New WNBA Injury Data Published!

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

Presenting at Seattle Children's Sports Symposium

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

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

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

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

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

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

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

What Do Physical Therapists Do? Installment #6: We Critically Appraise Research

Link

I'm long overdue for another installment of my "What Do Physical Therapists Do?" series.  I've previously written about the PT role in emergency response, return to sport participation, strength training, therapeutic alliance and listening, and assess biomechanics.

Have you ever seen a toothpaste commercial saying "100% of Dentists Recommend that particular brand?"  Do you think to yourself, 1) "Ooohh, I should go buy that right now!?"  Do you wonder, 2) "Would I like that flavor?"  Do you consider,  3) "I wonder if they surveyed one dentist or 1,000 dentists to get that outcome?"  Or do you 4) just let the commercial come and go and ignore it entirely?

I'm very particular when it comes to all things related to teeth... I hate when people walk around brushing their teeth, I can't stand the sound of the electric tooth brush, I gag in response to watching others floss in my presence. I can't understand why they made cinnamon or grape or bubble gum flavored toothpaste when it's clearly meant to be mint-flavored. Only. And chocolate with mint has been ruined.  Tragedy.  Today I'm giving these commercials more thought than they deserve.

I think that many people probably just follow option 4, completely ignoring the commercial and moving on with their show.  But that path ignores that behind that advertisement, there was some amount of research done, data was compiled, and the information was put out into the world for you to interpret.  So the purpose of this blog post is really about choice number 3) "I wonder if they surveyed one dentist or 1,000 dentists to get that outcome."  This isn't where my mind automatically goes, but it's the way that scientific research needs to be considered.  And it makes me nervous to think that there are physical therapists who don't read any research at all - or who read a paper but then ignore the findings entirely.  Just like option 4. 

Let's say you're a physical therapist and you're working with a patient who recently sprained their ankle.  What does the research say is the best thing to do for this patient?  Did one physical therapist present a case study that you read and you're taking their word for the best approach?  Have you, yourself, done a treatment with a similar patient before and found that it worked so you now think it's the best option for everyone with this condition?  Is there a journal article that says to do certain things, but other papers that show the opposite information?  Were the research tests done on a teenage male, like the patient you're working with, or were they conducted on a group of women in their 40's... and does that matter?  These are just the beginning of the thoughts involved in using Evidence-Based Practice in medical care and show why this is so complicated.  What does the research say?  What does it actually mean?  Is it clinically relevant to your patient? 

I've previously written about the changes that healthcare is experiencing here, but in that post, I didn't give enough credit to the transition in healthcare to more use of evidence-based practice.  I think use of research to support the decisions made with patients is very important, but I also find it to be incredibly difficult.  The example above with the patient with the ankle sprain is just one possible scenario out of tons of different ones to see in the clinic.  There isn't research to support all of our decisions, and even if there was research covering all aspects, there's no way I could ever read it all.

For myself, I work in pediatric orthopedics.  In a typical day, I will see eleven patients.  No two are the same, even if three of them are recovering from ankle sprains.  My job limits me to seeing patients between ages 5-21, which is far more restrictive than most people who work in an orthopedics setting.  But research on kids is often lacking, so to try to make decisions for kids based on research in adults tends to happen a lot.  I know that it may not be accurate - but I also know that I don't have anything else to base my decisions on.  While there is an increase in research available for teenagers with ACL tears, there are many conditions and treatment approaches that have not been well studied with matching characteristics to my patients.  And, again, even if I had all the time in the world and devoted it to reading, I could never read all the papers and really know what all the researchers recommend to make the most educated decisions possible.  So we work to make our best decision and review the literature as much as possible, and this requires the ability to critically appraise the literature.  Reading the papers is only the first step.  Understanding their meaning is even more complicated.

I mentioned in my last blog post (here) that I recently launched the Seattle Children's Hospital Sports Physical Therapy Journal Club.  So far, this project is in its infancy.  To get it started, I was advised by several physical therapists working elsewhere who already participate in a journal club to start by focusing on papers that help you critically appraise literature.  I followed their advice, but had to start with learning more about what that even meant. 

Journal of Sports Physical Therapy

According to the Center for Evidence Based Management, "Critical appraisal is the process of carefully and systematically assessing the outcome of scientific research (evidence) to judge its trustworthiness, value and relevance in a particular context. Critical appraisal looks at the way a study is conducted and examines factors such as internal validity, generalizability and relevance."  The Journal of Sports Physical Therapy (JOSPT) has been publishing a series of articles to help Critically Appraise Scientific papers here and as I've been reading through them and collecting information for the journal club, I've been finding that 1) the topic of critical appraisal of the literature is not very interesting, and as such, I have never previously given it much consideration to learn as a skill and better question the research I'm reading. Lack of interest is a poor excuse for something this important.  I'm also not interested in gymnastics, but I work with gymnasts so I need to take an interest in it to sufficiently work with that patient population. 2) There are a whole lot of ways for a scientific study to go wrong - without the researchers having that intent or despite their efforts to avoid it.  Things like bias, blinding study participants, misunderstanding confounding variables or inclusion and exclusion criteria for subjects, insufficient sample size, improper use of certain types of statistics, lack of awareness to the true definition of terms and what they mean in a scientific setting, and I'm sure more ways that I don't even know yet. 3) Research is super complicated and cannot be taken solely at face value.  Simply reading an abstract and the conclusions of a paper can be incredibly misleading if authors have put a spin on their findings or if the methods of the paper are ignored.  Critical Appraisal requires thought, analysis, interpretation, and questioning.  

As clinicians, I think learning about how to appraise the literature is something many of us need to do better.  As physical therapists, many of us did not have to go through the full research process to get to our clinical status.  This may be a shortcoming of our learning because too many of us are not considering whether or not the findings of a study really mean what is presented and whether or not a lab study actually applies to the clinical setting.   It seems like a lot of research principles come from the pharmaceutical world.  If a medication is provided to 100 people and nobody dies and an abstract for the paper says it saves lives, that is a misrepresentation of data.  What if the methods show that the criteria to select the participants in the study excluded people who would really need that medicine?  What if they only tested the medicine on people over age 75 and you work with children - would it also save them?  What if, when the study is expanded further to maybe 1,000 people, there are deaths in the bigger group?  This is a call for us all to be better about consideration of the research with a healthy skepticism towards methodology and interpretation.  

So the next time you want to do a treatment technique on a patient, have you considered the literature supporting or refuting the efficacy of that approach? This could be anything.  Dry needling.  Massage.  Cupping.  Specific types of exercise - maybe yoga or pilates.  Stretching.  Strength training.  Breathing.  Biofeedback. Foam rolling. Desensitization.  We have a lot of tools available to us - many with different levels of support in the literature. And have you looked to see if there is a paper that suggests outcomes to the contrary?  What do you think is the best option for this specific patient?  I'm struggling so much to read papers that, for example, suggest that manual therapy is no better than exercise.  Some patients really do seem to need manual therapy.  There are lots of papers that suggest it isn't useful, and there are also whole institutes, like the North American Institute of Orthopedic Manual Therapy (NAIOMT), who have evidence to support the exact opposite. A paper cannot study every circumstance, so the setting and the patient demographics and pathological condition have to be considered. 

I'm hoping this post just encourages you to question how you use research and evidence-based practice, which you should definitely be doing, and perhaps you can teach me ways to more critically appraise what I'm reading.  We can all get better at doing this.  And we can all hold each other accountable to be better clinicians. 

The Level Up Initiative

with permission from the Level Up Initiative

The healthcare industry, including the field of physical therapy, is experiencing a revolution.  A paradigm shift. A wave of new thought. A reform. A change in perspective. An upgrade, in my opinion. Despite Dr. George Engel defining the biopsychosocial model in 1977, it has only recently become more common for clinicians to consider this form of practice. Chronic pain as a health condition is costing a ton of money in the US, and I think that this is one of the drivers for change. Healthcare providers and researchers are looking for ways to improve our treatment approach for people who are suffering.  The Level Up Initiative is trailblazing the path for young clinicians to better learn this model and tools for patient-client relations that the model inherently requires, which is not the typical model taught in healthcare education programs. If you're a physical therapist - new grad, student, or even a veteran - and you haven't heard of the Level Up Initiative, click that link and check it out.

Zak Gabor with me in 2017

I met Zak Gabor, founder of the Level Up Initiative, in November 2017 at his "Hip Hinge 101" course which I blogged about here. He included a patient case (who happened to be my friend from high school). She was experiencing low back pain and Zak showed her MRI along with cartoon images of a stick figure bending forward and an explosion coming out of its back. The MRI showed disc herniations and the patient had been told her back was "destroyed" and that she shouldn't bend over to pick up her kids. Imagine being a young mom with two active little boys and being told you can't pick them up because you could risk damaging your back! What would you do? When this type of message comes from a medical provider, a patient will often take the advice to heart and follow it with blind faith. This is why healthcare providers have a HUGE responsibility to consider the impact of the words we use with our patients. (Click here for JOSPT "Sticks and Stones" article on this topic.)

The Level Up Initiative strives to educate physical therapists (and other healthcare providers) on a biopsychosocial approach to patient care focusing on soft skills and therapeutic alliance in addition to the anatomical tissue healing factors and movement patterns we learn in school. The goal is to teach clinicians ways to interact with their patients with critical thinking, to connect, to prioritize using positive language and a growth mindset, and to focus less on a medical diagnosis and more on the whole person. Increased consideration for mental health and psychology, far more than what I learned in PT School is a factor of the paradigm shift.  My school taught the biomedical model with primary consideration of anatomy and biomechanics without much attention to the psyche or nutrition or sleep or a whole host of other stressors that impact our patients.  Most schools are just like this, though as the shift continues, more programs are giving attention to these considerations.

Ellie leading our Mentorship Group

As a company, The Level Up Initiative puts out content on various social media outlets including Facebook and Instagram posts, as well as having a podcast, a recently initiated blog, and a free mentorship program. I participated in the third cohort of their mentorship program where my mentor was Ellie Somers, owner of Sisu Sports Performance. ***Sign up for the next cohort NOW!  Enrollment ends November 24, 2019*** I enjoyed my experience working through this program and wanted to explain what it was like for those who are unfamiliar with it. Again, I can't recommend checking out their website strongly enough. It has impacted my patient care in only positive ways and I hope I'll have the chance to serve as a mentor in their program in the future.

The mentorship program lasts four months and, as already mentioned, is free. Free! These skills will immediately impact your patient care, but you have to put in the effort to go through their materials. They send you the full course syllabus in advance which outlines the recommended books, podcast episodes, TED talks, and publications to go through over the program and you can really dive in at your own pace. The course is organized with themes that help to focus the group discussions, but going out-of-order with the reading didn't impact my experience.  I chose to complete all the tasks on the syllabus, but I could see that if your schedule didn't allow for that, you could take it as a reading list to work through in the future while still getting a lot out of the discussions and watching the modules.

I won't tell too many details about the specific resources because you should participate in it to get the full experience, but I do want to share some of my favorite parts and describe the structure hoping that it will encourage you to sign up for their next cohort (HERE). The three key topics explored in the mentorship program are Growth Mindset, Critical Thinking, and Communication. Even as a PT for the past five years, I learned new things with each topic, and regularly wished I could have had this knowledge as a new grad. Each topic had discussions amongst our assigned mentorship group as well as reflection questions to consider for personal growth.

Photo from Module 1 with permission from Level Up

Module 1 examined "Growth Mindset."  If you're not familiar with this concept, start reading about it! Once I learned it, I could easily identify when this was an issue with a patient and there are some simple strategies on how to approach this problem to optimize patient care. Our group had an awesome discussion about failure during this module. I personally have experienced some professional failures this year... I submitted a manuscript for publication that was rejected, worked on a project for the WNBA that seemed to crash and burn.  With a growth mindset, I can look at those failures as opportunities rather than disasters. One of my personal favorite strategies is to encourage the use of the word "yet."  Working in pediatrics, it is a frequent experience that my patients may not have done an activity before - so when I ask them to try, sometimes they default to "I can't."  And I tell them, they need to try.  Maybe they can't complete that task, yet - but they need to try, and maybe they'll surprise themselves!

Module 2 dove into Critical Thinking. If we want to see change across PT and across healthcare, we have to start changing how we practice so that the field can catch up to our individual change.  We need to challenge the things we learn in school and we need to challenge our own thought processes in order to grow.  Critical Thinking is an umbrella term that really encompasses many concepts - including an open mindset (like module 1) and communication (the next two modules), but for me, the biggest part of critical thinking is to recognize our own biases and look for ways to disprove our own opinions and beliefs.  When I took Greg Lehman's "Reconciling Pain Science with Biomechanics" Class which I wrote about last week here, I asked him how he organized his learning because he reads SO MANY articles.  He told me that he will pick a topic and then collect several resources on that same topic looking for ways that his beliefs can be changed while reading the collection.  That is intentional critical thinking.

with Permission from the Level Up Initiative

Module 3 and 4: Communication
One of the recommended books for this topic was the toughest book I've read since "Explain Pain Supercharged," but once I got past the big words I needed to learn, I was really impressed by the brilliance of the book and by the importance of the concepts outlined in it.  Where does vulnerability fit into our careers as heathcare providers?  How much can we tolerate uncertainty?  We need to reflect on the care we provide so that we can identify our personal areas with room for growth.  We also need to recognize that our interactions with our patients are directly impacted by our own beliefs and the patient's beliefs.  The motivation of a patient will impact their participation in your home exercise program.  If it looks relevant to an activity they strongly want to return to, that's different than if your recommendations seem arbitrary and unable to help them achieve their goals.  If I believe that jumping up and down is going to help my patients and I can convince them to do it with intelligent rationale of how it will help them return to running, they're going to do it.  If my coworker uses a different approach, they're going to use an alternative treatment technique. Potentially neither of us wrong, but if the patient thinks my way is better, it will impact their care. Because of this, earning a patient's trust can really outweigh other things in care.  Remember, we're not treating robots.  To focus entirely on the objective and ignore what the patient thinks is going on with their own body, aka the subjective, leaves holes in their story and makes it harder for you to effectively treat patients.

So after four months and lots of new learning, I'm excited to share about the experience with you, and hope that if you're a new graduate PT, you'll consider participating in this mentorship program in the future.  Sign up this week, or wait until the next round.  Follow the Level Up Initiative on their social media sites, all linked above.  And then let me know what you think.  Tell them I sent you.

Reconciling Pain Science and Biomechanics

Greg Lehman

It's finally happened. I finally attended a course presented by a Canadian! I also work with a
Canadian Occupational Therapist and from my sample size of n=2, I think it's possible that Canadians are smarter than Americans. Why is it that Canadians seem to know more about American politics than we do? I can only inadequately describe how our government operates and I know absolutely nothing about theirs.  It's like they care about what happens in the world, or something. We should do better, America.

Anyways, since I'm sure you also want to take a course instructed by a Canadian, I'm sure you want to know what course it was? "Reconciling Pain Science and Biomechanics" by Greg Lehman. Greg is a physiotherapist, chiropractor, strength and conditioning specialist, and biomechanist who also teaches a course called Running Resiliency, which is probably excellent if you run or treat runners, which I try to avoid.  (I avoid running.  I don't mind rehabbing runners).  "Reconciling Pain Science and Biomechanics" is a two day course that bridges the gap between the clinicians who focus heavily on pain neuroscience education and the psychological side of the biopsychosocial model versus practitioners who tend to focus primarily on perfection of movement patterns and anatomical tissue structural damage as potential drivers of pain.  If you're working in orthopedics or with pain management you should definitely check this one out.  The course was overall broad with big concepts that ideally could apply in multiple situations.  It also came with an extensive set of resources including his presentation and a huge number of literature papers for consideration.  So much evidence to support the discussions. 

I've previously written about pain here (and several other posts).  Greg defines pain for this course as "When all your loads/stressors exceed your ability to adapt/cope."  Pain is the balance between all the things that are harmful to you and all the things that are good to you. I often like to use the concept of inputs versus outputs with my patients, especially because people often don't recognize that pain is an output. I can't put pain into you. Pain is an output message from your brain in response to stresses that have been applied.  I can apply stresses to you so that a painful output occurs, but instead I try to find the minimum effective dose of stress to input so that your output is positive adaptation, not pain. 

Some examples of inputs: mechanical stress to tissue such as an incision or deep touch or the feeling of your rear end on the chair you're sitting on, chemical stress such as dehydration or improper nutrition, emotional stress such as those from your family or your job, light, sound, and temperature changes.  Inputs are not good or bad, they are just stresses that we have to process in our body.

Some examples of outputs: pain, emotions, sweat (loss of heat), neuromuscular adaptations such as increased strength, seeing your mental health counselor and talking it out, breathing, coping/calming strategies.

So when a person is experiencing pain, anywhere, the options for treatment could include:
1) Can you decrease some of the inputs?  Examples: Turn off the lights, focus on some breathing strategies, go for a walk, change your body position, change the temperature, increase or decrease the amount of touch on the area that hurts. 
2) Can you increase some of the outputs?  These could actually be the same as above because of things like hot versus cold where changing temperature in one way actually accommodates both, but also doing some yoga, exercise, see your therapist, take your regularly prescribed medication if you have diagnosed anxiety or depression that is being medically managed, or spend time with friends.
3) Or can you make it so that you're able to accommodate for more inputs without changing the input or output?  Again, there is overlap here.  But for many people, building up tolerance through strength training or meditation practices or learning ways to desensitize your skin can all have this sort of impact. 

It's important to also consider what is getting in the way of making some of these changes. Is the patient fearful of going for a walk because they have pain in their foot?  Are they catastrophizing or perseverating on horrible possible outcomes by participating in a certain activity so they're unwilling to try?  What are the current beliefs and expectations about their condition?  Knowledge about how the mind and body connect and work together can help decrease these roadblocks to facilitate recovery.

Greg provided some important questions to ask patients to help them return to their favorite things.  For example, "In what ways do you think you could be healthier?"  This open-ended question allows a person with headaches to consider that maybe they could better hydrate, have more nutritious meals, sleep at more optimal times, go for a walk at lunch time, maybe acknowledge some of the recent spikes in stress at their job or school... but it allows them to identify potential sources of their pain, allows them to outline what they believe is happening, and also gives you a chance to better learn about the patient. 

Greg Lehman and Me

He also discussed the importance of asking "What activities are meaningful to you?"  So, for me, I really like to play softball.  When I hurt my knee a few months ago, I was disappointed that I couldn't play for a week or two, but then I was able to return in a modified way.  If I hit well enough, I could hobble my way to first base and get myself a substitute runner for the rest of the bases.  I didn't think I would damage my knee worse by doing this, and I actually didn't have much pain when I tried that.  I spent a little more time in the dugout instead of alternating innings so I could avoid spending so much time in my catcher's squat position.  So, I was able to dose my activity so that I could do some rather than none at all, and this actually built my confidence to return back to my usual level of participation after healing and recovering. 

Which leads perfectly into "Encourage the patient to ask themselves 'Will the activity harm me? and/or 'Will I pay for this later?'"  Like with my softball example, I didn't hurt myself worse by participating and I didn't hurt more after playing. Certainly there are times when doing activities can be harmful. As a physical therapist, it is our job to recognize when that is the case and appropriately guide our patients, but modifications are often possible.  In particular, I really think it's important for our post-surgical patients who can't be playing their sport to spend time around their teammates. Be the team manager!  Learn more about your sport.  Spend that time with your friends.  It's better for mood, learning of the game, growth with teammates (and they'll get better support if they're around and showing their progress over time." 

Best Thanksgiving Food

In another example, this past weekend I attended a delicious Friendsgiving dinner at my friend's home. I've been managing some gut issues lately and had been eliminating several foods to try to identify where the problem was coming from. After a month with no wheat and two weeks without any onions or garlic, I wasn't exactly sure what would happen if I had some stuffing... but I really wanted it!  I actually did use this line of reasoning while I ate.  Will I do any permanent damage to my body by eating this? Not likely, no. Will I pay for it later? When I made the decision, I wasn't entirely sure, but I thought it was possible, which impacted my decision for quantity of stuffing that I took (dose). And yes, I felt like crap from it.  But was it worth it? That's very individual, and up for me to decide, and now I have data. Next week when I'm home for family Thanksgiving, I get to decide if I want to repeat this same thing knowing what the likely outcome will be, or not.  But I'm empowered to determine what I do to my own body, and that's something I think we can teach our patients, too. 

What else can we do as physical therapists to help our patients who are experiencing pain?  We need to help make sense of their pain using their own understanding of what's going on. A person who thinks their "back is out" can't just be told "that isn't really a thing, backs don't ''go out.'"  They'll never buy into your message if they have a belief of what's wrong and you just strong-arm them into an opposing idea.  So instead, we acknowledge their beliefs, educate them on how adaptive the human body is, and we facilitate cognitive restructuring.  An example that was suggested in the class was "I bet someone has told you that your spine is twisted," and by acknowledging their perspective, you can try to bend that belief just a little bit, "but actually your pain could be from something else, so why don't we work on getting you moving in ways you can tolerate."  You create a small hint of doubt into their beliefs and see if the patient gives you an opening and slowly you can chip away at the beliefs over time.  We can facilitate adaptability by using intentional application of specific stressors that induce adaptation for increased resiliency, and this includes with beliefs. We must meet our patients where they are at with the psychological and physical approaches, progressive loading ooth their thoughts and their tissues, which might be a really little bit of loading at the start, but sometimes that's all they can manage. We work hard to encourage their autonomy and self efficacy.  One of Greg's quotes which I really enjoyed: "Requirements for adaptability: 1) Human. 2) Not Dead."  He also made sure to include a statement about how physical therapists don't fix people.  We facilitate them.

Bob Ross

And so physical therapists need to understand barriers to recovery, which could be at the tissue healing level, or could be in the psychosocial realm, or a whole host of areas in between.  And we need to appreciate that what we do is, in fact, an art, while also being a science.  That makes Greg Lehman just like Bob Ross, I think.  He painted this one beautifully. So many happy trees.

And with that, I'll finish with another quote from the course "Limping is a helpful adaptive pattern. It is successful in keeping people moving. It decreases pain. But should we advocate for everyone to start limping?"

Thanks so much, Greg.  I hope you'll come back to the USA soon!

Online Knee Seminar and Three Key Components to Patient Care

© Drpluton

ID 8194008 | Dreamstime Stock Photos

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

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

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

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

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

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

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

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

Sleep Deprivation and Risk of Injuries

© creativecommonsstockphotos - ID 96494735 | Dreamstime Stock Photos

A few days ago, I wrote this post describing some recent air travel stories.  Included was the plight of the Las Vegas Aces WNBA team whose travel delays heading toward Washington D.C. to play the Mystics ended up with the Aces cancelling their game - and a twitter storm of discussion over whether or not that should have been allowed.   At the time of this writing, the WNBA has not yet presented its decision on what will be the outcome of the Aces canceling the game - since they did ultimately make it to D.C. in time to physically be present.  The delay in the outcome of this saga is a bit surprising... twitter has been buzzing waiting to see what will happen... and it has huge playoff implications for both teams. 
The Aces released this (abridged) statement:  "To all of our WNBA fans around the world: We are so sorry that the Aces were not able to take the court tonight against the Washington Mystics. We trust that you know this decision was not made lightly...Given the travel issues we faced over the past two days—25+ hours spent in airports and airplanes, in cramped quarters and having not slept in a bed since Wednesday night—and after consulting with Players Association leadership and medical professionals, we concluded that playing tonight’s game would put us at too great a risk for injury. Naturally, the issue of player safety is of paramount concern for all involved in the WNBA..."

As a WNBA fan - I was sad that the game didn't occur.  If I had tickets, I'm sure I would have been disappointed, especially since people travel to get to games, and they canceled only an hour and a half before tip off.  But as a physical therapist who works with a WNBA team (and would never play any role in making the decision of if we would be playing), I think this was the right decision.  I didn't have enough research to back it up before - so now I've gone searching.  Full disclosure - I'm biased.  I searched for research relating sleep deprivation and fatigue to injuries.  I'm sure I could potentially find papers that would state the opposite outcome... but this is one of the problems with practicing evidence-based medicine.  For every paper that has an outcome, there could be differently designed papers that have the opposite outcome.  So here's what I found, and we can take it with a grain of salt...

1) Durmer et al wrote in a a 2005 about the "Neurocognitive Consequences of Sleep Deprivation."  They wrote about increased risk of car crashes in sleep-deprived males with injury severity and frequency of accidents similar to those of alcohol-related incidents.  This paper focused more on the chronically sleep deprived - people who sleep less than 7 hours per night consistently - though it does mention other types of sleep deprivation such as short term sleep deprivation for less than 45 hours or long term for greater than 45 hours.  Changes in mood, confusion, anxiety, and depression are noted issues across types of sleep deprivation.  Of key importance is that there was a correlation with decreased response time and increased rate of errors with multitasking... which is essential for sports participation.

2) Milewski et al in 2014 also examined more chronic sleep deprivation and found increased risk of injury in adolescent athletes who slept less than 8 hours compared to those who slept more than 8 hours.  Higher grade level in school (older kids) also had increased risk of injury in this study. 

3) Of course I did a search for the relationship between ACL injuries and fatigue...because in the women's basketball world, a torn ACL is considered one of the worst things that could happen. Last month, this brief article was published summarizing increased risk of ACL injury when jump-landing mechanics were assessed following aerobic exercise (acute bout of fatigue) which corresponded with 20% of local muscular fatigue.  It's hard to compare this to 25 hours of travel like the Las Vegas Aces underwent - but in that case we're talking about more of a full-body fatigue with increased risk because of the above-mentioned cognitive factors - in addition to this localized muscle fatigue which would potentially also be present from sleep deficits.  In 2008, Borotikar et al published this paper looking at central and peripheral fatigue influence on ACL injury in females. Again, the fatigue factor was not induced by air travel... it was caused by repeated squatting or jumping tasks, so the correlation is difficult to make.  This study was interesting because it looked at muscular (peripheral) fatigue as well as decision making (cognition/central fatigue) in tandem where previous studies had only looked at the impact of either type of fatigue on ACL injury.  Based on the length of the Aces travel, it is likely that they were mentally fatigued and muscularly fatigued... so it is absolutely reasonable to extrapolate from this particular study that their risk of ACL injury would have been increased by playing under their conditions.

I know there are plenty of people who say they should have played.  I understand those reasons... it's better for the league not to miss games, it's essential for fans to see their favorite players - especially since the teams only would meet in DC twice this season and it's close to South Carolina where Aces superstar A'ja Wilson played in college... South Carolina fans would really have to go to either DC or Atlanta to get to see her, and I saw a few posts online with some devastated fans that they couldn't see her play.  But the statement released by the Aces was clear that there was concern for injury - and thruthfully, if someone tore their ACL in this game - win or lose - that's a huge loss for someone's career and for the team finishing out the season.  Taking a single loss might just have been the best protection for the health of their team.

I can't believe we don't know what the league will do about this yet... but I'll go ahead and guess that the Aces will take the forfeit, the Mystics will get a win, the game won't be made up, there will likely be some financial penalty the Aces will have to pay to the Mystics for imposed costs... and the league will continue to move forward.  Even better - the WNBA players union will open up conversations in a few weeks for their collective bargaining agreement, and travel expectations are bound to be part of their negotiations moving forward.

The end of the WNBA regular season is rapidly approaching - last day is August 19th and then straight into the playoffs.  The blog may be a little heavy on WNBA basketball right now... and then I'll go through my end-of-season mourning period and return to more writing about physical therapy topics... at least until college basketball starts.  Can't wait to see what the league decides for the Aces... it could set a major precedent moving forward.

More about PAIN

Last week I posted this blog introducing my recent studies regarding pain science starting with a few basics I learned from Explain Pain, by David Butler and Lorimer Moseley.  I also recently finished reading their 2017 edition, Explain Pain Supercharged, an awesome book, particularly in its use of easily understood metaphors and stories to help illustrate the concepts, but those underlying concepts are more complex than anything else I've ever read.  It made me think of first grade when the librarian was teaching us how to determine if  books were appropriate for us to read. She instructed us to select a book that might be interesting, ( I wanted to read the Boxcar Children), sit down in a quiet corner, open the book to any page, and read that page holding up one finger for every word we didn't know. If we didn't know five words when we finished the page, it was a little too tough for right now, but maybe next time back at the library it wouldn't be.  I still love the library and quiet corners.

This timing of my focus on pain science is intentional. I've mentioned that I've been working with more patients who are experiencing chronic pain - both at Seattle Children's and when I'm with the adult population.  The patient with chronic pain is interesting because they continue to experience pain long beyond the normal tissue healing time expected with injury and often to a degree that is not proportional to the injury that was originally sustained. Picture stubbing your toe on the corner of a table.  It hurts, but you keep going about your day, maybe hobbling a little bit, but then days later you're still hobbling and it still hurts, and then a month has gone by and now you're avoiding weight bearing at all. This progresses until you reach a point where you stop putting your foot on the floor entirely, switch to crutches or a wheel chair, become fearful of any possible touch to your leg, and consistently report high levels of pain.

For these patients, the nervous system has found a way to overprotect their body. It has gone from working a 9-5 job to becoming a workaholic where every increased responsibility at work just makes them more and more irritable - only we're talking about how the body works from the inside!  In the end, the principles to working with these patients are largely the same as any other patient - if you can understand the mindset of needing to unload the stresses on the nervous system and then progressively load that - rather than focusing on unloading other body tissues of the musculoskeletal system which we so typically target.  AKA - take a vacation, break the overwork cycle, read a book by the pool, have a pina colada, and then when you return, maybe take an extended lunch break or two to slowly get back into the swing of the job without it taking over life.

In addition to the clinical utility of learning about pain, Lorimer Moseley was in Seattle this past week and I went to hear him speak at the University of Washington. I attended the event with a crew of fellow PTs who have been learning and teaching me about pain science, using the framework of the biopsychosocial model with patients. Who better to help me understand the impact of my words on the patients I work with?  Dr. Moseley's presentation was entitled "Seven Amazing Pain Facts that Could Change Your Life."  Here they are, with a few thoughts on each:

1) All pain is real, regardless of cause.
Just because there is nothing on an XRAY or an MRI showing that there is something wrong, does not mean there is no pain or that nothing is wrong. Pain does not correlate with tissue damage.  Sometimes people have major injuries without pain.  And doesn't a paper cut hurt like the dickens?  (I typed that - then had to look up the origin of that phrase - the dickens is used to represent the devil because some people don't believe in talking about the devil.  Fun fact.)

2) Your brain is like a jungle.
Everything is connected in a complicated ecosystem with interdependence between creatures.  A little bit of Darwinian survival of the fittest with regard to the more you use certain brain pathways - including a pain pathway - the more intensified that pattern becomes.

3) Your brain is looking out for you in sneaky ways.
Pain is normal as a protective mechanism for your body.  But like my above example of a stubbed toe taking over, sometimes the protective mechanism is overactive and needs to be re-trained.

4) Your brain uses all incoming data.
This is consideration for that biopsychosocial model I've previously talked about here. Pain is influenced by numerous factors - including the tissues of the body, relationships with other people, stresses at work, diet, nutrition, exercise - the list continues.  It is also influenced by the words we use with our patients to describe their pathologies.

5) Your brain uses all the data already stored. 
If you've previously stubbed your toe and recovered with a typical pattern of recovery, you're more likely to have a similar recovery pattern.  If this is the first time you're stubbing your toe and the brain goes into it's overprotective mode, it's learning this pain pattern.  The brain remembers what it has done for similar events in the past and uses prior experience to guide responses to recurrence of similar activities.

6) Our nervous system learns pain.
Just like I said above.  We're like elephants... we don't forget.  And the more the pain cycle continues, the more re-inforced it gets into your brain until you can break the cycle.

7) Understanding contemporary pain biology may be the missing link.
For some patients, educating them about how pain works makes it less scary and helps them to break their pain cycle to start the road to recovery.  I'm thrilled to report that my first attempt to use my new knowledge appears to have had positive impact on the specific patient I chose to use it with, and that my colleagues are also having positive outcomes using this framework.  But I'm currently operating with an n=1, so I need a lot more practice on educating patients about their pain, and I'm working on further organizing my learning on this subject so that I can better choose when to focus on this treatment pathway rather than what I've always done in the past.

This is the link to the video clip I've started using for kids dealing with chronic pain. The video isn't actually targeting children, but it's the best one I've found, and, at the very least it is entertaining and parents can help their kids to better understand.  Check it out.  Notice the resemblance between cartoon Lorimer Moseley and real-life Lorimer Moseley, and let me know what you think!  I actually asked Professor Moseley about using the video for children and he said it's on his list to make a new, updated version, that's more kid-friendly.  But for now, this version seems like a good place to start. I hope I'm not boring anyone with my repeated topic of pain - especially because I anticipate one more upcoming post on the subject in the near future!

Me with Professor Lorimer Moseley

February Challenge: Read 28 papers in 28 days!

I decided to participate in a challenge to read 28 journal articles during the 28 days of February.  This challenge was organized by: Jacob Manley and Michael Fitzpatrick (a PT and PT Student, among several other areas of expertise - the Movement Doc), Samuel Spinelli (a PT - The Strength Therapist), and Jason LePage (Prime Physio Fitness - a PT Student at Quinnipiac University in CT so he automatically gets my support!). 

(P.S. Please don't tell Dave Ramsey I'm going off track of my current plan to get through a boat load of research articles - this was time sensitive and felt like a great opportunity!)

The idea that these guys have - to read more of the literature to improve their practice and knowledge - is commendable.  Way to go fellas!  Their goal is "to improve our ability to read research, improve our evidence appraisal skills, and read research studies that we may not have read before." They post the articles open access and they also write up a summary on the article to start conversation and get feedback.

I won't be posting about all the articles they've selected to discuss this month - but I wanted to share about the challenge in case others might want to participate - it's definitely not too late to jump on board.  Also, the first article they included deserves some attention as it fits into the chronic pain theme that I've already started posting and learning about.  I may do others moving forward - but since I haven't seen those topics at the time I'm writing this - it's too soon to tell.  Also- I should note that I'm writing this post as I read the article with all my thoughts on it and will read their posted review of the article afterwards so it won't bias my process. 

This particular article (and the entire challenge), can be found by going to the Movement Doc site and joining their members only section, is entitled, "Indviduals' Explanations for their persistent or recurrent low back pain: a cross sectional survey." It is from 2017 by Jenny Setchell et al.

Introduction: The study begins with a description of the biomedical model versus the biopsychosocial model.  I've previously mentioned pain with consideration for the biopsychosocial model and the need to consider non-anatomical contributors to pain here, here, and here.  If you're new here - it's the idea that psychological components such as stress, anxiety, depression, and even the word choice used to describe pathology can impact our patients and their pain.  In consideration of this model, the article states, "how people think about their pain is an important predictor of severity and chronicity." 

Purpose: This paper examines patients with low back pain to determine what caused their pain and where their understanding of their condition came from.

Methods: The study used a survey marketed via social media and postings in local health centers to recruit participants with low back pain.  The majority lived in Australia - locale of the primary investigator - and about 75% were female.  My thoughts: Whenever I see that a study was marketed in this manner, I immediately consider the fact that this means that participants had to have the time and the means to participate as well as a way to come across the study in the first place.  It automatically rules out those who don't have a computer or health club membership from participation which might mean an influence of socioeconomic status of participants.  I consider this important because, based on the biopsychosocial model, a person with less financial means has been excluded, but this financial status could be a significant impactor to their pain experience. 

Analysis: The authors used "discourse analysis"  - a statistics term I had never heard before.  "Discourse analysis is based on the premise that the language we use has a role in creating or constituting reality, rather than simply reflecting it thus discourses are seen as having a real world effect."  It is a way to assess how people think.  This is the basis of the fear-avoidance behavior model- where, for example, if someone was told they herniated a disc in their back, they may avoid certain motions that they think are associated with that pathology.  The study responses were analyzed to determine four discourses which all the participants were then categorized into. My thoughts: statistics is super hard and I'm so thankful that there are people who specialize in studying this.  This concept, discourse analysis, is really interesting because in my mind, no two people will respond the same way to the same input information so to categorize responses into groups for better understanding seems sensible.

Study results: The four categories (discourses) to the question "What is your understanding of why your low back pain is persisting or recurring" were: 1) the body is a machine that has a defective part - this is the biomedical model and was most common, 2) Low back pain is permanent, 3) LBP is complex.  Those who were unsure of the cause of their pain were ultimately included in this grouping. This is the biopsychosocial model.  4) LBP is negative, should be avoided, and has a poor impact on life.  The second question was "Where does this understanding come from?" and 89% of the responses identified a health care provider as the supplier of these discourses as well as about 25% from the internet!!! My thoughts: WE'RE HARMING OUR PATIENTS!  We need to do a better job communicating with patients as healthcare providers.  Hippocratic Oath People!

Discussion: The authors summarize that most of the surveyed participants responded with biomedical responses as to the cause of their low back pain and that they learned this information from their healthcare providers and/or the internet.  There was an expression of hope as some responses to where the pain came from included both an anatomical/biomedical response as well as a biopsychosocial model type response

My assessment: I thought this article was very interesting and that it aligned with the recent articles I've read on chronic back pain and the biopsychosocial model.  It is clinically applicable and relevant as it is a strong reminder of the importance of the language that clinicians use with patients.  Following my write up of the above information, I read the review document from the challengers and was able to recognize a few differences in how I interpreted the information versus how they did.  First, in the introductory portion, I had picked up on the interests of the authors looking at the biopsychosocial model as contributing to the patient's outcomes, but I had not picked up on the idea that the authors include here that how the patients perceive their pain and what they think their outcomes will be, are also contributors here.  For example, if a person thinks their back pain will never get better, this can impact their outcome.  Overall, the study limitations the group found were all similar to my understanding, which was pleasing to me, and this experience of literature appraisal with someone else to compare to was overwhelmingly beneficial.  I'm looking forward to the rest of the articles this month - and you should feel free to join in or check out the articles - or even the reviews being posted - because it's a fast way for you to get a lot of information!

Article referenced:
Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskeletal Disorders. 2017;18(1). doi:10.1186/s12891-017-1831-7..

Book Alert: Deep Nutrition By Dr. Catherine Shanahan

I just finished reading Deep Nutrition by Dr. Catherine Shanahan.  Fascinating stuff.  And if Kobe Bryant endorses it, as one of the few who was able to play NBA elite level hoops for 20 years, it has to be worthy of a few weeks of my reading time, right?

A few snippets that I found fascinating from this book:

1) Nutrition can affect genetics in later on generations but these may not be permanent changes.  The idea that DNA and genes are a series of light switches turned on or off by what is available is novel to me.  One example in the book describes a 1930 study conducted using pigs that were deprived of vitamin A before they reproduced.  The litter of these deprived pigs were born without eyeballs because the mother had no supply available and vitamin A is essential to formation of the eye.  The blind piglets, however, were fed normal diets that contained vitamin A and they were able to give birth to pigs with eyeballs. Unreal!

2) The science of food is considered with respect to the biochemistry of oils and how certain ones (particularly vegetable oils) are dangerous for consumption. Dr Cate shows how vegetable oils have multiple double bonds in their chains which break apart when heated leaving reactive compounds in our bodies that can wreak havoc on the system. My inner chemistry nerd loved trying to comprehend the complexity that she simplified here.  Additionally, there is a lengthy discussion of the science of all the ways vegetable oils can affect the body- and none of them sounds good!  This book is a challenging read- even with boat loads of science learning behind me, I had to really work to gain full understanding of some of the biochemistry going on- but it is definitely making me think about my food in a new way.

3) Following oil, the book went on to discuss the negative effects of sugar consumption. After completing five rounds of the whole 30, I'm positive that my body hates sugar... though my mind continues to crave it and give in to the temptation of its deliciousness. Discussions of how sugar influences cholesterol levels, diabetes, migraines, erectile dysfunction, and cardiac issues were outlined. I doubt I’ll ever be able to completely exclude my favorite treats from my diet, but the anecdotes and research outlined in this book will certainly make me think more about the treats I’m consuming and whether or not they’re worth it. 

4) Consider food as medicine. If you focus on what we eat as the problem, it might be hard to realize that food is also the solution.  The book looks at a few conditions - particularly concussion, Alzheimer’s, and autism- and discusses how oxidative stress contributes to these diagnoses. Did you know that what you eat after a concussion can impact your potential recovery because certain foods increase oxidative stress on the brain which it is already overloaded with from the injury? I had never thought about it from that perspective, and I treat people who have experienced concussions!  The book outlines "The Human Diet" with the four key components of what you should be eating. 

Overall, I definitely recommend the book but think it’s only fare to mention it felt like hard work to get through some of the heavy science portions. Ultimately I’m so glad I did and will definitely be applying some of the principles I learned to how I eat and cook.

Check it out!  Next up to read: "The Origin of Species."

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

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

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

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

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

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

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

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

Looking ahead to 2018: what do I have planned?

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

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

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

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

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

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