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.

Seattle Children's Inaugural Sports Medicine Symposium: Mental Health

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© Abidal

 

| Dreamstime.com

On November 14th, Seattle Children's Hospital held their Inaugural Sports Medicine Symposium with the topic of Mental Health Care for Athletes.  As I briefly mentioned in my Blogiversary post, here, Mental Health is something that interests me and that I have been learning more about because of its relationship with chronic pain (which I have previously written about several times.)  It is also something I've been learning more about regarding my own mental health practices, lately, which I hope to explore in the blog in the future.

The Symposium was a multi-disciplinary event including the orthopedic physicians and surgeons and their PAs, the sports physical therapists, and the athletic trainers from Seattle Children's Hospital.  In my almost 2 years working at Seattle Children's, it has historically been a rare occurrence for all of these providers to be in one place at the same time - but we're treating the same conditions and working together on so many patients, that it was neat to have this opportunity. 

There were two speakers at the event discussing various topics from mental health.  First, Dr. Cora Breuner, a physician at Seattle Children's and a professor at the University of Washington with expertise in pediatrics, adolescent medicine, orthopedics, and sports medicine discussed some of the critical components of evaluating patients with consideration for finding mental health or substance abuse red flags.  She was listed as one of Seattle's best doctors in 2018 (and several previous years!) by Seattle Magazine, and her presentation was engaging, informative, and entertaining. 

From her presentation, I learned two new acronyms to include in my evaluations which I previously had only included small parts of, but now have better understanding for the importance of going into more detail.  These are mental health screening tools meant for the adolescent population and which fit into the biopsychosocial model of care nicely. The acronyms: HEEADSSS and CRAFFT examine the adolescent's personal life while CRAFFT is a screening tool for substance-related risks such as drugs or alcohol that fits into the HEEAADSSS assessment. 

HEEADSSS breaks down into: Home, Education, Eating, Activities, Drugs, Suicidality, Sex, and Safety.  There are a few different versions when I searched for better understanding of this acronym - where some of the dual letters are combined into groups.  Let's look at these in a little bit of detail.  Every time I sit down with a patient, and usually they have a parent with them, my first job is to make them comfortable and try to connect with them.  If I'm going to treat you and help you manage your pain, there's a chance I'll need to touch you or have you move your body in ways that are new to you - so I need to earn the kid's trust.

Ever try to make friends in Seattle as an adult?  It's hard!  Want to make friends with a teenager in less than 5 minutes?  Find out what they like and make sure they know you're talking to them - rather than their parent - and you might have hope!  Fortunately I have a wide array of interests and background- so I can talk a little bit of sports, a little bit about music, a little bit about Harry Potter, a little bit of Disney Movies, and a little bit of "I also went to high school once so I can relate to your hatred for Spanish Class" to try to connect with these teenagers!  I always ask components of the HEEADSSS assessment because it's an easy way to break the ice with a kid.  Here's some of what I already would typically ask: Home: Who brought you to the appointment? Who do you live with? Do you have any pets? Are you nice to their little brother or sister?  Education:   What grade are you in and what school do you attend? Do you have friends? What are your favorite classes?   Activities: What do you do for fun? Any sports, musical instruments, clubs or after school activities/hobbies.  How about a job?

You might notice that I've left out some of the essential topics with my usual line of questioning.  I rarely ask about Eating, and I don't think I've ever asked about Drugs, Suicidality, Sex, or Safety.  That doesn't mean these things have never come up... I've had more than one patient in my career (adult and under-aged) tell me they're using some sort of marijuana product for their pain control.  I've worked with a few patients who have had issues with suicide in their history and who bring it up as something to be aware of in their past.  Discussing eating habits is a great way to assess the basic health understanding of the child and family or to gauge an understanding of the basic needs of the patient.  I'm glad I can give out snacks to kids who may not have enough to eat. 

Questions about drugs should include the use of alcohol, marijuana, or any other substance to get high in the past year.   Those drug questions are followed by the CRAFFT acronym which stands for: Car, Relax, Alone, Family/Friends, Forget, Trouble.  These are specific questions:  Have you ridden in a Car where the driver (which could be you) was high?  Have you taken drugs to Relax?  Do you ever use drugs or alcohol Alone?  Do any of your Family or friends tell you to cut back on your use of drugs or alcohol? Do you ever Forget things because you were using drugs or alcohol?  Have you ever gotten into Trouble while using drugs or alcohol? This assessment can be scored to determine high risk of substance abuse.  It was also discussed that kids are much less likely to have these conversations in front of their parents - and they're also more likely to talk about their friends than themselves - so asking your patient if any of their friends use these substances might get you more information than starting out asking them about personal use. 

With kids who may have some mental health issues that need to be considered as a component of their care, adding these areas will be vital and incredibly challenging at first.  But as healthcare providers, we have a responsibility to look out for these teenagers who may not have any other way to get help if they're in need. There were some interesting and startling statistics presented regarding some of the high risk behaviors.  Particularly memorable to me were: 1) In a survey of high school-aged kids, 94% of the ones who used drugs or alcohol started between ages 11-15.  2) In a survey of high school-aged kids, less than half had engaged in sexual intercourse, but only 60% of those had used a condom. 3) Condoms only prevent pregnancy about 82% of the time.  That's a B- grade. So too many kids are having unprotected sex and even those who are trying to be protected don't have the best stats on their side. 

Dr. Breuner also discussed the importance of recognizing the rights of a teenager.  In the state of Washington (this could vary where you live), a teenager can have their mental health records kept confidential starting at age 13 and their reproductive health records kept confidential at age 14.  This means that a healthcare provider can discuss this information with the child and does not have to inform the parents - or anyone else - unless the child is being hurt or is hurting themself or another person.  The information should be documented in their medical record but is not to be released to the parents.  We need to be educated so we can serve as resources to teenagers who need help.

The second speaker was Sport Psychologist Dr. Elizabeth Boyer, owner of Northwest Performance Psychology.  Dr. Boyer gave numerous examples of ways that injury can influence mental health.  We see this in the clinic often - where an athlete is working to get back to their sport and is sad or depressed or fearful... for a wide variety of reasons.  Athletes who are injured often feel like they have let their team down.  They may lose confidence and could become more isolated from being separated from their teammates and friends.  They should go to practice!  Maybe not every single day, particularly if they need to be doing regular rehab appointments, but we can easily encourage injured athletes to attend a practice every week and be part of their team.

A key takeaway from this presentation was that developing some mental health skills for recovery can also help improve athletic performance.  Skills like imagery - where you visualize drills in your head - or goal setting - in the short and long term - can both help with recovery and with performance.  While we always set goals for our patients in the clinic, the patients should have more say in their own goals rather than having a therapist select things that may seem arbitrary.  And reminding patients of their goals throughout the treatment so they can see their progress is also a useful tool. 

Lastly, Dr. Boyer mentioned the importance of self-care as a healthcare provider.  I love my job.  Every day.  I can't believe how blessed I am.  But sometimes I forget how much of myself I'm giving to others and how little I'm giving to myself.  Sounds like I need to find some different options for that for the new year... more focus on my own mental health will only help me better serve the patients I'm working with, and keep myself going. 

And with that, a Happy Thanksgiving to all my readers.  I hope you'll take the chance to care for yourself this holiday season.  And to care for those around you. 

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

REI Seattle Outdoor Space

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

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

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

Fake Makeup Hand Injury

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

Key tips and tricks I learned in this course:

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

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

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

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

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

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

Women in Sports in the News!

I have several blog posts that I have started drafting that are in skeleton form.  Ideas pop into my head while I'm doing my continuing education work or reading things online that I think I'll want to learn more about in the future and I start up a draft for later.  I had plans for this week's blog because I just finished reading a book I really enjoyed... and then I hopped onto my Twitter and Facebook accounts and saw two really awesome articles about some amazing women in sports.  Change of plans! This week we're looking at some real trailblazers.

First: this awesome video from Gatorade Performance Partners about the Female Athletic Trainers serving in the NFL. Maybe someday, it won't matter that we identify them as females... but for now, this is important!  I came upon this post because the Head Team Physician and Orthopedic Surgeon for the Connecticut Sun, Dr. Katherine Coyner, tweeted it.  I recently connected with her and have been following her work at the University of Connecticut Health Center and with the Connecticut Sun from afar.  (To my knowledge, there are four WNBA teams that have head physicians who are women, two of which are orthopedic surgeons.  The Minnesota Lynx operate with surgeon Dr. Nancy Cummings, the New York Liberty work with Dr. Lisa Callahan, and the Phoenix Mercury work with Dr. Amy Jo Overlin.  These women are trailblazers and their career paths are inspiring!)  Back to the video... there are six female athletic trainers in the NFL out of 145.  But more than 50% of athletic trainers are females and more than half of the current students in athletic training programs are also females (according to the clip).  I'm sure these ATCs don't all want to work in the NFL - or potentially any of the professional men's sports... but opportunities for women in professional sports are limited.   Check it out!


I saw this video first thing this morning while I was perusing my social media over breakfast.  I then went to work... treated some kiddos at Seattle Children's Hospital... and came home to find this post:

<--Jenny Boucek, former Seattle Storm Head Coach, now Assistant to the Coaching Staff/Special Projects with the Dallas Mavericks

I first met Coach Jenny Boucek when I was an undergraduate at UConn and she came to watch practice before an upcoming WNBA draft.  I remember asking her if she wanted to draft a team manager... I already knew where I wanted to go after college.  We had a nice chat and our paths crossed numerous times over the years.  I loved that she was the Head Coach when I first came to Seattle to serve as the Storm Physical Therapist.  She's a wonderful person.  And now she's navigating uncharted waters as a pregnant coaching staff member for an NBA Team!  I can't wait to hear more about how her story unfolds, but this first article about her job prospects from a few NBA teams gives me hope. I truly believe that with ANY job... it should only matter that the best candidate is hired.  Based on this, it looks like employers are now starting to join in that belief and cross the gender boundaries that were so much more rigid in the past. Way to go, Mark Cuban.

Both of these news clips brought me joy.  The opportunities for women are growing right in front of my eyes, particularly in sports - and not just in women's sports.  We can still do better - but let's enjoy these moments and then get to work on making more progress.  This upcoming weekend is the WNBA All Star Game and I can't wait to watch while I'm on a quick visit home to the East Coast! 

Any other inspiring stories you've come across and want to share!?  Post a comment... and consider following the blog!

Concussion Protocol and the WNBA

This week the Seattle Storm played two home games - Tuesday versus the LA Sparks and Saturday versus the Dallas Wings.  Both games were hard fought battles.  As I've previously written about here, the 2018 WNBA season is shortened due to the upcoming World Championships in September,  so teams are cramming the same 34-games into a shorter length season.  I was concerned that the increased level of fatigue could correspond with increased injuries.

Unfortunately, one of the Storm players experienced a concussion this week - media release here.  I of course cannot blame the season schedule on the concussion - there's no way to determine cause and effect here - but there have been several injuries throughout the WNBA this year, and it seems like there are more than in previous seasons, though I don't have the data to be certain.  (This is one of my concerns about WNBA injury reporting - I wish this data was more readily available!)  Anyways, I thought this would be a great opportunity to discuss concussions a little bit from an acute response perspective - rather than what the longer term care looks like when I treat kids who've experienced a concussion at Seattle Children's Hospital. 

I think it is of key importance to mention that a concussion is a brain injury.  No two people experiencing a concussion have the same symptoms or present the same way.  This differs from your general ankle sprain patients where they mostly behave similarly and follow a similar trajectory for recovery.  Where there is a similarity: athletes at all levels who experience a concussion generally want to get right back into the game.  It makes sense - they're competitors.  But this is dangerous and as a sports medicine provider, it would be irresponsible to allow a symptomatic athlete to participate in activities that could be life-threatening.  I'll say it again - a concussion is a mild traumatic brain injury.

Every (major male) professional sports league has a concussion policy.  During WNBA training camp before the season gets underway, players complete a baseline testing on a computer for neurological and cognitive function.  If a concussion occurs in a game, a physician evaluates the athlete and then this same computer testing can be completed for comparison.  You can see the moment of injury at the Storm versus Sparks game at the 2:45 mark in this video - also included below.   

If a head injury occurs on the basketball court, the athlete needs to be evaluated in a quiet area without distractions.  This initial screening is conducted by an athletic trainer or team physician and includes a lot of questions such as any symptoms they may be experiencing: headache, dizziness, nausea, sensitivity to light or sound.  Then a physical exam including a screen of what the eyes are doing - if they can track a moving target or if they operate abnormally, an evaluation of the neck is conducted, the nervous system is assessed, and balance, memory, and comprehension are all considered.  Generally concussion symptoms don't always show up right away and it's best to wait several minutes to determine if anything comes on after a delay.  This is a complication for sports such as football where an athlete may take a hard hit and initially seem symptom-free, only to worsen a few minutes later where sideline assessment often occurs on the field where there isn't really a quiet place to conduct a thorough assessment. 

The NBA announced that they would initiate a concussion protocol in 2011 - following in the steps of many other professional sports leagues, particularly the NFL who was dealing with CTE (chronic traumatic encephalopathy - a neurological disease found in athletes and veterans likely related to repeated hits to the head and diagnosed post-mortem).  The WNBA Concussion Protocol wasn't easily accessible from my search - but it's based on the NBA's policies which are summarized here.  Basically the athlete will go through five stages of recovery including 1) asymptomatic at rest, 2) asymptomatic with bike riding, 3) asymptomatic with jogging, 4) asymptomatic with basketball drills without defense, and 5) asymptomatic in full practice.  The computerized testing will be conducted between stages to compare to baseline and determine that the athlete is not having increased symptoms.  These stages can be completed in as few as about 3 days, more typically a minimum of 5 days based on articles about players I've read about online - but the maximum duration varies based on the individual athlete's response to their progressively increasing activity level.

The stages for recovery are fairly similar to what is used at Seattle Children's - but the key difference is that physical therapy interventions on kids who have experienced a concussion generally only occur if the child has been experiencing post-concussion syndrome (sometimes referred to as delayed symptom resolution).  By definition - this means they've had symptoms for at least a month, but usually by the time I'm evaluating a kid for concussion in the clinic, they've generally been experiencing symptoms for more than 3 months. (At least 70% recover spontaneously in less than one month).  

This paper that examined concussions in multiple sports found that 4.7% of all injuries in women's basketball are concussions.  In general, only football, women's soccer, men's and women's ice hockey, and men's and women's lacrosse had more concussions than in women's basketball.  Across all sports, 5% of all sports injuries were concussion.  The paper also breaks down mechanisms of injury for concussion for each sport which interestingly showed that, in basketball, women tend to experience the injury while ball handling or playing defense whereas men tend to have it diving for a loose ball or rebounding.  Interestingly, the mechanism of injury you'll see in the video link above for the Storm injury was a loose ball retrieval effort.  In my personal opinion, as the level of play of the WNBA has gotten increasingly better year after year, the difference in mechanism of injury is likely to change.  WNBA athletes are incredibly athletic and are doing things on the basketball court that we didn't see in women's sports 15 years ago when this data was collected. 

If you or someone you know experiences a head injury, please get them examined by the appropriate healthcare provider. 

2018 WNBA Season Update - A Race to Stay Healthy!

Throwback to my Connecticut Sun Days with Allison Hightower, Kelsey Griffin, and Tina Charles

The 2018 WNBA Season is heading into its second trimester.  How quickly time flies when you love watching your favorite teams and favorite athletes who play a short 34-game season (plus some pre-season and playoffs) with most teams around 11 games in.  This season is condensed with the upcoming FIBA World Cup being held in Spain starting September 21st, with a USA National Team that will take the greatest stars from all the WNBA Teams resulting in this abbreviated schedule.  The usual length season, which already felt like a whirlwind, is now a hectic schedule with games practically every other day. This week the Seattle Storm played three home games in six days, but recovering and preparation between games becomes a challenge under these scheduling circumstances. And above all that, if a team is influenced by injury, how does this affect ticket sales and the entertainment on the court?

I've spent many years on the WNBA sidelines, but now that I'm a healthcare provider, my perspective on the league is different.  When I started working for the Connecticut Sun in 2007 as their Travel Coordinator and Equipment Manager, I helped out in the athletic training room, but I was in charge of laundry and buses.  My biggest concern for players' health was if their sneakers were giving them blisters. I also needed to remember to pack uniforms for injured reserve players who generally were not listed on the line-up but could potentially play if someone else got hurt.  At that time, teams could keep a player available to fill an injured player's spot... that doesn't exist anymore.  

From a physical therapy perspective - this season's playoff contenders will likely be the teams that can stay healthy despite the crazy schedule.  Rookie players will need to learn how to take care of themselves in ways they didn't have to in college. When I was at UConn, we had meals as a team that offered nutritious options and salads pretty much daily.  It is easy to see that a new grad WNBA player might not know how to cook because they never had to before.  They also need to self regulate their recovery, figure out what works best for them, and start taking direction from new athletic trainers than the ones they've used for the past four years. It's a little bit of a relationship-building game in a really quick span of time, and it's been really interesting to watch how that develops year after year. 

Veteran players will also need to find ways to take the best care of themselves to recover between games.  There aren't many days off and the need to re-fuel, rest, and feel good through massage or chiropractic care or ice baths or foam rolling need to be well managed and consistently available.  The WNBA could not have picked a better season to get a league-wide partnership with Cortiva, a massage therapy training school, to have more massage therapists available in certain cities.  Recovery will be key this season.

Since I wrote my PT School thesis on women's basketball players' injuries at the college and WNBA level, I've been thinking about player injuries in this league for a long time.  Feel free to be the fourth person to ever read that paper in your spare time. I try to follow what's going on around the league with regard to injuries - and have several ways of doing so. This website and this website (and there are several others that are similar) list WNBA injuries and stay fairly current... but the first website lists injuries as a service for people who are betting (gambling) on women's basketball and the second one is a fantasy sports team database.  They generally seem to be getting their information from news articles so it's not certain how reputable any of the sites are.  There are currently injuries listed on 9 of the 12 teams, with several teams listing multiple injuries.  I also follow numerous writers on Twitter who write about the injured athletes for their local teams.  The schedule has been up for discussion quite a bit more this season than in the past. 

What I keep waiting for is a bigger entity to start organizing this information.  ESPN has an NBA Injury Report page, but no WNBA Injury Report page, CBS Sports has an NBA Injury Report Page but doesn't have one for the WNBA - nor does their header even include a link to the WNBA at all!  Research publications in the WNBA are limited, but this 2006 paper examined WNBA versus NBA injuries and acknowledges that, even at that time 12 years ago, the rates in the WNBA were higher.  So why isn't this information more readily available yet?  Part of the problem is that the NBA has an Athletic Trainer's Association (NBATA)  which reports and tracks their injuries whereas the WNBA Athletic Trainers report their injuries to the WNBA, and then nothing happens with that information (or at least it is not published and made available for public consumption).  This is something I, personally, am hoping to remedy in the future.  

I didn't look to the research for specific data on the impact of fatigue on injuries - but I learned in school that there is a likely correlation, particularly with postural muscles which would include the muscles of the calf and also with reaction time where the brain is slower to react when it is fatigued which could impact injuries.  Since ankle sprains are always considered the most frequent injury in basketball players, it's not really surprising that we're seeing a lot of ankle injuries already this season.  Here's to hoping that these injuries are low grade and the athletes will recover quickly and get back to playing - but there's a lot of basketball left to be played by fatigued athletes.

I'm already trying to prepare myself for the dark ages that will come between the end of the 2018 WNBA Season and the beginning of NCAA Women's College Basketball almost two months later... it's going to be rough.  Fortunately there is time to continue enjoying WNBA basketball right now while it's here.  Good luck to all the WNBA Athletes, Athletic Trainers, Strength Coaches, and team personnel this season.  And a friendly reminder - if you're part of the travel party - you need to take care of yourself too!  Hydrate and recover!

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

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

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

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

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

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

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

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

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

ACL Injuries

Of course ACL Injury would be an early topic of conversation on the Blog.  After watching several friends tear their ACL and rehab for months on end to get back to the basketball court, I applied to PT School with the intent of learning how to contribute to ACL injury prevention.  There's tons of research saying how common ACL injury is, particularly in women's sports, and there are also numerous programs available working to prevent it.

But there are also countless sports teams and sporting organizations that don't implement any of these practices.  It's a little bit shocking to me since an injury prevention program could equally be called a performance enhancement program.  Some of these programs have published research showing they decrease risk in injury - but they could easily be assessed differently.  For example - complete the program for 6 weeks and compare maximal strength in a squat and it would be expected that these athletes would improve.  They'll have increased motor control and core stability from the program translating into functional testing.  I guess there's a study to be had there. The way to teach your body to move to avoid injury is the same way to move to be an all around better athlete.

As a component of my graduate school research, I surveyed 35 athletic trainers and strength/conditioning coaches working with women's basketball teams at the Division I and WNBA levels.  In my unpublished data, I asked these individuals if they implemented any injury prevention techniques with their athletes: Twenty three out of the thirty five said yes. That's 66%. Two thirds.  So... what exactly are they doing if not focused on improving performance.. and at this elite level?!  No look at a younger population, such as middle school, where overall the coaches don't have specific training on how to improve human body movement.  How can this group possibly implement programs when they aren't trained in how to use them properly?

Even more startling than the providers who answered that they were not incorporating these routines into their athlete's programs the results of the next question.  When asked what sort of measures were implemented to specifically prevent ACL injury, every single answer was different and not one of them utilized an organized injury prevention program.  So everyone is trying to do it their own way, based on whatever they've learned in the past.

Last night the Seattle Pediatric Sports Medicine ACL Injury Prevention Task Force met to plan implementation stages of their new program.  It was inspiring to see physicians, physical therapists, and athletic trainers brainstorming ways to prevent injury in the kids of our region.  Their intentions are great.  The program is comprehensive.  I'm concerned for the potential obstacles the group will face as far as resources to implement the program and coaching buy-in.  I'm also optimistic that they can sell the program as a combination of injury prevention AND performance enhancer.

The program, once it has been well learned, is 4 components that takes about 15 minutes to complete.  It is intended to be the daily warm-up for practices and games - but could be split into parts if needed.  Videos of each component are available on the website, and each activity has proper mechanics that need to be adhered to and properly trained.  Untrained coaches simply printing the program and trying to teach it to teams won't provide the proper mechanics.  Basically - we need to teach sports team coaches how their players should be moving, so they can help guide them through this process.

Preliminary implementation of the program has had athlete feedback that they feel stronger and move better.  The detractor from coaches is that it takes 15 minutes of their valuable practice time - but in comparison - is a warm-up of arbitrary jogging and sprints without proper body control really making these players better at their sport?

As I see it, there are two primary goals here: 1) Get these athletes moving in a purposeful manner on a routine basis because kids need to learn how to move properly and 2) Educate coaches and parents so that they can help improve the way their athletes are moving to prevent injury.

Here's the outline of the program. Ultimately it gets the blood flowing so the team is ready to participate in practice when they're done.  Interestingly, it similarly mirrors several components of a post-op ACL Injury Rehabilitation Program in many ways.

1) Dynamic Mobility: 
Open/Close Gate, Forward Jog, Side Lunges, Backwards Jog, Cradle Walk, High Skips, Quad Stretch with Reach, Carioca, Butt Kickers, Lateral Shuffle with High Knees, Lunge with Rotation, Inch Worms

2) Strength:
Rotating Side Planks to Prone Planks, T's, Double Leg Squat, Single Leg Kick Stand Squat, Double Leg Squat Jumps

3)Motor Control:
Single Leg Deceleration, L Hops, Diagonal Hops

4) Agility
Partner Jump Bump, Diagonal Backwards Shuffle, Cone Weaving, Bounding

Check out the program if you're interested and reach out if you have a group that would benefit from being trained to participate and I'll help get it set up.

Abby