like I just keep devouring more and more, but each thing I read just shows me multiple new sources I can add to my list.  I remember fondly the days when I only read fiction, many years ago, and I'm embracing the transition that I've gone through to make it so I'm about 60% non-fiction and 40% fiction reader now.  I love getting lost in a tale of unique characters or far away places and won't really ever stop reading fiction entirely, but the non-fiction and the science are so fascinating, too!  I read about a huge variety of topics  But I also like reading things that help me grow as a physical therapist and as a person.

Last week I was working with a teenage patient in the clinic who I have had the opportunity to work with over more than two years following multiple surgeries.  She was telling me about her most recent Netflix binge and asked what I was watching.  When I told her that I didn't have a TV or a Netflix account, her jaw hit the floor.  It's not like I don't waste plenty of time on Facebook or goofing off on my phone or watching movies or occasional shows.  For certain, I do. Some days I want to go back to my old flip phone so I could have less access to all the distractions my Smartphone provides.  When I told her I read books, she called me a nerd.  And I wear that title with pride.

Until now, I've kept a running list of books I want to read on Goodreads and as I get close to finishing one, I just pick the next one. Sometimes a friend or coworker recommends a book and I pick it instead of what's been on my list for a while. I'm a regular at the local library and when they don't have something I'm interested in getting, I can use the Seattle Children's Hospital Inter-Library Loan System to get my more sciency books.  I've had a list of the "Top Five To Read Next" books on my list for years... but some of those books have never moved off the list because I read others first.  I've never really wanted to commit to making a plan of topics or books to read and sticking to it because I liked the flexibility, because I don't want reading to feel like an obligation, and because I have been reading so much, that I didn't think it really mattered.  But I'm not reading some of the things I really want to get to, so I'm going to try a plan this time.

For 2020, I'm picking a few work-related topics ahead of time with the goal of reading at least one book for each of those topics.  The books have all been on my list, some for years.  They've been recommended by people I respect.  Some match my personal beliefs and some are a bit more contrary. They seem interesting from their descriptions.  They're bound to help me grow as a physical therapist, and also likely as a human being.  Though I've written them as if they are in some sort of order, that may change.

Graded Motor Imagery Handbook + Mocha = JOY

The first book is "The Graded Motor Imagery Handbook" by Lorimer Moseley, David Butler, Timothy Beames, and Thomas Giles. You may have read my previous post about when I met Lorimer Moseley as his team studies pain extensively and he's written several books, which I've also written about here and here.  I don't actually know what topic this specifically falls under.  Maybe pain, maybe physical therapy treatment, maybe neuroscience.  Either way, this book has been on my list for a long time.  I just started it and can already tell it's going to be a journey. I expect this experience will be like climbing the mountain that "Explain Pain Supercharged" was.  In the event I decide to dig even deeper into this topic, I'll read some of the resources or books recommended within it, such as "Phantoms in the Brain" by V.S. Ramachandran, or one of his other books.  This is how I start to fall down the rabbit hole.  Speaking of which, I hope to read "The Adventures of Alice in Wonderland" in 2020, also.

The second topic will be pain.  Shocker, right?  The pain saga continues.  I've been wanting to read "Gift of Injury" by Stuart McGill which is about recovery from lower back injury and if I'm able to get access to it, I'll also read his book "Back Mechanic" to make a more focused reading cluster about low back pain.  And I also have "The Gift of Pain" by Dr. Paul Brand and Phillip Yancey on my list.

The final subject will bring me back to the basics: a look at Anatomy by reading "Anatomy Trains" by Thomas Myers.  Hopefully a refresher on the basics of anatomy with new learning about the fascial system.  I think this book is going to go against some of my biases, but I'm not sure yet. The list of these six books is now at the right side of the blog and I'll be checking them off as I complete them throughout the year.

In addition to these books, I recently launched the Seattle Children's Hospital Sports Physical Therapy Journal Club.  After recommendations from many of the physical therapists I met at the AASPT Fellowship I wrote about here, a few editions have already gone out looking at the "Linking Evidence to Practice" series in JOSPT written by Dr. Stephen J. Kemper that teach readers how to critically evaluate scientific literature.  I won't lie... those papers were a bit dry, but they're important. Too often we read a journal article and take every word of it like it's gospel when in reality there are other papers that share opposing views or the methodology is not really sound.  I'm guilty of this myself, and hope to learn more about the biases I fail to recognize in my own treatment methods. I'm really looking forward to getting into some more interesting papers that have been recommended and I hope to share some of those here on the blog, also.  Specific topics I'm looking forward to reading about in the scientific literature include: the basics of tendon structure and healing, more about evaluation and treatment for concussions, therapeutic alliance, the mechanisms of manual therapy (this will be the next paper, thanks for the recommendation Jarod Hall), and looking at different conditions we treat in the clinic.  Anybody who wants to join in on our journal club emails, just say the word and I'm happy to share.

I guess I've been blogging more and more about PT-related topics, though once the WNBA season starts back up, I'll still write about basketball... or maybe about things that interest people that are not physical therapists.  Until then, I'm loving all this PT learning and personal growth and want to know what others are reading to help grow their clinical practice.  Or just books you liked.  There's always room for more on my list.