The Government is After Me!

Photo Credit: Michelle Vieira at London 2012 Olympics

This morning I have a long layover at JFK airport en route to Africa!  As I've been observing TSA, watching the news sitting in horribly uncomfortable chairs, and seeing what's going on in the world, it got me thinking a little bit about our government. Earlier this year, I was home in Connecticut visiting my family when I received a letter stating that I had been selected for Jury Duty.  In the State of Connecticut.  Where I have not lived for the past 4.5 years.  Fortunately, it was easy for them to verify that I no longer live there and was able to get out of it - but that's my second Jury Duty Selection and some people have never been picked!  How does this happen?  What fortunate - or unfortunate - thing have I done to put me on a list saying I should serve when others have not been chosen?

My first jury duty selection was in the summer of 2004, right after my freshman year of college.  It was a trial where a man had been running in the early morning and he had been struck by a car resulting in severe, long-lasting injuries.  The runner was suing the driver of the car, who happened to be the newspaper delivery guy.  He was also suing the newspaper company and their insurance company.  I spent 5 days in the New Haven County Courthouse listening to testimony, reviewing medical bills and photos of the injuries. This was long before I was a physical therapist, so while I was a bit annoyed to be missing my summer vacation, my job paid me for the time and it was definitely a better learning experience than being at work in the bakery at Everybody's Supermarket would have been.

Anyways, I returned to Seattle after a great snowy East Coast trip and arrived to find a letter from the State of Washington Department of Health that my PT License was being audited and that I needed to show proof of all of my continuing education.  I was certain the government was out to get me!

So... for my fellow PTs - in or out of Washington State, here are a few pointers, should this happen to you, because I found the letter indicating my audit - and the details of what was needed- to be quite lacking.
1) Keep track of your continuing education!  Names of courses and the presenters, dates and locations of where you took them, number of hours, a list of objectives for the course, and keep the copies of the certificates.  My certificates are in a binder and I have a google doc with my annual course titles/hours already, but I didn't have all the required information that was asked of me.  For example, I've talked about the courses I took with Mike Reinold and Lenny Macrina a few times on the blog like here and here, but I couldn't have told you their credentials and didn't have access to written objectives for the two courses I took from them.  Fortunately, their credentials were listed on the certificates and they were more than willing to send me a list of objectives since their classes have been approved by continuing education review boards.  Medbridge also supplies all this information on all of their certificates.
2) Know the rules of your state.  Washington does not require verification of your courses for PT.  Neither does Connecticut.  Three states (Maine, Massachusetts, and South Dakota, which I wrote about here do not require continuing education at all.  But if you practice in those states and then try to switch states, this may cause you some problems in transitioning your license elsewhere. (Also- how are you practicing physical therapy without participating in continuing education?!? My education was great at UConn but seriously- you’re left needing to know so much more!) You may have specific things you need to have specific education for, varying by state. Examples of unique circumstances that some states have for continuing education:

• Suicide prevention training - required in Washington, course is available on Medbridge - probably a really good thing for any physical therapist to have!
• Spine manipulation - can get a special endorsement in the state of Washington, which I hold, and which has its own continuing education requirements. If I had to guess, this is the reason why I was audited... but maybe it's just random.
• Dry Needling - not permitted in Washington, but is allowed in many other states.  My understanding is that dry needling certifications tend to be regulated carefully in some states.
• Somewhat related - if you are a Certified Strength and Conditioning Coach through the NSCA, you cannot use almost any physical therapy courses for your continuing education for your CSCS.  They have a list, here, which includes First Aid/CPR as an option - which we cannot claim for continuing education for our PT licenses.

If you're in Washington, the letter for audit basically says you should read the laws and see what applies to you and submit sufficient information to cover your own requirements.  Here's where you would go to find that information:

1) Physical Therapy Requirements: here for your initial license and here for continuing education requirements

2) Spine Manipulation Endorsement Requirements: here
3) Dry needling is not permitted in the state of Washington under the Physical Therapist practice act,, so we don't have regulations for it. 

I asked a lot of PTs if they've ever been audited... zero coworkers or PT friends have been, but some had friends or family members who've had to submit their information.  Overall, the process wasn't really that difficult because I have all my certificates and track my hours - plus I have more than enough hours for everything I need.

Ultimately, this is my PSA that you should keep track of - at the very least - the minimum requirements you need for your license to remain active - because this is a real thing and to track those things down later would have been much more difficult. 

Abby 2 - Government 0.   See ya in two weeks, America!

Conflicted

Hey everyone.  This past week I've been conflicted with something I use in my patient care.  Conflicted enough that I've brought up this conversation with my coworkers and a close PT friend and it's still weighing heavily on my mind. So now it's here for others to read and comment on. Please send your thoughts, fellow PTs.

There is a physiotherapist out of the UK named Adam Meakins who posts regularly about various physical therapy topics including issues with the profession, our techniques, and our shortcomings. He goes by "The Sports Physio" and has a very respectable social media following: 54.4K twitter followers and 76,000 followers on his blog... compared to my 270 twitter followers and 9 blog followers (plus my mom).  I present these numbers for the sole purpose of demonstrating that he's a well-known PT.  I have followed him and read his materials for about a year and have come to find that he challenges my thought processes, which is essential for my growth, though sometimes is hard to swallow.

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| Dreamstime.com

In the past week, two physical therapists who I respect - but also occasionally differ in opinion with - have mentioned Adam Meakins. One of them linked to a video Adam posted on Facebook which he further discussed in this recent blog post and he was also interviewed on this podcast about a different subject - so he's just come up a lot more this week than usual and his messages have been on my mind.

This post is not meant to be an attack on Adam.  He works hard to improve healthcare and physical therapy practices - noble efforts with messages I often agree with.  He expresses his perspectives confidently in an unapologetic abrasive manner that has a certain appeal for getting his message across.  (AKA - there's no bullshit.  He tells it like he sees it.  I love this about him.) He's a physio and he's trying to help people live healthier lives doing the things they love to do... so I respect him. I have never met him in person (yet), but I do pay attention to what he's posting because I think his perspective is really valuable, even if mine differs, like it does right now.  I wonder what it would be like to shadow him treating patients for a day.

The blog (and video) he posted discuss the use of palpation (evaluative touch) and how we present our findings to patients.  

Adam listed multiple studies as his references, many of which I have now read, which report that either more research is needed or that palpation techniques are not reliable. To my knowledge, there are not many papers that say the opposite, and my skills of critically appraising research are certainly inferior to Adam's, but this paper contradicts the research presented in Adam's blog post.  I had to search to find that one.  I searched because I have found multiple occasions where someone has told me to do something with patients because they read an article about it - and I was able to find multiple publications that stated the opposite information.  So when I read his post and immediately felt like it didn't sit right with me, I had to do some searching. Maybe I don't understand his message properly.  Maybe I'm too biased to see through my own thought processes.  Regardless, I am conflicted.

Adam points out that physical therapists are not good at palpating things like "knots" or "trigger points" or "tight bands" or "joint play at the spine" and that we are not consistent between providers or even consistent with our own practices.  In non-medical terms - if you smell pizza in the morning and identify that it is, in fact, pizza - but in the afternoon smell the same exact thing and identify it as a cheeseburger, you're not being consistent with your own findings.  And to tell someone that you have a cheeseburger when it's actually a pizza could be confusing or problematic.  Scientific research says that physical therapists touch patients to evaluate them but report different findings. The research also says that we cannot identify if parts of the spine moves abnormally or identify which level of the spine we're touching with consistent results.

Now... when I palpate a patient and feel like a segment of their lumbar spine feels hypomobile, I agree with Adam that it makes no sense for me to state the specific level of the spine to the patient, because I don't have XRAY vision to know I'm 100% accurate and, working with kids, it probably doesn't have much meaning to them anyways.  I worked with a patient with neck pain today and, as I've previously mentioned, I currently have a student.  So when I palpated a segment that I thought was hypomobile (and reproduced the patient's symptoms), I relayed to my student that she should look around where C3 would likely be because I can't actually be certain that it is C3.  I think it is, I'll document it as such, but the reality is - I don't actually care exactly what level it is.  I feel something, it reproduces my patient's symptoms, it's where I want to treat.  I don't know how I could have better directed my student to what I found for her to feel it herself, but the patient felt relief with mobilizations at this region.  Adam's post suggests that this confirms my bias to this being a useful technique.

Maybe it's more about the way the care is interpreted and explained to the patient than the actual identification of specific structures and the interventions that are applied that Adam has a problem with.  I agree with him that we really need to STOP TELLING PEOPLE their L5 is rotated or their back is out. What does it mean for you to throw your back out?  That is not medical terminology.  Can your back ever be in?

But... when I palpate, particularly at the spine, I do feel "something." Of course I'm biased on my opinion of my own patient care...it would be wrong of me to use interventions that I did not believe were helpful and, since I also manipulate the spine on occasion, I feel it is essential for me to use palpation to identify hypomobile segments of the spine.  I feel hypomobility in some regions compared to other regions in the same person.  While I don't generally compare spinal mobility person to person because I don't find that useful, I do correlate certain patient responses with what I'm feeling in soft tissues in my hands and compare that to what I've felt with others.  If a person laying on the table in front of me presents with a neck that is tender to palpation and their cervical and thoracic spine feel stiff compared to their lumbar spine, I want to treat this issue.  Maybe with manual therapy.  Maybe with exercise.  Maybe with both.

I used to do things very differently.  I no longer say to my patients, "Wow your neck is really stiff," or "Your 1st rib is stuck"- though I do sometimes feel a stiff neck and a hypomobile first rib... which I treat.  I don't say these things any more because it freaked out the patients.  They'd worry about their rib being a problem.

I used to look at the pelvis and tell patients that they had one leg longer than the other. All the time.  Guilty. I didn't know better, then! I used long axis distraction of a leg to distract the hip while simultaneously re-aligning the SI Joint.  That's what I truly believed.  I'm telling you that I used to regularly yank on people's legs. Maybe as often as daily. Wanna know why I did it so much?  Because sometimes IT ACTUALLY WORKED.  And they felt better.  And that's a bit of what Adam Meakins is saying... that we can be convinced that the care we're providing is beneficial, even when it is not supported by research. I eventually learned that it didn't work as much as I thought it did.  It didn't help enough people.  It could have been harmful to the patients and I constantly felt like I was doing something to patients to try to fix them rather than guiding them towards ways to fix themselves.

Humans can't be symmetrical if we have hand dominance and we move to get in and out of a car in the same way all the time but less frequently on the other side of the car. Our heart is not centered in our chest cavity.  There is only one spleen and one liver and they're not in the middle perfectly symmetrical....  So while Adam Meakins is practically pleading with physical therapists (and hopefully chiropractors and physicians) to STOP telling our patients that they have anatomical problems that are probably not actually problems, and I agree with that message... I still feel "something" when I palpate the spine.

If patients ask, I now use an explanation about the nervous system having a reason to try to protect that particular region of the body and that by using load management strategies, it may calm down. I explain that "hurt does not equal harm"... that the tissues of the body may hurt even though damage is not occurring.  The body uses pain to protect itself.  And then I give a home exercise program to guide them on restoring motion, strength, or function based on what I determine the patient needs... which I did by using palpation.

I remember sitting in PT school and being taught how to palpate the multifius and the transverse abdominus musculature to assess if they're contracting.  I could never feel the multifidi.  Never.  And then the PTs at my first job out of PT school encouraged me to focus on assessing the multifidi in various positions and using abdominal bracing and using electric stimulation in conjunction with abdominal bracing on my patients.  I tried to use that.  But I could not feel it.  This is what Adam seems to be describing but relevant to palpating the spine.  Is it possible that we have different skills with regard to palpation?  Is it possible that while I cannot feel the multifidi, I could feel hypomobility at the spine?  Is it possible that the issue is not about what we identify, but more in how we express it to our patients?  We are definitely impacting the beliefs of the patients we see.

The podcast interview goes a bit more into the discussion of the narratives that physical therapists (and healthcare providers) present to their patients and how this can negatively impact them.  I like that Adam states in the podcast that removal of pain is the wrong way for PT to be going as a profession.  We need to be empowering patients, give them realistic expectations, and help them operate within the constraints that their individual bodies allow.  The goal should be developing resilience and tolerance - not elimination of pain.  I agree with Adam on all these points.

I also agree that we are over-treating patients.  Too many visits.  Too many referrals from person to person rather than really understanding what's going on.
I also agree that the medical system doesn't operate in an ideal fashion.  Insurance companies limiting treatment influence the care that patients get.  This is wrong.
I also agree that sometimes the best treatment for a patient is NO TREATMENT.  I recently was working with a patient who was seeing so many different providers that I just sat her down and told her - I think you're trying to find too many solutions to a small number of problems and can't follow a single path to your recovery.  I recommended that she sit down and write a list of all the people she had been seeking answers from, and pick the one that she wanted to commit to.  Who do you believe is helping you?  Follow that person.  Get rid of the rest of us.  Everyone telling you different things is confusing and ineffective.   I don't actually care if physical therapy is her solution.  The best solution for every patient is the one they buy into and helps them find a way to get back to their function.  Period.

Even as I write this, I'm feeling my thought processes shift about what I say, but I"m not ready to throw away palpation yet.  I like that I'm trained to provide spine manipulations and have had some really great results using it. I use it selectively and in conjunction with movement.  And so, I'm unwilling to throw away a tool from my toolbox that I sometimes find essential.  At least for now.

Take Home Message: There are lots of really good physical therapists out there, many of which are creating content that is easily accessible and easy to apply.  The messages differ between them.  But patient populations differ and you have to believe in what you're selling to your patients.  I believe in a little Mike Reinold and a little Lenny Macrina and a little Lorimer Moseley and a little Adam Meakins and then I add some strength and conditioning with Eric Cressey and a little breathing from yoga practices and a little mental health... and I'm my own unique clinical provider because of all those influences... which is why I keep writing about all of them!  So use a variety of backgrounds and consider opposing opinions, try out different techniques, challenge your own beliefs and welcome growth along with failure.  Feel free to tell me if I'm wrong... I may not like that, but I'd like to think I'll be respectful and consider the alternatives.

Above all else - Do No Harm.

2018 Year in Review

The last blog post of 2018! Since I started writing in November 2017, Abby's World has had 14,000 visitors.  I still don't like the title... Some posts were really popular... four posts had over 400 readers, others had less interest... and that's ok.  I think it's safe to say that I'm still figuring things out a bit to narrow down the scope, but I'm enjoying the variety of topics right now.  Thank you, so much, to everyone who has stopped by! I hope you've learned something and that I've been helpful to you in some way.

Today's post will serve as recap of 2018 - both personally and professionally - and a look back at some of my favorite posts of 2018.  As for 2019, I don't think I'm going to write a plan or set goals - other than to keep writing.

The Seattle Storm and UConn Connection

My 2018 biggest moments:
I'll start with the Seattle Storm winning the WNBA Championship, which I wrote about here.  I was so fortunate to be able to attend WNBA Finals Game 3 in Washington, D.C. with my brother, and still love basketball despite my poor skills at playing the game. I'm already looking forward to next season and it's still several months away.

Dear Evan Hansen, New York City, July 2018

As great as the championship was, my family celebrated a huge milestone this year.  In May, my niece and nephew became B'nai Mitzvah, which is a Jewish coming-of-age or right of passage.  They're thirteen years old, now!  The actual events for the B'Nai Mitzvah were incredible and I'm so proud of them for their accomplishment and hard work, but more special was the opportunity to celebrate them each in their own individual way.  I asked them a few months before-hand what they would want most, and I love how different they are and what they chose.  I celebrated my niece by taking her, my sister, and my mom to see the musical Dear Evan Hansen in New York City.  If you haven't heard much about this story, I encourage you to check it out, particularly if you have teenagers in the house. I'm so glad we could do that together, and that it was what she wanted to do - with her aunt, mom, and grandma.  I celebrated my nephew at the Denver Broncos versus Seattle Seahawks game in Denver, CO.  He's been a Broncos fan since birth because he liked the color orange and had always wanted to see their stadium.  As a sports fan myself, I really loved watching him experience something he had wanted to so much... and the rivalry of rooting for opposite teams but in a mature manner.  It was a chance to spend time with my favorite people as they head into teenage-hood and, soon, adulthood.  Next year they'll both attend Cheshire High School, the same school I graduated from fifteen years ago.  I remember holding them when they were born and all of these events were a flood of pride and emotions.   Because of them, I spent more quality time with my family in 2018 than I had since I moved to Seattle.  That was the best part of 2018.

Seattle Seahawks @ Denver Broncos, September 2018

Some of my other favorite things from 2018 that have nothing to do with Physical Therapy:
I saw the Goo Goo Dolls perform their 20th Anniversary celebration of Dizzy Up The Girls.
I rode in a helicopter for the first time. Total trip time was about 3 minutes.  It was awesome.
I read the first five books of the Harry Potter Series and watched the first three movies... my first time for all of that.  Don't worry, book six is in progress and I'll finish all of it in 2019.
I read a lot of books in 2018, actually.  Some really deep, sciency stuff.  Some much lighter and more relaxing.  I have come to embrace the audio book for commutes. I read The Origin of Species which I wrote about here and definitely do not recommend others read, but feel like I can read anything if I could get through that.
I got addicted to yoga.  And then dropped out of yoga.  I miss yoga.

My 2018 Physical Therapy Continuing Education was primarily focused on three areas.
1) Orthopedics from Mike Reinold, Lenny Macrina, and Eric Cressey.  I took Mike's shoulder seminar, which I wrote about here, Lenny's knee seminar which I wrote about here (and his elbow course), and Eric's shoulder course which I wrote about here.  I'm so grateful that there are mentors willing to share their expertise and knowledge online, and who also have made trips out to the West Coast for me to learn from in person.

2) Chronic Pain, primarily from Lorimer Moseley and Adriaan Louw.  I've written about those experiences here - from reading Explain Pain, and here from reading Explain Pain Supercharged and from meeting Lorimer Moseley at his presentation at the University of Washington.  Starting in two weeks, I'll be working with the Seattle Children's Pain Clinic as part of a collaborative team to help kids experiencing chronic pain.  I'm looking forward to putting all that learning to good use.

3) Strength and Conditioning.  I passed the CSCS (Certified Strength and Conditioning Specialist) exam in 2018, which I wrote about here and took a Medbridge Education Course instructed by Sue Falsone on this topic as well.  This has definitely made an impact on how I treat patients, specifically by loading them more and manipulating rep/set schemes a little bit more than I did in the past.  A few PTs have asked me if I thought this process was worth it, and for my patient population and side gigs, I feel that it is definitely useful.  I work in Pediatric Sports Medicine so my patient population is mostly athletic and getting back to sports.  They've generally never worked with a strength and conditioning coach or a physical therapist and don't understand any of the key basics of movement or how the body works.  I love having this background knowledge to educate them!

I feel like I spent a lot of time working towards growing as a physical therapist in 2018, but when I look back, it wasn't even close to what was most important.

Looking forward to 2019:  I'd be lying if I pretended that 2018 was perfect. Social media sometimes has that impact...  nobody posts their tears and struggles on Facebook and Instagram.  I certainly only post the happy times and the beauty I see around me. In truth, 2018 was a hard year.  I'm not sure 2019 will be easier... but there will be more family time and more hard work and growth.  And for all that, I'm grateful.

Happy New Year!

Online Knee Seminar and Three Key Components to Patient Care

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I’m starting to look like a groupie of Champion Physical Therapy and Performance in Boston, MA- but that’s for good reason! I’ve previously written about this crew, particularly Mike Reinold and Lenny Macrina here and I just completed their Online Knee Seminar.  This class was awesome- and I’ll tell you about it - but I also want to share some of the underlying themes about patient care that were introduced that relate to how they (and I) practice physical therapy. This could be particularly helpful for the new grad PTs entering the work force after passing the NPTE exams in July but as a PT who is almost four years into my career, I still learned a ton from taking this class.

On my first orthopedic clinical rotation during PT School, I worked with Craig Katko - then the PT for the Connecticut Sun WNBA team and now the PT for the New England Black Wolves National Lacrosse League team. As far as clinical rotations go, Craig was the best instructor for my first time working in orthopedics.  I was very lucky to have that opportunity. As I prepare to take my first student, I'm reflecting on what my rotations were like and what helped me most.  What I remember from my time with Craig was mirrored in the introductory portion of the knee seminar, and I was grateful for the refresher:

First - Patient history and evaluation components are essential to guiding your treatment, but learning how to do an evaluation, and getting to be good at it, is challenging.  Craig recommended that I find an evaluation system that I trusted to use consistently until I was confident in recognizing patterns, and then to later on use as a fall-back plan.  He lent me his copy of Grey Cook's "Movement" book to read - and I learned the SFMA - which I used for my rotation with him. Lenny Macrina has mentioned the SFMA in a few of his courses, and every time he mentions it, I think to myself - he's not checking cervical range of motion in a patient with knee pain.  (Are you, Lenny?)  New grads - you may want to check out the SFMA principles if you haven't yet learned them - especially if you're not confident in your evaluation skills, yet. Now, four years out of school, I don't use the full SFMA for every patient... but I use many of the principles from it constantly. Specifically - I examine neighboring joints proximal and distal to the pain region and check mobility and stability in those regions - both key concepts in the SFMA.  These apply to the knee in numerous ways.  You must clear the spine with patients who have pain in their extremities, and for a patient with knee pain, you need to consider both the hips and feet.  When a patient doesn't fit a pattern that you've come to recognize, the SFMA is always there as an option to re-assess them.

Second - Don’t get too bogged down with diagnostics.  As the PT profession moved into Direct Access and patients started coming into the clinic without seeing a doctor first, I was excited to try to identify patient pathologies. What I came to realize was a specific diagnosis usually doesn't really matter! There are a lot of structures involved in the knee (or elsewhere) that need to be checked, but special tests don't have great reliability and use of palpation to diagnose an isolated structure being injured is about as good as guessing.  As I've learned more about the biopsychosocial model, and treated more patients, it has become apparent that sometimes specific tissue diagnoses do more harm than good, and they often don't help guide treatment. For example, as described in the Knee Seminar, a patient can have patellofemoral syndrome from numerous causes: foot mobility or control issues, strength deficits or imbalances of the hips, overuse, improper jump-landing mechanics, body alignment considerations... the list goes on.  If you tell a patient that their leg is lined up improperly - something that genetically they're unlikely to change - you can create a fearful situation that is unnecessary.  I've actually come to prefer referrals that list a diagnosis as "right knee pain" because I'm not treating a diagnosis... I'm treating the specific person sitting right in front of me with their unique presentation. While clinicians do need to be able to explain what's going on to patients, you can do it in a way that will empower the patient/client to embrace their personalized recovery strategy.  I work with kids.  It's really easy to tell them that I can see some reasons why their knee might be hurting... tell them they're strong... and then give them a home exercise program with some things they can do to make themselves move in new ways that should change the way their body is loaded.

Third - Use functional impairments to guide treatment. I use the slogan "find a problem, fix a problem" as my guide.  This might infuriate some of my PT colleagues because it isn't how their belief system works... but there are lots of patterns that can be applied to all body parts for rehab and progressing through these in a sensible manner to achieve optimal function leads to patients achieving goals.   For example... if I'm working with someone experiencing knee pain and they can't tolerate going down stairs (function), I can break that down to see why (impairments).  Following the progression of working to improve inflammatory processes, then to restoring range of motion, then increasing strength, and finally focusing on proprioception/motor control/higher level activities applies to all knee pathologies, though the timeline of progression varies by person.

So these three concepts were identified in the introductory portion of the Knee Seminar and reminded me of when I first started learning about patient care.  I found these concepts valuable to get my career started and have built on them and developed my habits with additional continuing education courses... which leads me back to the Knee Seminar.  If you're looking for a continuing education course specific to the knee - this is the most comprehensive one I've seen. 

The seminar is broken down into seven key components: 1) examination of the knee, 2) treatment of the knee, 3) ACL, 4) Patellofemoral Syndrome, 5) Meniscus, 6) Articular Cartilage, and 7) Osteoarthritis.  There are videos for each section along with some key selected articles.  Just like I experienced with their Shoulder Seminar - the articles they picked were really useful and I'm glad to have added them to my library for future reference.  The top three considerations that I'm looking forward to implementing in my own patient care were 1) The biomechanics of the knee, particularly with regard to the forces at the patella at different points in the knee range of motion, 2) better understanding of the meniscus anatomy, how it moves, when it is stressed, and considerations with rehabilitation for repair versus removal, and 3) treatment options with regard to articular cartilage pathologies.  There are new surgeries (at least new to me) being used to treat these conditions - such as the OATS (Osteochondral Allograft Transplantation Surgery) and the ACI (Autologous Chondrocyte Implantation) procedures.  If you're a new grad and you haven't seen these yet, this course helped me understand the procedure and the rehabilitation protocols, but better yet - when you would use these treatments and why the rehab is progressed so slowly.  This was a great continuing education course!

Good luck, new grad PTs!  I hope this is helpful.  And just remember, ask for help.  And teach us more seasoned PTs the things you're learning in school so we can all make the profession better!

Shoulder Care with Eric Cressey

Last weekend I jetted off to Denver for a visit with family and a continuing education course.  The family time was fantastic - a few hours of biking around Denver - far more than I'm used to doing as I'm not a fan of bike seats - some really delicious tacos - beautiful art and the backdrop of the Rocky Mountains!

The course was "Shoulder Assessment, Corrective Exercise, and Programming" presented by Eric Cressey of Cressey Sports Performance and it was hosted at Landow Performance in Centennial CO.  Loren Landow is the newly hired Strength and Conditioning Coach for the Denver Broncos and his facility is beautiful with state-of-the-art equipment and autographed jerseys all over the walls from numerous professional athletes.  His bio says he has trained WNBA athletes, too - so extra points in my book!  If you're not familiar with Eric's work, he's a Strength and Conditioning coach with facilities in Hudson, MA and Jupiter, FL and, though he is most well known for his work with professional baseball players, he also works with the general population and is considered to be an expert in the shoulder.  He's published tons of research and has a blog with articles posted starting in 2002 with regular high quality content.  I previously wrote about one of his older blog posts here.  Most importantly, Eric is a UConn grad, so I've followed his work since I first learned about him somewhere around 2005 when I was in a class with Dr. William Kraemer, one of Eric's mentors, and have been looking forward to meeting him and attending one of his seminars for a long time.

With Eric Cressey June 24, 2018

Why did I want to take this class?  Beyond wanting to hear Eric speak live and get the chance to ask him questions, I previously took a course with a strength and conditioning coach (Matthew Ibrahim) in conjunction with a physical therapist (Zak Gabor) which I wrote about here, and felt that learning from people with different backgrounds was really impactful for me.  The audience was primarily strength and conditioning coaches who work with baseball players... but there were also a handful of physical therapists, chiropractors, massage therapists, personal trainers, and baseball coaches.  People had traveled from Australia and Korea and all over the United States, some of which trained athletes from unique sports like Professional Disc Golf or MMA fighters. The variety of people present was really neat... but also, the content is applicable to so many other sports.

More importantly, I have been treating a lot of patients and athletes with shoulder injuries and recently completed Mike Reinold's shoulder seminar, but also wanted a live course to better observe how other providers evaluate and treat shoulder pathologies. Eric's approach to shoulder treatment does not look like Mike's.  They have different "favorite" screening tools and exercises that they use.  If you observe their social media, you could probably pick up on these differences and similarities.  I'd say the biggest overlap I observed was that both of them regularly use the prone low trap exercise for rotator cuff strengthening which Eric has a video for here.

When it comes to my work with the Seattle Storm, though, we also have to consider that we're working in an overhead sport with repetitive action.  Shooting a basketball is nothing like the motion of throwing a baseball, but it still requires significant mobility and stability - and very different from baseball, it requires the athlete to be reactive to opponent players slapping at their arms while they're doing it.  The arm care programs used by the Seattle Storm should not look like the arm care programs used by the Boston Red Sox - but the principles involved in developing them do match.

I learned a lot from this course which I'm still processing, but was able to immediately use some of the skills in the clinic. Here are my top 5 favorite Eric Cressey quotes and take-aways from the weekend.

1) The biggest key for the shoulder is "Keep the ball on the socket." Simple.  Having a better biomechanical understanding of the force vectors of the rotator cuff is vital. If the scapula is sitting in a depressed position, the lats may be over-active which will influence upward rotation when getting overhead.  Similarly, if the scapula is tilted anteriorly, could there be shoulder impingement with elevation or is there enough muscular balance to safely overhead press?

2) Rehab and training are the same thing!  I've previously written about physical therapists' role as strength coaches here - and this came up in the course.  Eric Cressey is not a physical therapist and he discloses this and discusses how he interacts with PTs all over the country.  So it surprised me to see the differences between what Mike Reinold and what Eric Cressey do considering this statement, but I would not expect Eric to be seeing athletes post-op day 1 following labrum repair.  So, I took this to mean that once the acute healing phase is completed, rehab and training are the same thing.  There is a need for progressive loading to tissues and a need to understand periodization, even if your PT treatment sessions are not written like a periodized training program.

3) Scapular winging is a garbage term. It does not describe what is going on with the scapula.  I document scapular winging all the time - so this will be a change I need to consider moving forward.  Is the scapula winging because it is anteriorly tilted?  Upwardly rotated?  Because there is a flat thoracic spine so the medial border is just more pronounced?  And is this inherently pathological?  Or just a finding that you're documenting.  I can't promise I'll stop using the term scapular winging entirely, but I can commit to adding at least one descriptor of the scapular position to better describe the situation moving forward.

4) Stop telling people to bring their shoulder blades down and back.  It would only be a slight exaggeration to say that Eric Cressey is begging people to stop using this cue.  Too many people use this resulting in patients pulling their elbows back with anterior humeral head translation and improper mechanics that we could be creating problems!  I asked him what cue he likes instead - and he said he manually puts people into the position he wants them to be in, using optimal muscle activation, until they can do it independently.

5) Push:Pull ratios are not accurate nor are they adequate.  It has been well ingrained into my training that for every push exercise, you should be doing at least 2, probably more like 3 pull exercises.  I've been trained to teach that focusing on the back musculature 2-3x more than the front helps combat many of the anterior shoulder issues that are seen in the clinic.  However, Eric points out two key points that make you think about this more carefully.  First, the push:pull ratio is almost always considered for front:back motion and ignores top:bottom... but both planes need to be considered.  I think John Rusin tries to deal with this by including upper body push, upper body pull, and carries into his 6 foundational movement patterns, but the balance needs to be considered for both planes.  Second: not all pushes can be considered alike.  The bench press is a push exercise that necessitates the scapulae being blocked on a bench... compared to the push up where they are moving freely on the body.  This is also an important consideration as you're not getting the benefit for scapular control through the pushing motion when doing a bench press - and Eric says he doesn't have his baseball players bench pressing.

I'd be lying if I said this even touched the surface of all the things I learned at the class... but these were big takeaways that made me think and will change how I operate to some degree.   Thanks for an awesome course, Eric!

Social Media Impact on my PT Practice

with Mike Reinold!

with Lenny Macrina!

I love social media.  If you've been following the news lately, you probably know that Mark Zuckerberg, Facebook CEO, has been testifying in front of Congress regarding improper use of data and basically explaining how the internet works.  Through social media, it is possible to interact with millions of people, watch silly cat videos, become a viral sensation, or watch my nephew on the ski slopes and my niece at her dance recital all the way across the country.

One thing I really like about social media is that I have the opportunity to interact with famous people.  For example, I wished Justin Timberlake a Happy Birthday.  He probably didn't see it because he has 49.4 Million Instagram followers, but I was able to do it.  There's a slight chance that he noticed my comment out of the 38,391 comments there. I recently read an article (but now can't remember where) that outlined the impact of the various ways you could interact on social media platforms.  A high percentage of followers may see a post, less will "like" it, but only a small fraction will comment on it, and even a smaller percentage will somehow directly connect, separating from the herd.

Slightly less famous than Justin Timberlake, (38 Million Facebook followers), are Mike Reinold (106,918 Facebook followers) and Lenny Macrina (1,788 followers on Facebook), co-owners of Champion PT and Performance (50,000 followers for the company) in Boston.  They're also the hosts of "The Ask Mike Reinold Show" podcast, and if you've read any of my previous work, they're major influences on how I practice physical therapy.  The connection here is that these guys do a lot of research, treat a lot of patients/clients, and own a business while regularly using various social medial platforms to spread their knowledge and have been able to impact me in this way.

Last week I attended Lenny's "Evaluation and Treatment Algorithm for Medial Elbow Pain" course at the Pacific Northwest Orthopedic and Sports Medicine Symposium in Portland, Oregon.  Because I've previously interacted with Lenny directly via Facebook and indirectly through their podcast,  he recognized me when he walked into the room.

SOAP BOX: To ALL student physical therapists and new grad physical therapists (and PTAs, and any other rehab/sports professionals), you need to follow this crew. NEED!  If you're interested in gymnastics at all - follow Dave Tilley.  If you're interested in Crossfit, follow Dan Pope.  If you're interested in golf - follow Mike Scaduto.  If you like UConn Basketball or want online personal training guidance, follow Kiefer Lammi, their Director of Fitness.  If you work with baseball players, they've developed Elite Baseball Performance. If you treat shoulders and knees - these guys are for you. And if you're a parent of a youth athlete, they're an awesome resource for that also. 

Moving on... I've previously written about how important it was for me to get a new mentor in this post.  But mentors don't necessarily need to be people you know or spend time with in real life.  They don't even need to be your teachers or coworkers.  I have mentors I can call or email at any time who filled those roles, but then there's Mike and Lenny - who really don't know me beyond the brief moments photographed above, but who I respect in the field of physical therapy and whose work I try to read consistently to improve my practice.

In addition to Lenny's Elbow class last week, I've taken the time to go through their podcast episodes - which are really great - and have had two of my questions answered in them: Episode #107 and Episode #109 so you can check them out.  The episodes are short and formatted as three questions and their answers.  I also just completed Mike's Shoulder Seminar. I happened to be attending Lenny's Elbow course while I was finishing the seminar and the two paralleled each other nicely.  Both have had an immediate impact on my treatments.  Following all the recent learning I've had from this crew, here are the four changes I've recently made in how I practice PT.  (Keep in mind - the two courses I took were intended for the upper extremity).

First - side-lying external rotation and prone row exercises were previously absent from my treatment sessions and home exercise programs.  Not any more! The Shoulder Seminar included the research supporting their use such including EMG studies on the muscles being used.  This paralleled with Lenny's course showing how he implements these exercises into his routines.

Second - rhythmic stabilizations and PNF patterns have often been in my treatment sessions in the past, but I've ramped up their volume considerably.  Where before I may have done 2-3 rounds of 30 seconds of rhythmic stabilizations and a set of 10 reps of resisted PNF D2 at occasional visits, I've now started doing the stabilizations in A LOT more positions with more total time spent on dynamic stability.  I'm not just doing this because Mike and Lenny said to... at Lenny's course we had lab sessions doing these treatments to each other so (thanks to my partner and fellow Seattle PT Bruk Ballenger) I felt the impact of doing these on my own shoulder.  These are really fatiguing!

Third - upper extremity weight bearing progressions.  I've never had someone standing at their treatment table with their hands on the surface with low loads of weight bearing in that position.  I like it for a gentle joint compression or co-contracting activity without the shoulder flexion in a quadruped or standing with the arm against the wall closed kinetic chain activity.

Fourth - I've been working with some coworkers at Seattle Children's Hospital on a return to sport testing protocol for patients following rehab for upper extremity injuries.  We've had numerous discussions about the components to include, but The Champion crew uses a hand-held dynamometer (HHD) for measurable strength testing.  Fortunately, I studied under HHD guru Dr. Richard Bohannon at UConn and Seattle Children's already uses it in our lower extremity testing.  Manual Muscle testing just isn't sufficient enough to identify the subtle but potentially significant differences in strength.

So, I've learned a lot from this crew, and I found them via Facebook and other social media means.  I'm looking forward to getting started on Mike and Lenny's knee seminar in the next few weeks, and if any of the Champion PT and Performance Crew comes across this post, please know how grateful I am for all that you do.

I Failed The 28 Day Challenge - and Built Up my Anti-Library

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ID 92330067 | Dreamstime Stock Photos

In early February, I wrote this blog post stating that I was planning to participate in the "28 Day Challenge" of reading a journal article every day for the month.  I failed.  Big time.

Here's what happened:  I started the challenge two days late and managed to catch up on day three.  I managed to stay on track through day 7.   (4 days... not so strong). And then the weekend came, and I had plans with friends and a job to go to with patients to treat and.... all of a sudden I had six more articles in my "to read" folder on my computer and I just couldn't get myself out of that hole. I think I got through 12 of the articles in total in the month. 

I find that I have been collecting papers to read later on because there's so much to read and so little time.  I have a file of them on my work email all about concussion research, a growing collection of journal articles about shoulders/throwing injuries and anything at all related to ACL injuries at home.  I follow several PTs online and when they recommend an article to read, I add it to the stack.  And so, my list of papers to read keeps growing.  It's the same with books.  My "to-read" shelf on Goodreads is now more than 600 books.  I don't have the space (or funds) to accumulate all those books - but if I did, my house would be overflowing with books.  My continuing education plan for the year is written out and developed and I work my way through it but other things I'm interested in keep coming in my path and leading me off course.

This week I was listening to "The Movement Fix" Podcast Episode #60 with guest Brett Bartholomew, author of Conscious Coaching (which happens to be on order and should be one of the next books I'll be reading). Ryan DeBell (founder of The Movement Fix, headquartered nearby in Lynwood, WA) asks Brett about how much he reads, and Brett presents the point that it's not about how much you read, but about taking the time to digest new learning so you can apply it.  Some days I feel like I'm bombarding my brain with loads of new knowledge, taking in whatever tidbits I can grasp.  Other days I can't shove anything into it no matter how hard I try.  And some days, I can read and take in so much information it's like I'm in the desert and was just given a tall glass of water.

That's right - in addition to journal articles and books, I also have a list of podcasts to work my way through and a list of blogs to read.  The approach I've been taking has been listening/reading from the oldest posts to the newest from the same authors until I've gotten through all of them and can just read or listen to the newest ones as they come out.  A few examples: I'm currently reading through all of Eric Cressey's old blog posts starting in 2002 when he wrote for "T-Nation." He posts several times per month so I need to get through more than he's currently posting to catch up.  I'm doing a better job now of skimming the topic and seeing if it is at all relevant to my practice - but most of the time, I read the whole article and keep track of my progress.  Hopefully in a few months, I'll catch up and then any time he posts something new, I'll have the background knowledge of his prior posts.  Similarly, I listened to all of "The Ask Mike Reinold Show" so now any time a new one is posted, I'm caught up and it's just the new one to listen to.

Sometimes, as I'm working my way through my plan, something with a deadline comes along and pushes me off my track.  I requested the book "Explain Pain Supercharged" from the work library and only have until April 7th to get through it or the Seattle Children's Library Overlords will come take it away from me.  So this is delaying my progress in reading everything Eric Cressey has ever written.

We're in an era of information overload and my colleagues and friends keep getting smarter and smarter and can cite literature easily - which is a struggle for me.  It's hard to keep up when you have so many interests and aren't a fast reader (or even worse, a fast comprehender).  I shouldn't compare myself to them or care - but of course I do. 

Then I came across  this article and the embedded six minute YouTube video that describes the concepts of the "Anti-Library" and the "Black Swan."  An Anti-library is a collection of resources to help you find an answer to a question on a topic you are aware of but that you are not fully educated on.  Because of the internet, we have a virtual anti-library at our fingertips constantly.  The anti-library is where you go to look into "known unknowns." For example, I treat patients who have experienced concussions, but I'm not skilled with vestibular rehabilitation.  I know that my list of saved concussion papers includes some research regarding this area, so if I face a patient who needs this knowledge, I can quickly access it and get better informed.  But right now, this isn't in my case load and to spend time focusing on that learning when I can't apply it doesn't make much sense for me.  In contrast, the Black Swan is the "unknown unknowns."  These are the topics that I know nothing about, where I would need to start from scratch to even start educating myself.  A possible example of this could be a patient coming in with a brand new surgical procedure that I've never heard of or a rare disease with unique complications where I have no knowledge and would need to hit the books and don't even have a list of resources to go through on my mind.

Surrounding myself with knowledge so that I can access it if I need it shows that I am aware that I have so much to learn and that I want to surround myself with ways to gain new knowledge.  The article made me feel better about having a growing anti-library.  Now I just need to figure out a more efficient organizational system to keep track of everything.  Any suggestions?

Physical Therapist Continuing Education Requirements

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This past week I was on an airplane reading some journal articles included in Mike Reinold’s “Shoulder Seminar” when the gentleman sitting next to me asked if I was still in school. (Yay for still looking young enough to be a student!) We discussed our careers and he explained that he is a home health nurse in Indiana where he is not required to do any continuing education.  Seriously?

I immediately shot off an email to a good friend who is a home health nurse in NY, soon to be in WA, and asked if she had the same requirements.  She told me that in NY State she also has no requirement, which she thinks is because of the administrative burden so many providers doing continuing education would cause on the state health department. As she’s preparing to relocate, however, she knows her requirements will change. Despite not having a requirement, she noted that she has participated in continuing education- some independently and some offered through her job. I didn't ask the gentleman on the plane if he did education even though it wasn't required - because I didn't think I'd like his answer.

This got me wondering about the requirements for continuing education as a Physical Therapist.  I have had a license in Connecticut and currently practice in Washington so I knew they both had requirements (that happen to be fairly similar).  My PT School classmates from UCONN are practicing in New Hampshire, Massachusetts, Rhode Island, New York, Colorado, and Texas (plus me in Washington).  For a class of sixteen people, we've spread out far and wide to be in seven different states! We're about to hit the four year mark out of school and I remember my friend who works in acute care in NYC telling me that she had no requirements for the first three years, but now does.  Thinking back to the past three years, I've probably averaged more than 75 hours per year of continuing education, far more than what was required of me, and can't imagine what it would be like to have not done all that work. 

I wanted to look at each state's requirements and was surprised to find that the APTA website links you to each state's practice act from which you could search for your specific requirements.  It makes sense that this would be the most up-to-date way to get the desired information, but I expected the APTA to have an easier way to look at the information.  Fortunately, WebPT has published a state by state list found here and published in December 2017.   I found several alternative lists of continuing education requirements for physical therapists such as this one from 2005 which only listed 29 states as having  requirements. That was a study examining practitioner opinion and healthcare outcomes along with continuing education and may have had an impact on states developing requirements.

 That paper outlined the following results:

1) "Of respondents from states without mandatory CE, 5.9% reported that they had not attended any CE over the preceding 5 years and 10.8% reported that they had attended, on average, 2 or fewer hours per year over the preceding 5 years"

2) Table 4 interestingly outlined that Washington State (where I live) Physical Therapists participate in 97% more continuing education than the required 40 hours every two years. 

3) "For the overall sample, respondents reporting membership in APTA participated in more CE than those who did not report membership in APTA."

4) "The overwhelming majority of all respondents, 96.2% (95.6% of therapists from states with a mandate and 97.2% of therapists from states without a mandate), believed that they improved as physical therapists from their participation in CE."

I went through WebPT's list and found that only Maine, Massachusetts, and South Dakota do not currently require continuing education for Physical Therapists. While each state varies, the average per year seemed to be between 10-20 hours of continuing education. Some states were very specific and others more vague regarding certain content and means of participation such as online versus in person course work. For example, in Washington, physical therapists must complete a three hour course for suicide prevention.  Many of the states also listed PTA requirements for continuing education which had a few more states that did not require hours.  

I wondered if any research has been done on the impact of continuing education requirements on patient outcomes. That search was a bit of a bust.  There were almost no articles that specifically examined physical therapists' education with patient outcomes. I did come across this paper which assessed patient outcomes following physical therapists completing a 2-day course for neck pain with minimal impact on their patients.  According to this 2010 paper from the Journal of the American Medical Association which looked at continuing education for physicians, the evidence for improving patient outcomes was not strong.  There isn't a strong body of evidence to support participation in continuing education, and what I could find showed minimal improvement in patient outcomes at best.  Both papers suggest that new ways of participating in continuing education may need to be developed and bigger sample sizes may also be beneficial.  More research on the topic is needed.

Regardless of these two papers, I'm not planning to stop my continuing education efforts any time soon.  I'll continue to pursue a variety of course topics and presentation methods including video presentations, in-person learning workshops and conferences, and self study, so that I can try to achieve optimal outcomes.  Also, in the future, when I'm the patient, I'm going to ask my providers what type of continuing education they've recently done because it shows a dedication to growth, and I want to be treated by practitioners who also value learning. Watch out Dr. Knudson - I'm asking you at my teeth cleaning next week!

Cyclops Lesion

Photo: http://www.kneeguru.co.uk/KNEEnotes/articles/general-articles/2016/cyclops-lesion-after-acl-reconstruction

I learned something new this week!  I was listening to an older episode of Mike Reinold's Podcast, "The Ask Mike Reinold Show," when Lenny Macrina mentioned a Cyclops Lesion, something I had never heard of before.

Of course I immediately googled to get a definition and then hit PubMed for a few articles.  A Cyclops Lesion, also discribed here, nicknamed the Cyclops Lesion for its appearance on imaging is also known as Localized Anterior Arthrofibrosis.  It is basically a build up of scar tissue in the intracondylar region of the femur.  It is a limiting factor in terminal knee extension (TKE) following ACL repair which is important because if TKE is not fully restored, future comorbidities are more likely later down the road.  According to this case study by Dhanda et al, 1-9.8% of patients who have had an ACL reconstruction may experience a cyclops lesion.  Most importantly from this article, "aggressive physical therapy does not improve extension loss associated with cyclops lesion."

I looked into this a little bit further and came across this study from Shelbourne which describes the importance of the relationship between surgeons and physical therapists as well as the key role in ROM symmetry in the knee.  They note that the surgical knee should be within 2* of hyperextension to the non surgical side and within 5* of flexion.  This is a case when symmetry matters, where so often in rehabilitation we allow for asymmetry because this is more natural.

After learning about the Cyclops Lesion, I went to PT Pub Night Seattle and met up with some fellow PTs and surveyed the crew... several had either not heard of or seen this in their practice despite mostly being in orthopedic practice.  I hope the new learning will benefit as much as I anticipate it will help me.  How could this affect my practice?

I definitely have a greater appreciation of the need for symmetry for post op ACL patients and I now know that this exists so that if I encounter issues with ROM, particularly achieving and sustaining terminal knee extension beyond around 8 weeks post op, I need to refer back to the surgeon with concerns.  Hopefully this will help others who may be unfamiliar with this condition.

Running Mechanics Assessment for Physical Therapists

Two days ago - I wrote that Physical Therapists should be looking at mechanics - triggered by a patient coming in needing their running mechanics assessed after a physical therapist said they didn't do this work.  I had every intention of writing my own blog post on some of the key things to look for to assess running - but then Mike Reinold posted a write up  this morning based on Chris Johnson's running training - and they're experts.  So rather than re-invent the wheel - Here's Mike's post from today entitled: "A Simple Approach to Running Mechanics for Clinicians." (Seriously this could not have been more timely!)

Quick Summary:  Chris and Mike are recommending you look at the Four S's: Sound, Strike, Step Rate, and Speed. While this is not exactly the same method that I assess running form - I'm thrilled to see how they do it, and I can't wait to update some of the techniques I've been using.  I'm big on listening to the sound that my patients make - with running, walking, jump-landing, and plyometric activities - so this was not new to me.  I've never seen an app to use for cadence - only learned about using a metronome which I have done on a few occasions.

Ultimately - check Mike's post to learn some simple things you can look at in a runner experiencing pain to try to fix their form.  If you can't fix it so they're pain-free, find someone who's an expert such as Mike and his crew in Boston or Chris who is here in Seattle.

Happy Holidays!

Year in Review - The best things I did in 2017 to become a better Physical Therapist

December flew by!  I love the end of the year as a time for reflection of the prior year and to make plans for what’s ahead.  I'm a planner.  Here are the top three things I did to help myself become a better physical therapist in 2017 as well as my plan for how I’ll get even better in 2018.

1) I’m three years out of PT School and have worked hard to build a professional support network with particular focus on having great mentors. It was a priority to me coming out of school to find a clinic that would provide this opportunity for me. I also had great mentors in school who guided me in my research plans and in determining my path. These mentors are always available to me and happy (I hope!) to give their input when needed - but they’ve been around for 3-6 years. The absolute best thing I did in 2017 was add a new mentor to my crew.  I have access to new perspectives, resources, a bigger network of professionals - all with different experiences and knowledge.  My original mentors haven’t lost any value- they’re huge influences on me both personally and professionally and I’m immensely grateful to them. But doing this has reinvigorated me to grow as a physical therapist and has provided me with new content to read, classes to consider, different ways to prioritize my continuing education towards certifications, and career and employment advice that ultimately doesn’t impact him. I highly recommend finding mentors that will take the time to put your best interests to heart and help you along the pathway and keep growing your professional network.

2) The second best thing I did in 2017 was to find myself a personal health coach that helped me get on track with work-life balance and develop my own routine.  She's like having a professional closet organizer come in and give me guidance towards organizing my life.  Even coaches need coaching- in lots of ways.  It's not just about a coach for the weight room. She's here to help me get balance and keep me accountable while I'm getting my diet and training into a regular routine as well as helping me with my mental focus.

I’m a huge fan of the idea that people should be doing training programs- not arbitrary workouts. This is something I have been guilty of for years.  I know enough to write a workout but never spent the time to write myself a program with consideration for microcycles or macrocycles working towards a longer term focus with targeted goals. Thus- my past was full of workouts - a habit that yielded plateaus, imperfect compliance, and failure to achieve the goals I have set for myself.  And I got bored with them!  Now, I have a plan and a timeline with an end date and know that as I reach its end, I will either get a coach to plan my next cycle or write a new one myself - but either way - my routine is planned and I know what I'm doing for the next several weeks of training.

So- that’s a glance into my current routine... but how does this help with patient care?  By working on my own training, I’ve seen how longer term planning and focus during sessions has impacted my own body and have started to implement this with patients. For example: I see lots of kids with ankle sprains. In the past, I might have done a session with strengthening, balance, mobility, and plyometrics all together. Now, especially if I’m not sharing the patient and plan to see them several sessions in a row, I might focus a whole session on balance in several ways and the next whole session might be a core training or core and strength focus. I think overall this will help me become more efficient and I’m looking forward to seeing how it impacts my patient outcomes.   Additionally, I've given a lot more thought to the dynamic warm up component of my own workouts and the rehab sessions... that's a post for another day, though!

3) In 2017, I dramatically increased my "reading," particularly because I discovered the world of audiobooks and podcasts. I know- a little late to the party. The experts in the field say you should be devoting an hour daily to learning/reading and many days that just wasn’t possible for me - but with a new longer commute after my job change, I can get an hour of audio time at least 3 days per week. Thus, I've been working my way through all of the existing episodes of “The Ask Mike Reinold Show” and have found that reading shorter blog posts during the day adds up to my hour when I can't sit down and read longer pieces.  Just like my workouts, I wrote myself a reading plan and am reading all the archived blog posts from Tim DiFrancesco (awesome variety of quick reads with the occasional basketball flare) and Lenny Macrina (new blog - with literature reviews! So good!), rather than just arbitrarily reading whatever comes into my inbox - and I have a plan for the next round of podcasts and blogs once these are completed.  Here are some of the great books I read in 2017 (and yes, I do also read novels - because I need to be able to talk to my patients about something, too!).

1. Sports biographies: Sum it up (Pat Summitt - Tennessee Women's Basketball),  Forward: A Memoir (Abby Wambach - USA Women's Soccer), Shoe Dog (Phil Knight - Founder of NIKE), Tuff Juice (Caron Butler - UConn and NBA Basketballer)
2. Unique in sports- Born to Run: a hidden tribe of super athletes and the greatest race the world has ever seen by Christopher McDougall
3. World Biography: Born a Crime (Trevor Noah), I am Malala (Malala Yousafzai)
4. Breathing: Science of Breath
5. Women in science: Headstrong: 52 women who changed Science and the World
6. Currently reading: Deep Nutrition by Dr. Catherine Shanahan (coming soon: blog post for book review!)

Looking ahead to 2018: what do I have planned?

1) I’ve got some shadowing/observation time that I'm arranging with various different practitioners including surgery observation, time with a chiropractor who values exercise, quality time with some experienced and up-and-coming strength coaches, and some amazing physical therapists with various specialties.

2) In addition to the blogs/podcast archives I'm finishing up, I have several new blogs planned to get through - particularly the works of Eric Cressey - which is a whole lot of reading because he's been writing for so long. Also, more books planned:

1. Nutrition: The Omnivores Dilemma by Michael Pollan and In Defense of Food by Michael Pollan
2. Evolution: The Origin of Species by Charles Darwin
3. Coaching: Conscious Coaching by Bret Bartholomew
4. Pain Science: Explain Pain: Supercharged by David Butler
5. Sports Biographies: Pre (Steve Prefontaine), In My Skin - My Life On and Off the Basketball Court (Brittney Griner),They Call Me Coach (John Wooden), From the outside. My Journey Through Life and the Game I Love. Ray Allen. 
6. Women's Basketball: Bird at the Buzzer by Jeff Goldberg

(Purposeful inclusion of UConn Basketball reads - and Eric Cressey is also UConn educated!)

3) Even bigger focus on sports periodization planned for my own training program to begin in March 2018 once my current program is completed.  I'm banking on this getting better from reading so much of Eric's work

4) More blogging.  Because I'm starting to really enjoy my visits to the local coffee shop where I'm becoming a Thursday morning regular and am loving their ginger peach pot of tea.