Jack of All Trades...

Master of none?  Of some?  Of one?  Of a few?

One of the great things about being a physical therapist is the variety of things available to you.  Numerous settings are available to work in - schools, hospitals, nursing homes, clinics, sports teams.  You can work with a narrow age of ranges like birth to three years old or the geriatric patient or the whole spectrum of age, gender, and a variety of levels of ability, disability - both physical and intellectual.  In my office alone, there are physical therapists who primarily focus on sports/orthopedics, others who primarily focus on developmental rehabilitation, and a specialized physical therapist who works on infant feeding.  Variety is the spice of life, right?  

Some days, the list of diagnoses between all the patients on my schedule looks a lot like: knee pain, knee pain, ankle sprain, knee pain, knee surgery... repeat.  The mechanisms of these injuries for knee pain and ankle sprains might vary - soccer, soccer, gymnastics, jumping, soccer, soccer - or not that much maybe. Some days that’s just how it is.  Not a whole lot of variability in the body region where pain is occurring. Not a lot of variety in age groups.  I've had days where I've seen only girls between age 12-15.  And I generally see eleven patients in a day, so that's a lot of "luck" to have so much congruency between patients. 

Because of how sports seasons work, there’s a tendency to see clusters of athletes from the same sport at once - like soccer players when their season is starting, baseball players at a different time.  We don't see many football injuries in middle of December, and it's rare to see a skiing injury in August. Teammates bumping into one another at the clinic is not usually a good sign, particularly if they have the same type of overuse injury, but it definitely happens.  Last winter, when 3 swimmers from the same team showed up with shoulder pain, it seemed imperative to reach out to the coaching staff and see if we could help the whole crew.  

So while I really do love days like this because I’m a sports physical therapist and I love helping kids get back to playing their favorite sport, there are days that are also quite different.  Days where the diagnoses on my schedule look like this: chronic regional pain syndrome, post concussion syndrome, post-op meniscus repair, broken humerus, knee pain, scapular dyskinesia, ankle sprain, osteomyelitis of the shoulder post irrigation and debridement, post-illness deconditioning.  When this happens, there's also a much wider spectrum of mechanisms of injury - like for these - skateboarding, soccer, trampoline park, fell off jungle gym, marching band, swimming, "my brother tripped me down the stairs", insidious/unknown, cancer.  The injuries and conditions can be much more variable and require a lot more knowledge and skill to treat. I love this, too, but it makes me think a lot about my strengths and weaknesses as a PT.  At the end of the day, all of them are trying to get back to something, usually a sport or activity of some kind, which means guiding them through restored function in more important things like going up and down the stairs or getting off the toilet- but after that boring stuff (kidding), we get to play soccer or basketball or hop scotch in the clinic. 

I’ve been thinking a lot about this second type of day and had this blog post almost entirely drafted when Lenny Macrina, who I've previously written about here and here, posted this on his twitter: "Hey PTs, if you could treat one only type of patient presentation for the rest of your career, what would it be?" (Side note, I'm currently running for the office of President of the Lenny Macrina Fan Club).

In high school we took career placement testing that suggested I should become a farmer.  In my head I thought - that's the most regimented routine EVER.  Up at sunrise with the chickens, milk the cows, maybe some change with seasons but overwhelmingly very similar day to day.  No thanks! I never considered being a dentist because I didn't want to look at people's teeth all the time.  Gross. I definitely didn't want to be a podiatrist, because I really don't like feet. Gross times a million. I didn't want to do any sort of work that was repetitive in nature. So thankfully, I don't get stuck treating tons of ankle sprains, and when the occasional one does, I make sure they're good about washing before I get near them.  I always knew I needed variety, which is what this post was about in the first place... and had to respond to Lenny's tweet: "Why Lenny?!?! This week my upcoming blog post is about days where all the patients have similar body part ailments or conditions versus days where they're all over the board.  Variety is the spice of life! I'd go nuts with the same all day."

I really, really love the variety. but I also recognize that by seeing this variety, does this mean that I've become a jack of all trades, capable of doing something to help everyone but not being really good at helping anyone in particular?  Is this a problem for PT practice that we don't really have to specialize much beyond our setting of practice?  

For me, there are certain patient types and conditions that I'm really interested in.  I primarily focus my continuing education on those areas.  Some injuries and conditions are simple to evaluate, simple to treat, quick to get the patient back to their normal self.  Some just aren’t. And, as I think I’ve said before, though physical therapy is based on science, there is definitely an art to it.  There is an art to connecting with people, encouraging behavior change and convincing people to exercise who normally wouldn't.  But beyond the connections, there is a real need to have a good understanding of the human body, the relevant components to a person's injury and to the needs of their activities, and to how the body heals. 

There are basic skills any physical therapist would use to evaluate the majority of their patients. We would assess their range of motion and strength and probably palpate some body regions to assess irritability of the tissue and mobility of a joint, and then maybe some special tests to identify certain tissue structures that may be involved.  And then we have to be more specific, like I mentioned earlier, in further assessment techniques and treatment options based on the needs of that individual person. 

So... should every PT be treating a case load that has so much diversity in diagnoses and patient presentations?  Should I be?  I do... but... should I?  Is it OK that I'm a Jack of All Trades?  

I'm here to say that I think this makes us even better.  If I only treated post-op ACL reconstructed patients every single day - but their sport or daily life needs vastly differed - and their concomitant injuries included many other things like meniscus pathology or PCL injury or traumatic fracture, I don't think I'd be as good at rehabilitating that patient population as if I worked with patients with all kinds of hip, knee, ankle/foot injuries playing a variety of sports.  And truly, a patient with an ACL injury is one of my favorites - but it's because of the duration of recovery and connection to the patient that I like it, along with the ability to use a whole lot of different treatment tactics with them! If I only saw kids with concussions, my vestibular rehabilitation skills would definitely improve - without question - but at what cost?  What would be lost by specializing in a specific patient population?  

So, the next time I need a physical therapist for myself, I’m going to ask them what they like to study and learn more about.  Do they choose to do continuing education on hip pain, while I'm experiencing hip pain, that they may have seen the most recent evidence of what they should consider for my care?  And also, do they treat a variety of patients, or only people with hip pain.  But most importantly, do I like them?  Can we connect at all?  Because truthfully, a lot of the time, I don't think it matters quite so much what we know or study or who we've treated the most, but how we interact with our patients and empower them to move forward.

Jack of All Trades, Master of None?  Fine by me. 

Concussion and the Brain

Happy October 1st! Fall is upon us and schools here in the Pacific Northwest has been up and running for about a month.  With the return of school comes the start of the local fall sports teams.  This year I've noticed several patients in the clinic coming in with a recent concussion.  For my caseload, they've all been girls and most of these have occurred with playing soccer.  This is of course not a rule - in the past I have worked with males who have experienced concussions and they've come from all sorts of mechanisms of injuries.  What comes to mind are falling off a bike, getting hit in the head playing softball, inner tubing, and trampoline parks.  Though football players statistically tend to have more concussions, I don't think I've treated any of those.

I personally have experienced two concussions myself!  My first one was in high school when a friend of mine and I were walking away from each other and she threw a basketball and it bounced off the back of my head.  I initially thought I was fine and later woke up on the bathroom floor.  I had a headache for a few days and saw a doctor for it but was ultimately fine.  My second concussion was getting hit in the face with a softball that broke my nose and I had a loss of consciousness for about 3 seconds.  Apparently that's what the glove is for... catching the ball.  I didn't see a doctor that time, which was not the smartest on my part.  With that one I also had headaches for a few days, dizziness, some nausea, and a lot of sensitivity to light.  My sleep was disrupted and I had trouble looking at my computer screen at work.  My glasses broke during the injury so I was wearing my prescription sunglasses at work which helped some.  I'm so fortunate that both of mine were years apart and that I recovered so quickly, and it helps me to relate to these patients since I've gone through it a little bit.  Plus this gives me a great opportunity to share the photos of my black eyes from when I had my last one!  Notice the softball stitches visibly imprinted into my face.

Concussions are a really interesting diagnosis because each person presents very differently.  I've previously written about the WNBA Concussion Protocol here following one of the Seattle Storm players experiencing a concussion this past season, but since I've been treating more of these patients in the clinic, I've been reviewing my previous Medbridge courses on concussion and refreshing my knowledge to better treat this patient population.  Here are some interesting things about concussions you should know.

1) Concussions are brain injuries.  Concussions get a reputation for being less significant than they are because people have used terms like "getting their bell rung" to describe what happened on the playing field when the injury occurred.  This is a problem because concussions are brain injuries.  Many of the kids who come in for concussion treatment have a variety of symptoms - headaches, dizziness, trouble with school from a variety of causes, difficulty sleeping... and they almost brush these off as normal because of a concussion.  But these are all symptoms of the brain going through a healing process!  You wouldn't act the same way if you had a fractured skull or a stroke - both also serious head injuries.  Let's start acknowledging how serious a concussion is so that kids who experience them take their recovery a little more seriously!

2) Concussions are not anatomical problems- they are physiological.  I'll simplify that.  Anatomy defined: the structure of something.  So with a concussion - we're not looking at the structure of the brain.  With an anatomical (structural) problem, when a doctor is trying to diagnose what is wrong, imaging is generally done.  Typically, a person who has experienced a concussion will not have anything wrong on XRAYS, CT Scan, or MRI.  These imaging studies are used to look at anatomy - again - like the skull fracture - to see if any structures have been damaged.  Imaging is helpful to rule out these other anatomical problems, but they don't tell us much about the concussion or the person experiencing it.  So - if the structure of the body isn't the problem - what is?  The function of these structures are what is affected in a concussion.  Physiology is how things work... so how the anatomical structure operates.  Example - your lungs are a structure which can be injured.  They also function to breathe.  Anatomy: lungs.  Physiology: breathing.  Concussion structure involved is the brain - but there is no anatomical problem.  The physiology of the brain is what has been injured.

This concept is important because it can impact expectations of recovery.  It's pretty easy for people to understand the idea of an anatomical injury and how that recovers.  A broken bone takes approximately 8 weeks to heal and can be seen on an XRAY broken and then healed later on.  Concussion recovery is much more complicated and you can't see a starting point or a finish line.  So what's actually happening?  Well.. that's what I'm working hard on learning to better understand. 

The brain is composed of about 100 billion neurons.  Neurons are the types of cells that make up nerves.  Neurons look a bit like this:

https://biology.stackexchange.com/questions/25967/nerves-neurons-axons-and-dendrites-by-example

These nerves interact with each other to send electrical signals throughout the brain and the body so you can do whatever task you want to do in life - and even the tasks you don't choose to do but that the body does for your survival, like breathe.  When a concussion occurs, these nerve structures can be stretched or twisted just enough that the way that the electrical signals are passed along is impacted and all different types of messages can be influenced.

If you fall on the ground and scrape your knee on the ground, your skin may experience an abrasion and bleed a little bit.  The skin cells near the surface will, over the next several days, heal.  Fortunately, with the type of injury that occurs to neurons (nerve cells) during a concussion, they can also generally heal.  Most concussions will heal spontaneously very quickly, but some take much longer to recover.  These patients with slower recovery concussions are the ones I generally work with in the clinic.  People whose neurons may have recovered from the initial concussion processes, but who are still experiencing symptoms.

3. Treatment varies for each person with a concussion. This is because every person who experiences a concussion will present differently.  Even better... a single person experiencing concussion symptoms can vary hour by hour or day by day with their own symptoms, particularly in the first few days after a concussion.  So I track symptoms (using a graded symptom checklist like this one) over time with these patients to see if they're trending towards improvement and I can't compare one person's recovery to any other.  Every time I have taken a course learning about symptoms with concussion, it has been important to recognize that the goal is not to be a 0 on all of these items.  Teenagers get headaches occasionally.  They also get emotional sometimes.  But the goal is to reduce the overall symptom total and get them to stay at a relatively consistent level that does not fluctuate in response to physical or mental stressors.

I will say that there are some common themes with treating these patients.  Just like I don't treat every patient who experiences an ankle sprain the same way - the components of treatment for those patients is usually similar.  With a person who has experienced a concussion, there is often a headache and neck pain which tends to come from the upper cervical spine more than the lower cervical spine.  Some have vision and vestibular symptoms that require completely different treatments.  Symptoms for concussion have been grouped together into four categories of concussions: 1) vestibular symptoms, 2) visual symptoms, 3) cognitive symptoms, and 4) migrainous/headache symptoms.  These can overlap, but the treatments tend to fall into the categories that match the symptoms.  If the person is experiencing headache symptoms alone, the treatment likely shouldn't target vestibular or vision problems.  This is important because a person experiencing vestibular symptoms likely won't recover from those without specific vestibular treatments and those should be addressed prior to the other considerations.

4. It is the law that you must be cleared by a medical provider to return to sport activities following a concussion.  Laws vary by state and Washington State was the first one to pass such a law in 2009.  However, if you are a coach, and you have an athlete who experiences a concussion, there are many states which require 1) That the athlete stop playing immediately and cannot return for a minimum of 24 hours and 2) that the athlete must be cleared by a healthcare provider to play.  Some states allow physical therapists to be the person who clears these athletes for return to activities - but at Seattle Children's Hospital, we leave that decision up to the diagnosing physician.  So any of these kids who I'm working with to get back to sports - they're not playing in a sport competition until the doctor says so.  And it's not just word of mouth.  Schools are supposed to require that the clearance comes in writing!  Here's why these rules are important.

First - let's say you hit your head in a game and show some mild signs of a concussion but then a few minutes later you think you're feeling ok and try to play again.  Concussion symptoms are not immediate to show up, but reaction time and coordination can be impacted by a concussion.  So now, you've just experienced a concussion and are re-entering your game at considerably higher risk for another injury.  This is dangerous.  No sporting event - championship or scrimmage - is ever important enough to risk a brain injury.  Second - there is actually a name for someone who experiences a concussion, and then experiences a second one before the first one has resolved.  It is called Second Impact Syndrome.  It has a name because it increases the risk of mortality by 50% and it increases morbidity by 100%.  That means that if you experience two concussions in close succession, you increase your risk of death by 50% and 100% of these people have significant delay in recovery.  Doesn't it just make more sense to recover fully from the first one to reduce the risk of these much more severe outcomes?

I'm really enjoying learning about this patient population because it is fairly complicated in comparison to some of the other things you treat, and once these patients start to feel better, their quality of life is significantly impacted for the better.  Concussions can affect tolerance to sitting through classes in school with reading or looking at the whiteboard, they can influence tolerance to lights and noises and participation in sports - which is huge for some of these kids.  They can make you dizzy which makes all activity terrible.  These are serious and I hope that writing this helps people better appreciate the need for them to be treated appropriately. 

Happy Fall Sports Season, everyone!  Let's try to play smart and safe!

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.