Physical Therapists in the WNBA (an update)

The 2021 WNBA Season is under way and the Seattle Storm is off to a great 4-1 start.  Every year, I look forward to seeing opponent staff members I've gotten to know over many years working around the league when they come to town. With last year's season being held in an isolated Wubble (WNBA + Bubble) in Florida, it has been a long time since I've seen some really awesome colleagues and I can't wait to catch up with them.  This also gives me the chance to see how the WNBA is growing and I often wonder if the opportunities for women in Professional Sports Medicine are improving.  

In May 2019, I wrote this blog post which looked at teams having physical therapists in the WNBA compared to the NBA.  At that time, based on team rosters and Google searching, I was able to find only three (out of 12) WNBA teams with physical therapists - the Atlanta Dream had Jess Cohen, a dual credentialed ATC/PT who is now with the Portland Trailblazers (YAY WOMEN IN THE NBA!), Emily Wert with the Minnesota Lynx and the Mayo Clinic, and myself with Seattle. In the NBA at that time, 14/30 teams had PTs on their rosters, many of them dual credentialed (licensed in physical therapy in addition to another area of practice - common in sports are athletic trainers (ATC) or strength and conditioning coaches (CSCS)).  At that time, 3 WNBA teams did not list their Head Athletic Trainers on their team rosters and most did not list team physicians. 

I recently came across this May 2021 (August 2020 online) publication "Gender disparity among NBA and WNBA team physicians," which got me thinking it was time to research for an updated post to see what has changed. The article summarized an October 2019 Google Search for team physicians over the past 10 years in each league, identifying 125 NBA Team Physicians (122 male, 3 female) and 28 WNBA Team Physicians (20 male, 8 female) and also considered the geographical location for these providers. The Northeast Region had the most female providers, but the disparity remained.  The paper cited a previous publication for finding the following:

"In professional sports, O’Reilly et al. demonstrated that 28 of 420 (6.7%) current team physicians were women. Of the 420 physicians included in this study, 224 (53.3%) were orthopedic surgeons. Among those, 14 of 224 (6.3%) were women. The authors also noted that the greatest proportion of female physicians among professional sports leagues was in the Women’s National Basketball Association (WNBA), with 11 female physicians out of 34 (32.4%) as opposed to 3 of 158 (1.9%), 7 of 117 (6.3%), and 11 of 139 (7.9%) team physicians in the National Football League (NFL), National Basketball Association (NBA), and Major League Baseball (MLB) respectively."

I'm pleased to report progress across the WNBA!  In today's search, I started with checking all the team rosters, front office pages, and then went to Google.  I also used LinkedIn to confirm names when it was hard to tell if the findings were current. I can now report that only two WNBA teams do not list a Head Athletic Trainer. Google easily found the Dallas Wing's ATC (Branay Hicks), but the Indiana Fever search came up empty - except their job posting looking to fill the position in April 2021.  It would be unfair of me to ignore that the season is 1 month in and that with COVID challenges and last year in a bubble, a little grace for delayed website updating should be permitted.  

Storm Head Athletic Trainer Caroline Durocher (far left)

Additionally, when specifically looking at ATCs, PTs, and Strength and Conditioning Coaches, the gender spread is now much more women with 18 females and 4 males identified around the league among these three jobs and only two teams have male athletic trainers in the league, now.  (This assumes the Indiana Fever Athletic Trainer is a man, which has historically been true and appeared to be the case when I last watched some clips of their games.) It brings me great joy to see the Seattle Storm with a Head Athletic Trainer, Strength Coach, and Physical Therapist (in addition to massage therapist and acupuncturist and additional providers) who are all women.  Also, big news release today, the Seattle Storm return to a female Head Coach with Noelle Quinn taking charge following the retirement of Dan Hughes.  Moving even further than gender, the number of non-white athletic trainers has also increased and the diversity in that group is noticeable, which is even better!

The biggest difference I've found is the increase in physical therapists around the league. The Las Vegas Aces lead the pack with a dual credentialed PT/ATC (Michelle Anumba) as well as a PT who is also a Certified Strength and Conditioning Coach (CSCS) (Chelsea Ortega).  While I'm trying to help elevate women in sports medicine, Chelsea has a company called "Clinic to Field" which offers a 20+ hours continuing education course, "Comprehensive Management of Sports-Related Concussion" approved for PTs and ATCs.  The Phoenix Mercury also have a PT/CSCS on their staff, Derrick Nillissen.  I think this transition, though slow, is going to be the best thing for the athletes.  Athletic Trainers and Physical Therapists do very different work.  To have the knowledge and skills of both on team staffs can only help improve athletic performance.  

I tried to find the current team physicians, too, but most WNBA teams don't have those listed.  My search was unable to find providers for several teams, but some teams list many.  If the count I found is accurate, I found 12 WNBA team physicians who are male and 5 who are female.  The New York Liberty, who partners with the Hospital for Special Surgery, highlighted their team physician group best.  To be fair - no healthcare provider joins a team medical staff for recognition, so the fact that their names are absent isn't that surprising.  But because these teams create platforms, it seems like one potential way to elevate women in sports medicine from a league who is already doing so much to elevate women in so many different spaces. 

How about progress in the NBA sports medicine staffs? When I looked in 2019, I was able to identify 6 women among the medical providers in the NBA through both their Athletic Trainer and Strength Coaches Associations.  This time around, again from the NBATA and NBSCA listings, I found even more!  From the Athletic Trainer's Group - there were 19 dual credentialed ATC/PT providers and there were 12 women ATCs.  From the Strength and Conditioning Association there were 3 women, bringing the total up to 22 women working in the NBA's sports medicine departments!  This ignores massage therapists, chiropractors, dieticians, dentists, acupuncturists, and many other providers.  This time around, we've got two women with dual designations in the WNBA and NBA with both Chalisa Fonza and Sarah Walls covering the Washington Mystics and Washington Wizards.  Of course, this is all based on what's currently posted on the internet - so it could be outdated-  but it's still better than 2019 which makes me happy.  

Unfortunately, the medical staffs around the WNBA continue to be miniscule in comparison to the NBA. It's hard to compare the numbers because there are so many more teams, but the NBATA has 82 athletic trainers listed for 30 teams.  The WNBA has 12 for 12 teams. And the WNBA providers are still not permitted to participate in the organizations for the NBA's sports medicine providers, which just means we have less access to basketball-related resources and research and knowledge sharing, though the WNBA athletic trainers have also made gains in that area by collectively gathering without their own organization.

I continue to hope that eventually the WNBA will have more providers and will be able to organize league-wide like the big men's leagues all do.  Every year I get a handful of emails and messages from college students asking me how I got to work in the WNBA, and I can see that the interest and aspirations are only getting stronger as the league gains more and more popularity.  I'll continue to try to find ways to help the league, but for now, let's take a moment to be grateful that progress is occurring and be excited for all the women in sports medicine across the WNBA and NBA.

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. 

WNBA Finals Despite the Injuries!

Yesterday was Game 3 of the WNBA Finals. If you're not familiar with this league, the Finals are a best-of-five series which means you need to win three games (out of five) to be crowned champion. Last year, the Seattle Storm swept the Washington Mystics 3-0.  It was glorious!  Right now, the Washington Mystics are 2-1 ahead of the Connecticut Sun, with Game 4 being held tomorrow night at Mohegan Sun Arena in Connecticut.

Why is this important to me?  First, as the physical therapist for the Seattle Storm, I wish the Storm were playing in the Finals and that I was there to watch.  I love basketball and this really is some of the best basketball you can watch.  Haven't been to a WNBA game?  What are you waiting for?!?! Second, despite being dedicated to the team I work with, I'm also a supporter of the league as a whole and have a long history with the teams currently competing.  The current Head Athletic Trainer for the Sun, Rosemary Ragle, was the UConn Women's Basketball Athletic Trainer while I was in college - and also worked with me on my Grad School thesis.  The current Washington Mystics Head Coach, Mike Thibault, hired me to work for the Connecticut Sun when I was graduating from UConn in 2007.  I worked for him - and the Sun - for four seasons before PT School.  Their assistant coaches include his son, Eric Thibault, and former UConn and Connecticut Sun standout and Olympic Gold Medalist Asjha Jones who were both with the Sun when I worked there.  I can't possibly root for one team over the other - though I have a lot more Connecticut Sun t-shirts in my closet than Mystics attire. 

So I'm following the WNBA Finals, watching teams compete for the highest position in Women's Basketball - perhaps falling only behind the glory of an Olympic Gold Medal or World Championship - and the headlines are riddled with descriptions of injuries these players are experiencing.

Like these tweets:

Alyssa Thomas has a torn labrum in BOTH of her shoulders.

Instead of missing games to have surgery, she modified her shot and played through the pain. 👏#WNBAFinals pic.twitter.com/cVkqss0cQz

— espnW (@espnW) October 2, 2019

The @ConnecticutSun say they'll prepare as if @De11eDonne will play Sunday. The @WashMystics have to prepare as if she won't. The MVP's status for Game 3 of @WNBA Finals expected to be announced Saturday. https://t.co/0Vuwyd1R5m

— Mechelle Voepel (@MechelleV) October 4, 2019

Or this article today in The Guardian:

Elena Delle Donne plays through injury to move Mystics one win from WNBA title

• Washington beat Connecticut Sun 91-81, lead series 2-1
• League MVP has a herniated disk pinching nerve in her back

Associated Press

Sun 6 Oct 2019 18.22 EDT

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 Elena Delle Donne drives the ball to the basket during Sunday’s game. Photograph: David Butler II/USA Today Sports

"Elena Delle Donne put forth a gutsy effort, playing through a back injury, and Washington beat the Connecticut Sun 94-81 on Sunday to move within a victory of winning the franchise’s first title. The league’s MVP has a herniated disk that is pinching a nerve in her back and was questionable to play in Game 3. She finished with 13 points, hitting five of her six shots and played 26 minutes."

I can't help but thinking - what message does this send to the fans, particularly the young ones?  Is this helpful?  What does it all mean, anyways?

First and foremost, a disclaimer. I am not working with either of these athletes.  I do not know what care they are receiving - but I would bet it's excellent from my years interacting with both organizations.  I care about the health practices around the WNBA and have been trying to help improve their standards for several years - so from the research I've done, I can say with confidence that it is highly likely that these basketball players are being well taken care of. 

Additionally, I absolutely 100% believe that the above-mentioned athletes with injuries are experiencing pain.  I read one account that said that Elena Delle Donne could not sit down because it was too painful, so the medical staff and coaching staff had devised a plan to bring her into their locker room when she was subbed out of the game to keep her moving and stretching and to avoid extended periods of sitting time.   This sounds like EXCELLENT collaboration between a medical and coaching staff and is something other teams should take notice of!  (The Storm is good at this, too, in my opinion!)  If an athlete is reporting pain, I believe that they have it.  All pain is real.  Pain is a personal experience that is influenced by many things.  But pain is also a protector and it doesn't necessarily mean these athletes can't be playing.  Here are my thoughts with what I've read and, more importantly, some thoughts on comments from fans who have opinions on the matter.

1) There are HUGE numbers of people with imaging showing torn labrums in their shoulders and disc herniations that DO NOT have pain.  This paper discusses the labrum tears and found that 55-72% of people without shoulder pain had a labrum tear. (The population was a little older than Alyssa Thomas, aged 45-60, but she is an overhead athlete so this presentation for her is not really that surprising).  Want something more specific to athletes?  This blog post from fellow UConn Graduate and well-known strength and conditioning coach with Major League Baseball players, Eric Cressey, presented the research on the same topic.  He quotes: " Miniaci et al. found that 79% of asymptomatic professional pitchers (28/40) had "abnormal labrum" features and noted that "magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of 'nonclinical' findings." This paper looked at a large sample (3110 subjects) without back pain and found on MRI that 30% of 20-year-olds have disc herniations and that the number increases over time.  This is why sometimes people have surgery but it does nothing to correct their pain... because the MRI findings and the surgical correction does not always fit with the pain.  

2) These are elite level athletes so it concerns me when I read that suggest they're "skipping surgery and playing through pain."  Tissue damage DOES NOT correlate with pain, so unless ESPNw was given reports from the teams stating that they had pre-participation MRIs that were normal and then started having pain the correlated with tissue damage (which goes against a lot of the evidence) a surgery may not even come close to fixing these problems.  Another way of looking at this is - why does their body adapt to present with the MRI findings that they have.  For example (hypothetically) is Alyssa Thomas' upper back too stiff for her to get her arms all the way overhead to shoot and rebound?  Because if that's happening, she's effectively cranking on her labrum to get her arms over head and then a shoulder surgery may fix her labrum, but it doesn't actually fix the initial cause of the problem.  She'll still have a stiff upper back, so it'll only be a matter of time until the labrum is reinjured unless the real underlying cause is addressed.  Why does everyone want people to rush straight to surgery, anyways?  That's painful!  As a physical therapist, my number one goal is to help athletes avoid having any surgery at all.  Sure - if it's necessary, such as in the case of Breanna Stewart having an entirely ruptured Achilles tendon, we're talking about something different.  But what if we just let these athletes recover after a grueling season (next week!).  

3) Can we acknowledge the additional stressors of playing in the WNBA Championships?  It is well known that emotional stress contributes to our experience of pain.  Elena Delle Donne was injured during Game 2 of the WNBA Finals.  Anybody else ever get injured at work and need to finish the shift or wake up with a super stiff neck or spasm in their low back and still have to go to their job the next day?  She has a job to do and it's far more in the spotlight than most people's work.  She'll get her symptoms managed and her pain will likely have a bigger impact on her job than on many other peoples' jobs, but she'll also participate in the conversation of whether or not she plays.  Or at least she'll have her agent do it.  Someone will be advocating on behalf of these players to protect their health. 

Many of the comments online were about how she was forced to play.  We don't really know that!  Any chance these commenters considered that she chose to play once the medical providers told her she would be allowed to?  The reality of this situation is that in less than one week the WNBA season ends, the physical and emotional stresses of the season will be reduced, and a period of relative rest (which means  they don't just curl up in a ball in bed) can begin.  What if they have some injuries, but they're also sleep deprived with elevated cortisol levels from their increased stress, not eating as healthy as usual with their family entourage visiting for the Finals and wanting to eat out?  It's so much more complicated than just "an MRI showed some damage." There will be time to stay away from the basketball court coming soon, time to reduce the amount of stress on their bodies and their minds with decreased physical activity including, less jumping, decreased torsion and load on injured anatomy, maybe some extra napping, some gentle swimming or yoga, and globally allowing the nervous system to calm down.  The Playoffs are three straight weeks of sympathetic Fight or Flight Mode... how about a nice parasympathetic Thanksgiving style dinner that puts you into rest and digest recovery mode?  Maybe we'll see that no surgeries will be needed for any of them!  

4) There are definitely circumstances where an injury to an athlete means they should not play their sport because it puts them at risk for further injury.  For example, after experiencing a concussion, it is dangerous to the athlete's health to compete before all symptoms have entirely resolved.  For example, if an athlete has a broken bone, not only could it be extremely painful to compete, but the athlete is at much worse damage with a subsequent injury.  For example, if an athlete cannot control their bowel or bladder or they have muscle weakness or numbness/tingling into their legs or arms - these can suggest a much bigger problem with the spinal cord. 

But there are many circumstances where an injury to an athlete means they will have pain while they do the things they love, but they may be OK to play with certain precautions.  For example, someone who recently sprained their ankle may be able to play while wearing an ankle brace.  The brace can protect from further injury while they are completing their healing.  For example, in many states it is approved for someone wearing a cast with a broken bone to pad the cast and play sports anyways.  The cast will protect the injured athlete from worse injury and the padding protects opponents from being hurt.  A torn labrum of the shoulder may be associated with a lot of pain for Alyssa Thomas, but is she at risk for any sort of red flag event by playing through it?  No.  And, without knowing the details of Elena Delle Donne's injury, I suspect she's experiencing a lot of back pain without the neurological symptoms into her legs that suggest spinal cord problems and that her medical team has determined it is safe to be playing.  She would not be on the court otherwise.

At the end of the day, tomorrow night could be the final game of the 2019 WNBA Season.  If it is, the Mystics go home with a Championship.  If not, they will play one more game.  I personally want to see all the best players on the court at the top of their performance.  So I'll send up some prayers for these two incredible athletes and role models and to all the other WNBA players currently having pain.  And I'll be rooting for the Sun and Mystics medical providers who will soon get a nice rest break, too. 

AASPT Traveling Fellowship

Fellows @ Cincinnati Football

Long before sunrise on the morning of Thursday, September 12, 2019, I boarded a sleepy airplane lightly coated in the typical Pacific Northwest mist heading towards a career-enhancing expedition.  After a brief pit stop in Denver, I continued on to Cincinnati airport, weirdly located across the Ohio River in Northern Kentucky.  Upon arrival at the CVG baggage claim I met two physical therapists who I would spend the next eleven days learning and observing various topics related to sports physical therapy. Rebecca Troulliet from North Oaks Health System in Louisiana and Patrick Barber from University of Rochester in New York joined me for the American Academy of Sports Physical Therapy (AASPT, formerly known as the Sports Section) Traveling Fellowship.  Sponsored by Kevin Wilk, LightForce and DJO Global/DonJoy. We spent about three days each at University of Cincinnati, Mayo Clinic locations in Minneapolis and Rochester, Minnesota, and The Ohio State University. 

What does it mean to be a Fellow?  According to Wikipedia, "a fellowship is a group of people who work together to pursue mutual knowledge or practice."  Though each of us had individual purposes for participation, we are all physical therapists working with athletes and we were all looking for growth in our careers.  Through observation and lecture attendance with more seasoned clinicians, we had exposure to different techniques and clinical approaches than our usual day-to-day experiences.  Now that I've returned to my usual swing of things and seeing my patients at Seattle Children's Hospital, I'm taking this opportunity to reflect on the experience and share why I chose to pursue this Fellowship along with some highlights from our trip. 

First: Why did I want to complete a Fellowship?
In May 2014, when I was completing PT School at the University of Connecticut, my career aspirations were to serve as a team physical therapist in the WNBA.  I had previously worked in a non-medical capacity for the Connecticut Sun for four seasons, but elevating to this new type of position as a new grad PT didn't seem remotely feasible.  Beyond the fact that I was a new clinician,  WNBA teams didn't have physical therapists, then, so this goal seemed unrealistic. (Most teams still don't, which I wrote about here)  I thought my fastest route to working with professional female athletes was to advance my education from PT School through a Sports PT Residency Program. In 2014 there were about twenty of those programs nation-wide, mostly offering one or two slots. I applied to three, including Ohio State, but was not successful in securing a position.  Now there are almost fifty SCS Residency programs with so many more opportunities nationwide! To search Residency programs in any PT Specialty area, click here.

Fortunately, physical therapists have an alternative route to obtaining board certification and specialization in sports physical therapy that does not require participation in a residency program.  You can find the requirements to do so here. As I pursued the alternative route, I also landed a role with the Seattle Storm, and in March 2019 completed my Board Certification Exam.  In our cohort, Pat also took his exam in March following completion of the University of Rochester Residency program and Becca is currently working through the alternative route requirements to specialize in the future.  So because I did not complete a residency program but did pursue specialization, I felt like I lacked some of the mentorship and on-field hours that a residency would have provided, and this fellowship filled some of that gap.  

Second: What was the Fellowship like? 
Each location was very different from the others which helped us gain a broad spectrum of the possible roles and responsibilities for a sports physical therapist.  

Fellows and PT staff @Cincinnati

At the University of Cincinnati, we were hosted by Bob Mangine and Tim Machan and primarily spent our time in their athletic training room with them and on the sideline.  We had the chance to watch game-time coverage, led by Head Athletic Trainer Aaron Himmler and had a sit-down discussion with their concussion program and vision training expert, neuroscientist Dr. Joe Clark. We attended lectures on a variety of topics by members of their staff including wearable technology, use of the ACL-Return to Sport Index Outcome Measure, Neuroplasticity, Prevention of Catastrophic Injuries, and and we each presented our own lectures. My presentation examined the Impact of Fear Avoidance on Return to Sport, Becca discussed Sudden Cardiac Death and Pat outlined Upper Extremity Return to Sport Tests.  

With Timberwolves Robby Sikka and Matt Duhamel

After exploring Cincinnati, the three of us packed our bags to head to Minneapolis for the first half of our visit to the Mayo Clinic.  Our host in Minnesota was Corey Kunzer who is the coordinator of the Mayo Residency program.  The clinic in Minneapolis serves the community as well as having partnerships with the Minnesota Lynx (WNBA), Minnesota Timberwolves (NBA),  and Minnesota Twins (MLB).  Only days before our arrival, the Seattle Storm had knocked the Lynx out of the WNBA playoffs so I felt a little like I was in enemy territory, but I was glad to finally meet Emily Beyer, Lynx Team Physical Therapist as well as Matt Duhamel, Team Physical Therapist/Director of Athletic Therapy for the Timberwolves and Jeff Lahti, PT for the Twins.  We also met Robby Sikka, Timberwolves VP of Basketball Performance and Technology who uses wearable technology with the basketball players to improve their on-court performance.  Their basketball facilities are fantastic and, according to their staff is considered to be the best training site in the NBA. They have practice basketball courts with athletic training rooms and locker rooms for the teams right next to the medical clinics where they have physical therapists, orthopedic surgeons, physicians, athletic trainers, and other specialties who can thoroughly care for the athletes alongside the general public.  Can you imagine being at your PT session and rehabbing alongside (Lynx superstar) Sylvia Fowles or  (Timberwolf and UConn great) Shabazz Napier?! The Mayo providers collaborate with the team providers in their biomechanics lab which includes force plates and multiple angles of cameras for jump-testing and movement assessment as well as for recommendations for optimal care.  It was a really interesting arrangement for sports medicine for all levels of athlete.

Diagnostic Imaging with Dr. Jay Smith @ Mayo

Then we drove down to Rochester, MN, home of the original Mayo Clinic.  Founded in 1889, the Mayo Clinic is basically the entire town of Rochester and the area is spotted with old historical buildings that contain the most beautiful old libraries and intricate marble ceilings that tell the history of medicine in the US along with more contemporary constructions housing the huge variety of specialties that the Mayo Clinic houses.   We learned about Diagnostic Ultrasound from expert Dr. Jay Smith were taken to the Mayo Clinic Biomechanics lab which houses the machine used by Dr. Tim Hewett to extensively study ACL injury, and participated in a golf biomechanics lab.

Coach Tamika (Williams) Jeter @ OSU

After Minnesota we headed to Columbus, Ohio, home of The Ohio State University Buckeyes.  Our host, John Dewitt took us on a tour of their athletics and training facilities where I ran into former UConn and Connecticut Sun basketball player Tamika Williams for a quick reunion.  We attended a discussion on articular cartilage surgical procedures presented by Caroline Brunst and a lecture presented by Dr. Ken Yeager on Building Resiliency observed the nationally recognized Ohio State Marching Band rehearse, attended the marching band Skull Session pep rally and another football game.  We had the chance to meet many of the Ohio State Physical Therapy Residents studying in a wide variety of specialties including performing arts, oncology, sports, orthopedics, women's health, and neurology.  And I got to see some of my Ohio family living nearby, which was the cherry on top of a really awesome collection of learning experiences.

Fellows with John DeWitt @The Ohio State University

I can't recommend this Fellowship highly enough, and would be happy to connect with anyone considering application for future participation.  I'm sure that if you asked Pat and Becca, they would select different portions of our trip as their highlights or what was most impactful based on the differences between our patient populations and professional goals, but I'm so glad I was able to share this impactful experience with them.  Thank you so much, American Academy of Sports Physical Therapy for this opportunity!

Ways to Move This Summer

Earlier this week, I had a unique opportunity to do some work with a small child, maybe about 3 years old? She wasn't my patient... it was a special circumstance...  and, though she was very, very cute, this was entirely out of my comfort zone.  Though I do work at Seattle Children's, my patient population is between ages 5-21, with the majority of them between ages 9-15.  That's right, I spend most of my day with teenagers. It's awesome.  The younger kids will still talk about Disney princesses or super heroes and the older ones can discuss books I read when I was a kid, sports, movies... nothing deep, nothing life shattering.  It is a rare occasion that an older patient comes in and discusses politics or religion or their job - though several of the younger kids talk about their church camps or youth organizations or really interesting volunteer projects they work on and some of the teenagers do work.  It's entirely different from the conversations I used to have when I worked with adults who had stress from jobs, older parents or younger children, money woes, car break downs, or deeper interests that required me to think.  A 3 year old was uncharted waters.

One does not simply sit and have a conversation with a child of this age.  This particular child didn't even really sit at all. She was constantly on the move, excited to explore the world around her, touch everything colorful in the Seattle Children's Rehab space.  I'm not sure how parents do it!?!  I'm not sure how my coworkers who do work with children this little do it!?!

Anyways, I was tasked with finding things for this little girl to do for about twenty minutes.  Fortunately, I had just read a new Community Education flyer from the Seattle Children's Sports Medicine Department entitled "35 Ways to Move Your Body This Summer."  My awesome colleagues - a rock star physician and three incredibly talented physical therapists (also team #StrongWomen) - collaborated on this project to provide families with ideas to keep moving.  (Message me or comment with email address and I'll send you the whole PDF!)  This list came in handy when trying to identify things to use with a small child - but could easily be applied to all ages - kids through adults - to find ways to stay active during the summer time - and beyond!  Here are some of my favorite suggestions from the list, and some that I used to survive working with a tiny kiddo!

1) Make an obstacle course: in the clinic we have access to lots of cool things to climb over, jump on and off of, balance on, and even a tunnel to crawl through. This is an easy thing for children to help build and then use to keep moving, and then rearranged.  Or, perhaps you're going to the playground and using the items there to make an obstacle course.  Either way - so much delight from that little girls face with crawling through the tunnel and jumping onto colorful circle dots.

https://www.amazon.com/Discovery-Kids-Adventure-Removable-Lightweight/dp/B07BR83L6J/ref=sr_1_55_sspa?keywords=crawl+tunnel&qid=1563483750&s=gateway&sr=8-55-spons&psc=1

2) Water Play: this could be in a pool or at the beach or running through the sprinkler in your back yard.  At the beach, you can bring various toys to play with - like a beach ball or shovels and pails to build a sand castle with a moat.  If the water isn't too cold where you are, and you're going in to swim - you can also play water games, swim races, hand stands in the water, or see how long you can balance on one foot while in the water.  For me, water play is kayaking.  In fact, I wish I was in my kayak right this minute.  But there are so many other options good for kids!  In Seattle, you can rent Canoes near UW, link  or rent kayaks or paddle boards at Green Lake or multiple places on Lake Union.  Tons of the teenagers coming into the clinic have been trying out paddle boarding this summer because it's so popular here.  Endless options to get outside and keep on moving.

3) Boot Camp or 4) Circuit Training and 5) Stretching: Attached to the "35 Activities" is a list of exercises and a list of stretches. But these additional lists can be organized in tons of different ways.  For example, boot camp directs you to choose a few exercises such as jumping jacks, push ups, sit ups, running in place and you do as many as you can for a minute, and repeat the routine a few times.  This idea is similar to circuit training, a technique I commonly use in the clinic, though the intensity is a bit different.  Using a variety of stretches, you could create your own home yoga class!  Even more fun, lay a towel out in the yard and do it outside!  I've previously written about my affinity for yoga here and strongly feel that though the intent is usually stretching, several stretches require you to work hard and also improve your strength and overall fitness. The list goes on with many ideas for games using these exercises such as assigning each one a letter, and then spelling out your name or a word.

So many great suggestions, and I've only touched the surface of the list from my coworkers!  This resource is really great - I can't wait to share it.  Don't forget about the tons of ways you can make walking fun: go somewhere different to explore a new neighborhood, make a list of objects to find (scavenger hunt) and see how many you find, walk your dog, go with friends, do it in the woods or at the beach, or make a game out of it like dancing every time you see a car drive by you.  Ride your bike or a skateboard or a scooter.  Also, a pack of sidewalk chalk makes your driveway into an endless number of games - like four square or hop scotch or into a race track.  My niece and nephew used to make a race track in their driveway with lava areas they had to avoid or stop signs or change of direction arrows that they drew before riding scooters or bikes or skates on it.

All these suggestions are a great follow up to my post last week about the negative impact of early sport specialization.  That post discussed concerns with athletes starting to play only one sport too young.  Though there is varying information, it is recommended that kids should play multiple sports until at least finishing middle school, probably somewhere around age 14.  This 3 year old had NO problem with wanting to climb on things, jump on things, stack cones, hop, skip, jump, squat, throw, kick... you name it, there was a TON of variety.  I don't think you need to be participating in multiple organized sports - you just need to move in more ways.  For example, strength training in an organized manner rather than playing your sport year-round could be a great way to improve your fitness and make a more skilled athlete.  Or, have a dance party with your friends... it's certain to look different than your usual sports.

Megan Rapinoe Used to Hoop, too!

Summer is here!  The barbecues are starting, fireworks and mini American flags are on sale everywhere, and the sun is finally shining in Seattle with WNBA basketball under way.  I've taken the kayak out already and saw some seals and I've lost and found my sunglasses at least three times with the bipolar nature of the weather in Seattle. I've been working on a blog post about sport specialization for a while, and it has been  moving too slowly for me - primarily because I've been spending a lot less time at my computer and a lot more time in the sunshine when it comes out, but also because other topics just keep popping up that I want to write about. And then I decided I really wanted to write about the United States Women's Soccer Team this week, but... that's what everyone else has been doing.  And so, I decided to combine the two.


First,  I'll start with a definition.  In 2002, Jayanthi et al defined sport specialization as "intensive, year-round training in a single sport at the exclusion of other sports."  This came along with: “The American academy of pediatrics and the American medical society for sports medicine have both discouraged sport specialization before adolescence but acknowledge that this recommendation is largely based on expert opinion...” What does it mean?  It means that medical professionals are supporting playing multiple sports, moving in multiple different ways, participating in unorganized play that isn't a sport at all - just like playing games of tag or riding bikes around the neighborhood, or climbing a tree - so that the body moves in different ways.  

There are considerable benefits to playing sports.  Health benefits, of course, including improved heart rate and blood pressure, cardiovascular endurance, and muscular strength.  There are also mental health benefits, particularly with team sports - but also with individual sports - like community interactions, competitive spirit, sportsmanship, and having a support system.  But there are also risks.  That same article from Jayanthi also found that youth athletes with a higher socioeconomic status were more likely to sport specialize and were also more likely to experience more serious overuse injuries than lower socioeconomic status athletes.  It was also found that those youth athletes who participated in team sports tended to have less frequent overuse injuries than individual sports.

Myer et al provides some interesting statistics about the success from sport specialization: Approximately 30% of American kids specialize in one sport with the goal of earning a scholarship and reaching the professional level in that sport, but only .2-.5% make it to the elite levels. Many parents and, more dangerously, coaches believe that focusing on one sport is the way to reaching this goal.  But using the same patterns over and over again may not help develop resiliency and strength in other movement patterns. 

Some quotes from that paper:

"Single-sport specialization was first reported in Eastern Europe with athletes involved in individual sports such as gymnastics, swimming, diving, and figure skating."

"Vaeyens and colleagues59 reviewed the training history of 2004 Olympians and found that the mean age of sport initiation was 11.5 years."

"At the collegiate level, a study of National Collegiate Athletic Association (NCAA) Division 1 athletes at one university found that 70% did not specialize in their sport until at least age 12 years, and 88% had participated in more than one sport."

Since I had already been doing research for a blog post on sports specialization, I looked into the roster of the USWNT and all the other sports those athletes played - other than soccer.  Here's what I've found.

Morgan Brian played varsity basketball through her senior year of high school before specializing in soccer.
Adrianna Franch was an all star high school basketball player.
Ashlyn Harris liked to surf and skateboard with her brother.
Tobin Heath reportedly likes tennis and surfing.
Jessica McDonald played four years of high school basketball and was a state champion and record holder in the 400m in track, also participating in the same three sports for two years of junior college before heading to North Carolina where she specialized.  The USWNT has a really long list of Tar Heels and a few Penn State Nittany Lions and Stanford Cardinal grads...I guess those would be the college power houses for women's soccer the way UConn is for women's basketball. 
Alex Morgan is listed as a multi-sport athlete.  As one of the most recognized athletes on the team, I think it's important to note that she tore her ACL when she was 17 and recovered to the extremely high level of play that she currently is at. In this chat, she says she started playing soccer around age 7 or 8, but played volleyball, basketball, and softball as well and didn't start playing club soccer until she was 14 years old.
Alyssa Naeher, my fellow Connecticut native, also played basketball in high school. 
Christen Press, (who I was insanely lucky to sit next to on a flight from Hartford to Chicago last summer in which the entire USWNT was on the plane and Sam Mewis sat behind us) played tennis and ran track before heading to Stanford for college. 
Megan Rapinoe played basketball and ran track.  
Becky Sauerbrunn also played basketball and volleyball. 

Megan Rapinoe celebrating the Storm Championship

Abby Dahlkemper, Tierna Davidson, Crystal Dunn, Julie Ertz, Lindsey Horan, Ali Krieger (did you know Krieger is German for warrior?!), Rose Lavelle, Carli Lloyd, Allie Long, Sam Mewis, Kelley O'Hara, Mallory Pugh, and Emily Sonnett - are not listed to play another sport on wikipedia, though that doesn't mean they didn't or haven't.  It most likely just means they didn't play another sport in high school and specialized before then, perhaps even playing something else through middle school.  Having ten out of 23 players noting what other sports they played until about age 18 has to help demonstrate the value in playing multiple sports!

So, what should we do about it?  We need to advocate for kids to play, to have recess, to move more, and to support participation in more than one sport.  My mentor from PT School, Lindsay DiStefano refers to this as Sport Sampling.  (I'm not sure if she coined this term, but it's the first place I ever heard it, and I like the idea - sample different activiites, find the ones you like, and move more!)  "Parents and educators should help provide opportunities for free unstructured play to improve motor skill development and youth should be encouraged to participate in a variety of sports during their growing years to influence the development of diverse motor skills" again Myer et al. 

And so, it's summer time.  Let your kids go out and play.  Run at the beach, play tag, kick a ball around, throw a frisbee, swim!  Don't let them play the same sports all year round.  And watch other sports too... like basketball, because now it's game time, and I'm off to go watch the Seattle Storm in action, hopefully with soccer star Megan Rapinoe in attendance!

Physical Therapist Board Certification

On a dreary morning in March 2019, shortly after we lost an hour for daylight savings and my internal clock was thrown for a disastrous loop like it does every half-year, I turned off my three alarm clocks which were completely unnecessary because I hadn't slept a wink, crawled out of bed, and drove over to a ProMetrics testing center near my house to complete the Sports Certified Specialist Physical Therapist exam.  I had my photo identification, my registration paperwork, and a list of test day reminders: make sure you remove all jewelry before going through the metal detector, be prepared to pull up your shirt and pants sleeves and have your ears checked, bring water and snacks because your exam is seven hours long but you can have a break in the middle, and a bathroom will be available.

Now, here we are almost the end of June 2019, more than four months later, and today I received the results - I passed my test!  I was walking out of basketball practice with the Storm when I glanced at my phone and saw the email with this report.  Without the Storm, I would not have met the criteria to even take this exam, because you need sideline coverage hours in a contact sport, and lots of them.  I'm so grateful for them.  Per the rules of the examination and ProMetrics, I won't go into any details on the actual content of this test, but I wanted to discuss the preparations I used and what advanced certification as a physical therapist even means.  Fortunately, I wrote many of these thoughts in March, because there's no way I would have remembered them now!  But I couldn't get myself to share it, in case I hadn't actually passed the test!

What does it mean to be a Board Certified Physical Therapist?  Right now, if you go to PT school in the USA, you're going to graduate as a DPT - Doctor of Physical Therapy - but you are a generalist.  You've learned the basics of physical therapy for all the areas of specialty that a physical therapist can work in and you took a big, terrible test that shows you are competent to practice physical therapy.  That test would cover all the different areas of practice and is very broad, covering a lot of topics.  After graduation, a new grad physical therapist will get a job and, with or without intention - begin to specialize.  To some extent, your job may dictate your specialty because that's the area of practice you're going to focus learning about moving forward.   The beauty of this is that you're able to change the area of specialty by working in different settings and pursuing alternative continuing education, but it also means that when we first come out of school - or if we change work settings - we're not very experienced in that care area early on.

When I first graduated, I worked at an adult orthopedic clinic while picking up shifts in a skilled nursing facility.  I focused my learning on orthopedics because it was my interest, but I had to learn the basics of the rehabilitation center because the needs of those patients were different.  Another example - if you came into the rehab gym at Seattle Children's where I work, you would see physical therapists working with children who have developmental conditions, which looks entirely different from what the sports physical therapists, like me are doing.  We're working side by side, all physical therapists, doing entirely different things from the same generalist education. I'm in awe of their work every day... and it's so different!

In some ways, the pathway of a physical therapist mirrors how a physician (MD) completes their schooling.  Any doctor you have seen - your primary care or specialist - went to medical school and graduated as a generalist.  However they can't practice medicine that way.  They are required to continue on their education pathway into a residency, determined by an intense matching program that I'm incredibly thankful I did not have to endure. They will be matched into the field they will pursue and specialize in, like emergency medicine, cardiology, orthopedics, family medicine... that list is super long.  And then, after another several years of working in their specialty while learning on the job, they become a specialized physician and can practice in their field.  But they don't have the wiggle room to wake up in the morning and say - I don't like being a heart doctor anymore, so I'm going to study diabetes and be a doctor for that.  They're a bit more restricted in their careers.

I have read articles recommending that physical therapy transition into the medical school model, requiring residencies to specialize.  This is an option now, but it is not required.  A physical therapist currently has the option to specialize in nine different areas, and this can be done by either completing a residency program and taking a big test, or by meeting a list of requirements and taking the same big test.  This is the test I took earlier this year and have been tortured into waiting four months to get my results. The residency program is meant to give you the hands-on experience and focused training needed to pass the test, but you're able to test without the residency and achieve the same end-goal if you meet specified criteria.

In early 2014 I had applied for residencies in Sports Physical Therapy.  I wanted to work in sports and having had years of experience working with women's basketball and a shortage of physical therapists working with the WNBA, I felt this was the direction I needed to go in.  At the time, I think there were fifteen programs, but only three had options that were not soccer (none had options specific to women's sports) - and those were the programs I decided to apply to.  (No offense soccer, but I'm a fair weather sports girl.  I'll support the USWNT all day long and cheer and attend games when the sun is shining, but a year of sideline coverage in the rain was NOT on my To-Do list.)  And so - I applied to University of Southern California, Ohio State University, and Duke University.  (It would have killed my Husky Heart to be a Blue Devil a little bit, though the education would have been superb at all three institutions).  Needless to say, I was not selected for one of the few slots available, a very sad failure, but a few months later I managed to secure a spot in the WNBA without it, so I took the alternative route. 

The options for physical therapist specialist certification right now are: Cardiovascular/Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Oncology, Orthopaedics, Pediatrics, Sports, Wound Management, and Women's Health.  The list of accredited residency programs is here for all the specialties.  A recent presentation I watched discussed focus on making a new specialty for Pain, which has not yet been established, but that seems like an interesting approach to try to advance the use of physical therapists in treating people with persisting pain. Since I've previously written about pain on many occasions, and I work with the Seattle Children's Chronic Pain Team, I'm excited to see if that will be specialty number ten.

A little about preparing for the exam:

The application deadline for the Sports specialty was July 31, 2018 to test in March 2019.  These dates have been consistent annually with all the specialties having application deadlines sometime in July the previous year for a March test date.  That means that if you want to take the test in 2020, you have 1 month to apply - or even less! The application process is pretty complicated for some of the specialties if you haven't completed a residency, so I advise you check it out soon.  All the information you could ever need is right here.

So, once you've applied, the American Board of Physical Therapy Specialties (ABPTS) reviews your qualifications to determine if you're eligible to take the test in your requested area.  That takes about 6 weeks.  I started studying when I applied, but I know others waited to make sure they could even take their exam.  Here's a look at how I prepared.

First, I gathered a bunch of materials to help me determine what content I needed to study.

The materials I used were:
1) The SCS Prep Course from MedBridge Education which has a nice table of contents covering all the content areas on the exam.  They have prep programs specific to many of the specialty areas.
2) I googled "SCS Residency Program Curriculum" on Google.  There are many, but I used this one which outlined a lot of the content topics.
3) I purchased "PT Sports Questions" by Matthew P. Brancaleone PT, DPT, SCS AT, CSCS" a question/answer book off Amazon for $35.
4) I already have my CSCS (Certified Strength and Conditioning Specialist) and the book "Essentials of Strength Training and Conditioning" and the study guide I made when preparing for that test.
5) I borrowed "The Fundamentals of Athletic Training" book from my boss
6) I found my course materials from the Emergency Management Course I took at REI which was a required pre-requisite to take the exam.
7) I borrowed the Manual of Structural Kinesiology from the Seattle Children's Inter Library Loan System for a review of anatomy and biomechanics basics, particularly with regard to the mechanics of the shoulder, and review of throwing motions and gait cycle.  My test was two weeks before giving this presentation at Seattle Children's so I was preparing for both at the same time.
8) Per the recommendations of the curriculum in #2, I secured copies of the National Athletic Training Association Position Statements, all of which are free here as well as many of their consensus statements and several of the APTA Clinical Practice Guidelines here.  The highlight of reading those was seeing how many of my UConn mentors were authors of them, including Lindsay DiStefano, Doug Casa, and Robert Huggins.  Man UConn puts out some amazing stuff!
9) Lastly, and probably most importantly, the Description of Specialty Practice (DSP) for my exam.  The APTA has a breakdown for each exam listing the material that would be covered on it. If you're approved to take the test, they send it to you as part of your application fee.  Or you can buy it before you apply.

Second, I took a practice test.  Right from the start.  The MedBridge Prep Course offered several practice exams that were shorter in duration than the actual test and covered a wide variety of topics.  Based on the results of my first practice test, where some of my outcomes were abysmal, I knew how to prioritize things.

Third, with my current skills clearly identified, and more importantly, my biggest weaknesses, I looked at this ginormous pile of stuff to read and the ~80 hours of online MedBridge videos available, and, I made a study schedule.  This is the same approach I took when studying for the PT licensing exam, so I was optimistic it could be successful again. I tried to cluster things together in a sensible way.  For example, when I read the chapter in the Athletic Training book about weather-related injuries like heat stroke or how to deal with lightning, I also read the NATA position statements related to the chapter, and then watched the Medbridge Video on that same topic.While I was studying the weather-related injuries, two quotes stuck out to me that I had saved for this post  With regard to cold-related illness: "Nobody is dead until they are warm and dead."  So, if you find someone buried in the snow, they're not dead until their body has been warmed up.  And with regard to lightning injuries, "In the contest between people and lightning, lightning always wins." So I got the repetitions for a topics and kept notes on things that I was unfamiliar with or wanted to come back to after I had gone through everything once.  Repetition is helpful for me, but also sometimes felt like I was beating a dead horse by the end of some of the longer (or less interesting) topics.

And then I took my test.  I'll be honest - I was behind on my schedule pretty much from the second week, but I just kept plugging along.  I had an excellent student in the clinic, who I wrote about here and here, and who was treating about half of my case load for several weeks leading up to the test, allowing me more time to devote to reading papers and studying.  I read A LOT of the materials listed above, but found some of it to be too inapplicable to the patient care I typically do, that I decided it was worth leaving out some chapters despite the risk of doing so.  I watched almost every single Medbridge course that was listed in their prep program, several just listening while I was driving, including most of the optional ones.  I was stuck on the Brooklyn Bridge for over an hour in traffic and watched an entire course on nutrition in that time.  And I was certain that I did not pass.  Today's news that I passed was super exciting.  Hopefully writing up my preparations will help someone else on their road to board certification.