APTA Delegate 101

With my new pal Jenny Jordan

I was watching Gilmore Girls re-runs one evening in November 2021 when an email notification popped up on my screen from Dr. Jenny Jordan, Physical Therapist, Professor in the Eastern Washington University PT Program, former Chief and current Delegate for APTA (American Physical Therapy Association) Washington, and - I would soon learn - incredible human being. Jenny's email asked if I would be willing to discuss an appointment to a one-year term as an Alternate Delegate representing APTA Washington.  

With my long-time pal, Maryclaire Capetta

I've been an APTA member since starting PT School in 2011, but despite how much money I've spent on membership, at the time of Jenny's message, I really couldn't explain what the APTA did. I joined as a student when it was compulsory, and I maintained membership because it discounted board certification and allowed me networking opportunities that I occasionally took advantage of.  Also, it felt like it was the right thing to do, supporting the leaders of my profession.  I knew that Delegates existed and that they worked on making changes that impact the physical therapy profession from a nation-wide perspective, but I had never given any thought to being a representative myself.  One of my Professors in PT School, Maryclaire Capetta, now a long-time friend, has been a Delegate in Connecticut for many years. She took me to a Delegation event at CSM in Chicago in 2012, which was my first glance at the politics of PT.  Over my eigght years attending PT Pub Night events living in Seattle, I've gotten to know several of our local Delegates including some who are good friends. All of this to say - I knew Delegates existed.  I did not know how they came to be in their role, what they did, or why I would ever want to be one.

We set up a time to chat and Jenny explained the responsibilities and the time commitment and asked if I wanted to join for a one-year term. Washington had enough elected Delegates to serve two-year terms, but because our group is pretty large, if the time came to vote and someone wasn't available, we needed to have alternates to step in. Our Alternate Delegates participate in all the regular meetings along with the rest of the Delegation and contribute to the discussions and can work on developing policies, but they do not have the ability to vote unless an elected Delegate is unavailable.  The usual process to be chosen for the Alternate Delegate spots is to be the next highest vote getter on the ballot after the votes are counted. Unfortunately, there weren't enough names on the ballot for the 2022 cycle to fill the Alternate slots. I said yes, and after one year of a much deeper dive into what the APTA does, how new policies are formed, and learning about the problems the Association and the Profession faces, I'm here to share some of that with you.

First and foremost, I want to be very clear: I’m really new at this and there are many others who have been working in leadership roles for far longer who know much more about the APTA.  I was just recently elected into a two-year term as a Delegate for the 2023 and 2024 House of Delegates Cycles and have only attended one House of Delegates meeting so far. This is my understanding of things and my experience- it’s true to the best of my knowledge.  If I'm wrong, for sure someone should tell me!  

Let’s talk about Delegations first.

I've come to understand the Delegation to be a little like the US Congress, but instead of two separate chambers, ours are combined.  In US politics, there’s the Senate with two Senators from each state, and the House of Representatives, with number of representatives based on population of the state. In the APTA, all the Academies/Sections (think specialty areas of practice: acute care, pediatrics, geriatrics, orthopedics, etc) have two votes, and the Chapters (each state and Washington DC) have representatives based on the number of APTA members in that state.  Link to see full apportionment list by state, but here's a tiny snapshot of the top of the list:

Just like in American politics, states with more members have a bigger impact on the direction of the profession. States also have Alternates, which was my role, which are included in all the regular meetings, but don’t vote unless one of the elected delegates isn’t available. According to this document, there were 73,525 members in the APTA as of July 2021. This includes professional Physical Therapists and Physical Therapist Assistants, but not our student members, which push our total membership closer to 100,000. I was curious, so I looked for comparisons from other large medical associations and found that the American Medical Association has about 250,000 members, the American Dental Association has about 160,000 members, and AOTA, the American Occupational Therapy Association, lists about 65,000 members. 

Delegates meet with their Delegations throughout the year, led by their Chiefs. Regionally, Chiefs gather at regular intervals to discuss what’s happening across the country and what groups are working on at their local levels. The whole group meets annually at the House of Delegates, led by a Speaker of the House. The purposes of the House of Delegates meetings are 1) to elect new officers to the Board for the APTA, 2) to debate and vote on motions to move the profession forward, 3) for the elected leaders of the Association to have opportunities to meet, network, recognize individuals who have done impactful work, and 4) learn about different topics related to leadership.  This year, House of Delegates was embedded into an entire Leadership Conference, including many students as well as the Delegates. If you want to find out who your Delegates are, you can search the rosters here. 

I've said Delegates too many times already...  So how about some of the work they're doing? How does a motion come to be?  In January, the elected representatives from Washington met for our regularly scheduled monthly meeting to brainstorm ideas for work that we would like to see done by the Association.  We came up with several possible ideas and broke off into smaller groups to do some early research on the topics, come up with basic rationale for why we felt the concepts were important, and then expand the concepts into more detail at subsequent meetings.  The group voted on each idea, deciding which ones we wanted to dedicate our time and effort to, and which ones did not seem to be optimal for continued work.  This year, Washington presented three motion concepts to the House of Delegates and members of our group spent about six months working on them. 

An important piece of motion development is collaboration with other Academies or Chapters.  Consider that priorities around the country differ, payment models are not the same state by state, challenges to patient care practices differ depending on the Academies and variation between settings.  So early on, we identified potential groups that might be helpful as co-makers to the motions, helping to develop statements in support, who would likely want to pursue the same outcomes.  For our three motions, we collaborated with three different Chapters and one Academy as co-makers.  I primarily worked on RC 16-22, APTA as an LGBTQIA+ inclusive organization in collaboration with the Academy of Leadership and Innovation and PT Proud, which ultimately passed by over 90% vote.  

There's a whole process that the Chief facilitates to take the motions and escalate them up the chain of the APTA to be reviewed by a Reference Committee (which I think makes sure we're not going to violate any of our own previous rules and regulations or any laws, and gives input on the language being used) as well as sharing the motions with the rest of the country's delegates for feedback and discussion.  Washington's Chief, Murray Maitland, had to do a lot of work to get our three motions reviewed and heard on the floor. Over time, updated versions are developed and the content and language can change until the minute it is debated on the floor of the House and voted on.  

This year the House had 22 motions up for debate, but did not end up completing the whole list, running out of time.  The whole operation follows Roberts Rules and Parliamentary Procedure and stays on time with an agenda - which can be amended - but which this year's delegation voted not to amend to increase the time.  It was really unfortunate because there are some really important issues that were waiting to be voted upon.  I pretty much live-tweeted the House of Delegates so you can find a barrage of my tweets from August 14th and 15th from me sharing how things were progressing as we worked through debate and voting.  

I could probably write a small book about my experience at the House of Delegates, but since I will

 Bringing RC 16-22 to the floor for vote

now have two more to attend in the future, I think I'll save those for another day.  It was incredibly exciting working on an important motion that will hopefully improve Diversity, Equity, and Inclusion in our profession.  It was amazing meeting the physical therapists who have worked so hard to shape our profession for many years - and who the leaders of tomorrow might be.  I hope this is helpful to anyone who is considering APTA membership. Know that your state IS impacted by your membership and that a small group of new members could influence how many delegates your local group has to vote on issues in the future.  I also hope that it helps more people to understand what APTA Delegates do - so if you have an issue, APTA member or not, find your local Delegates and share your concerns so they can try to help.  Feel free to reach out to me if you're looking for ways to get involved!

What Do Physical Therapists Do? Installment #7: We Collaborate

Today is my three-year workiversary at Seattle Children's Hospital.  To celebrate, this blog post will be the newest edition on my "What Do Physical Therapists Do?" series where I'll share a recent experience collaborating with a non-PT colleague. I've previously written six other posts regarding things that PTs do: those can be found here. I think there are many careers or jobs which encourage collaboration, but the variety of people I work with is so vast, that its worthy to give this some consideration.

One of my favorite parts of working at the Seattle Children's North Clinic is the way the rehab work space is organized.  I share my work area (documentation space and the gym) with my colleague sports physical therapists as well as rehab physical therapists, occupational therapists, speech language pathologists, and rehab aides. My desk faces the rehab PTs desks.  They treat an entirely different patient population than I do.  I'm so grateful that there are PTs who do what they do, because despite what my license says, that work is not what I was meant for. They're amazing clinicians.  It's no secret in my office that I struggle to work with shy kids.  I fill awkward silences with awkward conversations.  The rehab therapists can spend an hour working with children who do not communicate at all.  It's amazing. They make rehab into games, balancing on one foot while playing connect for or pretending to be dinosaurs or avoiding lava while they're walking across balance beams or completing obstacle courses. They use the same equipment I do and I absolutely steal their ideas to use with my patients.  My fellow Sports PTs also come up with creative approaches towards rehab.  We don't have a sled in the clinic which is a tool you can use to load up some weights for patients to push or pull to build up some leg and core strength and endurance.  One of my coworkers has become the sled of the office - kids drag him while he holds onto a jump rope with his feet on sliders.  I'm too scared to attempt that one, but for sure I steal from my colleague Sports PTs in numerous ways. Call it collaboration or call it learning or call it stealing ... whatever word you prefer, being around this group of providers helps us all learn.

An OT, PT, and SLP collaborating at the North Clinic

I recently worked with a patient who had pain related to prior surgeries on their face and mouth. I have previously worked with patients with jaw pain and cervicogenic headaches and concussions, so this body region isn't too unfamiliar to me, however her condition was unique and I wanted to give tongue exercises as part of her home exercise program. I needed help, so I went straight to the speech pathologist who sits three desks away to get recommendations for my treatment plan.  She was super helpful in considering my thought process for a patient who didn't fit into her usual case load either.  There were no language issues involved. But her knowledge of the way the face and mouth work combined with my understanding of strengthening principles and chronic pain were a perfect combination to help this patient.

Beyond my coworkers, I also work with a huge variety of healthcare providers and non-medical personnel.  This includes community pediatricians, orthopedic physicians and surgeons, athletic trainers, rheumatologists, mental health providers, podiatrists, biofeedback technicians, anesthesiologists, neurologists, interpreters, adolescent medicine, social workers, supply chain workers, family service coordinators, the billing department, nurses, medical assistants, our information technology representatives (without which I'm sure I would have somehow made a computer blow up by now) and occasionally oncologists, endocrinologists, and cardiologists. Of course let's not forget the most important people we collaborate with: the patients and their families!  I have previously written about how important I think therapeutic alliance is several times such as here, but this is just another excuse to mention how much I love connecting with patients and people in general. The rehab PTs work with a different set of providers than I do, adding in durable medical equipment contractors, prosthetists, school and community resources, and certainly many more that I'm not even aware of.  It's really cool to have this large of a network to interact with, particularly because the human body is so complex.

And so, in celebration of my workiversary, I'm really excited to share another edition of "What Do Physical Therapists Do?"  Without question, this field encourages collaboration.  My experiences are certainly unique, but this is just one of many ways to say that communication skills are essential in healthcare. It is also an extra opportunity for me to give thanks for all the people I work with, including my patients and their families.  For sure I am a better physical therapist because of all of you.

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. 

Do No Harm.

This week on the social media interwebs, I saw a startling video of a rehab session of WNBA Player Angel McCoughtry. Angel is a two-time Olympic Gold Medalist and five-time WNBA All-Star who plays for the Atlanta Dream. She's a star on the basketball court.   The first time I saw her play in person was when her Louisville Cardinals lost to UConn in the 2009 NCAA Women's Basketball Championship in St. Louis but I've easily been watching her play since 2005 when Louisville entered the Big East Conference... she's a really fun player to watch, very dynamic and energetic.  I saw Kevin Garnett play in Boston for the first time after I had seen Angel play and thought he reminded me of her.  Unfortunately, Angel hurt her knee towards the end of this past WNBA Season and required surgery - information she posted on her social media pages.

Last week, Angel posted this video of her recent rehab session on her twitter and instagram accounts:

It’s easy to see the glits and glam of success , but this is what it looks like behind closed doors! pic.twitter.com/dtjy28QRmU

— Angel McCoughtry (@angel_35) February 14, 2019

I'm speechless watching this. It takes a lot to make me speechless... but this did the trick.

I'm not treating Angel's knee condition so I don't know what she's gone through to this point - or what the goal of this particular moment is - but I can make some educated guesses based on my work as a physical therapist and with women's basketball players.

Trying to bend a joint past what it is able to do is incredibly painful. The mobility is necessary, so it's possible that this rehab team has tried numerous other options before using this technique to try to get her knee to bend sufficiently. I'd have no way of knowing, but I do know that even if I had tried everything I could think of - this would not be in my list of treatment options.

There are many studies that show the need to have symmetrical knee mobility (both sides bend and straighten the same amount) to have normal walking pattern which would translate to normal running pattern.  However, this paper also examined the number of post-op ACL patients who don't get back their full mobility and found it to be 11% in a sample of 244 patients. This paper discusses the way that scar tissue build-up in a knee is classified and what is generally done if physical therapy intervention is insufficient.  Asymmetrical mobility increases risk of injury - and nobody wants that.  While I agree that she should have matching mobility on both knees, the method being used to achieve this seems inappropriate.  I have never done this in over four years as a physical therapist and, when I saw the video, I distributed it to several other physical therapists and athletic trainers, all of which agreed that there are numerous better ways to achieve the goal they're trying to achieve in the video.

It looks like someone is trying to make Angel's knee bend more than it currently does.  Knee flexion (bending) is a challenging thing to achieve sometimes, particularly after surgery, and sometimes it even requires an additional surgical treatment called a manipulation under anesthesia, in which a person is medicated so that they won't feel it when their knee is forcefully bent all the way to restore full motion.  These can be incredibly painful procedures and with the WNBA season starting in just about two months, nobody would want her to have another surgery when she;s starting to get back onto the basketball court to prepare for the season.

This research article from 2008 uses a similar position to try to get knee flexion but describes the need to hold the position for extended periods of time - at least 10 minutes - and notes that having a physical therapist apply this type of sustained hold is incredibly fatiguing to the therapist so it recommends using belts on a table to achieve long duration, low load stretching.  However, it also specifically states that the hold should be to the tolerance of the patient and may be a little uncomfortable.  I would argue that the session in this video is not to the patient's tolerance and is therefore harmful.

These papers: 1, 2, 3, 4, 5, are just a few which suggest alternative ways to achieve the same goal - or the last one talks about the lack of evidence to support what's going on in the video. A brief summary of each:
1) An alternative technique to use to try to gain knee flexion range of motion
2) Another alternative technique to use to try to gain knee range of motion
3) A list of manual therapy options with photos from a University of Kentucky physical therapist - none of which are what is used in this video.
4) This is from the PhysioPedia which includes videos that even include knee flexion in the prone (face down) position like the one in Angel's video, however you will notice joint mobilization is being used rather than just a cranking technique, and, if your sound is on, you will also notice an absence of apparent pain.
5) This is a much older paper from 1992 that looks at ways to change the length of connective tissue (like the ACL or capsule around the knee joint) which is composed primarily of collagen.  It describes that there is not sufficient understanding of how much force would need to be applied to make change in length of these tissues - but that if that force were measureable, it would require some amount of damage to the tissue.

So, if you're receiving physical therapy treatment and you're experiencing pain during the session that feels like it is harmful to you, tell your provider to STOP.  Sometimes treatment may be uncomfortable - and that's ok - but if you're yelling out, that's not ok.  You should ALWAYS feel like the treatments you are receiving are helpful.  You should ALWAYS know that you have the say of what is being done to your body.  And you should know that you ALWAYS have the right to ask why something is being done to you - and if there is another way it can be done.  Because in this case, I strongly believe there are alternative ways that are safer, more effective, and that do not look like torture.  Physical therapy gets a bad reputation because the abbreviation, PT, also is jokingly referred to as Pain and Torture.  This is wrong.  And if you feel like your PT session is more like pain and torture, please get another physical therapist.  We take an oath to Do No Harm.  The Hippocratic Oath of healthcare providers.  We should be living up to our oath.

Wishing a very speedy recovery to Angel McCoughtry.  I can't wait to see her back on the basketball court. And I hope her rehab is not painful in the future.

Basketball Bucket List

Sometimes I write about basketball.  This is one of those times.

Do you ever write a list of things to do for the day, and then when you realize you've completed something that wasn't on the list, so you add it on to feel like you've achieved more tasks?

I have a bucket list....places I'd love to go, people I hope to meet, events I'd like to attend, even some personal accomplishments I'm striving to achieve.  I started the list the day after I met Michael Jordan because I realized that meeting Michael Jordan would have been on a list if I already had one.  Like when I go about my day running errands and then realize I did my laundry but it had never been on the list!  I wrote the list in 2009, but added things on there I had already accomplished, because they would have definitely been on my bucket list if I had written it sooner.

Michael Jordan

Michael Jordan played in the NBA from 1984 (the year I was born) until 1993, then again from 1995-1998, and then from 2001-2003 (the year I graduated from High School).  I started watching UConn Women's Basketball in the 1990's and definitely was not watching the NBA while MJ was playing.

Sometimes events transpire that make it impossible for me to check off an item on my bucket list.  For example - I never had the opportunity to meet Pat Summitt, legendary women's basketball coach at the University of Tennessee.  When I was in college, I disliked her for what she represented and for the rivalry between our teams, but as a fan of women's basketball, I now appreciate that she made significant contributions to women's basketball that have allowed me to experience many incredible opportunities.  Knowing I'll never meet her is a big disappointment.  Watching Michael Jordan play NBA basketball is another thing I'll never achieve. Bucket list failures. Never to be checked off the list.

I don't want this to happen with other trailblazers and superstars in the basketball world.  I want to meet so many people and watch many others play in person. My first NBA game was in Boston and I remember seeing Ray Allen and Kevin Garnett and Paul Pierce plaing together and dunking.  Kevin Garnett had always been portrayed like a bit of an animal - and his energy came across even bigger than that at the Boston Garden. They were SO big. SO athletic. SO much higher up in the air. And, in the moments when they made an amazing play, the world seemed to slow down for a few seconds.  But those were just moments.

It was on my bucket list to watch Kobe Bryant play.  I bought tickets to the Lakers @ Nuggets game while I was on clinical rotation in Denver on March 7, 2014.  He did not arrive with the team and was announced to be out for the rest of the season with a knee injury. I'm pretty sure he had a tibial plateau fracture.  It made me really sad to miss that opportunity because, just like taking a photo of the mountains - the scale is changed when you look at things through a screen.  I needed to see him in person.  He retired from basketball and I'll never get to see it.

This past weekend, I headed to Oakland, CA for the Golden State Warriors versus the Los Angeles Lakers.  If I couldn't see Kobe, at least I could see LeBron James in action. He's the greatest of my time.  But LeBron didn't play this past weekend. Bucket list fail. Again.

LeBron was taking the night off for "load management."  The Storm Strength and Conditioning Coach who was with me for the game said to me, "Well, LeBron's old, so that might start happening a lot more, now."  Excuse me, WE are not old!  His glory days are not yet over.  I'm not crossing it off my bucket list yet because it can still happen, but I feel like I've had three basketball bucket list fails. I was disappointed that I missed a chance to see one of the greatest men's basketball players of all time playing live, but I loved the reason they used.  As a phyical therapist, all I really do is load management.

My favorite thing about LeBron James, beyond the fact that he's an amazing basketball player, is that his birthdate is December 30, 1984.  Two days after my own. So, really, the only differences between me and LeBron James are two days and a few dollars.  Nothing else. Ha!

It hurts too much when you run, but you can tolerate walking?  There's a load you can manage.  A ten pound bicep curl hurts but five pounds doesn't?  We've identified a load you can use.  "Shin splints" from ramping up your training volume too quickly for a marathon?  Improper load management could be to blame. If you had to define what physical therapists do in two words, I think it would be appropriate to say, we "manage load."

So... while I'm bummed that LeBron didn't play, and I don't know that I'll ever get the chance to see him again, I'm glad to know that the Lakers are at least using terminology that makes sense from a rehabilitation perspective. 

Enough of the bucket list fails. I've also had bucket list successes.  The basketball bucket list includes a ton of women's basketball opportunities and must-see/must-meet experiences, and that's where my heart truly lies.  Also, this week (February 6, 2019) was National Girls and Women in Sports Day.  This is a special day that gives a chance to pay tribute to the women in sports who have helped paved the road to allow for more opportunities for girls and women in sports today.  I've previously written posts here and here about women in sports and am so grateful to those who have paved the way.

Attending a UConn National Championship win in person would also have been on my bucket list, except I wrote the list after having that chance.  My freshman year of college, the team won, but I wasn't traveling with the team.  I had attended the National Championship in 2006 when the University of Maryland - with current Seattle Storm power forward Crystal Langhorne - beat Duke University in Boston. It was incredibly fun, especially because I've always loved the Maryland Terrapins and was so close to going there myself - but it wasn't my team.  So when a group of us were able to attend the 2009 National Championship in St. Louis, MO when UConn beat Louisville, it checked off a box on my future list.

The NBA has been around much longer than the WNBA, so where I didn't have the chance to see the pioneers of the NBA, it's an entirely different story for the WNBA. I saw Rebecca Lobo play live basketball. And Lisa Leslie.  And Tina Thompson.  And Katie Smith.  And Sheryl Swoopes.  And Katie Douglas. And Becky Hammon.  And Nykesha Sales.  And Kara Lawson.  And Tamika Catchings. And Lindsay Whalen.  The pioneers of the WNBA.  In most of those cases, I didn't just get to watch them play some exceptional basketball, I also met them, occasionally had meals with them, traveled the world with a few of them, and got to learn about basketball and how the women's basketball world works.  The game that they play is the same game the men are playing.  But the women's basketball world is not the same as the men's basketball world, and having an appreciation for how hard these athletes are working year-round is inspiring to me.

There are still basketball related items to check off my list.  I'm working on those.  If given the choice to watch the Golden State Warriors versus the Los Angeles Lakers, including a healthy LeBron James - or the Seattle Storm versus the Phoenix Mercury of the WNBA... I'd pick the WNBA game EVERY SINGLE TIME.  If you haven't been to a game, the season is coming.  Reach out and let me know when you want to go.  Add it to your bucket list.  Let's make it happen.

Anatomy Semantics

I got an email from someone who has recently gotten into a regular workout routine, trying to get into better shape with some weight loss and increased strength.  He was wondering if I would look at the program he's been using for a while and make some recommendations on how it could be improved for better gains.  The program was made from snippets he put together from men's health magazine.  So we set up a phone call to go through the program.  I've previously written a little bit about strength training in this post, entitled "What do physical therapists do? We Strength Train."

Biceps - Two Muscle Bellies 

The strengths of the program he already had going were three:
1) He was regularly participating in exercise and the workouts were planned and programmed with ways he could progress them.  In my opinion, the best training program is one you will do consistently.  But once you've got consistency down... all programs are not created equal.
2) Pretty much all the body parts were covered in some way.
3) He had learned to squat and deadlift.  Though we've previously worked on his form via Skype when he was having some pain doing it.  I had him using a broom in his house to hip hinge and weight shift and change his set up and we had a blast doing that probably two years ago.

The key weaknesses that I noticed were:
1) The program was separated out into six different days: arms, shoulders, chest, back, legs, and core.  He spent 1 hour focusing on that body region when he did that training day, and he strength trains about 3 times per week.  Because of that, each body region was only getting targeted twice per month - and that was only if no days were missed due to scheduling complications.
2) There were several single muscle exercises including wrist curls and wrist extensions or hamstring curls that would be fine for some training goals, but really didn't optimize him reaching the goals he stated.  In my opinion, these take up time and energy from bigger bang-for-your-buck activities.  They have a place - and I use them with patients sometimes - but in general I'm team multi-joint exercise.

Triceps: Three Muscle Bellies

3) There were no single leg activities.  I use single leg exercises a lot with patients and have also written about the seven key movements a la John Rusin here. squat, deadlift, lunge, upper body push, upper body pull, and carries.  One of those key movement patterns is the lunge... and this program didn't include those. I really like single leg activities because it gives you a chance to work on balance which also incorporates the core and because it changes the stability demands that aren't present with a double leg exercise.  Also, life requires us to operate on one leg fairly often - going up/down stairs, walking, a curb, getting in/out of the car, playing sports... it's functional to train on one leg.  And when I mentioned this, he noted that he didn't like single leg exercises because of poor balance... soooo obvious solution.
4) It was a very high volume program... three sets of 15 for each of five different exercises that he then repeated a second time through.  He probably got some cardiovascular system development from this scheme, and maybe even some muscle toning, but felt that he wasn't making considerable strength gains, which makes sense.  With a volume like that, you're not recruiting enough muscle fibers.

Since he has no background in strength training or anatomy, we discussed some of the key concepts of training.  Ideas like the three planes of the body, push versus pull, horizontal versus vertical actions, pairing exercises a little more purposefully to either alternate body parts: like a bicep curl to a triceps extension or to overload the same one in different ways.  And then he said - "Oh ya, I've been meaning to ask you about that.  I recently was thinking about muscles while working out and wanted to know more about the semantics of the names biceps, triceps, and quadriceps. Bi = 2, tri = 3, quad = 4... of what?!" This was the moment. 

Quadriceps: Four Muscle Bellies

This was the moment when I realized that there have to be loads of people who go through life never studying anatomy or how the body works.  Working in pediatrics, I generally assume my patient population has not yet learned about anatomy.  Most haven't. Some know a little from playing sports.  But I've taken at least seven anatomy classes in my life and didn't think it was possible for an adult to have gone through all of their schooling (he has a bachelor's and two master's degrees!) without ever taking anatomy. I don't know how to write computer code or how to wire a light fixture or fix a leaky sink... why should I expect that everyone understands basic anatomy?  We're all capable of learning these things... but we don't all know them.  Talk about being a bit close-minded!

This was the moment I realized how much education it takes to be a physical therapist.  This is the moment I gained new appreciation for how people can really hurt themselves when they don't know enough about the human body and try to load it - whether intentionally through training, or unintentionally overloading through sporting activities or daily activities that their body isn't prepared for.  This was the moment when I realized that personal trainers, strength coaches, physical therapists, and anyone else suggesting exercises to clients or patients needs to understand how the body works and the concepts that the clients should understand to be more independent in helping themselves.

And so I taught him about the difference between the biceps, the triceps, and the quadriceps.  The body actually has two different biceps muscles - the biceps brachii in the arm and the biceps femoris in the back of the thigh. "Ceps" comes from the latin word caput which means head, and so each of these muscles has multiple heads.  The biceps of the arm has two heads - also often referred to as muscle bellies.  The triceps on the back of the arm has three muscle heads.  And the quadriceps of the front of the thigh has four muscle bellies.  I had to send him pictures to show what I was talking about because just saying the words was meaningless.  These muscle clusters are named as a group because they work together to elicit the same action. For example, the quadriceps, as a group, straighten the knee.

Combine the new basic knowledge of what a muscle looks like with those key concepts we already discussed such as the three planes the body can move in - front to back, side to side, and a rotational plane and how muscles work in certain directions and how important it is to consider all the directions for a well-rounded program.  We discussed some of the basics of muscle growth - and how there are muscle fibers that are more meant for endurance like high repetitions - which is what he had mostly been doing, but also muscle fibers that focus on strength and need to be more overloaded with heavier weight to use those, which had been missing in his routine.

I really enjoyed this conversation because it opened my eyes to the reality of the world... how could I have thought so many people understood these concepts which just come so much more naturally to me!?  I can't wait to take the opportunity to help more people better understand how their body works.  I also enjoyed the opportunity to educate someone so they can make changes to their workout program and develop a plan that could be more effective, and that they can modify independently.  I'm not an expert in training programs, but now he has three options of workouts and can hit each body region at least four times per month, he has a better understanding of how to change reps/sets and that there's a reason to choose these, that he probably was under loading himself, and that above all else, he has found the number one key to training: consistency.  Just by training regularly and making it part of his weekly routine, he's already miles ahead of everyone on the couch.

Can't wait to see what kind of results he gets!

What Do Physical Therapists Do? Installment #5: Emergency Response

REI Seattle Outdoor Space

Welcome back to the recurring segment on the blog: "What do Physical Therapists Do?"  I've previously written four other posts on this topic, all tagged with #WhatDoPTsDo so you can search the blog for those previous posts if you're interested.  I spent the last two days getting my certificate in Wilderness Emergency Response and First Aid hosted by the REI flagship store in Seattle.  (Beautiful fall weather and somehow managed to get out of there without buying anything!)

Before you get too far into this, you should know that in general, many physical therapists are not trained for emergency response care.  As trained healthcare providers who usually have training in CPR and First Aid, I would think that a physical therapist would be better in an emergency than someone without any training - but in general we're not trained for emergency response.  But we can be!  This is a key difference between physical therapists and athletic trainers where, generally, physical therapists are not present when an injury occurs and help rehabilitate the injury days or weeks (or sometimes much more time) later.  Athletic trainers are specifically trained to respond at the time of an injury or to an onset of illness to the athletes they work with. There are many ways in which PTs and Athletic Trainers With regard to urgent response, athletic trainers and educated physical therapists also differ from EMTs in many ways.  In the case of an emergency, 911 is still your best bet, but since I just attended the course, I thought I'd share why I would learn about emergency response and some of the tips and tricks I learned.

The class was structured with didactic learning intertwined with case scenarios.  We'd learn how to assess a patient and then practice in groups. Then we'd learn about various signs and symptoms of different conditions and then assess patients again.  There were numerous repetitions and they even used makeup to make bleeding/bruising so that you were looking for injuries to treat.  Conditions we discussed included musculoskeletal injuries - like I'm used to treating - and special focus on injuries to the spine, plus wounds, burns, weather-related conditions, abdominal pain, chest pain, allergic reactions.  We learned basic treatment techniques to help determine needs for evacuation/emergency care as well as splinting and wound care.

Fake Makeup Hand Injury

Why would a physical therapist get trained in emergency response?  Many physical therapists are also athletic trainers and, as such, need to keep their education current to best treat urgent cases.  There are, however, PTs who are not athletic trainers who also provide sideline coverage for sporting events (like myself with the Seattle Storm) and who can take these advanced courses in order to work towards board certification as a Sports Certified Specialist Physical Therapist.  For me, personally, I was also an EMT in my previous life and have always loved learning about urgent response.  I like knowing that I can be a helpful resource in an emergency situation.  The courses are also great reviews of basic anatomy and common illness or injury situations.

Key tips and tricks I learned in this course:

1) If you ever come across a person or group of people who are in need of emergency response, you must first make sure that the area is safe.  Otherwise you risk becoming an additional victim!  A person who fell off their bike in the middle of the street or someone who experienced a snake bite are both scenarios in which you could be putting yourself in danger and need to consider the surroundings before you can really provide adequate care.

2) Once the surroundings are determined to be safe, start with the key life threatening findings which are remembered by ABC.  Airway.  Breathing.  Circulation.  If a person is sitting up and talking to you after an injury - their airway is open and they are breathing and have a pulse - but you should still look for major bleeding that can impact circulation.  Nothing else matters if the person does not have an adequate airway, respiration, or circulatory system because those are life threatening situations.

3)  Medicine happens at the skin level.  This is something that was discussed a lot in PT school and I appreciated this reminder.  If someone says their shoulder hurts - LOOK AT THEIR SHOULDER! I remember a case we discussed in school where a patient came to PT complaining of back pain.  He went to the doctor first, was given pain medications (that weren't helping) and was sent to PT.  The physical therapist started their examination by lifting up the shirt to look at the back and see if there was any bruising - only to find a large rash.  PT wasn't going to help that condition.  Once life threatening conditions are ruled out, an injured person should be assessed from head to toe and any pain region should be exposed.

4) Failing to prepare is preparing to fail.  Take a first aid kit with you when you go hiking or backpacking in the woods.  At the very least, have the ability to splint an injury, protect injured skin, and stay hydrated and energized with enough water and food.  And always tell someone where you're going and when you should be back.  If you don't return by a certain time, they should send for help because if you're stuck in the wilderness with a major injury, you're going to need help.

5) Injuries may be easy to see, but illness may not be.  Things like heat exhaustion, altitude sickness, hypothermia, allergic reaction, diabetic emergency, or a heart attack are hard to identify if you don't know what to look for.  If you're concerned about someone feeling poorly but you can't see anything - you're better off calling for help!

I hope this is helpful if you ever find yourself in a situation where someone needs emergency care - but know that this was a 5 minute overview of a 2 day course, and that my EMT training was weeks long with ambulance calls and real life response training.  Again, you should always call 911 in an emergency situation, and only help a person in ways that you have been trained to do so.  If you're an adventurer, you should probably take a course in emergency response and/or first aid, whether or not it's specific to the wilderness, because many of the principles are similar.  I hope you go learn all this information and never need to use it!

What Do Physical Therapists Do? Installment #4: We Return Athletes to Sports Participation

Welcome to the fourth installment of "What Do Physical Therapists Do?" I chose to use this as a recurring segment because there are several common misconceptions about what we actually do, probably because we do so many different things! This 2006 paper noted that over 1/3rd of participants surveyed (college-aged potential physical therapy students) were unaware of PTs' ability to help decrease pain and promote health. That same paper mentions the lack of knowledge of the general public regarding the amount of education required to be a physical therapist and what that training would include. 

Overall, the key underlying action of a physical therapist is guiding our patients or clients back to their optimal function - whatever that function may be.  I often feel like people think our primary purpose is to help people get out of pain, despite the report from the previously mentioned 2006 paper.  While pain relief is a consideration, it's really more about the activities. So this recurring segment looks at various ways we help people get back to their chosen functional activities.  In the past, I've discussed that we strength train (#3) here, we listen to the needs of our patients (#2) here, and we examine body mechanics with different movement patterns (#1) here. 

One of the most common questions I'm asked by patients and their family members is "When can I get back to X activity?"  In this scenario, X can be anything.  Some are obvious functions or activities that aren't surprising... when can I run or exercise, when can I lift my toddler, when can I go back to work, when can I walk without crutches, when will I be able to reach the top shelf of my closet... an endless list.  Some activities have been less obvious (or less sensible)... when can I get back to head-banging at concerts was a surprising question I've been asked by a gentleman recovering from neck pain after a car accident.  It surprised me - but that's what he wanted to do.  And why a teenager who had a severe injury on a trampoline would ever want to get back onto a trampoline shocked me... but they ask! (Side note - if I ever have my own children, I hope to find a way to ban them from trampolines.  SO MANY injuries.)

The activities are frequently sports-related so it is a responsibility of a physical therapist to clear athletes to return to sports. This week, I was fortunate enough to present the new Upper Extremity Return To Sports Assessment that will be implemented at Seattle Children's Hospital to the Sports Medicine Team of Physical Therapists and Athletic Trainers.  The program we developed has not yet been thoroughly tested despite being based on published research, so it's still a work in progress.  It includes a group of tests to assess athletes who have had upper body injuries and/or surgeries as criteria to get back on the field/court.

Seattle Children's Hospital already has protocols for returning kids to sports after ankle and knee injuries, so we had a template to use of what has been helpful in the past.  I like using the lower extremity assessments because they make it easy for a kid and their family to understand that they can go back to their sports when they pass all their tests. There are benchmark goals that help them progress in activity as you go along so having a series of tests at the end fits into the way things progress along the way.  Using tests and goals motivates patients.  For example, with consideration for surgical protocols and healing timelines, I tell kids that they can stop walking with crutches when they can stand on their injured leg for 30 seconds with steady balance and when they can complete 10 straight leg raises without any bend in their knee.  Those are usually components of their home exercise programs and they often know if they're getting better and coming closer to meeting the goal. The goals help motivate them to work on their home exercises and they're measurable.

Did you know that if you are a healthcare provider - of any kind - and you clear an athlete to return to sports prematurely, you can be held liable if they get re-injured?  You can.  Did you know that a physician who clears an athlete back to their sports usually bases this on a tissue healing timeline whereas a physical therapist who clears an athlete back to their sports bases the decision on movement mechanics and other test criteria - such as the tests in this protocol - to make the decision?  Something I find interesting about myself as a healthcare provider is that I rarely tell a patient to stop participating in an activity if they're tolerating it enough - but when it becomes my responsibility to allow them to return to a sport that a physician has discontinued their activity from, I'm much more confident in my decision if they have to complete tests showing they're ready in a controlled environment.

A basic summary of the categories of tests included in the protocol for upper extremity injured athletes returning to sport are as follows:
1) Range of motion comparison between shoulders with consideration for the total arc of motion for internal and external rotation.
2) Strength testing comparison for shoulder internal and external rotation as well as for grip.
3) Endurance testing observing how many push ups can be done with proper form.  There are published normal values for this test by age and gender and, in the USA, this is part of the physical fitness testing conducted.
4) Upper body stability testing including the upper quarter Y Balance Test and the Closed Kinetic Chain Upper Extremity Stability Test
5) Power assessment using a seated shotput test.
6) Biodex testing as available.

Using numerous published papers on each of these tests, criteria were developed and the sports medicine crew at Seattle Children's will start to use the tests to determine if kids are ready to go back to their activities.  There is still not enough published evidence for returning athletes to sport from any injury, so developing a protocol like this is not only challenging, but needs to be supported by clinical judgment.  If you or someone you know is being treated by a physical therapist to get back to playing sports, you should ask them what criteria they use to determine if you are ready.  Feeling good and being pain-free isn't enough and we want to prevent future injury as much as possible.

What do Physical Therapists Do: Installment #3 - We Strength Train

© creativecommonsstockphotos - ID 96113980

In the first installment of "What Do Physical Therapists Do? We Look at Mechanics," I described an experience with a patient who came to Seattle Children's with doctor's orders to do a biomechanical assessment to clear him for return to sport and discussed how it is our job to be "movement specialists."  In the second installment, "What Do Physical Therapists Do? We Listen," I touched upon the biopsychosocial model and the importance of considering the psychological stressors in addition to the internal biological influences on pathology.

Today I'm back with the third installment: "What Do Physical Therapists Do? We Strength Train."  I don't mean that we necessarily pump iron... although I do like to lift heavy things from time to time. Earlier this week, for example, I carried my ~50 pound kayak overhead about 1/4 of a mile to put it into the water... some overhead pressing would probably make that a bit easier.  It would be even cooler if I could suitcase carry it - but so far I'm not able to.  Some of my PT coworkers lift. Others do yoga, or ride horses, or ski, or hike, or play hockey, or lacrosse.  In general we're an active group which helps us to better understand how the body moves.  I once had a clinical instructor tell me that I should try out (or at least watch) any activity available so I could best understand where frequent injuries in that activity could come from and see the things the body is capable of.  It led me to take a snowboarding lesson and watch sumo wrestling - talk about immensely different ways for the body to move!  But that's not what this is about... I'm talking about what we do for our patients.

A common (and essential) physical therapy treatment is exercise.  Exercise covers a wide variety of topics, so the focus today is on strength training.  I'm not here to debate whether or not soft tissue work improves mobility of tissues or has neurological effects or changes the chemical composition of body tissues.  I believe all of these things happen to some extent and know there is debate in the literature on this topic.  Regardless of how soft tissue treatments are applied and what is happening in the body, after some mobility work is completed we need to load our patients. Here's why this is a problem:

Physical therapists guide their patients in strength training exercises but, in my opinion, we barely touch on the basic principles of resistance training and we certainly did not apply them sufficiently in PT school.  Earlier this week, I passed the Certified Strength and Conditioning Specialist (CSCS) exam by the National Strength and Conditioning Association (NSCA). "Certified Strength and Conditioning Specialists are professionals who apply scientific knowledge to train athletes for the primary goal of improving athletic performance."  Some of my patients are not participating in athletic endeavors, but all humans are athletes and all athletes are humans - so we need to treat them as such.  (I can't remember where that line came from - it's not mine, though).  So physical therapists serve a similar role as strength coaches in many ways.

While preparing for the CSCS exam, I was overwhelmed by how much I didn't know. When checking the literature for articles about physical therapists and strength training, I came upon this 2016 article entitled "Periodization and physical therapy: Bridging the gap between training and rehabilitation."  The paper also presented the basics of resistance training and the similarities and differences between physical therapy rehabilitation programs and strength and conditioning programs.

Both physical therapists and strength coaches apply the General Adaptation Syndrome.  "Physical activity is better described as a physiological stressor... when physical activity is properly dosed in individuals who possess the physiological capacity to respond acutely, homeostasis is restored."  The idea is that the body has a baseline set point that it normally operates at and a threshold beyond which it cannot properly recover.  Exercise is one type of stressor following which the body moves away from its set point, towards a threshold, and needs to have processes available to return to baseline.  There are baseline settings for numerous things in the body, all of which can be influenced by exercise including: fluctuation in blood pH, stimulus of hormonal changes and immune responses, changes to the cardiovascular and respiratory systems, altered hydration status, potential tissue damage... the list of is extensive.  The body is generally amazing in its ability to adapt and respond to this variety of changes to return the body to its resting state.   However, if the stresses are too high, injury, illness, or death (at extremes) can occur.  The goal from physical therapy and from strength training is to operate within the boundaries of applying stress so the body can adapt to and recover without over-reaching.

How do you structure this into patient/client programs in a way that makes their threshold improve so they can do more work or lift more weight over time?  Both Physical Therapy and Strength Training use the concept of progressive overload described in Essentials of Strength Training and Conditioning as "progressively placing greater-than-normal demands on the exercising musculature - applies to training to increase bone mass as well as training to improve muscle strength."  For example, we start with a movement pattern such as the squat, and we train it as a movement with just body weight and then progressively load it with dumbbells or barbells and we fluctuate the variables of our training volume and intensity so that the body has time to adjust and adapt and learn.  This means that the homeostasis set point and the thresholds from the general adaptation syndrome are flexible and can be improved with the possible exception of someone who has reached their full genetic potential.

With consideration for progressive overload, strength trainers design training programs for their clients.  In my opinion, based on my observations in numerous clinics over the past 3.5 years, this is where the two fields diverge and physical therapists don't use the same principles.  When planning for resistance training, we can consider four target outcomes: 1) strength gains, 2) improved power, 3) muscle hypertrophy, 4) muscular endurance.  Programming for a specific target outcome means varying the volume (reps/sets), the load (percentage of maximum able to be lifted), frequency of training, and rest breaks.   To target these outcomes, those variables have been studied and summarized as follows:

Target Outcome	Reps per set	Sets	Percentage of 1RM	Rest
Strength	< 6	2-6	> 85	2-5 mins, full recovery
Power	1-2 or 3-5	3-5	depends but >75	2-5 mins, full recovery
Hypertrophy	6-12	3-6	67-85	30 sec - 1.5 mins
Endurance	> 12	2-3	< 67	< 30 sec

Also important to consider is Matveyev's model of Periodization which considers the preparatory phase (basically off-season), transition period (changing over from off-season to in-season), and competition periods, but the preparatory period is broken down into three more sections: hypertrophy and endurance early on, moving into a basic strength phase, and then more of a sport specific strength and power phase.  So understanding how to vary the volume and align it with time on the field or court is essential.  But in the PT clinic, we don't usually program or progress in this manner.  We may consider similar rep schemes and progressive resistance, but we don't typically use loads of this magnitude because we're rehabbing people who either can't or should not yet be lifting loads of that intensity.  At the end of the day, we're all loading up our patients/clients.

Lastly, consider teaching a person a new task such as a squat.  At first, regardless of reps and sets selected, the initial changes that person will experience will be the brain learning how to squat.  This is the same for any activity - your body needs to learn the pattern and get the neurons linked together before you can experience significant muscle gains, improvement in function, and changes in strength.  They may feel stronger or that the task is easier, but these initial changes are neuromotor.  In the context of pain, people move differently and their neuromotor patterns change.  So, since about 99% of the patients I treat are in pain, I'm basically coaching them to make neuromotor changes and as they go through that work, their symptoms resolve, and they're done with physical therapy (because insurance dictates this).  Thus, they have so much remaining potential for strength gains, endurance training, hypertrophy, power, agility, and all the physiological benefits that remain for a strength coach to guide them.  I'm a little bit jealous that I don't generally get to observe these adaptations in my patients, but I get to see them in my own training.

What do Physical Therapists Do? Installment #2: We Listen.

\

© Anatoly Tiplyashin

ID 595706 | Dreamstime Stock Photos

We listen to you describe your physical ailments.  This is usually what brought you in for treatment.
We listen to your stories about mechanisms of injury.  Many of these stories are fairly straight forward and simple.  Occasionally they're a hoot.  It's only funny if you're laughing, too.
We listen to how your pain or pathology affects your daily life.  Can you sleep?  Can you bathe?  Can you get dressed?  Can you drive? Can you work?
We listen to how your current issues are affecting your favorite activities. Can you run?  Can you jump?  Can you play a sport?  Can you read a book?  Can you do a hand stand?
We listen to you describing your family - in positive and negative ways: Upcoming weddings.  A new baby on the way. Divorce concerns.  Challenges with children and siblings.  Helping your parents with aging. Loss of a pet.
We listen to you telling us about your day or your week.  You just went on a trip? You just bought a new house?  Your favorite co-worker just quit?  You got a promotion?
We listen to what you've been eating, cooking, and the diet you're interested in pursuing.  Paleo, Whole 30, Keto, Weight watchers, Dairy Free, Nut Free, Gluten Free, South Beach, Atkins, 30/10, Low FODMAP, calorie counting, intermittent fasting, Kosher, Vegetarian, Vegan, The Purple Diet, Jenny Craig, Egg free, Mediterranean... so many choices!
We listen to your political views, and may have even cried together when our candidate didn't win the election.
We listen to you describe the books you're reading and maybe have read them...  like Dave Ramsey's financial stuff or some of the Classics - or 50 Shades of Grey. (and we might pretend we haven't read some of those, too!)
We listen to your dreams: getting into college, making the varsity team, writing your first novel, making first chair of your band, running a mile in a certain time, losing a certain amount of weight, owning your own company, traveling the world.
We listen to your troubles in relationships, financially, legally, negotiating obstacles, managing time.
We listen.

Why do we listen? We listen because all of these things can impact YOUR outcomes.  According to the biopsychosocial model of pain, if we didn't listen and find some of these issues to be relevant to your healing, we'd be neglecting an important part of who YOU are.  We listen because we care.  And because even though we're physical therapists, sometimes the name therapist is all you hear  - or care about - or need - and that's ok.  We're happy to help you.

Just know that at some point after I'm done listening to you, you're going to get moving, lift heavy stuff, and get to healing.