"Pain is ALWAYS both physical AND emotional 100% of the time."

As a Sports Physical Therapist at Seattle Children's Hospital and a member of their Pain Medicine Team, I work with many kids experiencing chronic pain. Most often, that includes seeing teenagers who can't tolerate going to school, hanging out with their friends, or participating in their favorite extracurricular activities. Sometimes it's even worse: kids who haven't been able to put a shoe or sock on (or walk) for many months because of chronic regional pain syndrome, which means a very long road back to their previous level of function.  Their pain could have started long ago with an injury or illness, and will hopefully improve with graded exposure to movement while learning about pain.  These patients can experience massive improvement in their lives if things go well.  I'm not crazy enough to think I can help everyone, but I've grown to embrace this work, including when I can't help my patients break their pain patterns.  To help kids with chronic pain with any success has required a commitment to collaboration with other healthcare providers and dedication to learning about pain neuroscience and pain management. To do that, I read. A lot. 

I also read a lot when I'm preparing to give a presentation.  This week, I was invited to talk about Pain Neuroscience and the Pain Medicine Clinic to the Seattle Children's Regional Rehabilitation Team. I like presenting because it requires me to focus learning on a specific subject and makes me seek out new resources. Educating clinicians is very different than patient care and it helps me consider my own beliefs, biases, and treatment approach.  I was fortunate to be partnered with Hematology/Oncology Physical Therapist Dr. Jacob Ross, who spoke about the intensive Pain Rehabilitation Program (PReP) where I sometimes refer patients when they need more care than 1 or 2 hours per week in my clinic will achieve.  If you're seeing Jacob at PReP, you're undergoing rehab or mental health or some school work Monday through Friday from 8AM-4PM for anywhere between two and four weeks! Based on this website, there are 83 pediatric pain clinics around the world, mostly (65%) in the United States, existing in 25 states plus Washington, D.C.  That means half of the states and the majority of the world doesn't have this available at all - and if you consider that the states who do offer these type of services only have it in a small number of places, tons of kids with chronic pain have no access to this care! In Seattle, I've worked with families from Alaska, Montana, Idaho, and Washington - and there are probably patients from many more places that my team members have worked with. 

If you're interested in learning about pain, I recommend you start with the work of Lorimer Moseley.  I've previously written about his books: Explain Pain, Explain Pain Supercharged and the Graded Motor Imagery Handbook, and I wrote about hearing him lecture and meeting him at the University of Washington, here. The NOI Group, who published those books, announced a new one coming out in December, "Pain and Perception: A Closer Look at Why We Hurt" which will be my next pain-related read.  From a different perspective, I also wrote about The Gift of Pain, which describes what happens when people are without the ability to experience pain. You don't pull your hand away from a hot pan or stop walking on a broken leg if you can't experience pain - a very dangerous scenario.  If you came upon this post looking to learn about pain management, any of those resources would be great places to start, but they're more about educating clinicians and, though they may be helpful for patients, I've now read a workbook more specifically intended for patients and think it's a great addition to this list.  

$19.95 on Amazon!

In preparation for our presentation, Jacob asked if I had heard of Dr. Rachel Zoffness. "Why yes, Jacob, I have. I follow her on all the social media and listen to her podcast episodes (OMG listen here or here or here or definitely my favorite: here), and I just finished reading one of her books."  The Chronic Pain &Illness Workbook for Teens was published in 2019 and was the first new resource I read for my presentation. Dr. Zoffness is a Pain Psychologist who teaches for multiple higher education institutions, she is the Co-President of the American Association for Pain Psychology, and she is on the Board of Directors for the Society of Pediatric Pain. Oh, and she treats patients experiencing chronic pain and has written two books. (She also wrote The Pain Management Workbook which I'm currently reading.) She's also released an $80 Workshop "Foundations of Pain Psychology" and more from that series are coming soon! Hopefully I'm not starting to look like a creeper because I've been fan-girling and re-sharing all her posts, podcast episodes, and books, so writing a blog about her work is probably the icing on the cake. When you find someone who can directly impact your patient care and knowledge, with easily digestible tools and clear, consistent messaging, I think you have to tell everyone.   

If this is your first time reading one of my blogs, you might not know that I write to organize and synthesize information I'm learning to refer back to or share with others.  Today's post starts with a look at a few of my favorite points from Dr. Z's Teen Workbook paired with information from two of the research papers I read for my presentation and it wraps up with a look at another pain management workbook from Dr. Greg Lehman. 

If you're a person living with chronic pain OR a clinician who works with patients experiencing chronic pain, in-person multidisciplinary care is the best treatment option, but that isn't available or affordable or feasible for so many people. The Teen Workbook could be a solution for patients who need something they can do independently.  It doesn't replace physical therapy or mental health counseling (or the many other treatments that may be appropriate and necessary), but it can certainly help educate patents and initiate behavior change that may be life changing.  

Jull 2017

1) Let's start with my favorite quote from Dr. Zoffness:"Pain is ALWAYS both physical AND emotional, 100% of the time."  This is the biopsychosocial (BPS) model at its heart and connected well to this image from Jull 2017 that I spent a lot of time discussing in my presentation. The Jull paper is a commentary on the BPS model and shows the idea that 3 different patients may have different amounts of biological - psychological - and sociological needs.  But also, the same patient at time 1, time 2, and time 3 has different amounts of these domain needs, too.  Today, for example, I might have a mild headache and I'm hungry but my mental health is good and I got to spend some time with friends so my social bucket has been filled, but my biological bucket may need more attention (maybe a sandwich for my blood sugar).  Tomorrow, I might have eaten enough for breakfast but be stressed about my pain presentation at work and spending a longer day at the office missing out on game night with friends - so my biological needs have been met, but not the social pieces that keep me going. You can't just look at your patient and think they only need biological care or mental health care at your evaluation and then assume it stays the same for all of their treatment.  I

The Workbook is clear about the role of the mind-body connection with regard to pain and explains what parts of the brain are involved.  It provides concrete examples, intentional questions for patients to consider, and a roadmap of strategies to try to better understand your own pain triggers from each of the three circles and identify solutions to try to reduce your pain volume.  Some of the pain books I mentioned above were really complex but this one is, without question, the easiest to understand and most user-friendly option for the general population, particularly when considering teenagers.  Too often the "Bio" portion is treated alone, with Physicians and PTs attributing pain to tissue damage or disease, but that (biomedical) approach ignores two major domains that impact the patient's presentation (Psych and Social circles). The unity of physical and emotional care is essential to patient success and Dr. Zoffness is screaming this message from the rooftops for everyone to hear.  I'm happy to amplify her message as often as possible to whoever will listen.  I actually ask my patients  "How's your mental health today?  Anything stressful going on?  When are your exams?  Have you done anything fun with your friends lately?"  If it's OK to ask them how their ankle is after they've sprained it, it should certainly be OK to also ask these questions.  Clinicians: please consider adding this to your day to day interactions with family, friends, and patients - and I don't just mean handing them the depression questionnaire and glancing at it.  Look them in their eyes and ask them how they're doing.  And mean it!

Tale of Two Nails

2) Metaphors, Analogies, and Stories help teach pain. It's no surprise that Lorimer Moseley is a mentor to Rachel Zoffness (and Greg Lehman) because they all use many of these to get their points across. I presented a few in my talk, also, but have a few favorites I use with patients.  One example that I liked from the Teen Handbook is about practice.  Think about an activity you wanted to learn. She uses playing piano, but I'm using basketball. At first, your hands struggle to dribble without staring at the ball and using your palm instead of your fingertips and the ball might bounce off your foot or miss the rim when you take a shot.  As a novice the task is more difficult and requires more effort and concentration.  So you practice.  And over time, you get better and better, until at some point, you've stopped looking at the ball and can run while handling it and can make shots from farther away and your form looks more consistent as it becomes automatic.  Your brain has developed new patterns that have been repeated enough times that the task is now easy.  With chronic pain, you're unintentionally practicing pain and your brain develops patterns that make it easier or more automatic to have pain.  The beauty of this is that with the appropriate treatment, the pain and learning can change.  Another example Dr. Z has written about, is "The Tale of Two Nails" which tells two really great stories that can inform our understanding of pain - but you should read those directly from her - so check out the article or buy her other book, because it's in there!

When Dr. Z is talking about practicing pain, she's explaining central sensitization, a phenomenon that I previously was struggling SO MUCH to understand. Central sensitization is a common characteristic of chronic pain, where you have an increased response to sensory stimuli resulting in hyperalgesia (increased sensitivity/bigger pain response to the same sensory input) AND allodynia (painful response to something that is normally not perceived as painful like hurting when you're touched by a feather on your skin.) Your nervous system changes when you experience pain for a long time. 

For my presentation, this 2011 Clifford Woolf paper depicts normal sensation compared to central sensitization.

Normal Sensation: On the left side there is an input - either something noxious (potentially dangerous - top) or a light touch (feather, bottom). Notice the black arrows for the top path (pain) and the bottom path (touch) don't converge and the brown blob (brain) is the same color as the rest of the  nerves.

Central Sensitization: Here, the same sensory stimulus occurs at the far left, but now the black arrows merge to the same destination (brain) and the color has changed because the system has adapted resulting in hyperalgesia and allodynia responses. 

3) It's a workbook: there are pages for you to do work.  This isn't just a book of education about pain. This is a guide with explanation of a key pain-related concept followed by actionable items to help improve your experience.  Sometimes I feel like patients who have had pain for a really long time are desperate for a physical therapist to DO whatever we can TO THEM hoping to dull the pain for just a few minutes.  What we really need is to serve as a guide, showing patients what THEY can DO on their own to turn down the pain.  They have to take control of their lives and do the work for any success to occur.  Physical therapists in chronic pain management should be cheerleaders, rooting on our patients as they make 1% progress day after day. People don't need to be 100% to live their lives fully, and often a really small amount of progress gets the ball rolling for a lot more progress to occur. I don't think patients realize how much control they have over their pain until someone empowers them to trust the process and themselves to get moving.  

Link

So, let's say you like the idea of a workbook and want to have multiple options to choose from, or you're an adult and want something a little deeper into the science. As I mentioned, I haven't yet finished Dr. Zoffness's other book, but I expect it might target that audience a bit more. There's another workbook I really like and was using prior to reading Dr. Zoffness's book. Dr. Greg Lehman's "Recovery Strategies" Pain Guidebook is available for patients or clinicians to access online.  I've previously written about attending his "Reconciling Biomechanics with Pain Science" course here and have appreciated learning from him both at the course and from his online presentations and social media. 

The workbooks are similar in their intent and both include key focus on the BPS model, describe how pain works, and provide action items for you to follow.  And both have many metaphors, analogies, and stories.  In particular I liked his metaphor for what happens to the brain with chronic pain: Consider that our brain is like a map of our body, and that a good map would be really clear, showing all the roads and rivers, but that with pain, things get smudged, almost as if you've spilled coffee on the map and the details get a little fuzzy.  The details of our body can get a little fuzzy with chronic pain, but with exercise and movement, we can clean up the coffee mess and the map gets clearer.  Overall, though, they're really quite different.  Dr. Lehman's book is written as a series of infographics, almost a choose your own adventure graphic novel, where you can take a single page out of it to educate your patient.  It includes pages of mythbusters, examining common misconceptions about various topics like "bones out of place," or how tissue damage found on imaging like an MRI doesn't always correlate with pain.  I think Greg's goes into more detail on how pain processes occur, looking deeper into the science of the nociceptive system, the spinal cord, and the brain, but he also acknowledges that it's meant to be used for patient and provider together because of its level of complexity. 

Also, I think that because Greg is a biomechanist, chiropractor, and physiotherapist, his handbook comes through from a more musculoskeletal lens. Though he fully emphasizes the BPS model, he's more from a bio background and gives adequate attention to the other bubbles.  Rachel is a pain psychologist who comes from a more psycho-social background, and thoguh she gives adequate attention to the bio, it's super interesting to look at their two workbooks and consider how they're trying to reach the same outcome for patients from different angles.  I think that patients would absolutely benefit from both. 

That's all for now.  December's blog post is about grief.  It's another long one and recommends several books on that topic, too. So if you're looking for holiday gifts that are books on pain, start with Dr. Zoffness's books - or if grief books might help one of your loved ones, there are several being reviewed next month.  Stay tuned!

TL;DR:

1) "Pain is ALWAYS both physical AND emotional, 100% of the time." 

2) Your nervous system changes when you experience pain for a long time.  This is called central sensitization which is characterized by hyperalgesia and allodynia. 

3) Teaching people about why we have pain and how the pain process works has been shown to help improve pain.  Multiple resources are listed to learn more about pain, often using metaphors, analogies, and stories to demonstrate complex concepts and make them more easily understandable.

4) The biopsychosocial model indicates necessity in attention to the biological, psychological, and social domains in treatment of chronic pain. 

To Clam, or Not to Clam

As the battle to annihilate the coronavirus continues, everyone is faced with new realities. For me, those realities include chatting with my teenage patients on the phone, transitioning to Telehealth, and only seeing "high priority" kids while covered head to toe in PPE. The patients are still the most important part (and my favorite), but the volume is dramatically reduced so the majority of my time has been spent learning. I've also been working on the Seattle Children's Sports Physical Therapy Journal Club, summarizing papers to share with the department on a monthly basis.  The May topic, coming out tomorrow, is a collective look at these four gluteal muscle electromyography (EMG) papers:

1. DiStefano LJ et al, “Gluteal muscle activation during common therapeutic exercises.”  JOSPT 2009.
2. Boren K et al, “Electromyographic analysis of gluteus medius and gluteus maximus during rehabilitation exercises.” IJSPT 2011.
3. Macadam P et al, “An Examination of the gluteal muscle activity associated with dynamic hip abduction and hip external rotation exercise: A systematic review.” IJSPT 2015.
4. Bishop BN et al, “Electromyographic Analysis of Gluteus Maximus, Gluteus Medius, and Tensor Fascia Latae during therapeutic exercises with and without elastic resistance.” IJSPT 2018.  

Why this topic? I believe it is imperative for clinicians to be lifelong learners and that reading research is one approach to improve your skills as a clinician.  I also think it's really hard to do this, which is why I stared writing this blog - a place where I could store things I've learned and write out my thought processes.  The impetus behind this particular topic of learning boils down to two key points.

Key point number one: The Clamshell Debate.

If you've ever gone to outpatient orthopedic physical therapy, you've likely done the clamshell exercise.  It's very common and frequently patients will say they've done them in the past.  Thanks to Seattle Storm Sports Performance Coach Emily Blurton for her video demonstration:

Early in my PT career, I frequently recommended this exercise.  I had pre-made exercise programs that I used repeatedly for multiple conditions.  Now I make every program for the patient in front of me, often updating them at every session, and this exercise rarely appears. To me, the clamshell doesn't look like anything a person does in daily life or in sports. Maybe it looks like you're lifting your leg to get into a car.  But that's standing up, so maybe not.  Even worse, a lot of patients do them incorrectly and find them boring and too easy.  I don't create exceptionally difficult exercise programs, but it's a lot easier to convince someone to work on something that's challenging than on something that's simple and mundane.  And most of the time I don't really harp on having proper form - but with this exercise, is there any benefit to doing it wrong?  Biomechanically speaking, an "incorrect" squat will still give you some strength gains, but potentially not where you may want to target them.  I don't think shooting for the moon, missing, and landing amongst the stars is actually meaningful in this scenario. 

The circumstances under which I will recommend the clamshell are very specific: the patient needs to 1) have a restricted weight bearing status from the physician due to a surgery or fracture and is therefore unable to do the exercises I prefer but would still benefit from strengthening or 2) have a significant deficit in their active hip external rotation movement with available passive mobility that I want them to purposefully control. (Translation - they're too weak to do any of the other exercises I like better, but I never actually tell patients they're weak!)

I share many of my patients with coworkers who like this exercise, so we've had conversations about clamshells for years.  The biggest discussion came when I had a student who I practically forbade from assigning clams without excessive clinical reasoning of why they were a good choice for that patient. Now that I have some extra time to dig into the research, I'm looking to prove myself wrong.  Does the evidence oppose my clinical bias? And how do you explore the efficacy of an exercise?  

Point Number Two:  What research should I be reading?  

Levels of Evidence - Creative Commons CC BY-NC 3.0

In case you're not familiar with the Levels of Evidence for scientific materials, here's a very basic overview.  Certain types of research can be "trusted" more than others, particularly when you're trying to generalize data to a larger population than was actually studied.  Here's an example: Let's say that tonight at dinner, you ask your child if they likes peas.  If they say no, can you now conclude that this single case of your own observation applies to all the kids of the same age in the USA?  Of course not. But it is your expert opinion that your own kid does not like peas and you understand how that data applies in your household.  Now what if you took a survey of your kid and your two next-door neighbors houses who happen to have seven more kids, asking all of them if they like peas.  You have more information about kids in your neighborhood and their feelings about peas, but still shouldn't make wide-spread assumptions about the whole country based on your small sample.  This would be closer to a small case study moving up the pyramid. If you surveyed your neighbors and then three other researchers did a similar study in different cities, asking fifty kids in second grade and then the same kids again in sixth grade and maybe one researcher also asks about carrots, the number of data points continues to increase and your ability to generalize information across a bigger group improves.  Now you've moved up into more of a cohort study.  

This is a very simplistic demonstration, but sometimes simple demonstrates a major point.  Right now with the Coronavirus Pandemic, small studies are being smeared all over the media without sufficient data and with incorrect descriptions.  It's a good time to point out that you need to be cautious about how you interpret what you read.  Notice at the top of the pyramid sits "systematic review." A systematic review takes multiple research papers into account to accumulate more data points to try to make conclusions.  It is based on a researcher compiling data from other researcher's published works.  Each individual study may not have done the same research, but their data overlaps and new conclusions are drawn from having more data points. I DID NOT USE SCIENTIFIC RIGOR in my collection of resources for this blog post and I have minimal experience in data analysis, so I'm certain there are flaws in what I've found by summarizing these four papers.  However, I basically (unintentionally) created a mini systematic review by reading four different papers (including one which was also a systematic review!). 

I collect articles to read in the future. This collection was one reason behind starting a journal club! I've previously written about the anti-library where you collect resources to learn about the things you know you don't know here. Along with my anti-library, I also have folders of papers I've previously read. I had already read Dr. Lindsay DiStefano's Glute EMG paper (the first in the list) which was probably the nail in the coffin for clamshells for me. Imagine assuming that all kids don't like peas because one kid said they didn't?  I've basically assumed that clamshells are a poor quality exercise based on the findings of one paper that studied 21 participants doing 12 exercises.  Dr. DiStefano was my research advisor in PT School so I almost always read her publications, or have them saved for the future. (Bias Alert!)  So I need more data points! I searched for more recent Glute EMG papers to compare to hers and found three more, intentionally choosing papers that included the clam shell exercise and ultimately including one with a somewhat contrary view.  Now the data I'm considering reflects over 500 participants and many more exercises including multiple variations of the clamshell.

EMG studies are used to understand muscle activity during movement.  Not only are these papers valuable, but they can also influence patient care by helping to better understand what exercises target which muscles.  I've previously hinted at reading EMG studies with regard to the shoulder here, and for sure that knowledge changed my PT practice for post-op shoulder patients. EMG studies aren't perfect, but by looking at a collection of them, you can assume similar risk of error for each study.  Participants in these papers were first assessed for their maximal volitional isometric contraction (MVIC) (aka how strong they were for a specific muscle).  Then, by placing sticky electrode sensors on the skin at certain locations, measurements of muscle activity were taken with each exercises and compared to the maximal strength possible for that person. For an exercise to improve strength, the exercise must elicit at least 40-60 % of maximal strength (MVIC) for gains to occur.  

Here's what the papers found:
DiStefano et al: The top exercises for glute medius based on % MVIC were side-lying hip abduction (81%), single limb squat (64%), lateral band walk (61%) and for the glute maximus were single limb squat (59 %) and single limb deadlift (59%). Clamshell exercises (depending on hip flexion position) were shown to have glute medius activation of: 38-40% MVIC and glute maximus activation of 34-39% MVIC.  (Clamshells don't pass the 40% minimum cut point which has been my rationale to discontinue using them in the clinic). Other exercises were examined in the study, but since they did not cross the 40% MVIC threshold, they are omitted here.

The Boren study used a cut-point of 70% MVIC as the minimum acceptable for strengthening and examined a larger variety of exercises. Glute med exercises with >70% (MVIC) were the side plank with hip abduction (103.11% bottom leg, 88.82% top leg), single leg squat (82.86%), clamshell variation #4 hold top leg in full hip extension while internally rotating (76.88%), and prone plank with hip extension (75.13%).  For the gluteus maximus, plank with hip extension (106.22%), glute squeeze (80.72%), side plank with hip abduction top leg (72.87%), bottom leg (70.96%) single leg squat (70.31%).  This paper suggested that the best exercises to target both glute med and glute max were the prone plank with hip extension, side-planks with hip abduction, and single limb squats.

The clamshell exercise had four variations in the Boren paper. Of these variations, #4 described above was the only option to reach their defined threshold of >70%.  If you use the criteria of 40-60% outlined in the DiStefano paper, all the clamshell variations would meet that target as sufficient for strenghtening for the glute med, but only the standard clamshell works for the glute max at 53.10% with other variations all below 30% MVIC.

The Systematic Review by Macadam et al reviews multiple papers and breaks down exercises by body position.  The cross-over step up and lateral step up had the highest average glute max and glute med % MVIC.  Pelvic drop, sidestepping with hip internally rotated and band at the ankle, standing hip abduction variations, rotational single leg squat and transverse lunges all had glute med % MVIC over 40%.  Standing hip abduction, rotational single leg squats and transverse lunges also had % MVIC over 40% for glute max. 

In sidelying, side planks with hip abduction had the highest average glute max and glute med % MVIC. (That exercise is really hard, though, and wouldn't actually be appropriate for the majority of my patients.)  The paper examined 13 clamshell variations including the standard hip external rotation and others.  In one study, three clam variations (not the standard hip external rotation) had average glute med % MVIC over 60% but other studies had clamshell averages in the 30% range.  From this paper, I can start to ease up on my thoughts that patients do the clamshell incorrectly - and more that they're just creating their own variation.

And finally, Bishop et al compared glute med and glute max EMG to tensor fascia latae (TFL) EMG creating a "Glute to TFL Index."  The TFL and gluteus maximus both insert on to the iliotibial band and contribute to hip abduction.  The TFL is sometimes considered to be a contributor to low back and lower extremity pains and/or injuries and may increase in tone or "tightness" to compensate for gluteal deficits.  Bishops "Glute to TFL Index" findings were that the clamshell with resistance was 99.54 and the clamshell without resistance was 87.89 meaning that the gluteal muscles were selectively used for these exercises much more than the TFL.  The clamshell exercises far surpassed all the other tested exercises in this study with the next best exercise being the bridge with resistance at 48.86 and prone hip extension with 48.57, both about half of the clamshell values.  Thus, this paper recommends use of the clamshell exercise as a glute-targeting exercise that does not incorporate the TFL.  To these findings, I'll add another dose of bias. Does this really matter?  Does the Glute to TFL Index have clinical meaning?  I'm not sure because I don't know if I really want to "turn off" the TFL. I'll let the clams have this one. 

Free photo 5470017 © Pavel Losevsky - Dreamstime.com

In the end, I haven't been convinced.  A healthy dose of confirmation bias potentially sprinkled with some self-serving bias may contribute to that decision, but to me, the evidence seems clear. Maybe I'll be nicer to those who know that the clamshell has the higher glute to TFL index, but without that rationale, these papers suggest many other glute strengthening exercises.  For sure, I'm open to hearing alternative opinions. Are you team clamshell?  Or team ANYTHING ELSE!  I use prone glute squeezes more often than I use clamshells.  And I'm incredibly grateful for my coworkers who challenge me to think about these topics. 

(Again - this is an abbreviated summary of the results sections of the papers.  More information looking at the discussions and limitations and other aspects of the research is available if you'd like more!  For the full written summary for Seattle Children's Journal Club, go ahead and email abby.gordon@seattlechildrens.org and I can send it any time). 

New WNBA Injury Data Published!

Alert! Hot off the Presses! Physical Therapists working in Sports... Athletic Trainers... Strength and Conditioning Coaches... High School Basketball Coaches... Female Athlete Parents... Orthopedic Surgeons... WNBA Colleagues... Basketball Fans... Any one else who is interested in learning something today... Check this one out.

Presenting at Seattle Children's Sports Symposium

A new paper was published (April 16, 2020) in Arthroscopy, Sports Medicine, and Rehabilitation entitled "Injury in the WNBA from 2015-2019."  You can find the paper here. I jumped for joy to see this new release when it was in my inbox this morning.  Gotta love alerts that know what I'm interested in.  In case you don't know, women's basketball player injuries was the topic of my PT School Thesis paper, "College and Professional Women's Basketball Players' Lower Extremity Injuries: A Survey of Career Incidence" which you can read here.  In November 2019, I
had the opportunity to present on this topic to the Sports Medicine Department at Seattle Children's Hospital, updating my findings and making it more applicable to our department's work in pediatric sports medicine.  This topic is on my mind constantly, and since WNBA Physicals were supposed to be this week, now postponed until the coronavirus battle is under control, I'm thrilled to have basketball on my mind.  A new publication five years after my own with some similar findings from an entirely different approach was both gratifying and validating and this paper could not have come at a better time.

The new paper, written by Orthopedic Surgeons at the University of Chicago summarized injuries in the WNBA between 2015 and 2019 which were compiled from publicly accessible websites.  Interestingly, the findings were similar to my research with regard to ankle sprains being the most common injury and both papers explore ACL Injuries.  My study only looked at lower body injuries so it did not examine concussions, but this recent paper did and I've previously written about the WNBA Concussion Protocol here.

Here's why this paper is important, in my opinion.

PubMed is a search engine for research papers, kind of like Google, only your search will bring scientific information. A PubMed Search conducted today, April 20th, for "WNBA AND Basketball" will give you EIGHT results.  In comparison, A PubMed Search for "NBA AND Basketball" will give you 120.  This new paper doesn't appear in that search.  Neither does mine.  I'm not sure what you need to do for PubMed to determine you're worthy, but it's apparent that the topic isn't a common one found in this search engine.  PubMed is where I go first when I want to find research on a specific topic that impacts my patients. 

So how about a different search engine like Google Scholar.  There "WNBA and Basketball" has 5,120 (94 results since 2020), including this new paper and my own, and "NBA and Basketball has 55,000 (1140 since 2020).  Obviously I did not screen every title to see if they actually refer to basketball and the NBA which is why I wrote the search this way, but it's SO EASY to see the discrepancy.  In my opinion, a new publication looking at the WNBA is a HUGE win for the WNBA. 

The papers that are found on the Google Scholar search are on all sorts of topics.  There are publications about injuries, like the ones I'm talking about and, as a physical therapist, which I find most interesting.  But there are papers about basketball, about female athletes, about gender differences from various perspectives including pay and spectator attitudes, differences between draft selection and playing times, sexuality, fan experiences, race, television time, and the list goes on. 

The battle to improve opportunities for women in sports continues.  The battle for pay equity, though improved with the new WNBA Players Association negotiations for their collective bargaining agreement, continues.  The battle for sports media to increase awareness of women's competitions and to increase support of elite female athletes continues.  And this week, the battle for increased awareness of injury data - which ultimately can help contribute to injury prevention strategies, continues, but with a step forward.  I tip my hat to you, University of Chicago Orthopedics. 

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.

Resilience

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

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

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

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

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

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

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

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

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

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

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

Thank you, Dr. Berry.  

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

Volunteering in Tanzania

Africa was never really on my bucket list. It's SO far away from Seattle and pretty expensive and I didn't see the point in taking so much vacation time to go somewhere that is portrayed the way Africa often is.  And on top of that, why would I take a vacation to work somewhere else for free?  I thought I was going to a very poor place, a desert that would have been all brown, ugly, and dirty, with people who I knew nothing about whose circumstances don't impact my life. I've heard that safaris were amazing, but I despise zoos because they make me sad for the animals and I thought that a safari would feel the same way.  So what reason would I have to put this on my bucket list?

Me and Kristen

A year ago, I met Kristen, my coworker at Seattle Children's Hospital and an East Coast transplant who says Florida like every other New Yorker ("Flaahhrida") and won't eat at a pizza restaurant that doesn't sell by the slice because that isn't the true New York way.  She exudes an incredible passion for life and is a really talented physical therapist.  And she LOVES Tanzania.  LOVES.  She invited me - and several of our coworkers- to go along with her as she supervised a group of PT students from her alma mater, Stony Brook University.  So with the above reasons I had identified not to go, among several others, one key reason on my "yes" list ultimately won: I realized that I wanted to.  It hadn't been on my bucket list because people weren't talking about it, because it's not a top travel destination, because I don't know anyone from Tanzania or even anyone who had ever visited. But I wanted to travel to a new place. I wanted to meet new people, experience new cultures and eat new foods.  I wanted to see an elephant and a giraffe and a zebra in the wild and see that it wasn't like the zoo.  I wanted to connect with my coworker outside our office - because we had already started to become friends - and what better way to really explore a new friendship than spending every minute together for two weeks?  I wanted to give my time to people who needed it more than those I usually give it to.  And I wanted to confirm or dispute all of my preconceived notions.

Mt. Meru

I learned that in many cases I was wrong.  I wasn't in the desert at all.  In fact, Tanzania doesn't have desert.  The Sahara doesn't cover the entire continent of Africa.  Yeesh...There were tons of sunflowers and trees and our hotel had this AWESOME view of Mt. Meru easily visible in the afternoons when the clouds had dissipated.  It even rained despite being the dry season.  The safari animals are truly free.  Lions out in the wild are breathtaking.  There are birds with so many bright colors, they gave Costa Rican parrots and exotic rain forest ornithological creatures a run for their money.  They cooked foods with curry and I didn't really have to eat that much rice, which was good, because I don't really like rice, but for some reason expected to be eating it all the time.  

In some cases I was also right.  I was eaten alive by mosquitoes despite bathing in bug spray and sunscreen.  If you've seen any of my Facebook posts where I'm wearing a bandana or a headband - those weren't for fashion.  They were bathed in permethrin in an effort to reduce my bug bites.  I think it helped - my face didn't suffer nearly as much as my arms and legs did.

Traveling Pharmacy

Our group collectively did need most of the pharmacy that I brought with me.  I exclusively consumed bottled water including for brushing my teeth, but many meals did not agree with  my digestive tract. I got a nasty cut on my finger that required first aid care. Others in my group experienced some illnesses. Plus, the anaphylactic reaction I wrote about here.  

Our work and the things we saw were emotionally intense and left my mind wandering into the wee hours of the night, limiting how much sleep I was getting. (I would never blame late night chats with Kristen for the lack of sleep... ) I over-estimated what was available to the people of Tanzania, and as such, was a bit shocked by what I saw and what I learned.  Now I've been back home for just over two weeks and I'm still processing the experience. When it came up in conversation today at work, a wave of emotions flushed over me, just as it did while I was there.  The number of times "how was your trip" gets asked declines exponentially, but the feeling hasn't changed yet. 

Sandals made from recycled rubber tires

I've really been struggling to write and talk about my experience volunteering in Tanzania.  As much as I have tried to explain it, my words and photos are insufficient.  It's far easier to talk about the animals on safari and pretend like the volunteer work never even happened.  The zebras don't really elicit my emotions.  But talking about my volunteer work sometimes comes out as if I saw a world of poverty, despair, and sadness.  This was not the case.  

The people I met in Tanzania were a wonderful community who prioritize hospitality, traditions, family, and kindness and who happen to live in a place that simply has less.  Less of pretty much everything.  Less material "stuff" available to them than where I come from. Like shoes - where multiple times I saw these sandals made from recycled car tires.  Less money (Tanzania has .03% of the world's wealth averaging $2716 per adult - 2nd from the bottom of this list - compared to the US which has 25% of the world's wealth and $201,319 per adult - 3rd from the top - and consider that we have 607 billionaires in America according to this article averaged in along with the Americans living beneath the poverty line).  Less opportunity.  Less healthcare (269 hospitals in the country for 50 million people over 365,000 square miles (5.38 hospitals per million people) compared to the US 6200 hospitals for a population around 320 million spanning 3.7 million square miles (19.375 hospitals per million people) which just means both countries have areas where people have to travel far for a hospital, but in Tanzania, there are many more people trying to use less facilities.  Shorter life expectancy: 61.8 years compared to the US 79 years. Less schooling for children with disabilities - we learned about every single school for children with disabilities and how many students they accommodate and how many teachers they had in less than 45 minutes.  For all of Tanzania. Less infrastructure.  Less electricity.  Less drinkable water.  Less education (27 universities and 15 colleges versus 4298 higher education institutions in the United States.

Shanga Employee Wheelchair

So they have less... but does that make it bad?  No. And in some cases, cases that really matter, they also have so much more.  They have more family time.  Families live in close proximity with one another and honor their past traditions as they try to be a little bit current while simultaneously adhering to their tribal laws.  They have more respect for their elders - in fact they even have a specific greeting intended to be used with elders rather than for peers. They have more kindness.  They have more generosity.  They have more sharing.  I'm pretty sure they have more work ethic than many of us, working in more labor intensive work than many of us face.  They have more connection to their land and to their animals and to their religion.  They have more healthful food that does not contain the chemicals and processing we add to ours. They have more national holidays.  They have better maternity leave (12 weeks fully paid). They have the same sun, moon, and stars in the sky, but less pollution obstructing your view to see them.  They have the benefit of waking daily to the crow of the rooster, rather than those annoying ring tones installed by Apple set to go off every 9 minutes.  I really started to like waking up to the roosters.

Despite what you may have heard, there may be one planet Earth, but the world is not the same everywhere.  Tanzania is nothing like the United States.  But that does not make the United States better.  It just makes us different.  And, at the end of the day, we're all human beings who bleed red and breathe the same air.

Glass beads made at Shanga

The group of volunteers I went with were four Physical Therapy students from Stony Brook, one of their professors, Kristen, and myself.  Seven Americans split between two facilities volunteering in Tanzania.  One of the facilities was a school for children with disabilities called Step by Step where Kristen supervised two students.  My team was at Shanga which is basically a workshop and store that makes and sells crafts from recycled products and employs people with physical disabilities.  Shanga provides employment and salaries to individuals who would otherwise have much more difficulty finding work  Through sale of their products, visitor donations, and their larger parent company, they can feed their families and have support with access to medical care and equipment.

George teaches group exercise class

At Shanga, we assessed the needs of the employees.  A year before us, they had been visited by Stony Brook students who had developed an exercise program that the staff would participate in about twice per week.  They embraced their new program last year and were eager for some upgrades.  The previous program had some limitations such as a key focus on mobility, but not very much on strength.  We were able to update the program and we taught the leadership team basic concepts of exercise and ways to modify the program to try to give them more ownership and ability to have variety.

We also did one-on-one evaluations of several employees experiencing pain or with mobility issues they were hoping to improve.  There were some employees who had amputations who needed assessments of their prosthetic limbs, something I never do at Seattle Children's but had done on my clinical affiliation in New Mexico during PT school.  Other employees had experienced injury or been having some health issues they wanted checked out like cardiac concerns.  Some had seen last year's PTs and wanted an updated program, as well.

And so, I've described my volunteering experience.  But really, I've tried to explain that the way we view the world from here is through a distorted lens.  I, too, am guilty of this.  It isn't gone now, I'm just a little more aware, now.  Our pre-occupation with money and objects in the United States may be holding us back from some of the other beautiful values seen around the world.  I pray that this experience helps me reflect on what is truly important and embrace those things more in the future.  

Vaccination for Africa!

In just a few days, I’m departing on an adventure, heading to Africa!   I’m headed specifically to Nairobi, Kenya for a day followed by two weeks in Arusha, Tanzania ending with a Safari!!!!  Thanks to my coworker pal Kristen who writes this blog (even more specifically, has several posts from her previous trips to Africa, here)... and we’re joining one of her PT School professors and 7 students from Stony Brook University to do some physical therapy-related work. I don’t have the details of what we’ll be doing yet- so stay tuned for the post-Africa blog posts for that... but the preparations for the trip have been very interesting and I thought I’d write about the medical preparations for the journey - along with some thoughts on vaccination.

From: http://pcwww.liv.ac.uk/epidemics/MAL_geography.htm

Let's talk about medications.  Thanks to Virginia Mason’s Infectious Disease Department- not only was I able to receive the shots and prescriptions I needed, but they also explained many of the possible risks and made recommendations for me. They collected my dates and destinations of travel in advance, prepared a stack of pamphlets for me, and had the shots and prescriptions I needed ready to go.  I now have a whole pharmacy packed based on things that my body might encounter that it doesn't generally experience at home. Specifically- Tanzania is in the malaria belt and Kenya has an escalated risk for contracting yellow fever. And so- I have malaria medications and I had a yellow fever vaccine this week. The provider who organized all my medical care for these travels, Lisa Roberts PA-C was very thorough and presented the options for all the medications - such as discussing my choices for malaria medicines because some of them can be hallucinogenic.

Some interesting facts about these diseases:
Malaria:
1) Link: There are five types of malaria parasites called plasmodium.  One type, Plasmodium Falciparum, can be life threatening and induce liver failure, kidney failure, and coma.  This is generally the type that you take preventive mediation for when traveling.
2) Link: Malaria is transmitted by mosquitos, so using bug repellent containing DEET, long sleeves and pants, and taking preventive medications are all useful preparations. The particular type of mosquito, the Anopheles Mosquito, cannot survive in climates cooler than 68*F, so since central Africa is so warm, this is a common region for the disease.  As global warming continues, the malaria belt is expanding.  Even though the United States has successfully managed to reduce malaria cases, we do house these mosquitos, so there is always the risk that malaria can become a bigger problem here at home.
3) Link: There is a malaria vaccine, but it has a low efficacy and requires four injections... so I'm not immunized, I'm taking preventive medications. The reason for this is that the DNA of that plasmodium reproduces so fast, it can build resistance - just like we've seen with antibiotics resulting in things like methicillin resistant staphylococcus aureus (MRSA - the SuperBug) which, by means of evolution do not respond to the usual medications.  I'm so glad I read "The Origin of Species" by Charles Darwin, and wrote about it here.

Yellow Fever:
1) Link: Yellow Fever is also transmitted by mosquitos.  About 15% of those who are infected will have severe symptoms including shock, organ failure, and possible death.
2) Link:  The vaccine against yellow fever is considered to be life-long protection and 99% effective.  and is a live vaccine, which means that scientists took the actual disease, weakened it, and then it gets injected into you to build up immunity to it. There is also a shortage of the vaccine with limited number of places where you can go to get one - so if you're looking to travel, plan ahead!  You need a specific yellow card marked with your immunization in some cases - for example if you spend time in Kenya before going to Tanzania, like we are, you need the shot.

In addition to malaria and yellow fever, we also discussed risks for hepatitis, rabies, measles, mumps, rubella, influenza, and diphtheria, along with multiple symptoms that could require treatment, particularly related to gastro-intestinal distress which I won't go into detail about but which also included some shots and medicines.

What is a vaccine, anyways?  A vaccine is a medicine used to prepare your immune system to fight a disease in case it ever comes into contact with it.  Our body fights off disease by using a system that requires exposure to something to build up a defense system.  The vaccine is the first exposure to a disease, usually a weakened or dead version of it, so the body can recognize invaders and be prepared to fight.  There is considerable controversy around the country with some parents believing that vaccines are dangerous - or they don't believe in inoculation for a variety of reasons.

While I've been going through these preparations and getting additional immunizations beyond the ones I've had for public schooling, college, graduate school, working on an ambulance and now working in a hospital-based system, Seattle Children's and many other places around the country, have been facing increased episodes of cases of measles. Seattle Children's publicized exposures there here and this article describes the over 1,000 cases identified in the US this year, a considerable increase since measles was considered to be eradicated in 2000.  Measles is a highly contagious disease spread through coughing or sneezing or bodily fluids of infected people and does not have a cure.  A contagious person will likely infect 90% of the non-immunized people they come into contact with.  There is a high risk of fatality from measles because of the complications of the condition - immune compromise and opportunistic infections like pneumonia.  The vaccine is only 97% effective, so even those who are immunized aren't perfectly protected, but because of the high risk, it's essential that people vaccinate their children.  I urge everyone to read about the signs and symptoms of measles, particularly if you are in an area where there has been a spike in cases as it looks like there is a current epidemic occurring or if you are a healthcare provider.

Volunteering Emergency Response in Israel in 2006

Several cases of measles in Washington have been linked back to being at Seattle-Tacoma International Airport, where I'll be headed to depart for Africa in just a few days.  Interestingly, I also found this article looking at the measles epidemic occurring on the east coast, reporting cases in New York in Orthodox Jews who do not inoculate their children and who had recently traveled from Israel (which has been having an outbreak as well).  This article also discusses the Orthodox Jews having this increase in cases.  Having been to Israel several times and lived there as a volunteer EMT in 2006, knowing that they're so advanced in their medical and technological developments, this shocked me!  Over 500 of the cases in the US are in NY in this population, and Washington is 2nd on the list.  As a Jew myself, I can't understand why the Orthodox aren't taking care of this.  It seems that some believe vaccination is against Jewish law, which is of course an interpretation of something, though I'm not sure what, because vaccines obviously did not exist at the time Jewish law was written. What is for certain part of Jewish law is to do anything that may save a life, and since vaccination can save lives, it seems to me that more Jews would support vaccination.

Even the APTA has a position on this.  Physical therapists are in a prime position to encourage families to get their immunizations as part of their regular health care.  The risks of not doing so many times could include fatality - to your own family member or to someone else.  The benefits far outweigh the risks.